Transcription
Hello guys, today I'm going to demonstrate you antilateral approach to tibil plateau. I think this will be the last approach in my series of tibil plateau. And if you watch all the approaches, I think now you should feel confident in approaching tibil plateau from all the sides and do a good job if you're dealing with uh tibble plate fracture which is quite common in India and I'm sure in other developing countries and developed countries as well.
So today my goal is to take you in a step-by-step fashion mainly to show you what entrilateral approach is and how to do it properly and I will also show you some minuscottomy how I do it and we will plate the lateral tibial plate as well. So I'll take you step by step as how to do this procedure in a safe and effective way.
This is our uh theta setup. So patient is of course supine. We are going to use tun um and I'm going to make a bolster which is going to give me around 20 30° of flexion when I'm making my skin incision. Now since it's the left side I am standing on the left side the all the trolley and everything equipment will be on the left side. The only thing that will be on the right side is my C arm and my CM screen. So it's just not in the right position but we'll reposition in the right place so that C arm can come from this side.
So next I will show you the skin incision. Now Prashant is on leave today. So I don't know Sanchu is doing the shooting. He's doing it for the first time. This is the patella. This is the anterity will crest. This is your jis tubercal and this is the lateral femoral condile. So your incision usually if it's a complicated fracture will be you know you just leave a cm here then curve it across the jubacle and this is the joint line I have used a C arm and I have used this is my joint line so I'm just going to curve it towards the lateral femoral condile.
Now there are many approaches where when you gain experience you can do meo and not all the time you need to do a subminiscal arthrotomy. Um but this is your usual skin incision for your antilateral approach. So again looking from the side this is gertis tubercal gird tubercal going up I will not go this far but maybe up to here. So you just need to go a couple of centimeters above the joint um so as that you can elevate the flaps and you can um do a submancal arthottomy and then you can inspect the joint.
So next I will show you my skin incision. So skin incision is pretty straightforward nothing spectacular. are just at an angle. When you're starting up doing your TBL plateau, I'm just going to restrict my incision. I will not go down, but because you can always increase the size of skin incision if you need to. So start with a smaller incision and if needed, you can always increase the skin incision. So can you see this? So just laid skin incision. Try to be as atroatic as possible. Okay.
So this is can I just have a selfiniary retractor please? So if I put a self at any retractor this is how it looks. Now if you see here this is your tibble tuberosity. This is your anterior table crest. This is your gdis tubercal here. Now you just need to leave a cuff of tissue here. So this is your crest. I'm just going to leave a cuff of tissue so that in the end I'm able to close it nicely. So this is gistical. That's it. That's it.
So now when you come up here, so I'm just going to this incision is also in same line as your skin incision. So this is your gird tubercal. Now once you take this off this is your tibialis anterior. Can you see this? If you just take perostium or cob whatever is handy you should be able to reflect this or sometimes even a piece of swab can do a brilliant dissection. So once you swipe it up can you see this? If I reposition the retractor, you should be able to see the lateral aspect of the proximal tibia. So can you see this? This is the antilateral surface. This is usually where the plate will go. Now this dissection is very easy because all you need to do is cut the fascia and reflect this deband and now you are on the surface.
Now the key is when you dissect here. Now the dection here is that you need to go in the right layer so that you are able to reflect this up in one big layer. That is the first requirement. Now if you see here, can I have a gilp retractor now if you focus here I am through the ITB but still I am extra capsu extra capsular. So I think I have the wrong forep. I'm just going to swap my forceps. And if you can give me a bigger tooth force up that will be handy. So the key is to reflect this up in a way that you stay extra capsular. So layer one thick layer here and reflect it in the front. You can use it use a dither if you want to but you need to reflect it as one thick layer. Can you see this? This is the anterior layer. So same way following the same principle lift this and stay in the extra capsular layer. Same way I'll try my hand not to come here not to come in your way. Stay and then stay extra capsular and start retracting. What it does is you will be able to do a good closure in the end. You don't necessarily need to open the joint. The key is to come in the right place. So if you see here, I have reflected a layer in the front and now I'm reflecting a layer in the back. Can you see this? Can you see the joint? No, because I'm still extra articular.
And that is what if I can have a gilpy retractor, please. So if I now place my gilpy retractor between this anterior and posterior layer you can see this this is where your miniscus is. So if at all you need to do a subminus arottomy this is the place you are going to make a vertical incision here. So now this is actually your antolateral approach completed. Now whatever is left is to dissect this tip end right up to the head of the fibula right on the back and which is a very easy step. So I'll just take a perryiosium and I will dissect and reflect the tib band. So use something like a cob or a perryioium and then you need to reflect this as one thick layer.
