JRGOS Case Corner

The JRGOS Case Corner is submitted by Stephen P. Canton, MD MSc, Gladden Resident Member (PGY5) at the University of Pittsburgh Medical Center (UPMC). Next year, he will begin his Orthopaedic Traumatology Fellowship at the R Adams Cowley Shock Trauma Center in Baltimore, Maryland.

Dr. Canton presents this month’s case in collaboration with faculty George V. Russell, MD, MBA, Professor and Executive Vice Chair of the UPMC Department of Orthopaedic Surgery, President of the J. Robert Gladden Orthopaedic Society, and Second President Elect of the Orthopaedic Trauma Association.

Case Presentation

A 53-year-old male with a history of Blounts disease, asthma, alcohol use disorder, and hypertension who presented after a fall on stairs while intoxicated. Orthopaedic surgery was consulted for evaluation and management recommendations of his RLE. He was a poor historian. The patient stated he was walking up the stairs and was unsure of what exactly happened. However, after the injury he was unable to bear weight on the RLE with pain.

The patient underwent two interventions (1) an index open reduction and internal fixation (ORIF) of the right tibia and (2) a revision ORIF due to a postoperative distal tibia peri-implant fracture.

Pre-Op X-Rays

Pre-Op CT

Diagnosis #1

Comminuted distal 1/3 tibia shaft fracture without intra-articular extension, with pre-existing tibia vara and procurvatum deformity from known Blount’s disease

Operative Plan #1

Tibia intramedullary nail using infrapatellar approach via a medial parapatellar arthrotomy, semi-extended on bone foam.

Intra-Op Images

Post-Op #1 Images

Pearls & Pitfalls

The pre-existing deformity from the Blount’s disease necessitated a careful preoperative plan for insertion of the intramedullary nail:

• Preoperative planning: anticipate the proximal tibial varus and procurvatum deformity, plan the starting point and nail trajectory accordingly.
• Patient positioning: a semi-extended position with bone foam facilitates fluoroscopic imaging and control of the starting point.
• Starting Point modification: Because of the tibial deformity, the starting point must be placed more medial and anterior to align with the canal distal to the deformity.
• Approach and trajectory: a medial parapatellar arthrotomy may be necessary to allow sufficient drop of the hand for proper guidewire insertion
• Nail Orientation: rotate the intramedullary nail 90° with the Herzog bend directed laterally, this modification allows the nail to conform to the tibial deformity while advancing distally.

Implants

Size 9, TN-Advanced Tibia Nail – DePuy Synthes

Post-Op Hardware Failure

The patient returned to the clinic ~ 1 month later with hardware failure of tibial nail with distal comminution of the fracture site.

Pre-Op Diagnosis #2

Retained right tibial nail, right peri-implant distal tibia fracture (about previously placed tibial nail).

Hardware Failure Pre-Op #2 X-Rays

Operative Plan #2

Removal of retained tibial nail, revision ORIF with posterior medial exposure and plating.

Intra-Op Images #2

Implants

3.5 mm LCP Posterior Distal Tibia T-Plate with 12 holes and a length of 184 mm – DePuy Synthes

Post-Op X-Rays #2

Post-Op Plan

The patient received perioperative antibiotics and was initiated on enoxaparin for DVT prophylaxis. He participated in physical therapy and was deemed appropriate for discharge in good condition. At discharge, he was instructed to remain non–weight bearing on the right lower extremity and to continue enoxaparin for DVT prophylaxis. Follow-up was scheduled in two weeks. Discharge instructions were reviewed, and the patient expressed understanding and agreement with the plan.

Post-Op Exam at 3 months

Examinations show that the incisions were well-healed. The patient’s ankle range of motion was dorsiflextion 20 degrees and plantarflexion 30 degrees. The patient is weightbearing as tolerated. Radiographs are shown below demonstrating that his that his fracture is healed.

Final Postoperative X-Rays

Pearls and Pitfalls

“If you want to know what your failure films will most likely look like, take the injury films and draw in broken hardware or intact hardware with implant/bone junction failure.” – Graves, Chapter 8, Skeletal Trauma.

This pearl is evident in this case here.

We revised improved the intrinsic stability of the fracture by correcting the apex anterior deformity and then placed an appropriately contoured posterior plate to facilitate healing.

Submitted by Stephen Canton, MD, MSc PGY5 & George V. Russell, MD, MBA