Bicondylar fractures – plating
Jan Erik Madsen
Orthopaedic Department OUS, Ullevål
This course is about....
Respecting the soft tissues
Reducing the fracture
Stabilizing it with the appropriate method
how I see it....
Frames and plates are not competing methods, but complementary tools
how I see it....
Frames and plates are not competing methods, but complementary tools
Select on the basis of fracture patterns and soft tissue status
Restoring function by reestablishing mechanical axis, joint stability and joint congruity is best performed by anatomic reduction of the joint in most complex fx patterns
how I see it....
Objectives - plating
Initial treatment
What are the problems?
Soft tissue and fracture analysis
Tips, tricks and pitfalls
Plating – what do we know?
The tibial fracture is a soft tissue
injury with a broken bone inside…
n=83 C-type fractures (11 open)
12/ 83 compartment syndromes (14.5%)
n= 356
Compartment syndrome in 9% (31/ 356)
0/ 166 in B- fxs
24/ 117 (21%) non- B types
CS related to bicondylar type fxs
Initial fracture treatment – high energy injuries
Bridging exfix – pull out to
length and avoid zone of injury
Monitor for compartment syndrome
CT
Surgery after soft tissues have settled (6-20 days)
Plating – what do we know?
High infection rates (up to 80%) in older litterature
n=655
5.3% deep infections (all plated fxs included)
n= 83
8.4% deep infections, 1 nonunion
22 pts reoperated, mostly hardware removals
11 open fxs (9 type III) and 12 CS
Risk factors?
n= 302
63% smokers, 7% diabetics
17% open fxs, 8% CS
17.5 days to final fixation
14% deep infections
Risk factors?
Risk factors (OR 2.4- 3.8) were
Smoking
CS
Open fxs
No of plates ≥2
n= 41, age mean 46, FU 59 months
MFA score 26 (1-62 points) (normative 9.3)
17 joints reduced within 2 mm step or gap
Improved MFA scores with improved radiology
Fracture analysis
Column classifications
Case
Male 33
Rodel off track, hit a tree
Single injury
Open fracture with 1.5 cm wound anteromedially
NV intact
• Day 1:
• Wound revision and closure
• Exfix
• Compartment pressure monitoring
• Final treatment?
• Soft tissues/ timing
• Approach(es)
• Modes of reduction
• Choice of fixation
ORIF on day 11:
1. Posteromedial approach prone
2. Medial and lateral approaches supine
Tricks and pitfalls
Be patient - wait for soft tissues to settle!
If they don’t – use a frame
Tricks and pitfalls
Combined approaches?
Can I fix that fx through one approach??
Consider reduction maneuvres and implant placements
Drape both legs to avoid malalignment
Tricks and pitfalls
Tricks and pitfalls
Stay away from the anterior midline – and keep your medial and lateral incisions well apart
From Raykovev et al 2014
Tricks and pitfalls
Start out by building a B- type fracture
Tricks and pitfalls
Use low- profile implants
Tricks and pitfalls
Posteromedial approach is easier prone
From: Weil et al, JOT 2008
From: Bhattacharrya et al, JOT 2005
Tricks and pitfalls
Work horses should be posteromedial, direct medial and direct lateral
To sum up...
Initial tx - span, scan & plan - and monitor for CS
Preop planning needs to address soft tissues/
timing, approaches, modes of reduction and implant placement
Use the 3(4) column classifications to plan your case
Plates and frames should be considered complementary fixation options
Bad soft tissues may favor a frame
Bad fracture configurations may favor plates
Tricks and pitfalls
Wait for soft tissues to settle
Wash and drape both legs
Dont ever use an extensile anterior approach
Keep distance between incisions anteriorly
Start out by building a B- type fracture
Use slim, low- profile implants
Posteromedial approach is easier prone
Work horses should be posteromedial, direct medial and direct lateral
