Plating the Fracture Works Every TimeAlmost-Be Careful Simon C. - PowerPoint PPT Presentation

Plating the Fracture Works Every Time…Almost-Be Careful Simon C. Mears, MD, PhD Orthopaedic Summit 2017 University of Arkansas for Medical Services

Disclosure • Deputy Editor: Geriatric Orthopaedic Surgery and Rehabilitation • Past President: International Geriatric Fracture Society

65 year old man with distal femur ppfx Decision making for periprosthetic distal femur fractures: • Determine if it can be fixed – If so use a plate – If not revise the knee replacement

How to know if you can fix? • How many fracture pieces? • How distal is the fracture? • You need enough bone to attach a plate • Consider CT scan to help you

Plate technique • Reduce the fracture with bump or bone foam • Small incision laterally to insert plate

Plate placement • Carefully place the plate distally • Make sure you have a true lateral view • Make sure the anterior cortex is aligned and not flexed • Anchor with kwires, proximal and distal

Reduce plate to bone • Multiple techniques • Large bone clamp • Small incision, pusher • Non locking screw to anchor plate to bone

Reduce the plate to bone • Proximally, minimally invasive techniques • Whirlibird to drag plate to bone • If it is not working, open the fracture and reduce • Cortical screws proximally

Double and triple check • It is easy not to have a true lateral view • Check this proximally and distally • Be critical • Do this before drilling and placing screws

Postop • WBAT • No brace • Immediate knee range of motion • Kammerlander C, Kates SL, Wagner M, Roth T, Blauth M. Minimally invasive periprosthetic plate osteosynthesis using the locking attachment plate. Oper Orthop Traumatol. 2013 Aug;25(4):398-408, 410. doi: 10.1007/s00064- 011-0091-1. Smith WR 1 , Stoneback JW 2 , Morgan SJ 1 , Stahel PF 3 . Is immediate weight bearing safe for periprosthetic • distal femur fractures treated by locked plating? A feasibility study in 52 consecutive patients. Patient Saf Surg. 2016 Dec 7;10:26. eCollection 2016.

Outcomes • Knees: poor outcomes 20% mortality at year, age was a factor in recovery Ruder JA 1 , Hart GP 2 , Kneisl JS 1 , Springer BD 3 , Karunakar MA 1 . Predictors of Functional Recovery Following Periprosthetic Distal Femur Fractures. J Arthroplasty. 2016 Dec 23. pii: S0883-5403(16)30898-1. • 1 in 5 distal femur fractures treated with ORIF develop nonunion Hart GP 1 , Kneisl JS 1 , Springer BD 1 , Patt JC 1 , Karunakar MA 1 . Open Reduction vs Distal Femoral Replacement Arthroplasty for Comminuted Distal Femur Fractures in the Patients 70 Years and Older. J Arthroplasty. 2017 Jan;32(1):202-206. doi: 10.1016/j.arth.2016.06.006. Epub 2016 Jun 23.

Do you need to worry about the implant type? • NO • It doesn’t matter • Can use for a plate for both CS and PS knees • Besides: us trauma docs don’t know the difference…

Do you need to find out how big the box is? • NO • It doesn’t matter • So don’t worry when the hospital that the surgery was performed no longer exists

Do you need to worry about flexion deformity • NO • You can put the plate where you want and not malreduce the fracture with the nail • You have control to reduce the fracture

Do you need to worry about the total hip above the fracture • NO • You can use a long plate and overlap the femoral stem

If you can’t fix, revise! • Loose implants • No distal bone

Distal Femoral Replacement • Pluses: – Relatively straightforward – Immediate weight bearing • Minuses – Rotating hinge – Problem if this needs to be revised

Conclusions Use a plate! Unless you take it all out and revise Either way weight bear as tolerated and get them moving

Conclusions • Avoid the nail – Don’t worry about implant details that you can’t get anyway – Don’t worry about malreductions due to posterior starting point due the implant – Don’t worry about proximal implants

Thank You

References • Kammerlander C, Kates SL, Wagner M, Roth T, Blauth M. Minimally invasive periprosthetic plate osteosynthesis using the locking attachment plate. Oper Orthop Traumatol. 2013 Aug;25(4):398-408, 410. doi: 10.1007/s00064-011-0091-1. • Smith WR 1 , Stoneback JW 2 , Morgan SJ 1 , Stahel PF 3 . Is immediate weight bearing safe for periprosthetic distal femur fractures treated by locked plating? A feasibility study in 52 consecutive patients. Patient Saf Surg. 2016 Dec 7;10:26. eCollection 2016. Hart GP 1 , Kneisl JS 1 , Springer BD 1 , Patt JC 1 , Karunakar MA 1 . Open Reduction vs Distal Femoral Replacement • Arthroplasty for Comminuted Distal Femur Fractures in the Patients 70 Years and Older. J Arthroplasty. 2017 Jan;32(1):202-206. doi: 10.1016/j.arth.2016.06.006. Epub 2016 Jun 23. Ruder JA 1 , Hart GP 2 , Kneisl JS 1 , Springer BD 3 , Karunakar MA 1 . Predictors of Functional Recovery Following • Periprosthetic Distal Femur Fractures. J Arthroplasty. 2016 Dec 23. pii: S0883-5403(16)30898-1.