Download - #6 Tornetta LE Evidence NY 2018
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Patella and Tibial Injuries
Paul Tornetta III, MDProfessor
Boston Medical CenterBoston Medical Center
Disclosures
• Smith Nephew: IP
•Wolters‐Kluwer: Royalties
Patella Fractures• Distal fractures
Keep or discard?
• Comminuted fractures
Fixation strategy?
Classic tension band
New roles of plating
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Tibial Plateau• Unicondylar
Void filler?
• Bicondylar
Dual thin vs larger locked?
Prone approaches?
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Tibial Plateau• Unicondylar
Void filler?
• Bicondylar
Dual thin vs larger locked?
Prone approaches?
Plate Choice• Dual always an option
• Large lateral locked Large medial condyle
Diaphyseal extension
•Can’t be nailed!
• Dual Posteromedial fragments
No long diaphyseal extension
Shaft• Closed
Proximal
• Semiextended vs suprapatellar
Distal
•Plate fibula?
• OpenOrder of fixation and flaps
Nail vs ex fix
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Position?
> 20°
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Semi-Extended
Fibula Plating?
• Malunions in distal fractures present IN the OR
• Can help with reduction
• NOT needed!
• Might slow healing
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Fibula Plating?
Plafond• Fibular plating?
• Trends
Multiple incisions
Smaller plates
Fragment specific
Posterior for special cases
Considerations• Anatomy of the fracture
Not all pilons are the same!
Individualized approach
Posterior Anterior Medial
• Condition of the skinOpen wounds
Swelling
Staged fixation
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Approaches• Anterior variants
Antero‐medial
Direct anterior
Antero‐lateral
• Medial
• Posterior Options Postero‐lateral
Postero‐medial
Anterior
Posterior
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Trends• Incisions
Different locations
Multiple
• Staged approaches
Fibula frame tibia
Posterior anterior
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Multiple Incisions• Fasciocutaneous flaps!
Bipedicle = 1.5:1 survival
• 7cm rule…silly
Shape, not distance!
• Sliding plates
Smaller incisions
Mini‐incisions proximally
Multiple Incisions• Fasciocutaneous flaps!
Bipedicle = 1.5:1 survival
• 7cm rule…silly
Shape, not distance!
• Sliding plates
Smaller incisions
Mini‐incisions proximally
Combinations
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Staged Approaches• C‐Type
• Posterior subluxation
• No posterior support
• Hard to get to the back
• Rotated out
• Short and tilted backwards
61 Year Old Male
Frame Then CT
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CT
Factors??
• Fragments?
• Anterolateral?
• Medial?
• Posterior?
• Amount of displacement
• Direction of displacement
Approach
• Posterior
ORIF posterior malleolus
ORIF fibula
Concerned about getting the PM
Rotationally difficult!
BUT…can’t box out the front!!
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Intraop..Stage 1• At 2 Weeks
After Stage 1
Stage 2• 3 Weeks out
• Antero‐medial approach
• Skin Bridge large
• Allows for fixation of the MM
Anterior buttress
Medial buttress (multifragmentary)
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Intraop
Intraop
Intraop
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Medial and Anterior
Final Joint
One Year
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Controversies• Not fixing the fibula
Multiple plates
Locked fixation
• Anterior approaches
Modifications
• Plate location
Anterior and anterolateral
Boston Medical Center