Now if I'm just I think I still need to go slightly anterior just as to see my fracture. If you can see here I've reflected all the way back. This is the tibialis anterior reflected back. This is a cuff of tissue I have left. This is extra sinovial or sorry extra articular dissection. We are not into the joint. So let me just go slightly more in the front and then we shall be able to identify our fracture site. So that will be your next step. So keep going front and identify where your fracture sighted. But now depending upon what fracture it is. If it is a type three fracture, all you need is to make a hole here and then elevate the articular surface, fill the bone graft and plate it. If it is a type two fracture, what I usually like is uh in more most most complex fracture is I open it like a book and then I see the fracture and then I in you know elevate the articular surface and then I will put a bone graft if needed and then put a plate.
So just let me go slightly in the front and once I have done that I will join you back. So so far we have reflected tant we have uh reflected um the ITB from Jis tubercal and now I have gone all the way in the front uh this is what is my usual preference and if you see here this is the fracture condile can you see this this is the area which is broken so I'm just going to release this slightly and I personally like to open it like a book so if you follow lu classification which I think is most important or revisiting scatteras classification the recent paper this is your wedge split wedge fragment so I need to put my thumb here in order to reduce so there definitely there will be butter split on this area so let me just reflect this area and so that I'm able to open this up more better and then I can have an access to the fracture fragments ends.
So just to reorient this is the head end. This is the foot end. This is the medial side. This is the lateral side. Now if you see here so far we have opened this fragment here. So this will give you a whole access. You are able to if I put a self retaining retractor in between or some kind of you know even if I put a gpy retractor here I shall be able to open this up or you can use a laminina spreader. This will give you a complete access to the fracture fragment. Here the depression is very minimal but on many occasion you will see the articular fragment sometimes flipped sometimes you know facing other way around but this will give you full access. Now at this point you shall be able to reduce the articular surface under direct vision. So you know laminina spreader is a better uh equipment because it's not pointed. I just want you to demonstrate that. So this way gives me a full access to the fracture fragments.
Now if you see here this is your lateral tibial uh condile. This is the lateral tibial plateau. This is where your miniscus is. This is your miniscus. So if you want to do a subminiscal arottomy just leave a cuff of tissue here. So at a minuscule capsular junction so that you can repair it in the end. So I'm just going to open this up and this will give you a direct access to the joint and this will also give you an opportunity to reassess how the miniscus looks whether it's damaged or not. You can see here I have left this I was just taking the peripheral bite. You can see here this is miniscus is torn at capsular minis capsular junction. So I'm just going to take this bite along with it so that in the end when I tie to the plate or to the tissue this gets repaired. So it is one example to show whenever there is a lateral til plateau there's a very good chance and if it is depressed a lot that the miniscus is also injured. So I'm just retaking my bites. If you can see here, this is through the capsule. And I showed you the torn miniscus. If you can see here, it's torn peripherilally. So, I'm just going to take a bite and then bring it back. Just a second. So, I'm just going to bring it back. So now if you see if I'm pulling it now it's pulling out the whole miniscus now. So this is also there is a small area. I'm just going to change this to a different suture as well. So I'm just taking bite through the capsule. Now this is through the periphery of the miniscus and again from periphery of miniscus onto the capsule. Now if you see here now I am now able to retract the whole of the miniscus and when I'm going to tie that this also will repair the tear which was at this junction. Now if you see here the miniscus was in fact even there was a small bit which was torn inside. Now I have option of either repairing it or I can do a mintomy. So I've just tried to repair it but now it's hard to show but I can inspect whole of the joint here.
Can I have a McDonald please? just here McDonald. So if I can lift it up here, I can virtually inspect. So I can see a small step there. Now this gives a through and through exposure. Through this you can elevate through this window. Through this you can satisfactoryy visually inspect whether this reduction is completely done or not. So these are the purpose of these two openings. So one is to make sure that you have elevated article fragment and here this window gives you an option of ensuring that everything is lifted to perfection before um you think of putting the final plates.
