Always use no. 5 fiberwire, the cuff movements generate great force, no. 2 fiber wire, in my opinion is weak for such strong force and can also cut through because of its thin cross-section. I use ethibond only for temporary bites through cuff attachments so that those can be pulled and better tissue can be visualized for fiber wire bites. Agai,n no.5 ethibond should be preferred when not using fiber wire.

Yes, one K wire was placed in the anterior half, as we kept the posterior half only for the DHS screw. The same anterior wire was then replaced with a fully threaded solid screw. We avoid drilling for that as we preserve as much bone as possible. Also, the K wire impacts the bone along its track and doesn't remove any bone like a drill bit, making the screw purchase strong.

Thanks for the feedback!!

Most welcome 🙏

Sure, will add soon. 👍

@ thanks sir

The problem with conventional screws is the constant irritation with screw heads, especially when wearing fitting shoes. Headless cancellous screws are costly, so they can't be routinely used. So locking screws are a good option. They are low-cost and can be buried in bone as the head also has threads. We don't aim for compression with those, as we use clamps to obtain compression prior to their insertion. I have been using such fixation for the past several years with "ZERO" skin problems and "ZERO" loss of reduction.

@ thank you so much , once again 🙏🙏

🙏

Hi, I hope you gain a speedy recovery. Open proximal tibia fracture is really challenging. If you have any query you can mail me your xrays/ records on [email protected]

@Justorthothings sir i also have pcl injury. I'll mail you so i can discuss something with you

Will add soon regarding such cases

The lateral image is attached here ibb.co/3mZ6sVPP

The approach in index case is a dual one, as you see the incisions. A single approach can provide maximum plating access to three zones, Lateral parapatellar approach= lateral plate+medial plate + posterolateral, Medial parapatellar= Medial lateral + posteromedial. Dual Approach: Lateral + medial parapatellar = all 4 zones. Here in the attached image, Lateral parapatellar is giving access to posterolateral + lateral ibb.co/3yYXVqv

Revision is good sir

Yes, you can save lot of complications by just not putting the plate.

ibb.co/3yYXVqv Check this image. We just do flexion and put the plate of posteromedial/posterolateral ridges.

Right

around 6 weeks

Step at sustentaculum is there, but the most important point is that the subtalar joint is not reduced well. In the lateral view, the posterior facet of calcaneum and under-surface of the talus are not matching which means that the posterior facet is still depressed.

Depression fragment needs rafting. Raft plates are good for depression but do not adequately stabilise the diaphyseal segment and sometimes are short in length. Dual plate is another valid alternative. 4.5 mm lateral plate is fine when when bicondylar fracture is there, but not suitable for rafting depression. Independent screws over that plate is also an option but those tend to displace with mobilization. Raft screws should better be through locking holes

Release of first traction is calibrated fluroscopically, you just need to ensure that fracture is not distracted and will remain positive cortex after compression. The proximal hohmann will take care of flexion while loss of reduction in slight varus wont be an issue as you can correct that after nail insertion but before guidepin insertion by just abducting the limb/ again calibrating traction after nail insertion but before guidepin insertion/ using a pushing device to valgise head and in most case medial entry automatically corrects slight varus.

One more thing Sir, if you get traction and ap , lateral c arm every on way, medial cortex is possitive so just release when compression is right? Thank you for your reply

@@vinhphaminh7007 yes, once compression right, traction won't be of any use.

In most case you need traction and rotational maneuvers under carm guidance. The moment use see reduction, clamp between anterolateral aspect of shin and posteromedial edges of tibia as those are safe for passing sharp spikes of clamp. If facing difficulty, there is no harm is giving a small incision just to visualize anterior spike and reduce it and then put clamp.

@@ziaulalam3382 the plate is on lateral side only, medial plate was not added in view of poor soft tissue condition

Sure, will update

Yes, Thanks

Sure, will add some videos on fracture exposure, reduction and fixation tips

@@docccdoccc8141 just antibiotic stimulan has been added in view of open fracture. Rest all healed biologically without any augmentation

The suction apparatus is there in the nail sleeve for intraop use only. Otherwise I have never put a drain in knee joint in suprapatellar nailing. Also, never faced any related complications.

simple fractures and healthy bone can allow early walking but in most cases 6-8 weeks is the time as fractures are often unstable

Long plate, if you put for diaphyseal stability, wont be a 3.5 mm plate, its going to be a 4.5 mm plate. Medial side skin has issues in proximal tibia fractures which often result in wound healing problems and sometimes skin irritation also. So the option left is of 4.5mm lateral plate, but that doesn’t provide a good raft for depression. That plate is good for condyle but not for depression. I do long medial plate in some cases but wont recommend for all.

ROM is near normal with full extension and minor restriction of terminal flexion. Post op Protocol is toe touch walking from day 1 and walker-assisted weight bearing when radiological healing is evident. So now, this patient has started bearing weight with walker assistance. The flexion-extension images are linked here: ibb.co/2yPPCfB ibb.co/w7Mmm3y

Yes

Pre-bending is done to create an angle at the bone and k wire junction. This bending is fixed as the K wires are locked with fixator rods. The resultant nonlinear relation between bone and wire makes the translation of bone difficult and adds to the stability. Thus bone can no more slide on wire as it is bend on both sides. Also there are multiple pre-bent k wires in the jess assembly. Thus the reduction remains stable. JESS can be used for pediatric distal femur but not for adult distal femur as bone needs more stable fixation and JESS is a light fixator

@Justorthothings if you prebend the wire and while drilling will not wiggle around because of the bend (not being straight )

Pre bending is done once the wire is inserted in bone and before tightening of clamps. I ll try to share a short video, explaining that.

@@Justorthothings please do. Thank you so much

It’s Johnson and Johnson (previously Synthes) TFNA

🙏 Thanks for your feedback!

In the condylar part of the distal femur, the vessel lies almost in the midline and posterior to the notch area of the distal femur. The rest of our working zones line over the bone surface, so we don't encounter vessels at all. On the medial side, we tend to avoid going deep to the adductor tubercle which can be easily identified with a tendinous insertion over it.

We follow patients and at 6 weeks if there is any sign of loosening or no evidence of bridging callus, then we go for medial plate. Decision of single plate depends on intactness of medial condyle, if screw purchase is sufficient (more then 5-6 locking screws), we wait for biological healing of medial side. Will share the follow up here. I have put a detailed video on medial plating with several case examples kzbin.info/www/bejne/fXiTg3WKhcSorLc