Safe leg surgery: the anatomic principles and techniques

Authors

  • Akshay Kumar S. V. Department of Orthopaedics and Trauma Surgery, Sri Sakthi Hospital, Tirunelveli, Tamil Nadu, India
  • Venkatesh Babu S. Department of Orthopaedics and Trauma Surgery, Sri Sakthi Hospital, Tirunelveli, Tamil Nadu, India

DOI:

https://doi.org/10.18203/2349-2902.isj20204174

Keywords:

Safe, Surgery, Trauma, Injury, Tibia, Fibula, Complications, Artery, Nerve

Abstract

The goals of surgical treatment of leg injury are to achieve soft tissue healing, good osseous union and to restore the length of the limb, correct alignment of both bones with their respective joints and normal range of movements of the entire limb at the earliest. Presently, the surgical treatment has been standardised for the tibia fractures for adults and children. Though the surgical progress made in the implants, instruments and techniques, there are considerable surgical complications happening. This article highlights the need of anatomical expertise and safe operative ability for the surgeon.

 

Author Biographies

Akshay Kumar S. V., Department of Orthopaedics and Trauma Surgery, Sri Sakthi Hospital, Tirunelveli, Tamil Nadu, India

Consultant Orthopaedic & Trauma Surgeon

Department of Orthopaedics & Trauma Surgery

Venkatesh Babu S., Department of Orthopaedics and Trauma Surgery, Sri Sakthi Hospital, Tirunelveli, Tamil Nadu, India

Specila trainee in Orthopaedics & Trauma Surgery

Department of Orthopaedics & Trauma Surgery

References

Madadi F, Eajazi A, Madadi F, Besheli LD, Sadeghian R, Lari MN. Adult tibial shaft fractures - different patterns, various treatments and complications. Med Sci Monit. 2011:17(11):640-5.

Courtney PM, Bernstein J, Ahn J. Closed Tibial Shaft Fractures. Clin Orthop Relat Res. 2011;469:3518-21.

Zelle BA, Boni G. Safe Surgical technique: intramedullary nail fixation of tibial fractures. Patient Safety in Surgery. 2015;9:40:1-17.

Pahlevanhosseini H, Shahbazi-Bilehsavar F, Abrisham SM, Shafiee M. Open tibial shaft fracture treatment with plating within 6 hours and between 6-24 hours after injury. Bali Med J. 2017;6(2):445-8.

Doshi P, Gopalan H, Sprague S, Pradhan C, Kulkarni S, Bhandari M. Incidence of infection following internal fixation of open and closed tibia fractures in India (INFINITI): a multi-centre observational cohort study. BMC Musculoskeletal Disorders. 2017;18:156:1-10.

Patel NK, Horstman J, Kuester V, Sambandam S, Mounasamy V. Paediatric Tibial Shaft Fractures. Indian J Orthop. 2018;52(5):522-8.

Koval KJ, Clapper MF, Brumback RJ, Ellison Jr PS, Poka A, Bathon GH, et al. Complications of Reamed Intramedullary Nailing of the Tibia. J Orthop Trauma. 1991;5(2):184-9.

Erin-Madsen N, Aasvang TK, Viberg B, Bloch T, Brix M, Tengberg PT. Knee Pain and associated complications after Intramedullary Nailing of Tibial Shaft Fracture. Dan Med J. 2019;66(8):A5554.

Leliveld MS, Verhofstad MHJ. Injury to the Infrapatellar Branch of the Saphenous nerve, a Possible cause of Anterior Knee Pain after Tibial Nailing? Injury. 2012;43(6):779-83.

Greitbauer M, Kaltenecker G, Vécsei V. Septic Complications after interlocking nailing of the tibia. Eur J Orthop Surg Traumatol. 1995;5:65-8.

Brinker MR, Bailey DR. Fracture Healing in Tibia Fractures with an associated Vascular Injury. J Trauma.1997;42(1):11-9.

Brinker MR, Caines MA, Kerstein MD, Elliott MN. Tibial shaft fractures with an associated Infrapopliteal arterial injury: A Survey of Vascular Surgeons Opinions on the need for vascular repair. J Orthop Trauma. 2000;14(3):194-8.

Drosos GI, Stavropoulos NI, Kazakos KI. Peroneal nerve damage by oblique proximal locking screw in tibial fracture nailing: a new emerging complication. Arch Orthop Trauma Surg. 2007;127(6):449-51.

