Principles of Management of Articular fractures

Dr. Emal Khan WardakAO SEC Mongolia

Goals of this lecture are:

• to understand the management of articular fractures incl. planning & timing

• to understand the pathophysiology of the articular segment

• to appreciate the need for anatomical reduction and rigid fixation allowing for early motion

• to understand the choice of implants

Articular cartilage & chondrocytes „live“ from diffusion of joint fluids and depend on regular movement and loading forces

Any changes of this environement lead to degenerative changesof both cartilage and underlying bone arthrosis / - itis

Already 100 years ago Lambotte had observed thatonly perfect anatomical reduction and stable fixationby screws together with early motion allows to obtain a good functional outcome in articular fractures !!

...result in a severeosteoarthitis as inthis case 20 years later

20 yLambotte 1902

Transfixation screw in an unreduced fibulamust....

Displaced articular are an absolute indication

for a correct ORIF

Articular fractures must be reduced anatomically, which requires good visualization of entire joint,incl. critical structures like the ulnar nerve

Only fixation by absolute stability allows early motion

30 we

M.M. 27y, athlete motorbike injury

2° open distal humerus C3 fracture right side neuro-vascular: OK

Result of 3 hours ofsurgery (elsewhere):immobilisation in a circular cast for 3 mo!!Infection?

poor surgery + cast is

a very bad combination

M.M. 27y, athlete motorbike injury

At 3mo: stiff elbow,pain non union AVN ??? wound healed

Surgery: olecranon osteotomy lots of fibrosis, no cartilage visible vascularity OK

3 months p-o

Plan: debride and reconstruct fragments anatomically rigid fixation to allow immediate physioth.

M.M. 27y, athlete motorbike injury

Extensive fibrolysis,Adaptation of main fragments,

Stabilisation with: pediatric osteotomy plate on radial side 1/3 tubular plate ulnar side

No cast, no splintImmediate physiotherapy

M.M. 27y, athlete motorbike injury

1 year after accident- fracture healed, no AVN- satisfactory function- can again play tennis

If surgery is chosenit must be done

correctly

Complications after surgery can resultfrom:

• wrong timing

• poor reduction

• inadequate fixation

• wrong implant

• poor soft tissue care

Most of which is avoidable with carefull planning

Where are we today?

We request - anatomical reconstruction of the articular surface and joint block

- rigid fixation by interfragmentary compression of the main fragments

- „stable link“ of the articular block to the diaphysis

- functional aftercare (including early partial weightbearing)

Meticulous preoperative planning

Preoperative Planning:• correct assessment of fracture and soft parts

• x-ray imaging incl. CT

• drawing of the fracture

• reduction on „paper“

• step- by- step procedure

• choice and position of implants (and instruments)

• selection of approach and position of patient

• need for bone graft ?

Evaluation of x-rays:

A step-off in the articular surfacemay show only after reductionon paper better planning

Same case

Post op One year

At one year follow- up: full functional recovery

51y female, Skiing injury 8 mo ago, still knee pain & instability

Not recognized, neglected Hoffa fracture of lateral femoral condyle

original x-ray

51y female, Skiing injury 8 mo ago, still knee pain & instability

Osteotomy in original fracture plane and fixation with 3 screws

Post-op 27 weeks

X-ray imaging:

Traction views and CT-scans (3D) are most instructive also in view of the planning of approaches

traction

Postero-medial approach

In articular fractures timing of surgery is most crucial

• thin subcutaneous fat, no muscles

• especially vunerable soft tissue cover

If in doubt dont do ORIF !! but stabilise joint & wait

• skin tension ischemia necrosis

Do not touch

Soft tissue evaluation:• history of injury – energy involved?

• interval since accident?

• swelling, skin tension, hematoma?• open / closed injury contamination?

• neuro- vascular status?

• compartment pressure?

Question of experience After 10 days OK

Timing of surgery:• primary definitive surgery

• staged surgery

• delayed definitive surgery

Each has advantages and draw backs,most important are the soft tissues

Primary definitive surgery requires:• „unproblematic“ soft tissues

• experienced team

• full equipment

• access to OR

• carefull planning

e.g : malleolar fractures type A / B fx simple pilon fx elbow fx

• complete work-up of patient

G.B.m. 1962 motorcycle injury III B open prox. tibia 41-C1

• Compartment release

• poor pulses emergency surgery w. „on- table“ angiography• medial approach to popliteal vessels and repair• ORIF with 3.5 angle blade plate (same approach & team)

