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Distal Femur Fracture ORIF with Single Lateral Plate

Planning

B

Preoperative Plan

1

Template fracture reductions

  • draw key fragments of fracture and plan forces required to obtain reductions
  • obtain order of reduction for fracture fragments
  • identify the main articular fragment
  • identify fracture pattern and method of plate fixation
  • for simple metaphyseal fracture pattern
  • anatomic reduction and interfragmentary compression is performed using a neutralization plate with 4 cortices above the fracture with tensioning of the plate
  • for multifragemted metadiaphyseal extension type fractures
  • the plate should be much longer
  • the plate should be two to three times the length of the fragmented section
  • 50% of the holes in the shaft component of the plate should be filled
  • apply as many screws as possible in the distal fragment to achieve stability

2

Template instrumentation

  • template size of instrumentation

3

Execute surgical walkthrough

  • resident can describe key steps of the operation verbally to attending prior to beginning of case.
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • periarticular clamps
  • K wires
  • cancellous or cortical screws
  • locking femoral condylar plate

2

Room setup and equipment

  • radiolucent flat top table
  • c-arm fluoroscopy

3

Patient positioning

  • place patient supine
  • place a sterile bump or triangle under the knee

Technique

D

Midline Approach with an Extended Lateral Parapatellar Arthrotomy

1

Mark out the incision

  • mark incision directly anterior starting 5 cm proximal to the superior pole of the patella

2

Make the skin incision

3

Develop the lateral skin flap

4

Perform arthrotomy

  • be sure that there is a cuff of tissue on the lateral aspect of the patella as well as medially for the quadriceps

5

Expose the condyles

  • sublux the patella medially or invert the patella during knee flexion

6

Perform periosteal elevation of the capsule off of the lateral condyle to prepare for the plate

  • be sure to preserve the lateral collateral ligament
  • the dissection should be limited to the anterior 2/3 of the lateral condyle
E

Reduction of the Articular Surfaces and Definitive Fixation of the Condyles

1

Evaluate the joint line

  • determine the amount of articular comminution present
  • assess each condyle for smaller fragments

2

Reduce the fracture fragments

  • use large pointed reduction forceps to reduce the fragments
  • assess each reduction under direct visualization at the trochlear region of the patellofemoral joint

3

Place temporary fixation

  • place temporary K wires of guide pins for locking screws for provisional fixation

4

Place definitive fixation

  • place screws in the periphery to avoid any interference with the plate placement itself
  • if this is not possible, place screws from medial to lateral to avoid interference of plate placement
F

Reduction of the Shaft to the Distal Segment

1

Reduce the fracture with K wires

  • place bumps under the leg to reduce extension of the distal segment to align it with the shaft of the femur
  • if temporary external fixation has been placed, it should be loosened to aid in the reduction

2

Provisionally fix the distal segment to the shaft

  • use K wires or steinmann pins for provisional fixation
G

Placement of the Plate

1

Place K wires

  • all fixed angle plate systems are designed to restore valgus alignment of the distal femur
  • place the guidewires for the screws in the distal portion of the plate parallel to the joint line
  • placement of these screws in a parallel fashion ensures that when the shaft is brought to the plate, the anatomic axis of the femur will be restored

2

Insert the plate in a submuscular fashion

  • in order to place the plate, drive the guidewires to the medial side of the knee
  • place the plate submuscularly
  • drive the guidewires back through the plate laterally
  • align the plate to the distal segment and confirm that the screw trajectory is parallel to the joint

3

Confirm the placement of the plate proximally with fluoroscopy

4

Stabilize the plate to the bone distally

  • place a guidewire in the center hole of the distal aspect of the plate

5

Confirm placement of the plate

  • use lateral fluoroscopic imaging to confirm the anterior and posterior placement of the plate

6

Stabilize the plate to the bone proximally

  • if no screw targeting guide is present, a percutaneous provisional fixation pin can be used to stabilize the plate

7

Check reduction

  • check the flexion-extension reduction using fluoroscopy
H

Screw placement

1

Place screws

  • use partially threaded or overdrilled fully threaded screws through the plate to provide interfragmentary compression
  • once the articular surface is reduced, place two locking screws to secure the plate and the alignment

2

Evaluate the intercondylar notch

  • use the notch view to ensure that penetration through the intercondylar notch did not occur
I

Attaching the Distal Segment to the Shaft and Placement of the Additional Screws

1

Assess placement of the plate

  • before placing the locking screws check the length, rotation and the alignment through fluoroscopy
  • the plate can be locked to the distal segment and then used to manipulate the distal segment relative to the shaft for flexion-extension reduction

2

Place additional screws proximally

  • place additional screws percutaneously using freehand under fluoroscopic guidance
  • if there is a targeting guide, place locking screws percutaneously

3

Check the final construct with lateral radiographs

J

Wound Closure

1

Irrigation, hemostasis, and drain

  • copiously irrigate the wound
  • irrigate until backflow is clear
  • cauterize peripheral bleeding vessels

2

Deep closure

  • close the arthrotomy with figure of eight 0 vicryl sutures
  • reinforce with fiberwire suture

3

Superficial closure

  • subcutaneous with 2-0 vicryl and skin closure with 3-0 vicryl and suture or staples

4

Dressings

  • soft incision dressings over the distal femur

Patient Care

K

Preoperative H & P

1

Performs focused orthopaedic exam

  • check for ipsilateral femoral neck fracture
  • check thigh compartments (anterior, posterior, adductor)

2

Appropriately orders basic imaging studies

  • order biplanar radiographs of the knee and femur shaft

3

Perform operative consent

  • describe complications of surgery including
  • neurovascular injury
  • infection
  • delayed union
  • nonunion
  • infection
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • advance diet as tolerated
  • pain control
  • prescribe appropriate DVT prophylaxis
  • wound management
  • remove dressings POD2
  • foley out when ambulating
  • check appropriate labs
  • antibiotics

2

Check radiographs in postop

  • check placement of implants

3

Initiate physical therapy on POD 1

4

Appropriate medical management and medical consultation

5

Discharges patient appropriately

  • pain meds
  • outpatient physical therapy
  • schedule 2 week follow up
M

Intermediate Evaluation and Management

1

Obtains focused history and performs focused exam

  • document distal neurovascular status
  • concomitant and associated orthopaedic injuries

2

Interpret basic imaging studies

  • biplanar films of the knee and the shaft of the femur

3

Prescribes nonoperative management

  • skeletal traction
  • cast bracing
  • knee immobilizer
  • long leg casting

4

Make informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • continue physical therapy and range of motion exercises
  • discontinue DVT prophylaxis
  • wound check
  • repeat radiographs of femur
  • staples/sutures removed
  • diagnose and management of early complications
  • start toe partial weight-bearing at 8 weeks and continue for 4-6 weeks
  • postop: ~ 3 month postoperative visit
  • repeat radiographs of the femur
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
N

Advanced Evaluation and Management

1

Prioritizes the needs of the polytrauma patient

  • works with consulting

2

Complex wound management and debridement

  • understanding need for consultation for flap coverage

3

Capable of treating complications both intraoperatively and post-operatively

  • manages post operative infection
O

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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