CASES: DISTAL FEMUR & PLATEAU. Distal Femur. Case 1: MC 25 foot fall 11/21/2016. What to do first? Ex Fix? CT?
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1 CASES: DISTAL FEMUR & PLATEAU Frank A. Liporace, MD Associate Professor Dept. of Orthopaedics Director Orthopaedic Trauma Research New York University / Hospital for Joint Diseases, NY, NY Chairman Dept. Of Orthopaedics, Jersey City Medical Ctr / RWJ Barnabas Health Distal Femur Case 1: MC 25 foot fall What to do first? Ex Fix? CT? 1
2 MC ER CT done pre exfix Limitations Compartment Syndrome Quad Tendon Tear MC : Ultimately had Ex Fix, Fasciotomy, Delayed Closure, Now Approach Anterior? Lateral? Medial? Combined? MC 2
3 MC Case 2 SG Firefighter fell off ladder Next Case? Ex Fix? CT? SG Fix? Medial? Lateral? 3
4 SG Subvastus Case 3: JV 75 yo male 3 time failed distal femoral nonunion ALL surgeries with lateral plate Previous Hip Fx short hip IMN above SOLUTION??? STEP 1 BIOPSY (significant history) B.S. sign Bone Stimulator NOTE ALLOGRAFT FIBULA INTRAMEDULLARY STRUT?!?!?!?!? NEGATIVE FOR INFECTION 4
5 Biopsy Results Not Infected What to do? 1) Repeat Lateral Plating with Compression Possible Blade 2) Dual Plate 3) Retrograde Nail 4) Other 5
6 2 years LINKED CONSTRUCT Appropriate Stability HEALED NO PAIN!!! Case 4: EV vacation in Mexico gone wrong; Pain & 6 months post-op 6
7 EV Now what? Bone Graft in situ? Change to Plate? Re IMN? Revision TKR? Other? EV Case 5: JZ Distal Femoral Fx 10 yrs ago w/ 4 time nonunion s/p platings above TKR & below THR Non ambulator x 2.5 years ***BIOPSY INFECTED 7
8 Biopsy Results Infected What to do? 1) I&D with acute fixation and post op antibiotics 2) I&D then picc / antibiotics 6 wks re ORIF 3) Resection of both joints with #2 + arthroplasty replantation 4) Other ROUND 1 RESECTION ATROPHIC NU ANTIBIOTIC PLATE 8
9 2.5 months post-definitive op Uses walker 1 st time in 2.5 yrs Proximal and Distal N/P Linkage CALLUS!!! Tibia Plateau 52 yo active male s/p Pedestrian Struck Isolated injury No NV deficits Case 1 9
10 Case 1 What would your management be? 1) ORIF within 6 hours 2) CT scan, ORIF within 2 days 3) External Fixation, CT scan, ORIF ~ 1 wk or more 4) External Fixation, ORIF when time available 5) Closed Management Case 1 What would your management be? 1) ORIF within 6 hours 2) CT scan, ORIF within 2 days 3) External Fixation, CT scan, ORIF ~ 1 wk or more 4) External Fixation, ORIF when time available 5) Closed Management 10
11 Case 1 Patience Timing critical Avoid 1-6 days Await soft tissue envelope (10-21 days) Note: Highest wound complications <7 days after injury (tibia plateau fractures) Wagner HE and Jakob RP: Unfallchirurg 1986 MEDIAL LATERAL 11
12 Case 2 38 yo female Ped struck Non palpable but Doppler able pulse ABI 0.7 in ER Case 2 12
13 Case 2 What is the most concerning acute aspect of this case? 1) Difficulty deciding definitive surgical approach 2) Concerns as in knee dislocation 3) Articular depression by tibial spine 4) Mechanical axis maintenance 5) Risk of infection after definitive care Case 2 What is the most concerning acute aspect of this case? 1) Difficulty deciding definitive surgical approach 2) Concerns as in knee dislocation 3) Articular depression by tibial spine 4) Mechanical axis maintenance 5) Risk of infection after definitive care 13
14 Case 3 14
15 Case 3 What is a potential concern with this fixation? 1) Inappropriate alignment 2) Malreduced articular surface 3) Stainless steel implant infection risk 4) Potential instability 5) Nothing Case 3 What is a potential concern with this fixation? 1) Inappropriate alignment 2) Malreduced articular surface 3) Stainless steel implant infection risk 4) Potential instability 5) Nothing Case 3 15
16 Case 3 Case 3 5 months Asymptomatic, Softening of Fx Lines 16
