bruce h. ziran md facs director of orthopaedic trauma the ... · • acumed, citieffe, synthes •...
TRANSCRIPT
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Distal Femoral Fixation:Where Are We Now
Bruce H. Ziran MD FACSDirector of Orthopaedic Trauma
The Hughston Clinic atGwinnett Medical Center
Atlanta , Georgia
Disclosures
• Speaker/Consultant• Acumed, Citieffe, Carbofix, Synthes
• Royalties• Acumed, Citieffe, Synthes
• Development/Design Team• Acumed, Synthes
• Committee/Misellaneous• ACS/COT-Verification Review• ABOS-Examiner
3 Things That Impacted Treatment of DF Fractures
• Minimally Invasive Osteosynthesis
• Locked Plate/Screw Technology
• Use of retrograde nails
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MIO
• Accurate reduction with least biologic disruption
• Exposure size does not need to be minimal
• Violation of bone biology does need to be minimal
• Common sense regarding goals
First: What is MIO?
What is NOT MIO?
Violation of the bone biology
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What is NOT MIO?
Small exposures at expense of acceptable reduction
Surgical Approach: Lateral
Anterolateral Approach
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Technical Tips: My Locking Technique
• Articular standard screw: plate to bone
• Diaphyseal standard screw: plate to bone
• Metaphyseal standard screw: tweak
• Assess stability
• Locking screws as needed (not so much)
The Ultimate MIO: IM Nail
• Best for A type fractures
• Some C1 and C2• Adequate articular reduction
• Sufficient bone for fixation
IM Nail
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IM Nail
• Prophylactic stabilization of distal extension
• Clamp assisted reduction
IM Nail
• Prophylactic blocking screws
IM Nail
• 3 mos
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IM Nail: Accessories
• Oblique screws
• Bolts
Reduction Help
Reduction Help
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Reduction Help
Reduction Help
The Co-Linear Clamp
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IM Nail: Special Circumstances
• 35 yo, male, open femur and medial condyle• Medial plating indicated
• Ligamentous injury
IM Nail: Special Circumstances
IM Nail: Special Circumstances
• Medial plate and nail construct
• Interlock screws shared with plate
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IM Nail: Instability After Nailing
• 50 yo male
• Isolated distal femur
• Is it crazy to use IM nail?
IM Nail: Instability After Nailing• Yes.
• Required supplemental plate
Beware: Hoffa Fracture
• Standard plates may not provide fixation• Address separately with screws or small plates• MIO becomes more MAXIMO
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Hoffa Fracture
Hoffa Fracture
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Poly Trauma
• 38yo M
• Head, face injury
• Bilateral tibia
• R SC femur
• L intertroch + shaft + SC
• R forearm
Contralateral L side: DCO
Medial+Lateral HoffaCentral defectNote: no levering retractors
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• Bioabsorbable pins
• DBM+allograft+small BMP
• Resorbable beads
4 mos
Other side:SC=lateral hoffa only
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• 56 yo F
• L plateau
• L SC
• L shaft
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Unusual Patterns
• 55 yo F
• RA, HTN, fibromyalgia
• Nicotine
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New Implant Materials
Stainless Steel
Titanium Composite Materials
Stainless Steel
Why Carbon Fiber?Modulus of Elasticity
0
20
40
60
80
100
120
140
160
180
200
25
75
100
200
Cortical Bone Piccolo Composite™ (CFR‐PEEK)
Titanium( Ti‐6Al‐4v)
Stainless Steel (Steel 316)
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> 1,000,000 cycles without failure
Why Carbon Fiber?Modulus of Elasticity
38yo F. Bilateral Femur
Bilateral Retro nailsBilateral knee extension block
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R bucket handle tearMeniscus in notch
L Bucket Handle TearMeniscus in notch
48yo F, Fall stairs
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2mos 6mos
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80 yo F, 100pack year nicotinePrevious proximal tibia (note backward plate)
New fall and fracture
Proximal Humeral Plate on medial femur
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73yo F. Visiting Family. GLFSurgeon error: No CT in osteopenic bone
Distal fibular plate medial + Poller screw. Then nail.
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New Problems
• Severe osteopenia
• TKA without sufficient bone for fixation
• Geriatric rehabilitation/deconditioning
Strauss and Ziran, OTA October, 2006
• Case
• 90yo F poly trauma
• L SC femur/shaft
• R tib plateau
• Open distal radius
Initial DCO
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Left
Left
Right
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Right
3 mos
WHY?Treat the patient, not the xray
• Immediate Arthroplasty• Each surgery ~ 2-3 hours
• Able to fully weight bear immediately
• Walked into office at 6 wks using a walker
• Risk of failure in her lifetime = low
• Cost ~ $20k (15K inpatient, 5k outpatient)
• ORIF• Surgery time ~ 2-3 hours
• Unable to weight bear for 3 months
• Deconditioning would cause permanent function loss
• Risk of failure = high
• Cost ~ $20K (10K inpatient, 10K outpatient)
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Thank You
Open Grade III
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Open Grade III
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Surgical Approach: Lateral
Surgical Approach: Lateral
Hoffa Fracture
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Peri-prosthetic
Yes No
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History
• “Those who don't know history are destined to repeat it”
• Edmund Burke 1729
• “Those who cannot remember the past are condemned to repeat it”
• George Santayana 1863
Insanity
• “Doing the same thing over and over again and expecting a different result”• Albert Einstein
Surgical Approach: Anterolateral
• Like TKA but lateral
• Controlled exposure
• View=superior
• Allows use of two plates 90 degrees to each other (similar to distal humerus)
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Key Tips
• Expose only enough for articular reduction• No medial dissection outside of capsule• Address bone defects from lateral• Ensure appropriate alignment• Use of graft as needed