Open articular fractures are emergencies

„second look“ with debridement and gastrocnemius flap

G.B.m. 1962 motorbike injury

G.B. m. 1962 motorcycle injury

• Gastrocemius flab to coveranterior defect

• No compli-cations

• Goodfunction

• Control-angiogram to prove patency

13 weeks

• one year FU1 year

Advantages of staged surgery:

• protects soft parts for better recovery

• patient remains „mobile“

• reduction aid for planned definitive surgery

• for the „less experienced“ at night e.g. complex type C fx open / poor soft tissues

• minimally invasive preliminary fixation eg. Joint bridging external fixation

Today the

preferred technique for

complex articular fractures

1st step:

• traction

• bone graft

• soft tissue cover

Staged procedures

• joint bridging external fixator: - per se - combined with screws/ wires/ plates

• ORIF / MIS

2nd step:

Delayed definitive surgery:

• „safer“ soft tissue conditions ?

• reduction more difficult !

• cartilage damage?

• slower return of function

• heterotopic bone formation

e.g. upper extremity in polytrauma calcaneus fx, complex pilon fx ? acetabulum

no later than 3 weeks

Reduction techniques:You need a good view of the articular surface!!

• by direct inspection• through arthroscope (???)

Impacted articular components are reduced exactly and supported by bone graft or substitute

- Joint bridging distractor to keep the alignment - but articular fragments must be handled directly,- percutaneous insertion of buttress plate

Choice of implant:For articular fractures screws & platesMore adequate than im-nails

• 3.5 implants best dimension• tubular, LC DCP, LCP• new: special form plates

LCP prox.Tibia

pilon

Distalhumerus

...but special plates are no garantee for

a good reconstruction and result !!

G. N, 25 y old lady, skiing accident on 27 Jan.1959 : Pilon 43-C3

only plain x-raysno Tomogr, no CT

emergency surgeryby M. Allgöwerlimited implants &instruments

Jan 27th 1959

3 different types of implants: - straigth non AO malleolar screw - Rush pin - AO 6.5mm Cancellous bone screw

satisfactory reduction, but

„horrible“, unstable fixation

by today‘s standards,

mix of implant & materials

G.N 25y

Jan 27th 1959 post-op

G. N. same patient in 2007, 48 y later,

Aug 28th 2007 No discomfortGood function

No signs of osteo-arthitis even after48 years !!

do we really need

LCP Pilon plates etc.??

or just a good surgeon ?

How to handle bony defects ?

Depends on purpose: - providing mechanical support? - filling up defect?

Bone substitute: - resorbable - non- resorbable - BMP etc.

Autologous graft: - cancellous - cortico- cancellous

Conclusions:• displaced articular fractures are an absolute indication for surgery, provided:

• anatomical reconstruction and rigid fixation is obtained

• correct timing and planning are crucial

• staged surgery may be advisable

• early postoperative mobilisation of injured joint is mandatory (CPM)

Post-operative care:“compliant“ pat.• CPM continuous passive motion for 5 - 6 days

• Immediate toe-touch (15kg) weightbearing

• No external splint

• 6 - 8 weeks: 30 - 40 kg

Results after ORIF in articular fractures:

are in general quite good, provided there is• anatomical reconstruction and rigid fixation

• an experienced surgeon

• early rehabilitation*

70-80% good or excellent

10-15% moderate

5-10% poor*Dammaged cartilage never „heals“ completely, but also normal cartilage „depends“ on early joint motion

.....however

• secondary reconstructions may be worth the effort !

• even the best surgery has its limits !!

• there is no cure against bad surgery !!

• not every joint incongruency means clinical impairment

Thank you !!

B.F. 39y.m MD, 6mo ago, malleolar fx and ORIF elsewhere• painful, disabling valgus position of foot, due to short fibula, tibial impaction (?), circumscribed osteoarthitis

• plan to lengthen fibula by 7 mm, anterolateral tibial osteotomy

• intraoperative view after exposure of involved area

B.F. 39y.m MD, 6mo ago, malleolar fx and ORIF elsewhere

• anterolat. block of tibia is removed, view into ankle joint

• the block has been moved distally + graft

• appearance on intraoperative x- rays

B.F. 39y.m MD, 6mo ago, malleolar fx and ORIF elsewhere

• buttressing of the reduced anterolateral tibia by 1/3 tubular plate

• fibula is lengthened and fixed with 3.5 LCP, transfixion to tibia

• 1 year follow up, with good joint space, walks for several hours function 0- 0- 20, no pain

36mo

51y female, Skiing injury 8 mo ago, still knee pain & instability

Not recognized, neglected Hoffa fracture of lateral femoral condyle

original x-ray

51y female, Skiing injury 8 mo ago, still knee pain & instability

Osteotomy in original fracture plane and fixation with 3 screws

Post-op 27 weeks