2016 Annual Meeting

Instructional Course
Lecture Handout

Course Number: 250

Course Title: Femur Fractures: Subtrochanteric to Supracondylar
Location: Room W307C
Date & Start Time: Mar 2 2016 1:30 PM

INSTRUCTORS WHO CONTRIBUTED TO THIS HANDOUT:

Robert F Ostrum, MD
Paul Tornetta III, MD
Philip R Wolinsky, MD

Femur Fractures: Subtrochanteric to Supracondylar

AAOS 2016
ICL 250
March 2, 2016
1:30-3:30

Robert F. Ostrum, M.D.
University of North Carolina Chapel Hill

Paul Tornetta, M.D.
Boston University Medical Center

Philip Wolinsky, M.D.
University of California Davis


5 minutes

Introduction



20 minutes
Subtrochanteric Fractures

20 minutes
Femoral Shaft Fractures

20 minutes
Supracondylar Fractures

10 minute break

15 minutes
Case Presentation


15 minutes
Case Presentations


15 minutes
Case Presentations/Adjourn

Robert F. Ostrum, M.D.

Robert F. Ostrum, M.D.
Philip Wolinsky, M.D.
Paul Tornetta, M.D.

Paul Tornetta, M.D.

Philip Wolinsky, M.D.
Robert F. Ostrum, M.D.

AAOS Femoral shaft fractures: Subtrochanteric to Supracondylar

ICL 250
IM Nailing of Subtrochanteric femur Fractures
Robert F. Ostrum, M.D.
University of North Carolina Chapel Hill

High compression/tension stress area with cantilever bend

Deformity: flexion, external rotation, and abduction of the small proximal

fragment making IM nailing difficult

Evaluation of fracture

Surgical Planning

Implant Choices

o Piriformis fossa
o Greater trochanter
o Lesser trochanter
o Supine
o Lateral
o Fracture Table
o Piriformis Nail
o Trochanteric Nail

Problems

Incorrect starting point

Lack of reduction while reaming

Poor trajectory of guide rod

IM nail with deformity

Wrong

Right

For IM nailing:
Reduction during reaming and the correct starting point are the keys to
optimal results
Operative tricks
Use instruments, clamps to reduce flexion and abduction
deformities prior to reaming
Start piriformis foss nail in line with shaft, guide pin NOT
pointing towards the lesser trochanter
The trochanteric insertion site should be just MEDIAL to the
tip of the trochanter
Skin incision for IM nailing is NOT at the tip of the trochanter
but rather 5-8 cms proximal and in line with the shaft
MUST have a way to assess LENGTH and ROTATION

References
1. Starr AJ, Hay MT, Reinert CM, Borer DS, Christensen KC.
Cephalomedullary nails in the treatment of high-energy proximal femur
fractures in young patients: a prospective, randomized comparison of
trochanteric versus piriformis fossa entry portal. J Orthop Trauma. 2006
Apr;20(4):240-6.
2. Perez EA, Jahangir AA, Mashru RP, Russell TA. Is there a gluteus
medius tendon injury during reaming through a modified medial trochanteric
portal? A cadaver study J Orthop Trauma. 2007 Oct;21(9):617-20.
3. Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the
eccentric starting point for trochanteric intramedullary femoral nailing.
J Orthop Trauma. 2005 Nov-Dec;19(10):681-6.
4. French BG, Tornetta P 3rd. Use of an interlocked cephalomedullary nail
for subtrochanteric fracture stabilization. Clin Orthop Relat Res. 1998
Mar;(348):95-100.
5. McConnell T, Tornetta P 3rd, Benson E, Manuel J.
Gluteus medius tendon injury during reaming for gamma nail insertion. Clin
Orthop Relat Res. 2003 Feb;(407):199-202.
6. Streubel PN, Wong AH, Ricci WM, Gardner MJ.
Is there a standard trochanteric entry site for nailing of subtrochanteric femur
fractures. J Orthop Trauma. 2011 Apr;25(4):202-7.

