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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.