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Cost and Time Considerations: Are Minifragment Plates Worth It?
Andrew Choo, MD
Vumedi Webinar
November 15, 2016
Disclosure
• Paid speaker: Depuy Synthes
More Disclosures
• Price quotes are estimates only!
• Most talks are evidence-based. This one is not.
• I am very, very biased towards minifragmentfixation
Are minifragment plates worth it?
…it depends!
• How they’re used
• How many are used
• How many locking screws
• How much longer it takes
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How can minifrag be cost-effective?
• Use instead of external fixators
• Use instead of anatomic plates
• Use it to do it right the first time!
Minifrag as an external fixator
16 y/o male s/p MCC
• < 1 cm open wound over medial leg
• Tense, swollen compartments
Case courtesy of Joshua Gary, MD
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Taken emergently…
• Fasciotomy
• I&D of open tibia fx
• Wound VAC
• Provisional stabilization of pelvic ring injury
…Returned for Staged IMN
Some quick math…
External fixation
• 5.0 mm Schantz pins x 4
• Bar-to-bar clamps x 4
• Carbon fiber rod x 1
Minifragment fixation
• 2.7 mm locking compression plate x 1
• 2.7 mm cortical screws x 4
≈ $3000 - $3500 ≈ $500 - $800
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34 y/o male s/p R shoulder injury
2 days ago?
2 weeks ago?
2 months ago?
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Minifrag as an anatomic plate
22 y/o femle s/p MVC
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37 y/o female s/p MVC
Management?
• Closed treatment
• ORIF
– Tension band
– Plate and screws
– Intramedullary device
– Hybrid
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39 y/o female s/p MVC
Surgical plan?
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Some more quick math…
Precontoured tibial plate Minifragment plate
≈ $800 - $1500 ≈ $400 - $600
6 months post-op
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23 y/o male s/p MCC
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44 y/o male s/p fall from roof
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47 y/o male s/p fall from ladder
Upright
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3.7% rate of hardware removal
Getting it right the first time!
17 y/o s/p MVC
• Posterior open wound over calf
• Pulseless LE
• Contralateral open femur fx
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Taken emergently to OR…
• I&D ex fix BLE
• Vascular repair
• Fasciotomies
…Definitive Fixation
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35 y/o male s/p MVC
How to obtain/maintain a reduction in the OR?
• K-wires
• Clamps
• Provisional ex fix/distractor
• Use plate as a template
• Intramedullary device
• Minifragment plates!
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Thank you.
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Take it or leave it...How do I Decide When To Use Mini
Fragment Plating?
John A. Scolaro, M.D., M.A.
Assistant Professor Orthopaedic Surgery
Chief, Orthopaedic Trauma
Associate Residency Program Director
Disclosures
• Consultant• Stryker
• Smith and Nephew
• Globus Medical
• Research Support• DePuy Synthes
• Orthopaedic Trauma Association
• Foundation for Orthopaedic Trauma
Objectives
•Technique
•Indications•Reduction•Adjunctive fixation
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Mini-fragment Implants
• 2.0mm, 2.4mm and 2.7mm implants
• Reconstruction/flexible and standard
• Non-locking/locking
• Variety of manufacturers
Reduction
•Long bones• Length• Alignment• Rotation
•Articular block• Anatomic
reduction• Compression
Reduction (progression)
• Closed manipulation• Skeletal traction
• Push/pull/bump/etc.