Diaphyseal Femur Fractures

Philip Wolinsky / University of California at Davis Medical Center

Anatomy
Tubular bone, anterior bow, flare at condyles

Femoral Diaphysis Blood Supply

Inner 2/3 of the cortex- Nutrient arteries
Outer 1/3 of the cortex- Periosteal vessels derived from the soft tissue
Cortical circulation is centrifugal
Predominant direction of blood flow is from the medullary canal
towards the outer cortex
Fractures disrupt the medullary blood supply
Leads to necrosis of 50%-70% of the cortical bone near the fracture
Following fractures, net cortical blood flow is centripetal (out to in)
A reversal from the normal state
Takes about 2 weeks

Fracture healing is dependent on re-establishment of blood flow to
disrupted cortical bone

Re-vascularization can be:
Endosteal/ Periosteal/Extraosseus flow derived from the
surrounding soft tissues
Particularly important for callus and detached fracture
fragments blood supply

Classification

AO Classification: 32
Winquist- Hansen Classification
Grade 0: no comminution
Grade 1: small butterfly
Grade 2: butterfly less than 50% of the diameter of the bone
Grade 3: butterfly >50%
Grade 4: segmental comminution
Grade 5: segmental bone defect


Initial Evaluation
Marker of energy transfer
ATLS
Good 2ndary/tertiary survey
Image joint above and joint below
Knee exam
Femoral neck

Blood Loss
1-3 units per femur
Never blame hypotension/ large hct drop on the femur shaft fracture
without working up the other potential sites of blood loss
External/ Chest/ Abdomen/ Pelvis

Ipsilateral Femoral Neck/ Shaft Fractures

2.5-5% of femoral shaft fractures
Vertically oriented fractures
Often minimally displaced
Preop x-rays, preop CT, C arm, post op x-rays

Injury AP Pelvis Challenge
Optimal view of neck is 15 degrees of IR
On the trauma AP pelvis the proximal femur is usually in ER

CT Scans
Lower cuts on the abdominal-pelvic CT include the femoral neck

Methods of Fixation
Many, many, many described in the literature
Depends on whether the femoral neck fracture is detected prior to or
after fixation of the femoral shaft fracture
Current recs: use 2 separate devices for reduction and stabilization of
each fracture individually

FN: Nonunion/ AVN
Predictors of success:
Less displacment

No postero-medial comminution
Anatomic reduction
Stable fixation

Fixation Options
1) Shaft: retrograde nail / Neck sliding hip screw and/ or cannulated
screws
2) Femoral shaft plate/ Neck: sliding hip screw and/ or cannulated
screws
3) Shaft: IMN/Neck: screws placed anterior to the nail
Useful: when neck fx is found after IMN
4) Shaft and neck:
Cephalomedullary nails
Stabilizes both fractures
Difficult to reduce/hold 2 deductions at one and stabilize two
fractures at the same time

Femoral Shaft Fracture Management

Management Options
Cast: not for anyone older than ???4-6ish
Traction- temporizing only
External fixation- temporizing only
IMN
Plating using MIPPO techniques

Traction
Initial treatment
Decreases pain
Decreases ongoing soft tissue damage
Traction pin
Evaluate the knee prior to pin placement
Knee effusion??

External Fixation
Use for definitive fixation is associated with multiple problems:
Knee stiffness
Malunion, nonunion
Pin site infection/ osteomyelitis

Due to the large amount of muscle surrounding the thigh

Temporary Ex Fix Indications
DCO: a bridge to a nail for a sick patient or a sick limb
Initial rx type IIIB and IIIC, or grossly contaminated fractures
Initial rx for fractures with vascular injuries and long ischemia time
Infected fractures

Intramedullary Fixation

IMN Choices
Antegrade/ Retrograde
GT vs PS starting point
Reamed/ Unreamed
Fracture table/ Radiolucent Table
Supine/ Lateral

Fx Table or Radiolucent Table Choice
Can be placed with or without a fracture table/ Both Work
No fracture table:
Quicker
No difference in post op alignment
Less table changes/ preps and drapes to address multiple
fractures
beneficial especially for the treatment of multiply injured patients.