Golubović Z, Stojiljković P, Macukanović-Golubović L, Milić D, Milenković S, Kadija M, Matović Z, et al. External fixation in the treatment of open tibial shaft fractures. Vojnosanit Pregl. 2008;65(5):343-8.

Lua JYC, Tan VH, Sivasubramanian H, Kwek EBK. Complications of Open Fracture management: Risk factors and treatment. Malaysian Orthop J. 2017;11(1):18-22.

Nayagam S. Safe Corridors in external fixation: the lowerleg (Tibia, fibula, hindfoot and forefoot). Strat Traum Limb Recon. 2007;2:105-10.

Schalamon J, Petnehazy T, Ainoedhofer H, Zwick EB, Singer G, Hoellwarth ME. Pin Tract Infection with External Fixation of Paediatric Fractures. J Paediatr Surg. 2007;42(9):1584-7.

Russo AP, Caubere A, Ghabi A, Grosset A, Mangin P, Rigal S, et al. Sequential management of tibial fractures using a temporary unicortical external fixator. Sicot-J. 2018;4:39:1-7.

Qiu S, Liu J, Liu C. Effects of external fixation technique on hospitalisation time, fracture healing time and complication rate of paediatric fracture. Int J Clin Exp Med. 2017:10(8):12179-85.

Dar RA, Lal T, Maajid S, Ganaie PA, Mir NA. Retrospective analysis on use of external fixation in paediatric extremity trauma and fractures as a damage control device and their outcome in a tertiary care set up. Int J Orthop Sc. 2019;5(1):292-4.

Stannard JP, Finkemeier CG, Lee J, Kregor PJ. Utilisation of the less-invasive stabilization system internal fixator for open fractures of the proximal tibia: A multi-center evaluation. Indian J Orthop. 2008;42(4):426-30.

Labronici PJ, Junior ILM, Lyra FS, Franco JS, Hoffmann R, Lourenço PRBT, et al. Localisation of the Tibial Entry Point. Rev Bras Ortop. 2010:45(4):375-81.

WHO guidelines for safe surgery: safe surgery saves lives. 2009. Available at: https://www.who.int/patientsafety/safesurgery/tools_resources/9789241598552/en/. Accessed on 26 May 2020.

Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. 2015. NICE Guidelines, UK. Available at: https://www.nice.org.uk/guidance/ng15. Accessed on 26 May 2020.

Seligman KM, Katz D, Farber MK. Preventing Surgical Site Infection after Cesarean Delivery-The Anaesthesia Professional’s role. APSF News Letter. 2018;25-7.

Surgical site infections: prevention and treatment. 2019. NICE Guidelines, UK. Available at: https://www.nice.org.uk/guidance/ng125. Accessed on 26 May 2020.

Antimicrobial stewardship programmes in health care facilities in Low and middle income countries, a World Health Organisation (WHO) Tool Kit. 2019.

Whiting PS, Galat DD, Zirkle LG, Shaw MK, Galat JD. Risk Factors for infection After Intramedullary Nailing of Open Tibial Shaft fractures in Low-and Middle-Income Countries. J Orthop Trauma. 2019;33(6):234-9.

Chitnis AS, Vanderkarr M, Sparks C, McGlohorn J, Holy CE. Complications and its impact in patients with closed and open tibial shaft fractures requiring open reduction and internal fixation. J Comp EFF Res. 2019;8(16):1405-16.

Farooqui HH, Mehta A, Selvaraj S. Outpatient antibiotic prescription rate and pattern in the private sector in India: Evidence from medical audit data. PLoS One. 2019;13:14(11).

Open fractures in hospital. NICE Guidelines, UK. 2020. Available at: https://pathways.nice.org.uk/pathways/trauma/open-fractures-in-hospital. Accessed on 26 May 2020.

Walters BB, Constant D, Anand P. Fibula Fractures. StatPearls [Internet]. Treasure Island (FL):StatPearls Publishing. 2020:1-4.

Hoppenfeld S, Deboer P, Buckley R. Surgical Exposures in Orthopaedics. The Anatomic Approach, Fourth Edition, Lippincott Williams & Wilkins. 2009.

Nanchahal J, Nayagam S, Khan U, Moran C, Barett S, Sanderson F, et al. Standards for the Management of Open fractures of the Lower Limb, Guidelines of the British Orthopaedic Association (BOA) and British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). 2009.

