Why Plates are the Solution - foreonline.org · 11/19/2018 11 Why I Use Plates More confidence in my ability to obtain and maintain reduction Large metaphysealspace Not concerned

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Fracture About a Total Knee:Why Plates are the Solution

Joseph Borrelli, Jr., MD, MBACollaborative Professor

Department of Orthopedics and Sports MedicineUniversity of South Florida, Morsani College of Medicine

BayCare Medical GroupTampa, FL

Introduction

Important Topic: Periprosthetic Supracondylar Femur Fracture 3-500,000 TKA performed per year in US, and increasing!!

SC Fractures seem to be increasing in number, as Patients living longer

TKA are being implanted in younger and younger patients

Greater number of revisions are being performed

Review Risk Factors for SC Peri-prosthetic Femur Fractures Rheumatoid Arthritis Osteolysis Osteopenic bone Steriod Use Frequent Falls Technique-specific risk factors anterior notching

Females Age >70 years Revision TKA

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Review Classification Systems

Lewis and Rorabeck

Su, DeWal and DiCesare

I II III

Challenges“No matter which implant you use, successful treatment of SC peri-prosthetic femur fractures requires a careful attention to many details” WM Ricci

Available distal bone stock = fracture pattern

Bone quality – osteopenic, large metaphysis

Obstructions - Prosthetic implant design (femoral component)

Stem from above

Strengths and limitations of the implant

Patient expectations and demands

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Goals Restoration of: Length

Alignment

Rotation

Stable fixation

Early mobilization of the patient and limb

Preservation of the soft tissues

Minimizing Complications

Options Non-operative Care

Sickest patients

Nondisplaced

ORIF – conventional plates

ORIF – locking plates

Retrograde Intramedullary Nailing

Why I Use:Locking Plate Fixation More consistently allows restoration of length, alignment

and rotation

Preservation of the surrounding soft tissues

Little need to be concerned about size of distal fragment

Little need to be concerned about bone quality – LP tech

Little need to be concerned about femoral implant type Femoral component with narrow notch, component causing

too posterior of starting point

JBJS Br. 2010

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Lack of metaphyseal fill Leading to windshield wiping

Varus and valgus instability, malunion/nonunion

Need for specially maneuvers – blocking screws

Requires familiarity with all types of femoral components

Many patients with TH above – can’t use short nails

Must have sufficient bone stock distally Extreme distal fractures

Why I DON’T Use:Intramedullary Fixation

Courtesy Wm Ricci, MD

Courtesy Wm Ricci, MD

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Courtesy Wm Ricci, MD

74y/o female, fell at home, total hip above,

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Anatomical Reduction of the Articular Surface

reduce and stabilize the intra-articular portion of the fracture

Restoration of Length, Alignment and Rotation

Insertion of Guide Wire

Parallel to the distal femoral condyle

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Apply plate with guide wire guides attached

Apply plate with guide wire guides attached

Check Fluoroscopy !!

Parallel to the Joint

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Extreme Distal

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Extreme Distal

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Why I Use Plates

More confidence in my ability to obtain and maintain reduction Large metaphyseal space

Not concerned about the femoral component

Not concerned that the femoral component will force me into a bad starting point

Can plate extreme distal fractures

Can plate those fractures with THA above

The Literature

The Literature

J Orthop Trauma, Volume 28, Number 5 May 2014

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The Literature

Journal of Arthroplasty 2014

Summary All of use should be familiar with each technique for fixing

SC distal peri-prosthetic femur fractures

All of us should be familiar with the advantages and limitations of each type of implant and their indications

Su, DeWall, DiCearse Classification