Radiolucent table:
Quicker
No difference in post op alignment
Less table changes/ preps and drapes to address multiple
fractures
Fracture table
Holds the reduction
Less assistants

Fracture Table Issues
Pudendal, femoral, and sciatic nerve palsies
Perineal skin sloughs
Well leg compartment syndrome

Block access to rest of leg/ other leg

More difficult for PF starting point in obese patients

Supine or Lateral/ Patient Positioning
Both work, depends on your comfort and the fracture patterns

Starting Sites: Where and When Is There a Difference in Outcomes
Starting Sites: They all Work

Antegrade
Piriformis
Trochanteric
Retrograde

I have no idea what starting point is the current gold standard or if
there even is one

Base it on the fracture patterns and what you are comfortable with
Each has advantageous and disadvantageous

Antegrade Start Points
Disadvantageous:

Hip abductor/ rotator muscle (PF) or tendon (GT) damage-

Trendelenburg gait
Hip pain
More difficult for obese (GT easier) or multiply injured patients
(bumped up)
More proximal starting points make it easier to find the PF/GT
and be in line with it
Start at the level of the iliac crest
Need special long guides
Easy to loose the starting hole when switching from the rigid
reamer to the guide wire

PF Antegrade Reamed Nails
Union rate between 95 and 99%
Infection rates < 1% (closed fractures)
Malunion rate <3% (if you know what you are doing)
Good return of hip and knee motion/ function


Piriformis Fossa Start
Co-linear with shaft/ Posterior
Advantage: In line with the axis of the femoral canal
PF Disadvantage: Anterior displacement by more than 6 mm causes
high hoop stresses that can cause bursting of the femoral cortex
Lateral or medial displacement does not have as great an effect

Lateral Trochanteric Entry
Obese & muscular patients :
Faster
Less radiation
Troch Nail Insertion for Femoral Shaft Fractures
Nail designed for troch insertion: Proximal lateral bend
Prospective trial/ 61 consecutive patients
46 patients with f/u of 12 months (12-25)
45/46 healed after 1 operation
No angular mal-unions (>10 degrees)

GT Start/ Femoral Shaft Fractures: Troch Nail Starting Point
5 different nails
3 different troch starting points:
Tip of the GT
2-3 mm medial
2-3 mm lateral
Subtroch reverse oblique osteotomy
21 cadaveric bones

The tip was the best starting point:
Best alignment regardless of the nail used
Lateral start was the worst
Always led to varus and gapping of the lateral cortex
Conclusions:
Start at the tip or just medial to it
Avoid a lateral start point
Dont ream out the lateral cortex

Retrograde Femoral Nailing Starting point
Just anterior to the ACL

Junction of the anterior portion of the intercondylar notch and inferior

posterior part of the patella femoral joint at Blumensaats line
Collinear with the canal on both views

Proximal Locks
Inserted anterior to posterior

At or proximal to the lesser trochanter
Cadaver study showed this places the fewest nerve and vascular
structures at risk
Suture the screw to the screwdriver or use a screwdriver that captures
the screw
Easy to loose the screw in a large thigh

Retrograde Nails
Place the nail at least flush with the articular surface
Patella femoral pressures increase with even 1 mm of nail prominence

Technique Retrograde IMN
Supine position
Radiolucent table
Bump under distal thigh:
Relaxes gastroc/ reduces fracture
Access to starting point

Incision options
Percutaneous:
Through the tendon: No increase in knee pain compared to
Para-patella
Open:
To address intra-articular fractures

