Open Reduction and Biologic

Fixation with Traditional AO

Implants and Techniques
Special thanks to
AONA Lecture Archives
Mike Stover and Jack Wilber

AO Basic Principles Course

Indianapolis, IN
May 7 – 9, 2009
 Objectives

 Understand principles of Relative

Stability
 Understand principles of Biologic
Fixation
 Understand how to apply techniques
to achieve biologic fixation with
traditional implants
 AO Principles
 Anatomic reduction
 Mechanical axes, joint surfaces restored
 Maintain soft tissue hinges = indirect red’n
 Internal fixation
 Atraumatic soft tissue dissection, MIPO
 Stable Fixation: absolute or relative
 Early functional rehabilitation
 Protected weight bearing
 Traditional AO Implants
LCDCP DCS

Blade Plates

Tubular Plates

Buttress Plates
 Stability

$$$$$

ORIF

MIPPO
Biologic
RIMN
Cost
UIMN

EF
cast

$
Stability
relative absolute
 Biologic Fixation
Principle
 Fracture fixation giving priority to
Biology
biology over mechanics Stability
 Fracture fixation with appropriate level
of stability to optimize healing
 “Balanced fixation”
 Longer plates, screw dispersion
 Performed with minimal devitalization
 Biologic Fixation
 Fractures Multi fragment
 Soft tissues Damaged
 Location Meta/diaphyseal
 Exposure Limited
 Reduction Indirect - alignment
 Fixation Relative stability
 Healing Callus
 Biologic Fixation
Indications
 Complex multifrag fractures
 Compromised soft tissues
 Multiple injuries
 Compromised host
 Biologic Fixation Techniques

Exposure
 Limited
 Carefully planned
 Meticulously executed
 Respectful retraction
 No violation of the injury zone
Minimize further damage
 Biologic Fixation Techniques
Reduction
 Indirect
 Preserve vascularity
 Realignment
 Restore
 Length
 Axis
 Rotation
 Biologic Fixation Techniques

Fixation
 Bridge plating
 Long plates
 Balanced
fixation
 Minimize
contact
 Biologic Fixation Principles

Articular fractures still require anatomic

reduction and stable fixation
 Biologic Fixation

With traditional implants requires:

 Understanding of biologic principles
 Proficiency with indirect reduction
 Knowledge of anatomy
 Osseous
 Soft tissue
 Ability to pre contour plates
 Mechanics
3 areas of interest:
 Couple to the bone
fragments
 Fracture gap
 Material of the plate
 Data: Bone Couple
 Gotzen: Heftezur unfallheikunde 1983
 10 hole plate with 2 screws similar stability
to 8 hole with 4 screws
 Laurence: JBJS 51B 1998
 highest tensile load to any screw is < 1/2
needed to pull out of bone, so only need 4
screws in plate
 Tornkvist: JOT 1996
 more widely placed screws increased
fixation strength
 Data
 Stoffel: JOT 2004
 Oblique screw at end of plate
construct strength
 Robert: J Trauma 2003
 Isolated screw pullout  with
>20˚insertion angle
 Angled screw placement with plates
construct strength
 Reason: volume of bone between
screw and plate
 Data
 Stofel JOT 2004

 distance from
fracture site to
nearest screw 
strength
 Couple to Bone
 Screws: where, how many and
direction
 Dependent on plate length
 No more than 3
 Well spaced: close to fracture site, at
end of plate and one in between
 Last screw in either end placed
obliquely away from fracture
 Balanced in each fragment
 Data: Plate Length
 Tornquist JOT 1996
 Relative length of
plate > effect than
more screws
  elastic
deformation with
long plate, resists
bending better
 Torsional
resistance
dependent on
screws
 Plate Length
Most important variable
The longer the better
Dependent on length of
fracture site
 Provide Ample Screw Spread
Applying long plate on tension side
 Spreads axial load to furthest screws.
 Spreads force over larger area
 Decreases the load per unit length of
the plate
Failure of Fixation
Stress concentration – Too stable?
Complex End Segment Intra-
articular Fracture

Indirect reduction with DCS as bridging plate

 Plates
 All plates are acceptable based
on anatomical location
 Femur: broad 4.5m plate, blade,
DCS
 Tibia, humerus: narrow 4.5m,
 Forearm: 3.5 mm plates
 Clinical Relevance
 Long plates
 2 to 3 screws in each
fragment
 Oblique end screws
 Avoid screw close to fracture
- leave closest hole to
fracture empty
 Clinical Relevance
Plate Span Ratio
Length of plate (PL)/length of
fracture (FL)

PL
PL/FL =/> 6

Plate Screw FL
Density
Plate screws/plate holes X
100
= 50%
Rozbruch CORR 354 195-208, 1998
 Biological Fixation

Plate length
 8-10 times the A

length of a simple 8-10xA

one

Gautier, Sommer, Injury 2003, 34, S2

 Subtrochanteric Fracture
Kinast, Bolhofner, Mast, Ganz 1989

 introduced indirect reduction

technique
 importance of a “stable” construct
 no need for bone grafting
 union rate of 100% vs. 84% with anatomic
reduction
 Supracondylar Femur
Bolhofner: JOT 1996

 57 fractures treated by indirect reduction,

single plate
 35 intraarticular, 9 C3, 11 open
 Union and FWB at 10.7 wks.
 2 delayed unions healed without treatment
 84% good or excellent with > 100 degrees
motion
 5% < 90 degrees motion
7 YR OLD, CAR VS PED. ASSOC. HEAD INJURY
POST OP
 “Percutaneous Plating” or “Minimally
Invasive Plating Osteosynthesis”
MIPO
 Minimal stripping
 Smaller Incisions
 Preserve periosteal
 Traditional
blood supply implants can be used
 Longer
withplates
special techniques
fewer
screws (locking)
 Use biologic low
profile contoured
implants
 Blood Supply
Periosteal blood supply is preserved
 Blood Supply
A 70% improvement in medullary blood flow

MIPPO

CPO

Minimally Invasive Plate Osteosynthesis: Does Percutaneous Plating Disrupt Femoral

Blood Supply Less Than the Traditional Technique?
Farouk, Osama; Krettek, Christian*; Miclau, Theodore†; Schandelmaier, Peter; Guy, Pierre;
Tscherne, Harald JOT 1999
L.C. 98.03.04
L.C. 98.03.04
MIPO
 Conclusions
Biologic Fixation:
 Preserves biology
 Biology over stability
 Relative stability
 Longer implants, fewer screws,
 Alters healing
 callus
 Possible with traditional implants
 By application not design
 Special techniques
“Bone is a plant with its
roots in the soft tissues.
It often requires not the
technique of a cabinet
maker, but the care
of a gardener.”

Girdlestone, 1930