• Percutaneous• Hooks
• Clamps
• Open• Limited
• Full
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Reduction (inhibitors)• Interposed tissue or bone
• Deforming muscle forces
• Multiple points of instability
• Limitations of other techniques• Bumps• Percutaneous clamps• Ex-fix/universal distractor• Poller/blocking/cortical replacing screws
• Available hands
…Dogma
•“Never open a closed fracture”
•“You are confusing the fracture”[using a minifragment plate with an IM nail]
Submitted for publication
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Technique
• Expose only what is necessary• Cortical read
• Plate application
• Avoid excessive periosteal stripping
• Plate selection
• Sharp drill bits
• Saline irrigation
• Minimum two points of fixation on each side
Reduction aid
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Reduction through an open wound
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Adjunctive fixation: articular injury
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“Other” fractures
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Conclusion
•Have a pre-operative plan• Fracture• Reduction• Fixation
•Utilize sound technique• Appropriately sized implants• Limit exposure, sharp drills, saline irrigation
Thank you
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Use of Minifragment Plates in
Upper Extremity Trauma
Eben A. Carroll, MD
Wake Forest University
Goals
• Mechanical stabilization (buttress, neutralization, compression)
• Adjunctive reductive aids (multiplanar/transverse)
• Case based
Mechanical stabilization
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70 yo male fall from tree
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27 yo male s/p MCC
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36 yo male s/p bicycle crash
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Adjunctive reductive aid
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21 year old male s/p hiking fall
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30 yo female s/p MCC
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30 yo female s/p MCC
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50 yo male s/p moped accident
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45 year old male s/p MVA
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Goals
• Mechanical stabilization (buttress, neutralization, compression)
• Adjunctive reductive aids (multiplanar/transverse)
• Useful in UE trauma
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Minifragment Implants in the Lower Extremity
John D Wyrick MD
Professor
University of Cincinnati
Disclosures
Consultant Stryker
Speakers bureau Smith Nephew
Introduction
Earliest teachings in ORIF
Exposure
Reduction
PROVISIONAL FIXATION
Definitive fixation
Started with UE fxs
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Introduction
Becoming very popular
Little literature
Once you try it you’ll like it
Advantage: decreased stripping
Introduction
Case based discussion
Periarticular to long bone
Hip to ankle
Proximal femur
35 y/o male
MVC
Isolated fem neck
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Proximal femur
Plan: ORIF with direct reduction
Minifrag plate for inferior buttress
Proximal femur
Provisional fixation
Increased stability
Cons
Some increased exposure
May get in the way of definitive implant
Proximal femur
Provisional fixation
Increased stability
Cons
Some increased exposure
May get in the way of definitive implant
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Proximal femurPeritroch Fxs
28 y/o female
Driving + heroin
Popular pastime in OH
Proximal femurPeritroch Fxs
Proximal femurPeritroch Fxs
Piece together the troch and subtrochfragments
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Proximal femurPeritroch Fxs
34 y/o male MCC
High energy peritrochplus neck fxs
Proximal femur
Proximal femur
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Proximal femur
Subtroch and shafts
Simplify holding reduction for IMN
Especially segmental fxs
Lateral nailing made easy
28 yo male, high speed MCC. Multiple injuries. R acetab, B femurs, L Lisfranc. L femur closed, segmental.
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Lateral position
Jackson table
2.7mm unicortical plate
Plate placed anterior
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24 y/o male, GSW to femur. Multiple GSWs, abdomen etc. Unstable for 3 days.
Struggled intraop getting length and reduction. Opened, unicortical 2.4mm plate, then IMN.
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Patella Fxs
60 y/o male, MVC, multiple trauma
Ipsilateral femoral neck, shaft, patella
Patella Fxs
Interfrag screws challenging due to soft tissue constraints
Patella Fxs
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28 y/o, high speed MCC, IIIA tibia fx. Involves lateral plateau and shaft
After provisional spanning ex fix
Joint fx not bad
Soft tissue closeable but not great
Unable to control shaft alignment with ex fix
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2.0mm rim plate for plateau. Difficulty controlling shaft fragment, used 2.4mm plate. ATB beads for dead space management.
After about 2 wks, treated with ring ex fix, then 4 wks later bone grafted.
He was allowed to WBAT. Preparation for fixator removal after 5 months.
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Concerned regarding strength of healed fx so percuateous plate place at time of ex fix removal.
Distal Tibia Pilon Fxs
Can use implants for provisional fix
Rim plates for small articular fragments
Definitive for smaller fragments
33 yo female, stepped in a hole, gr II open R trimall fx.
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SummaryMini-fragment Implants
Multiple applications, limited only by imagination
Can be applied with minimal stripping
Becoming as routine as bone clamps in fxsurgery.