Cost and Time Considerations: Are Minifragment Plates Worth It? Andrew Choo, MD Vumedi Webinar November 15, 2016 Disclosure Paid speaker: Depuy Synthes More Disclosures Price quotes are estimates only! Most talks are evidence-based. This one is not. I am very, very biased towards minifragment fixation Are minifragment plates worth it? it depends! How they re used How many are used How many locking screws How much longer it takes 1
How can minifrag be cost-effective? Use instead of external fixators Use instead of anatomic plates Use it to do it right the first time! Minifrag as an external fixator 16 y/o male s/p MCC < 1 cm open wound over medial leg Tense, swollen compartments Case courtesy of Joshua Gary, MD 2
Taken emergently Fasciotomy I&D of open tibia fx Wound VAC Provisional stabilization of pelvic ring injury Returned for Staged IMN Some quick math External fixation 5.0 mm Schantz pins x 4 Bar-to-bar clamps x 4 Carbon fiber rod x 1 Minifragment fixation 2.7 mm locking compression plate x 1 2.7 mm cortical screws x 4 $3000 - $3500 $500 - $800 3
34 y/o male s/p R shoulder injury 2 days ago? 2 weeks ago? 2 months ago? 4
Minifrag as an anatomic plate 22 y/o femle s/p MVC 5
37 y/o female s/p MVC Closed treatment ORIF Tension band Plate and screws Intramedullary device Hybrid Management? 6
39 y/o female s/p MVC Surgical plan? 7
Some more quick math Precontoured tibial plate Minifragment plate $800 - $1500 $400 - $600 6 months post-op 8
23 y/o male s/p MCC 9
44 y/o male s/p fall from roof 10
47 y/o male s/p fall from ladder Upright 11
3.7% rate of hardware removal Getting it right the first time! 17 y/o s/p MVC Posterior open wound over calf Pulseless LE Contralateral open femur fx 12
Taken emergently to OR I&D ex fix BLE Vascular repair Fasciotomies Definitive Fixation 13
35 y/o male s/p MVC How to obtain/maintain a reduction in the OR? K-wires Clamps Provisional ex fix/distractor Use plate as a template Intramedullary device Minifragment plates! 14
Thank you. 15
Take it or leave it...how do I Decide When To Use Mini Fragment Plating? John A. Scolaro, M.D., M.A. Assistant Professor Orthopaedic Surgery Chief, Orthopaedic Trauma Associate Residency Program Director Disclosures Consultant Stryker Smith and Nephew Globus Medical Research Support DePuy Synthes Orthopaedic Trauma Association Foundation for Orthopaedic Trauma Objectives Technique Indications Reduction Adjunctive fixation 1
Mini-fragment Implants 2.0mm, 2.4mm and 2.7mm implants Reconstruction/flexi ble and standard Non-locking/locking Variety of manufacturers Reduction Long bones Length Alignment Rotation Articular block Anatomic reduction Compression Reduction (progression) Closed manipulation Skeletal traction Push/pull/bump/etc. Percutaneous Hooks Clamps Open Limited Full 2
Reduction (inhibitors) Interposed tissue or bone Deforming muscle forces Multiple points of instability Limitations of other techniques Bumps Percutaneous clamps Ex-fix/universal distractor Poller/blocking/cortical replacing screws Available hands Dogma Never open a closed fracture You are confusing the fracture [using a minifragment plate with an IM nail] Submitted for publication 3
Technique Expose only what is necessary Cortical read Plate application Avoid excessive periosteal stripping Plate selection Sharp drill bits Saline irrigation Minimum two points of fixation on each side Reduction aid 4
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Reduction through an open wound 9
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Adjunctive fixation: articular injury 11
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Other fractures 14
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Conclusion Have a pre-operative plan Fracture Reduction Fixation Utilize sound technique Appropriately sized implants Limit exposure, sharp drills, saline irrigation Thank you 16
Use of Minifragment Plates in Upper Extremity Trauma Eben A. Carroll, MD Wake Forest University Goals Mechanical stabilization (buttress, neutralization, compression) Adjunctive reductive aids (multiplanar/transverse) Case based Mechanical stabilization 1
70 yo male fall from tree 2
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27 yo male s/p MCC 4
36 yo male s/p bicycle crash 5
Adjunctive reductive aid 6
21 year old male s/p hiking fall 7
30 yo female s/p MCC 8
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30 yo female s/p MCC 11
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50 yo male s/p moped accident 13
45 year old male s/p MVA 14
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Goals Mechanical stabilization (buttress, neutralization, compression) Adjunctive reductive aids (multiplanar/transverse) Useful in UE trauma 16
Minifragment Implants in the Lower Extremity John D Wyrick MD Professor University of Cincinnati Disclosures Consultant Stryker Speakers bureau Smith Nephew Introduction Earliest teachings in ORIF Exposure Reduction PROVISIONAL FIXATION Definitive fixation Started with UE fxs 1
Introduction Becoming very popular Little literature Once you try it you ll like it Advantage: decreased stripping Introduction Case based discussion Periarticular to long bone Hip to ankle Proximal femur 35 y/o male MVC Isolated fem neck 2
Proximal femur Plan: ORIF with direct reduction Minifrag plate for inferior buttress Proximal femur Provisional fixation Increased stability Cons Some increased exposure May get in the way of definitive implant Proximal femur Provisional fixation Increased stability Cons Some increased exposure May get in the way of definitive implant 3
28 y/o female Driving + heroin Popular pastime in OH Proximal femur Peritroch Fxs Proximal femur Peritroch Fxs Piece together the troch and subtroch fragments Proximal femur Peritroch Fxs 4
34 y/o male MCC High energy peritroch plus neck fxs Proximal femur Peritroch Fxs Proximal femur Proximal femur 5
Proximal femur Subtroch and shafts Simplify holding reduction for IMN Especially segmental fxs Lateral nailing made easy 28 yo male, high speed MCC. Multiple injuries. R acetab, B femurs, L Lisfranc. L femur closed, segmental. 6
Lateral position Jackson table 2.7mm unicortical plate Plate placed anterior 7
24 y/o male, GSW to femur. Multiple GSWs, abdomen etc. Unstable for 3 days. Struggled intraop getting length and reduction. Opened, unicortical 2.4mm plate, then IMN. 8
Patella Fxs 60 y/o male, MVC, multiple trauma Ipsilateral femoral neck, shaft, patella Patella Fxs Interfrag screws challenging due to soft tissue constraints Patella Fxs 9
28 y/o, high speed MCC, IIIA tibia fx. Involves lateral plateau and shaft After provisional spanning ex fix Joint fx not bad Soft tissue closeable but not great Unable to control shaft alignment with ex fix 10
2.0mm rim plate for plateau. Difficulty controlling shaft fragment, used 2.4mm plate. ATB beads for dead space management. After about 2 wks, treated with ring ex fix, then 4 wks later bone grafted. He was allowed to WBAT. Preparation for fixator removal after 5 months. 11
Concerned regarding strength of healed fx so percuateous plate place at time of ex fix removal. Distal Tibia Pilon Fxs Can use implants for provisional fix Rim plates for small articular fragments Definitive for smaller fragments 33 yo female, stepped in a hole, gr II open R trimall fx. 12
Summary Mini-fragment Implants Multiple applications, limited only by imagination Can be applied with minimal stripping Becoming as routine as bone clamps in fx surgery. 13