5/31/2018

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Patella and Tibial Injuries

Paul Tornetta III, MDProfessor

Boston Medical CenterBoston 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

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Tibial Plateau• Unicondylar

Void filler?

• Bicondylar

Dual thin vs larger locked?

Prone approaches?

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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?

• OpenOrder of fixation and flaps

Nail vs ex fix

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Position?

> 20°

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Semi-Extended

Fibula Plating?

• Malunions in distal fractures present IN the OR

• Can help with reduction

• NOT needed!

• Might slow healing

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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 skinOpen wounds

Swelling

Staged fixation

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Approaches• Anterior variants

Antero‐medial

Direct anterior

Antero‐lateral

• Medial

• Posterior Options Postero‐lateral

Postero‐medial

Anterior

Posterior

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Trends• Incisions

Different locations

Multiple

• Staged approaches

Fibula  frame  tibia

Posterior  anterior

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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

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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

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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!!

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Intraop..Stage 1• 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)

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Intraop

Intraop

Intraop

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Medial and Anterior

Final Joint

One Year

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Controversies• Not fixing the fibula

Multiple plates 

Locked fixation

• Anterior approaches

Modifications

• Plate location

Anterior and anterolateral

Boston Medical Center