5/31/2018
Patella and Tibial Injuries
Paul Tornetta III, MD Professor BostonBoston Medical Medical Center
Disclosures
• Smith Nephew: IP • Wolters‐Kluwer: Royalties
Patella Fractures • Distal fractures
Keep or discard? • Comminuted fractures
Fixation strategy?
Classic tension band
New roles of plating
1 5/31/2018
Tibial Plateau • Unicondylar
Void filler?
• Bicondylar
Dual thin vs larger locked?
Prone approaches?
2 5/31/2018
Tibial Plateau • Unicondylar
Void filler?
• Bicondylar
Dual thin vs larger locked?
Prone approaches?
Plate Choice • Dual always an option • Large lateral locked
Large medial condyle Diaphyseal extension • Can’t be nailed! • Dual
Posteromedial fragments No long diaphyseal extension
Shaft • Closed
Proximal • Semiextended vs suprapatellar Distal • Plate fibula? • Open
Order of fixation and flaps Nail vs ex fix
3 5/31/2018
Position?
> 20°
4 5/31/2018
Semi-Extended
Fibula Plating?
• Malunions in distal fractures present IN the OR • Can help with reduction • NOT needed! • Might slow healing
5 5/31/2018
Fibula Plating?
Plafond • Fibular plating? • Trends
Multiple incisions
Smaller plates
Fragment specific
Posterior for special cases
Considerations • Anatomy of the fracture
Not all pilons are the same!
Individualized approach Posterior Anterior Medial • Condition of the skin
Open wounds
Swelling Staged fixation
6 5/31/2018
Approaches • Anterior variants
Antero‐medial
Direct anterior Antero‐lateral • Medial • Posterior Options
Postero‐lateral Postero‐medial
Anterior
Posterior
7 5/31/2018
Trends • Incisions
Different locations
Multiple • Staged approaches
Fibula frame tibia
Posterior anterior
8 5/31/2018
Multiple Incisions • Fasciocutaneous flaps!
Bipedicle = 1.5:1 survival • 7cm rule…silly
Shape, not distance! • Sliding plates
Smaller incisions
Mini‐incisions proximally
Multiple Incisions • Fasciocutaneous flaps!
Bipedicle = 1.5:1 survival • 7cm rule…silly
Shape, not distance! • Sliding plates
Smaller incisions
Mini‐incisions proximally
Combinations
9 5/31/2018
Staged Approaches • C‐Type • Posterior subluxation • No posterior support • Hard to get to the back • Rotated out • Short and tilted backwards
61 Year Old Male
Frame Then CT
10 5/31/2018
CT
Factors??
• Fragments? • Anterolateral? • Medial? • Posterior? • Amount of displacement • Direction of displacement
Approach
• Posterior
ORIF posterior malleolus
ORIF fibula
Concerned about getting the PM
Rotationally difficult!
BUT…can’t box out the front!!
11 5/31/2018
Intraop..Stage1 • At 2 Weeks
After Stage 1
Stage 2 • 3 Weeks out • Antero‐medial approach • Skin Bridge large • Allows for fixation of the MM
Anterior buttress
Medial buttress (multifragmentary)
12 5/31/2018
Intraop
Intraop
Intraop
13 5/31/2018
Medial and Anterior
Final Joint
One Year
14 5/31/2018
Controversies • Not fixing the fibula
Multiple plates
Locked fixation • Anterior approaches
Modifications • Plate location
Anterior and anterolateral
Boston Medical Center
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