Potential complications are associated with the intra-articular
entry point
Never really shown up
Damage to the articular surface
? long term effects with OA
knee stiffness
Infection- the knee joint now communicates with the femoral shaft

fracture
Worry with open fractures

Damage to the ACL during insertion

Indications for Retrograde IMN
1) Multiple Injuries
No need for a fracture table/ or bumps
Can prep and drape all four extremities at the same time
Access to chest and abdomen not blocked
2) Ipsilateral Femoral Neck/ Shaft Fractures
Treat each fracture with a separate device
3) Obese Patients
Very, very difficult to get an antegrade starting hole
4) Floating Knee
Same incision fir the tibial and femoral nails
5) Pre-existing Hardware
Antegrade starting site is blocked
THR, prior hip fractures, etc
6) Peri-prosthetic Fractures TKA
The prosthesis has to have a box in it
Make sure you know if its there/ the diameter of it/ an if it is in line
with the canal
7) Knee Arthrotomy
Incision is already there
Contraindicated with gross contamination because the wound will
now communicate with the fracture site
8) Ipsilateral acetabulum fractures that require ORIF
Keep away from the area of future incisions
9) Pregnancy
??? Decreases fetal radiation exposure????
10) Through knee amputations
Looking at the starting point
11) Contamination of the antegrade starting hole locations (burns, open
wounds, etc)

12) Unstable spine injuries
Patient is supine on the table without the need for any bumps

Results of Retrograde Femoral Nails vs Antegrade IMNs

Does the Femur Really Know/ Care Which Way the Nail Goes In?
Union rates equivalent to antegrade nails when using a canal filling
implant

Ostrum et al JOT 14(7), 2000:496-501
Ricci et al JOT 15(3), 2001: 161-169

Intermediate ( 5-7 year) and short term knee results show no adverse
effects if the nail is countersunk below the articular surface


Interlocking Screws
Into the LT (Not the Head/ Neck)
When the LT is still attached to the proximal piece
Easier- dont need to image the neck and head

Into the Neck/ Head
When the fracture line extends into or above the LT
Need to image the head and neck

Distal Locks
The distal femur is a trapeziod
Dont leave the screws long
To avoid penetration of the medial cortex and irritation of the MCL
screws must be 8-10 mm short of the projected image of the
medial wall
Oblique views



Acute Fx: Always Statically Lock
Locked on both sides of fracture
Controls length & rotation

Brumback:
10% failure rate for fractures judged to be stable
98% union rate for statically locked nails

In The OR- EVERY TIME

Before you leave- always check:
1. Femoral Neck
2. Length
3. Rotation
4. Alignment
5. Knee Exam do exam under anesthesia
6. Hardware!

Full Weight Bearing Post Op
Post OP WB: Brumback et al
Clinical part of their study:
Large diameter (12 mm) nail/ 2 distal locks placed
22/23 comminuted fractures that were immediate WBAT healed

Biomechanics part of the study:
2 distal locks were shown to be stronger than 1
Cycled 500,000 times without failure
3 times the body weight of a 70 kg person
10 weeks walking 5 miles/ day, 7 days a week

Determining Length and Rotation for Comminuted Fractures
No cortex(s) to line up
Before you prep and drape:
Know what length nail you are going to use
Know how to determine what the correct rotation is
Use the good leg

Length:
Nail in the Box
Ruler

Rotational Malalignment after IMN of Femur Fractures
67 patients
Fracture table/ antegrade nail
CT scan post op
21 patients (28%) were off by 15 degrees or more
12 (16%) were off by >=20 degrees
Torsional differences of < 10 are normal

10-14 is a grey area

Rotation: Clinical Assessment
Test hip IR and ER on the intact side prior to prepping and draping
When the locks are in one end of the nail and one drill bit I in the other
(rotationally stable but not committed)
Test hip ER and IR to see if its close to the other side

Rotation X-ray Method
Perfect AP of the Knee

Slide up to the hip and get an AP
Look at the shape of the GT and LT

Femoral Shaft Fracture Plating

Older Plating Techniques
Extensile exposures - open, direct reduction
Tends not to work out weel

MIPPO ORIF Techniques
More protective of biology

Some ORIF Indications
1) Femoral shaft with extension
Subtrochanteric
Supracondylar
2) Neck and shaft Fxs
3) Open fractures
4) Vascular injury requiring repair
5) Peri-prosthetic fxs
6) Preexisting malunion
7) Skeletally immature patients with comminuted fxs
8) Abnormal anatomy
No canal
Too narrow
Too bowed
Previous malunion
TKA, THA
9) Significant soft tissue injury/infection at insertion portals


