andrew h. schmidt, m.d. · 2017. 5. 10. · 5/9/2017 4 plates • multiple screw options within the...
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Supracondylar Femur Fracture-What Works?
Hennepin County Medical CenterUniversity of Minnesota
Andrew H. Schmidt, M.D.
Orthopaedics
Disclosure InformationAndrew H. Schmidt, M.D.
Conflicts of Commitment/ EffortEditorial Board: JBJS Essential Surgical Techniques, J Knee Surgery, J Orthopaedic TraumaChief, Dept. of Orthopaedic Surgery: Hennepin County Med Ctr.
Disclosure of Financial RelationshipsRoyalties: Thieme, Inc.; Smith and Nephew.Consultant: Acumed; Conventus Orthopaedics; St. Jude Medical (spouse)Stock: Conventus Orthopaedics; Twin Star Medical; Twin Star ECS; Epien; PreferUS Healthcare, EpixResearch Support: Dept. of Defense, Univ. of Minnesota
Disclosure of Off-Label and/or investigative Uses
I will not discuss off label use and/or investigational use in my presentation.
Distal Femur Fractures
• Relatively non-controversial injury– Well understood fracture patterns– Operative indications defined– Treatment principles straightforward
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Goals
• Reconstruction of the articular surface
• Restoration of the mechanical axis– Length, alignment, rotation
• Stable fixation
• Early return of function
Yet, there remain ?’s
Yet, there remain ?’s
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Yet, there remain ?’s
Plate Nail
• Articular Reduction
• Restoration of Mechanical Axis
• Stable Fixation
• Restoration of Function
Plating• Advantages
– Direct joint visualization– Multiple options for screw fixation– Familiar
• Disadvantages– Blood loss, larger incisions– Quad scarring– Infection
Submuscular Locked Plating has significantly reduced these complications
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Plates
• Multiple screw options within the plate– Locking– Nonlocking– Variable angle locking
• Additional screws outside plate
Nails
• Few screw options within the nail– Mostly nonlocking– Newest nails have locking screws– Limited # of interlocking options
• Blocking screws add significant stability and help maintain reduction
• Additional screws can be placed outside nail.
• Reductions typically percutaneous.
Plates versus Nails
How do they compare?
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Biomechanical Comparison
• LISS vs retrograde IM Nail
• LISS 13% stronger axial loading• LISS 45% weaker torsional loading
• Loss of distal fixation during axial loading occurred in 1/16 LISS and 8/8 retrograde IM Nail
Zlowodzki et al, JOT, 2004
• 12 nails, 3 revision surgery to remove implants– 2 for collapse and nail protrusion, 1 painful screws
• 11 blade plates, no revision surgery.
Femur-LISS and distal femoral nail for fixation of distal femoral fractures: are there differences in
outcome and complications?
Markmiller M; Konrad G; Sudkamp N
• 16 cases of each followedPLATE NAIL
1 yr ROM 110 plate 103 nailLysholm-Gillquist =Malunion 3 2Reoperation 2 1
Clin Orthop Relat Res 2004 Sep;(426):252-7
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Plating
• Fractures with intra-articular involvement
• Multiplanar fractures• Peri-prosthetic fractures• Bone quality of less concern with use
of longer locking plates
2 typical patients
Elderly Female Young Male
Can one repair the geriatric supracondylar fracture with a plate?
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• 54 patients• Mean age 57 (15-99)• 94% united
Clinical results indicate that plate fixation of the distal femur works very well for all fracture patterns
For years, the main issue was coronal plane stability
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Locking plates solved that…
But gave us a new problem
instead…
• 86 fractures• 14% failed to unite• More empty holes
in the plate in those that healed
• Less callus in stainless compared to titanium
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What is the appropriate stiffness and how do you achieve it?
• Working length (do you fill every screw hole?)
• Over-drill the near cortex so the screw is only fixed in the far cortex.
• “Active” or “dynamic” locking.
proximal screw density (PSD) defined as the ratio of the total number of screws applied proximal to the fracture to the total number of screws holes in the shaft section of the plate
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Plating Technique
• Minimally invasive approach• Pre-contoured, Angular-stable locking
plates
“Lines of Weakness”
From Forster et al, Injury, 2005
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Treatment Principles
• Reconstruct condyles first– K-wires, clamps– Lag screws
• Reduce and Fix condyles to shaft• No need to expose and repair the
metaphyseal fracture
Surgical Technique
• Radiolucent table, supine position.
• Triangle• Femoral distractor.
Surgical Approach
• 2 choices for incision– Lateral: Simple Fractures– Lateral peripatellar: Complex Fractures
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Traditional Exposure
Anterolateral Approach
Tibial Tubercle
Midline Femur
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Lateral Peripatellar Approach
From Haidukewych et al, JBJS 2008 90A Suppl 2(1): 120
Lateral Peripatellar Approach
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Step 1: Articular Reconstruction
• Goal is anatomic restoration of the articular surface
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Reduction Aids
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Step 2: Reduction of Condyles to Femoral Shaft
• Bumps / Triangle• Mallet• Joysticks• Clamps
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From Haidukewych et al, JBJS 2008 90A Suppl 2(1): 120
Step 3: Insertion of Final Fixation
Appropriate placement of plate on distal femur
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Check reduction and fix to proximal femur
Correction of alignment
• Clamp
• P-Fix Pin
• Non-locking screw
Place distal screws
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Tips and Tricks
• Understand articular anatomy before surgery.
– Medial Hoffa nearly impossible to treat via lateral approach
• 86 fractures• 40% complications• 20% failed to unite, more empty holes in
fractures that healed.
233 mm3 95 mm3
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Tips and Tricks
• Create a more flexible construct by using a long plate with fewer screws.
Tips and Tricks
• Create a more flexible construct by using a long plate with fewer screws.
Tips and Tricks
• Common deformity is excess valgus, hyperextension of distal femur, and external rotation. Know how to correct these.
– “Notch view” appearanceof distal femur on AP x-ray
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Nailing
• Initial reduction techniques same as plate• Blocking screws aid in reduction and afford
better stability• Entry point variable – depends on nail
curvature– Radius of curvature varies from 150 cm to 400
cm
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Reduction with a nail
• Trajectory control as nail enters distal fragment.
• Must have correct entry portal and insert nail colinear to the axis of the distal fragment.
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Summary
• Plating remains the best option for comminuted, intra-articular distal femur fractures.
• One can adapt the fixation to all fracture patterns - No Surprises!
• With new techniques, plating is no more invasive than nailing.
Plate vs Nail
• Nail OK for simple fractures• May be better in morbidly obese.
• All others = plate
Thank You
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