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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SOLVED (unpublished)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