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Distal Femoral Fixation:Where Are We Now

Bruce H. Ziran MD FACSDirector of Orthopaedic Trauma

The Hughston Clinic atGwinnett Medical Center

Atlanta , Georgia

Disclosures

• Speaker/Consultant• Acumed, Citieffe, Carbofix, Synthes

• Royalties• Acumed, Citieffe, Synthes

• Development/Design Team• Acumed, Synthes

• Committee/Misellaneous• ACS/COT-Verification Review• ABOS-Examiner

3 Things That Impacted Treatment of DF Fractures

• Minimally Invasive Osteosynthesis

• Locked Plate/Screw Technology

• Use of retrograde nails

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MIO

• Accurate reduction with least biologic disruption

• Exposure size does not need to be minimal

• Violation of bone biology does need to be minimal

• Common sense regarding goals

First: What is MIO?

What is NOT MIO?

Violation of the bone biology

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What is NOT MIO?

Small exposures at expense of acceptable reduction

Surgical Approach: Lateral

Anterolateral Approach

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Technical Tips: My Locking Technique

• Articular standard screw: plate to bone

• Diaphyseal standard screw: plate to bone

• Metaphyseal standard screw: tweak

• Assess stability

• Locking screws as needed (not so much)

The Ultimate MIO: IM Nail

• Best for A type fractures

• Some C1 and C2• Adequate articular reduction

• Sufficient bone for fixation

IM Nail

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IM Nail

• Prophylactic stabilization of distal extension

• Clamp assisted reduction

IM Nail

• Prophylactic blocking screws

IM Nail

• 3 mos

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IM Nail: Accessories

• Oblique screws

• Bolts

Reduction Help

Reduction Help

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Reduction Help

Reduction Help

The Co-Linear Clamp

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IM Nail: Special Circumstances

• 35 yo, male, open femur and medial condyle• Medial plating indicated

• Ligamentous injury

IM Nail: Special Circumstances

IM Nail: Special Circumstances

• Medial plate and nail construct

• Interlock screws shared with plate

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IM Nail: Instability After Nailing

• 50 yo male

• Isolated distal femur

• Is it crazy to use IM nail?

IM Nail: Instability After Nailing• Yes.

• Required supplemental plate

Beware: Hoffa Fracture

• Standard plates may not provide fixation• Address separately with screws or small plates• MIO becomes more MAXIMO

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Hoffa Fracture

Hoffa Fracture

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Poly Trauma

• 38yo M

• Head, face injury

• Bilateral tibia

• R SC femur

• L intertroch + shaft + SC

• R forearm

Contralateral L side: DCO

Medial+Lateral HoffaCentral defectNote: no levering retractors

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• Bioabsorbable pins

• DBM+allograft+small BMP

• Resorbable beads

4 mos

Other side:SC=lateral hoffa only

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• 56 yo F

• L plateau

• L SC

• L shaft

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Unusual Patterns

• 55 yo F

• RA, HTN, fibromyalgia

• Nicotine

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New Implant Materials

Stainless Steel

Titanium Composite Materials

Stainless Steel

Why Carbon Fiber?Modulus of Elasticity

0

20

40

60

80

100

120

140

160

180

200

25

75

100

200

Cortical Bone Piccolo Composite™ (CFR‐PEEK)

Titanium( Ti‐6Al‐4v)

Stainless Steel  (Steel 316)

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> 1,000,000 cycles without failure

Why Carbon Fiber?Modulus of Elasticity

38yo F. Bilateral Femur

Bilateral Retro nailsBilateral knee extension block

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R bucket handle tearMeniscus in notch

L Bucket Handle TearMeniscus in notch

48yo F, Fall stairs

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2mos 6mos

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80 yo F, 100pack year nicotinePrevious proximal tibia (note backward plate)

New fall and fracture

Proximal Humeral Plate on medial femur

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73yo F. Visiting Family. GLFSurgeon error: No CT in osteopenic bone

Distal fibular plate medial + Poller screw. Then nail.

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New Problems

• Severe osteopenia

• TKA without sufficient bone for fixation

• Geriatric rehabilitation/deconditioning

Strauss and Ziran, OTA October, 2006

• Case

• 90yo F poly trauma

• L SC femur/shaft

• R tib plateau

• Open distal radius

Initial DCO

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Left

Left

Right

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Right

3 mos

WHY?Treat the patient, not the xray

• Immediate Arthroplasty• Each surgery ~ 2-3 hours

• Able to fully weight bear immediately

• Walked into office at 6 wks using a walker

• Risk of failure in her lifetime = low

• Cost ~ $20k (15K inpatient, 5k outpatient)

• ORIF• Surgery time ~ 2-3 hours

• Unable to weight bear for 3 months

• Deconditioning would cause permanent function loss

• Risk of failure = high

• Cost ~ $20K (10K inpatient, 10K outpatient)

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Thank You

Open Grade III

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Open Grade III

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Surgical Approach: Lateral

Surgical Approach: Lateral

Hoffa Fracture

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Peri-prosthetic

Yes No

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History

• “Those who don't know history are destined to repeat it”

• Edmund Burke 1729

• “Those who cannot remember the past are condemned to repeat it”

• George Santayana 1863

Insanity

• “Doing the same thing over and over again and expecting a different result”• Albert Einstein

Surgical Approach: Anterolateral

• Like TKA but lateral

• Controlled exposure

• View=superior

• Allows use of two plates 90 degrees to each other (similar to distal humerus)

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Key Tips

• Expose only enough for articular reduction• No medial dissection outside of capsule• Address bone defects from lateral• Ensure appropriate alignment• Use of graft as needed