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Cory Collinge, MDProfessor of Orthopedic Surgery

Vanderbilt University Medical Center

Nashville, TN

Distal Femur Fractures: Tips and Tricks for Plating and

Nailing?

• Consultant: Smith & Nephew, Biomet, Stryker

• Royalty: Smith & Nephew, Biomet Advanced Orthopedic Systems, Synthes

• Editorial Board: J Ortho Trauma, JBJS

• BOD: Foundation for Orthopedic Trauma

Conflict of Interest

From my lecture files: 2004

• 75 yo woman fell off step ladder

Principles of Early Plating Methods

• Anatomical restoration of bone

• Rigid stability

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Traditional Open Plating: Case Example

Early Plating Methods Required:

• Soft-tissue stripping

• Evacuation of fracture hematoma

Traditional Open Plating: Case Example

6 mos

Often …..nonunion & fixation failure

Early Plating Methods: Distal Femur

• 10-40% nonunions

• 5-25% infections

• 5-20% malunion

• 10-95% bone graft

Slatis et al., Acta Orthop Scand, 1971Neer et al., Injury, 1975Olerud, J Bone Joint Surg Am 1972Schatzker and Lambert, Clin Orthop, 1979Siliski et al., J Bone Joint Surg-Am, 1989

Traditional Open Plating: Case Example

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“Indirect reduction”: fracture realignment is obtained without direct visualization

• Rationale: Maintain fracture environment (vascularity and hematoma) to achieve….– Early healing

– Fewer bone grafts

– Lessen infection risk

Evolution of Plating Techniques

Mast et al. Planning and Reduction Techniques in Fracture Surgery, 1989

• Condylar fixation

“Locked Plating”

“Locked Plating”

• Great case, man!

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Standard ORIF

• 10-40% nonunions

• 5-25% infections

• 5-20% malunion

• 10-95% bone graft“… mostly attributable to a learning curve”

MIPO1,2,3,4

→ 0-3%

→ 0-3%

→ 5-35%

→ 0-3%

1. Schutz et al., Injury, 20012. Schandelmaier et al. Injury, 2001 3. Kregor et al. Injury, 2001 4. Others

Results of MIPO: Distal Femur

J Am Acad Orthop Surg 2000;8:211‐216

J Am Acad Orthop Surg 2000;8:211‐216

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J Am Acad Orthop Surg 2000;8:211‐216

104°

J Am Acad Orthop Surg 2000;8:211‐216

So…..what’s the deal?

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• 33 A1-3, C1 fractures at 12 trauma centers• 126 pts: 76 locked plates vs 80 nails• No difference in pts or injuries

SOLVED (unpublished)

Locked Plating vs. Retrograde Nailing for Distal Femur Fractures: A Multicenter Randomized Trial, Tornetta et al. Presented at OTA 2013, Phoenix, AZ

vs.

Nails Locked plates

Surgical times (min): 125 +/- 61 124 +/- 51 0.9

Malalignment >5° 22% 32% 0.4

Nonunion surgery 5% 8%

P

Locked Plating vs. Retrograde Nailing for Distal Femur Fractures: A Multicenter Randomized Trial, Tornetta et al. Presented at OTA 2013, Phoenix, AZ

SOLVED (unpublished)

• All patients have disability at 1 year

Locked Plating vs. Retrograde Nailing for Distal Femur Fractures: A Multicenter Randomized Trial, Tornetta et al. Presented at OTA 2013, Phoenix, AZ

SOLVED (unpublished)

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Similar to Plating

• MIPO or open

• New technology

Evolution of Nails

Evolution of Nails

Advances in IM nails

• More locking screws

• Fixed angled screws

• Open Rx of articular component

• Anatomical geometry– CT “averaging” of population

How is a Plate Designed?

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1

2

3 4 5

How is a Plate Designed?

Modern Plate Design

• “Anatomical” plates do not fit everybody!

Anything else?

• Technical screw-ups

• “Rule of too’s”

Plate Misapplication & Malalignment

Collinge et al. J Ortho Trauma, 2012

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Case 1

Case 2

Case 3

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Case 4

Case 5

Case 6

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Case 7

Case 8

Case 9

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Standard ORIF

• 10-40% nonunions

• 5-25% infections

• 5-20% malunion

• 10-95% bone graft“… mostly attributable to a learning curve”

MIPO1,2,3,4

→ 0-3%

→ 0-3%

→ 5-35%

→ 0-3%

1. Schutz et al., Injury, 20012. Schandelmaier et al. Injury, 2001 3. Kregor et al. Injury, 2001 4. Others

Results of MIPO: Distal Femur

Modern Open Plating: Case Example

• 37 yo woman shot by “boyfriend”

• Type 33A

C-arm opposite

Pre-op planning

Reduction aids

Set-up

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Indirect Reduction

• Femoral Distractor

Loss of anterior bow Anterior bow restored

Adjust bump

Indirect Reduction

• Knee roll

• Fracture reduced

Ready to Plate

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Lateral Skin Incision

Incise IT band

Plate insertion

~95‐98°

Plate design & anatomy

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Position Plate

Position Plate “Rectangularize” Plate-Targetter Construct

Confirm Quality Radiographs: Proximal & Distal

Fine Tune Reduction

Lag Screw King Tong Clamp

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Fine Tune Reduction

Fine Tune Reduction

Lag Screw @ Shaft

Add Necessary Screws

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Review Radiology

10 mos. healed

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Case Example: Osteoporotic Distal Femur

• Anterolateral approach is extensile

Approaches

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So what are we to do?

Do a nice plating:

• Pre-op plan

• Plate carefully- radiography

• High threshold for alignment

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Nailing

• Minimally invasive

• Open (biologically friendly)

So what can we do?

Modern Nailing

Critical elements

• Starting point

• Reduction

• Nail geometry

Thank You