Reamed vs Unreamed Nails

Reaming: Advantages?
Larger diameter nail
WBAT on 12mm nails
Increased contact area between IMN and endosteal bone
Temporary endosteal perfusion injury with hyperemic periosteal
response
Autogenous bone-grafting

The Lung and Reaming
Reaming Femoral Shaft Fx
Thoracic injury determines the pulmonary complications!!!
In a resuscitated patient
Notthe Use Of A Reamed IM Nail
Charash J Trauma 1994
Van Os J Trauma 1994
Ziran J Trauma 1997
Bone Clin Orthop 1998
Bosse JBJS 79A 1997

Prospective , randomized, multi-center trial
322 fractures:
Divided based on ISS < > 18
Then randomized to either reamed (171 fxs) or unreamed IMN
(151 fxs)
All were nailed within 24 hours of injury
Unreamed group:
2/46 ARDS
P=.42 (not sig)
2 deaths
Reamed group:
3/63 ARDS
2 deaths
Need 39,817 patients in each group to detect a difference between
reamed and unreamed nails

Canadian Orthopedic Trauma Society JBJS 2003

Higher Union Rate:

Reamed: 98.3%
Unreamed: 92.5%

Reamed vs Unreamed Nails
Meta-analysis of femur and tibia trials
9 acceptable trials, 646 patients
One nonunion can be prevented for every 14 patients treated with a
reamed nail
Absolute risk reduction of 7%

Effective/ Safe Reaming
Sharp, deep flutes
Full speed
Advance/withdraw slowly
Start with small reamer head
No tourniquet

Summary
Reamed IM Nailing Gold Standard
Start point/ position/ table
Depends on Fx
Depends on Pt
Depends on Surgeon
Statically Lock = All Fxs
WBAT Femoral Shaft Fx Rxd w/ IM Nail

1/2/16

Supracondylar fxs:
Nail vs Plate
Paul Tornetta III
Professor
Boston Medical Center

Boston Medical Center

Disclosures!
Publications:

Rockwood and Green, Tornetta and Ricci TIFS, Tornetta and Einhorn;
Subspecialty series, Court-Brown, Tornetta; Trauma, AAOS; OKU
Trauma, ICL Trauma, Tornetta; Op Techn in Ortho Surg, OTA Slide
project;Journals:; JOT; Deputy editor, CORR, JAAOS, JBJS; Reviewer

Research and Trial Support:

OTA, FOT, AIOD, NIH, DOD

Intellectual Property

Smith and Nephew, Exactech

What to Choose?

A vs B vs C

A: extraarticular

B: partial articular

B: partial articular

Intact

portion of joint to
stabilize to

C: extraarticular with
intraarticular extension

A vs B vs C
A: extraarticular
B: partial articular
Intact

portion of joint to
stabilize to

C: extraarticular with
intraarticular extension

A vs B vs C

A: extraarticular

Principles
Restore

Intact

portion of joint to
stabilize to

C: extraarticular with
intraarticular extension

Principles
Restore

Length

Length

Alignment

Alignment

Angular

Angular

Rotational

Rotational

Shaft is the stable portion

Shaft is the stable portion

1/2/16

A Fractures

A Fractures

A Fractures

Options

Options

Options

Nail

Nail

Nail

Enough

room for
locking screws

Plate

Enough

room for
locking screws

Plate

Fixed

angle

room for
locking screws

Plate

Fixed

B Fractures

Enough

angle

B Fracture

Fixed

angle

Percutaneous ORIF

Shear fractures
Stabilize
To

the rest of the joint

the shaft
Lag screws
Buttress
Antiglide
To

B Fracture

C Fractures
Combination of A and B
Principles:
Restore

joint . C A

Stabilize

the metaphysis to the

shaft
Complexity

of joint determines
options for stabilization

Simple Joint Injury

Lag screws for the joint
Metaphysis
Nail
Plate

Fixed angle

1/2/16

Supracondylar Fractures
Short IM nails (GSH type)
Compared to fixed angle:
Equal

to varus load

to bending and torsion

Failure mode: shaft fracture

through proximal screw hole

Indications

IM Nails
Advantages
Midline

Disadvantages

incision

Indirect reduction
Minimal stripping
Blood loss
Reaming

IM Nails

distributes bone graft

Intraarticular
Large

Locking

screws may be through

coronal fracture lines

Stress
Metaphyseal

comminution irrelevant

starting point

intercondylar portal ?