17 Case 4 FQ 46 year old male s/p fall 20 feet on construction site PMH: HTN PSH: appendectomy Rx: Metoprolol Allergies: NKDA FQ Exam: DP/PT + Sensation intact to light touch all dermatomes Swollen, painful knee No reported hip or ankle pain ABI 0.9 NIGHT 1 Concerns? Compartment Syndrome Vascular Injury 17
18 Next Morning POST Ex Fix CT scan POST Ex Fix CT scan ExFix Goals Achieved? Length Coronal Alignment Sagittal Alignment 18
19 Revision Exfix Remember CT scan? Definitive Fixation? Lateral Medial Both 3 months 19
20 12 months returned to construction ROM slight distal tip plate pain doesn t want ROH Case 5 JG 22 yo female MVA ejected + LOC B/L open talus and right calcaneus Swollen and tense L calf with PAIN! JG 20
21 JG JG night 1 JG: Night 1 + Fasciotomy 21
22 JG after ex fix Fasciotomy closure: Medial First? Lateral First? ORIF when? During final fasciotomy Coverage / closure? MEDIAL Delayed after final Coverage / closure? LATERAL JG after ex fix When Soft tissue ready: Approach Anterior Lateral Medial Medial / Lateral? MEDIAL One Stage ORIF? Two Stage ORIF? LATERAL JG 2 weeks 22
23 JG final JG 16 months JG 16 mo Needs R TTC fusion L ankle with some evidence AVN talus but minimal symptoms other than stiffness L knee: No instability Intermittent pain at times at lateral joint line but satisfied currently 23
24 Case 6 TD 25 yo 350 lb male who fell after lay up at 8pm CC: Right knee pain TD Admitted overnight TD 3 am bothering staff that he needs more pain meds 5am I can t feel all of my toes 24
25 TD 5:45 am TD TD 25
26 TD 10 months TD Mild pain over MCL No instability Back to basketball but prefers jump shot to lay ups now Case 7 PR: June 30, y.o. Motorcycle accident IDDM x 10 years 1ppd smoker Very swollen, no compartment syndrome 26
27 PR July 1, 2007 PR July 1, 2007 Lateral Lateral PR July 1, 2007 Anterior Midline Posterior 27
28 PR July 24, 2007 PR September 26, 2007 PR August 27,
29 PR August 27, 2008 OUCH!!! PR September 23, 2008 H.O. resection Knee stable intra op PR March 15, 2010 ROH:? Painful Also Bx at that time Bx NEGATIVE 29
30 PR June 15, 2010 PR July 2013 Case8: WT December
31 WT December 2010 WT December 2010 WT Night 1 31
32 WT 2.5 weeks s/p injury WT 11 months s/p injury, pain over plate ROH and NEGATIVE BX WT No change in Xrays 6 more months non op Tx, Too much Pain, ROM
33 WT 1 yr s/p TKR: ROM 5 110, No pain Case 9: RM RM 33
34 RM RM Optimizing the Management of Moore Type I Postero Medial Split Fracture Dislocations of the Tibial Head: Description of the Lobenhoffer Approach. Fakler, Johannes; Ryzewicz, Mark; Hartshorn, Cody; Morgan, Steven; Stahel, Philip; Smith, Wade Journal of Orthopaedic Trauma. 21(5): , May A, Skin incision along the medial head of the gastrocnemius, not crossing the popliteal fossa. B, Incision down to the fascia. 2 34
35 Optimizing the Management of Moore Type I Postero Medial Split Fracture Dislocations of the Tibial Head: Description of the Lobenhoffer Approach. Fakler, Johannes; Ryzewicz, Mark; Hartshorn, Cody; Morgan, Steven; Stahel, Philip; Smith, Wade Journal of Orthopaedic Trauma. 21(5): , May Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 3 Optimizing the Management of Moore Type I Postero Medial Split Fracture Dislocations of the Tibial Head: Description of the Lobenhoffer Approach. Fakler, Johannes; Ryzewicz, Mark; Hartshorn, Cody; Morgan, Steven; Stahel, Philip; Smith, Wade Journal of Orthopaedic Trauma. 21(5): , May Case 10: LT 62 year old Healthy Female Fall down stairs, no prior knee pain 35
36 LT Ex Fix? Straight to ORIF? LT ORIF approach: Lateral? Medial? Both? Other? LT 36
37 LT JM JM 37
38 Posterior Bicondylar Tibial Plateau Fractures. Carlson, DuWayne Journal of Orthopaedic Trauma. 19(2):73 78, February Case 11: JM JM 38
39 JM JM JM 39
40 JM Posterior Bicondylar Tibial Plateau Fractures. Carlson, DuWayne Journal of Orthopaedic Trauma. 19(2):73 78, February
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