Distal Femur Fractures in The Elderly The Ideal Construct

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Transcription:

Distal Femur Fractures in The Elderly The Ideal Construct Tak-Wing Lau Department of Orthopaedics and Traumatology Queen Mary Hospital The University of Hong Kong Singapore Trauma 2015 Trauma Through the Ages 18 th - 19 th April 2015. Tan Tock Seng Hospital

Geriatric Distal Femoral Fracture Low energy trauma Osteoporotic bone >>> Difficulty in fixation Open reduction, extensive dissection >>> may delay the speed of union

Chairbound patients Conservative treatment???

2 weeks later in a slab...

3 months later if no open wound...

Choice of Implant Supracondylar ( A1-A3) Locking plate IM Nail Intercondylar (C1-C2) Locking plate + lag screws IM Nail + lag screws Bi-condylar with comminution in articular surface ( C3 ) Locking plate + lag screws (3.5mm for small fragments)

Choice of Implant Supracondylar ( A1-A3) Locking plate IM Nail Intercondylar (C1-C2) Locking plate + lag screws IM Nail + lag screws Bi-condylar with comminution in articular surface ( C3 ) Locking plate + lag screws (3.5mm for small fragments)

Decide the approach Prepare implant of adequate length Reconstruction of articular fracture Application of the plate first at distal part

Positioning Supine with foam support > C-arm control Good for intra-articular fracture Traction table with manipulation

Pathoanatomy of distal femur Deforming ligament pulls Deforming muscle vectors

Planning Approach Reduction Maintain Fixation Reduction technique Articular reduction first (Direct reduction) Bridge articular block to shaft (Indirect reduction)

How to reduce?

For Type C fractures

74 yr old lady C2 distal femur fracture Single intercondylar fracture line Comminuted metaphyseal area Reduction: Anterolateral approach Lag screw first Then MIPO

Lower border of plate must be parallel to posterior femoral cortex

Coronal plane alignment Planning Approach Reduction Maintain Fixation

87y, distal femur A3

87y, distal femur A3

87y, distal femur A3 Post-op 3 months comminuted fracture bridged

COMMON PROBLEMS AND PITFALLS...

SIMPLE A1 FRACTURE: EASIER TO TREAT???

F/ 71 33A1 fracture

Post-op 1 week Post-op 6 month A good reduction is important in A1 fractures. It may not tolerate any gap!

MONOCORTICAL OR BICORTICAL

Mode of Failure No angular stability Individual screw loosened Angular stability Whole fixation pull out

Problem of short monocortical screws in 2 patients Wong, Leung, Chow Intern Orthop 2005

ANATOMICALLY PRE-SHAPED PLATE?

European femur Asian femur

Sagittal plane mismatch

Coronal plane mismatch

Increase the working length = stronger fixation

SPECIAL CONSIDERATIONS

F/89 Walk with stick Hemiarthoplasty done 5 years ago Total knee replacement done 10 years ago Slipped and fell C/O knee pain and unable to walk

CT scan

Lateral DF-LCP with medial LCP

2 months after operation

2 years after operation Walk with stick

F/98, Chairbound patients

Goals of treatment Summary Anatomical reduction of joint surface Good reduction of metaphysis and diaphysis Stable internal fixation Early mobilization Locking plate fixation for all type A and type C fractures Medial augmentation plating in severe osteoporotic fractures or in special case, e.g. periprosthetic fracture

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