riser through unfilled

holes

26 Year Old MVA

S/P Nailing

Lag Screws + Nail

Final

Metaphyseal injuries > 4 cm

from notch (type A)
Minimal intraarticular extension
Large condylar fragments that
can be fixed with lag screws
(C1)

Grade 3 Open C2 Fx

1/2/16

Nonunion.BG

Technique
Midline incision
Poke

hole vs arthrotomy

Reduce and lag intercondylar

fracture first
Indirect reduction of the
metaphysis

Technique
Radiolucent table
Bolster
Distractor ?
Portal
Direct up shaft on AP and lat
Over-ream 1.5 mm
Lock at lesser trochanter

Incision

Free Medial Side

Arthrotomy

Portal Location

Canal Location

Nail Curvature

ch
Tro

Blu

men

ov
Gro
lear

stat

1/2/16

Portal Location

Portal Location
Even 1 mm
Proud is Bad!!

AP View

AP View

Flexion Arc

Avg arc 17
34 - 51

AP View
Physiologic
Valgus

Starter Reamer

Distally Lock

Check Length

1/2/16

Proximal Locking

Example

Nailed.. Too High!!

Level of the lesser trochanter

Safest level
Nerves
Artery

cross

1 cm medial

Just at the piriformis

Blocking Screws

Watch Sagital Alignment

Blocking Reduction!

Results

Finals

Lucas 1993
25

Fractures (9 open)
A (6), type C (19)
6 Acute bone grafts
Avg. ROM > 100
Type

6 Required manipulation
1

Short, 1 12 varus
Late intraarticular infection
Two iatrogenic fractures
1

1/2/16

Results

Fractures Above TKA

Iannacone 1994
41

Fractures (22 open)

A (19), type C (22)
80% Union by 4 months
Delayed / non union due to injury
Nail failure (6.4 screws in 11mm nail)
87% > 90 Motion
All < 5 VV and < 10 AP angulation
Type

Technique

Incidence 0.5% - 2.0%

Fractures Above TKA

Requires 12 mm intercondylar
region

Bone quality
Distal femoral notching
Arthrofibrosis

Contraindicated if closed
intercondylar box

74 Year Old Woman

Treatment

Plates

Old Plate Case

Midline incision
Slightly

larger than standard

Obtain reduction
Ream 1.5 mm over nail size
Statically lock
Postop early motion

Results
Union in > 90%

Indications
Complex

Time to union < 12 weeks

Below
Low

Motion compared with

preinjury

Intraarticular

THA

A type fractures

Bowed
Distal

femora

1/3 fractures

1/2/16

Deformity

Intraarticular Fragment

Articular Reduction

Articular Reduction

Planned Axis

95

AP VIEW

Affix to Screw

LATERAL VIEW

Reduction

Fluoro

1/2/16

Fluoro

Affix Plate to Bone

Affix Plate to Bone

Incisions

2 Weeks

2 Weeks

1/2/16

6 Weeks

4 Months

Complex Joint Injury

Joint has comminution
Posterior fragments
Will not accept nail
Hoop

stresses

Poor

fixation of the locking

screws

Complex Joint Injury

Plate is treatment of
choice
Fix joint (screws)
Connect to shaft
Fixed angle!!
Prevents

varus collapse

Problems
Locked plates:
Fixed

angle periarticular
segments

Indirect

reductions

Biologically

friendly

Osteoporotic

bone

Different failure modes

Problems..
Locked plates:
Fixed

angle periarticular
segments

Indirect

reductions

Biologically

friendly

Osteoporotic

bone

Different failure modes

Old IdeasNew Tricks?