Yaligod V, Rudrappa GH, Nagendra S, Shivanna UM. Minimising the complications of intramedullary nailing for distal third tibial shaft and metaphyseal fractures. J Orthop. 2014;11:10-8.

Humphrey JA, Gillani S, Barry MJ. The role of external fixators in paediatric trauma. Acta Orthop Belg. 2015;81:363-7.

Open Fractures, British Orthopaedic Association (BOA) and British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) Audit Standards for Trauma. 2017. Available at: https://www.bapras.org.uk/professionals/clinical-guidance/open-fractures-of-the-lower-limb. Accessed on 26 May 2020.

Elniel AR, Giannoudis PV. Open fractures of the lower extremity: current management and clinical outcomes. EFORT. 2018;(3):316-25.

AO Surgery. Available at: https://surgeryreference.aofoundation.org/. Accessed on: 20 May 2020.

Pobłocki K, Domaradzki M, Gawdzik J, Prochacki P, Rajewski R. Complications after Intramedullary nailing of the tibia, Chir Narzadow Ruchu Prtop Pol. 2011:76(5):274-7.

Joveniaux P, Ohl X, Harisboure A, Berrichi A, Labatut L, Simon P, et al. Distal tibia fractures: management and complications of 101 cases. Int Orthop (SICOT). 2010;34:583-8.

Neumann MV, Strohm PC, Reising K, Zwingmann J, Hammer TO, Suedkamp NP. Complications after surgical management of distal lower leg fractures. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2016;24(146):1-7.

Yin B, Chen W, Zhang Q, Wang J, Su Y, Xu G, et al. Tibial fracture treated by minimally invasive plating using a novel low-cost, high-technique system. International Orthopaedics (SICOT). 2012;36:1687-93.

Zarad AL. Flexible Intramedullary nails for unstable fractures of the tibia in children: a retrospective evaluation of effectiveness. Egyptian Orthopaedic Journal. 2014;49:281-5.

Uludag A, Tosun HB. Treatment of unstable paediatric tibial shaft fractures with Titanium Elastic Nails. Medicina. 2019;55(266):1-8.

Srivastava AK, Mehlman CT, Wall EJ, Do TT. Elastic Stable Intramedullary Nailing of Tibial Shaft Fractures in Children. J Paediatr Orthop. 2008;28(2):152-8.

Ahmed KFE, Zakaria B, Hadhood M, Shaheen A. Management of diaphysealtibial fracture in paediatrics by elastic stable intramedullary nails. Menoufia Medical Journal. 2014;27(2):401-6.

Heo J, Oh CW, Park KH, Kim JW, Kim HJ, Lee JC, Park IH. Elastic Nailing of Tibia Shaft Fractures in Young Children up to 10 years of age. Injury. 2016;47(4):832-6.

Pandya NK, Edmonds EW. Immediate Intramedullary Flexible Nailing of open Paediatric tibial shaft fractures. J Paediatr Orthop. 2012;32(8):770-6.

Aslani H, Tabrizi A, Sadighi A, Mirblok AR. Treatment of open paediatric tibial fractures by external fixation versus flexible Intramedullary Nailing : a comparative study. Arch Trauma Res. 2013;2(3):108-12.

Patil C, Amar J. Study of the outcome of titanium elastic nail system (TENS) in diaphyseal fractures of femur and tibia in children. Int J Orthop Sc. 2019;5(3):617-20.

Ceroni D, Grumetz C, Desvachez O, Pusateri S, Dunand P, Samara E. From prevention of pin-tract infection to treatment of osteomyelitis during paediatric external fixation. J Child Orthop. 2016;10:605-12.

Roussignol X, Sigonney G, Potage D, Etienne M, Duparc F, Dujardin F. Secondary Nailing after external fixation for tibial shaft fractures: Risk factors for union and infection: a 55 case series. OrthopTraumatol: Surg Res. 2015;101:89-92.

O'Malley O, Trompeter AJ, Krishnanandan S, Vesely M, Holt P, Goh G, et al. How common are vascular injuries in open tibial fractures? A Prospective longitudinal cohort study. Eur J Orthop Surg Traumatol. 2019;29:1119-24.

Xu YQ, Zhu YL, Fan XY, Jin T, Li Y, He XQ. Implant-Related Infection in the Tibia: Surgical Revision Strategy with Vancomycin Cement. Scientific World J. 2014;124864:1-6.

Downloads

Published

2020-09-23

Issue

Section

Review Articles