Now we have uh we cleaned it up, we reflected it under direct vision. Um the articular surface seems to be in a good position and we have used this clamp to compress it. Now once you're happy that you have compressed it just get an X-ray or a CM image just to ensure that your reduction is pretty good. Now if you see here the height of the lateral condile is restored the articular congreity is restored. The fracture nice line is nicely compressed. Now it's entirely up to you whether you want to put a plate um and butress it or you can put one or two um wrapped screen form of 6.5 and then you can pay put a plate on top. So I'm just going to just open the cortex and I'm just going to pass one screw so as to compress the fracture site and I'm just going to put the plate on top. Now the only advantage of putting this screw is that once you have put this screw, it nicely compresses the fracture. You can get rid of your clamps and you will have full working space. So I have just compressed it. It looks pretty nice. I'm just going to take this off and I'm going to show you how it looks on a CM.
Now if you see here the height of the lateral tibil plateau is nicely restored. And this is the most important aspect. um articular congregative is important but the most important is the height. The height of the tibial plate must be uh reconstructed. If the height is reconstructed well then everything else the chances are you're going to have a great result. Now you have two options while repairing uh your ligament. I've left a cuff of tissue here. You can if you want you can repair it there. Uh the other option is to pass this through the holes as you have in this plate. So once you pass this through the holes, let me pass it like this and then you can tie it on top of the plate. So before if at all you want to do this, you need to pass all your sutures through these holes before you think of uh you know putting the plate in C2. Now we had four sutures. Two have gone through this. One have gone through this hole and other has gone through this hole. Now now it's just matter of repositioning the plate in the correct plane. So this looks pretty good to me. I'm just going to secure it in place and then I'm going to check it in the C arm to see if the height of the plate is good.
Now we have checked the height. The height of the plate looks pretty good. So the first screw that I'm going to pass is a cortical screw to compress the fracture so that it butresses the fragment nicely. That's it. Now the plate height looks pretty good. the screw length is bit long but I'm going to change it in the end because it's holding the place nicely reduced. Now um once you have compressed it it's just matter of filling the rest of the holes. Uh and you can do it whatever way you like but I'm going to start with my subarticular raft screws and then I'm going to fill the rest. We're just going to fill these holes. So I'm just putting another cautical screw here on the bottom. And then I'm going to replace the previous screw with a right size screw. I think it was long. That looks pretty good. Second cortex coming.
Now we have uh passed all our screw. I think we forgot to show you how it looks. We'll show you. But now the next important thing is to tie down the suture. So these are two front sutures. This plate has got only three holes. So we could pass only through three holes. So I'm just going to tie this knot here. And again we are going to tie this nicely. So this is one secure way of tying the knot. I think I've messed it up slightly. Just give me a second. That looks pretty good. So that's it. That's it. Now we have tied this uh sutures here. So miniscus is nicely repaired here. If you can see it, it's nicely stuck down.
Now it's just a matter of closing this. So deep fascia. I start with one end and we can continue in a continuous fashion so as to do an anatomical closure. So start I usually start from bottom but you can start from top. It's entirely up to you. See I've left a cuff of tissue here. Can you see this? And it will just help you in your closure. So that's it. So just keep working it here. And let me carry forward a little bit and then I will join you how it looks. Now the problem here is if you don't fix your plate well and especially with these bulky plates that we are using sometimes it's not possible to close it. However, if a dissection is good, if you can see here that we even here we are able to cover the plate completely with your fascia, you know the that will be lifted off from gistle. So if you see here it's nice. So I'm just going to run it to the top and then I'm just going to tighten the end. Now if you can see here we have nicely covered everything. So whatever we cut we have repositioned it back. And now I will just take few interrupted stitches and then I will close the skin with the clips. And once I have closed I will join you back.
So this is our skin closed. We are just going to put a small dressing. We putting some compression bandage but we are not going to put any plaster. This gentleman will start moving the knees from tomorrow. If you see the plate position, the lateral looks pretty good. The articular surface is good. Here the articular surface is good. The height is good. There was this fragment was split into two. Very small 1 mm step but I think that will be absolutely fine. It's the height which is the most important thing. So we have reconstructed the height and we don't give any plaster. This gentleman will go in ROM brace and we'll start moving his knee from tomorrow.
So viewers this was a demonstration of how to do a antrolateral approach and lateral tibial plateau plating for a tibial plateau fracture. Now most of the tibial plate require combined approach um especially the patients I deal with. I rarely see a straightforward tibial plateau fracture. Now I think I have covered all approaches which should make you capable in dealing with these fractures. I think the only thing that might be left is if you have an isolated type three depression isolated depression fracture how I make a window and elevate it and if I find a suitable case and if I have time on that day I will make that video uh very soon. So I hope you enjoy this video and this will give you confidence in how to do an antilateral approach and do a lateral tibil plate plating.
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