How can we improve?
Plate contours
Hole configuration
Screw direction
Reduction techniques
Instrumentation

Problems
Locked plates:
Fixed

angle periarticular
segments

Indirect

reductions

Biologically

friendly

Osteoporotic

bone

Different failure modes

When do we need them?

Periarticular fractures
With

metadiaphyseal
dissociation

Poor bone quality

Osteoporosis
Nonunions
Revision

surgery

10

1/2/16

Locked Plating

Incision

Deep Incision

Screws Around Plate

Lag Screw Position

Outrigger

Metadiaphyseal Reduction

Intraarticular fractures
Joint fixation
Outside

plate

Metadiaphyseal

reduction

Extraarticular fractures
Around knee implants

Visualization

Lag Screw Position

11

1/2/16

Instrumentation

Slide in Plate

Provisionally Fix

Simple
Keep angles correct
Appropriate guides
Limit pieces
Screw options

Place Fixation

Final Alignment

Healing is Good
Grade 3A fx at 10
weeks
Good principles
Indirect reduction

Worst Problems

Initial Treatment

Delayed Fixation

Grade 3 open

12

1/2/16

Delayed Grafting

Delayed Grafting

Lateral Postop

5 Months

Periprosthetic Fractures

Periprosthetic Fractures

Periprosthetic Fractures

Periprosthetic Fractures

Periprosthetic Fractures

13

1/2/16

Henderson, et al

Henderson, et al

12 Matched pairs
Not for reduction
Review 15 pubs, 3 abstracts

Plate vs nail

Healing complications 0% - 32%

More callus for nail in all areas

75% Failures > 3 months

50% Failures > 6 months

SOLVED

SOLVED

www.orthotraumaresearch.com

SOLVED

158 Patients

SMFA

Bother

EQ
Health

EQ
Index

Malalignment >5
22%

Nails

Nail

22.2

22.9

79.1

0.76

32%

Plates

Plate

26.8

28.5

72

0.70

p=

0.29

0.3

0.11

0.25

No difference
WB,

Alignment

SOLVED
114

6.2

2.8

2.4

Plate 111

3.7

2.81

2.7

0.63

0.57

0.71

0.33

p=

15% Flexion Contracture > 10

Alignment

Valgus > 5

Varus > 5

Nail

12%

10%

Plate

28%

4%

Flexion Extension Walking Stairs

Nail

ROM, revision, outcomes

Valgus > 5

Varus > 5

Nail

12%

10%

Plate

28%

4%

P = 0.05

14

1/2/16

SMFA

SOLVED

So Far
143 Patients (target 160)

45
40
35
30
25

75

Nails

68

Plates

Adverse events

20

52

15
10

Total

25%

20

3 Months

6 Months

12 Months

Alignment

for both nail and plate

Device related

Alignment

Valgus > 5

Varus > 5

Nail

9 (12%)

Plate

14 (20%)

1 (2%)

Adverse Events

Complications

Valgus > 5

Varus > 5

Nail

9 (12%)

Plate

14 (20%)

1 (2%)

Case Example

Nail

Plate

2 Nail
8 Screws
3

8 Plates
(3 out)
2

Nonunion

Infection

Arthrofibrosis

Painful Implant
Loose

Postop

5 DVT, 1 Death
20% Both groups
Revision
5%
8%

Nails
Plates

Hardware removal
15%
10%

Nails (90% screws)

Plates

15

1/2/16

3 Weeks

Nail!!!

Multitrauma..Open

14 Months, New Pain

CT

Intraop

Plate

Final

Summary
Nails
Metaphyseal
Long

comminution

shaft extension

Elderly

patients

Minimal

intraarticular extension

Large condylar fragments

16

1/2/16

Summary
Plates
Complex

joint injury

Lock distally
Flexible construct
Deformity
TKA

of shaft

with no box

Boston Medical Center

Boston Medical Center

17