1. Principles of Management of Articular fractures Dr. Emal Khan Wardak AO SEC Mongolia

2. Goals of this lecture are: to understand the management of articular fractures incl. planning & timing to understand the pathophysiology of the articular segment to appreciate the need for anatomical reduction and rigid fixation allowing for early motion to understand the choice of implants

3. Articular cartilage & chondrocytes „live“ from diffusion of joint fluids and depend on regular movement and loading forces Any changes of this environement lead to degenerative changes of both cartilage and underlying bone arthrosis / - itis

4. Already 100 years ago Lambotte had observed that only perfect anatomical reduction and stable fixation by screws together with early motion allows to obtain a good functional outcome in articular fractures !!...result in a severe osteoarthitis as in this case 20 years later 20 y Lambotte 1902 Transfixation screw in an unreduced fibula must.... Displaced articular are an absolute indication for a correct ORIF

5. Articular fractures must be reduced anatomically, which requires good visualization of entire joint, incl. critical structures like the ulnar nerve Only fixation by absolute stability allows early motion 30 we

6. M.M. 27y, athlete motorbike injury 2° open distal humerus C3 fracture right side neuro-vascular: OK Result of 3 hours of surgery (elsewhere): immobilisation in a circular cast for 3 mo!! Infection? poor surgery + cast is a very bad combination

7. M.M. 27y, athlete motorbike injury At 3mo: stiff elbow,pain non union AVN ??? wound healed Surgery: olecranon osteotomy lots of fibrosis, no cartilage visible vascularity OK 3 months p-o Plan: debride and reconstruct fragments anatomically rigid fixation to allow immediate physioth.

8. M.M. 27y, athlete motorbike injury Extensive fibrolysis, Adaptation of main fragments, Stabilisation with: pediatric osteotomy plate on radial side 1/3 tubular plate ulnar side No cast, no splint Immediate physiotherapy

9. M.M. 27y, athlete motorbike injury 1 year after accident - fracture healed, no AVN - satisfactory function - can again play tennis If surgery is chosen it must be done correctly

10. When AO was founded in 1958, both operative and conservative ways of treatment were unsatisfactory with poor results and too many complications: mal- & non- unions Algodystrophy infections

11. There were also: - no decent concepts for the treatment and aftercare of articular fractures - no adequate implants nor instruments to provide rigid fixation that allowed for early joint movement Most articular fractures were considered not amenable to surgery, so good luck or bad fate decided on the outcome !......and even today we still see disasters

12. Complications after surgery can result from: wrong timing poor reduction inadequate fixation wrong implant poor soft tissue care Most of which is avoidable with carefull planning

13. Where are we today? We request - anatomical reconstruction of the articular surface and joint block - rigid fixation by interfragmentary compression of the main fragments - „stable link“ of the articular block to the diaphysis - functional aftercare (including early partial weightbearing) Meticulous preoperative planning

14. Preoperative Planning: correct assessment of fracture and soft parts x-ray imaging incl. CT drawing of the fracture reduction on „paper“ step- by- step procedure choice and position of implants ( and instruments) selection of approach and position of patient need for bone graft ?

15. Evaluation of x-rays: A step-off in the articular surface may show only after reduction on paper better planning

16. Same case Post op One year At one year follow- up: full functional recovery

17. 51y female, Skiing injury 8 mo ago, still knee pain & instability Not recognized, neglected Hoffa fracture of lateral femoral condyle original x-ray

18. 51y female, Skiing injury 8 mo ago, still knee pain & instability Osteotomy in original fracture plane and fixation with 3 screws Post-op 27 weeks

19. X-ray imaging: Traction views and CT-scans (3D) are most instructive also in view of the planning of approaches traction Postero-medial approach

20. In articular fractures timing of surgery is most crucial thin subcutaneous fat, no muscles especially vunerable soft tissue cover If in doubt dont do ORIF !! but stabilise joint & wait skin tension ischemia necrosis Do not touch

21. Soft tissue evaluation: history of injury – energy involved? interval since accident? swelling, skin tension, hematoma? open / closed injury contamination? neuro- vascular status? compartment pressure? Question of experience After 10 days OK

22. Timing of surgery: primary definitive surgery staged surgery delayed definitive surgery Each has advantages and draw backs, most important are the soft tissues

23. Primary definitive surgery requires: „unproblematic“ soft tissues experienced team full equipment access to OR carefull planning e.g : malleolar fractures type A / B fx simple pilon fx elbow fx complete work-up of patient

24. G.B.m. 1962 motorcycle injury III B open prox. tibia 41-C1 Compartment release poor pulses emergency surgery w. „on- table“ angiography medial approach to popliteal vessels and repair ORIF with 3.5 angle blade plate (same approach & team) Open articular fractures are emergencies

25. „second look“ with debridement and gastrocnemius flap G.B.m. 1962 motorbike injury

26. G.B. m. 1962 motorcycle injury Gastrocemius flab to cover anterior defect No compli- cations Good function Control-angiogram to prove patency 13 weeks one year FU 1 year

27. Advantages of staged surgery: protects soft parts for better recovery patient remains „mobile“ reduction aid for planned definitive surgery for the „less experienced“ at night e.g. complex type C fx open / poor soft tissues minimally invasive preliminary fixation eg. Joint bridging external fixation Today the preferred technique for complex articular fractures

28. 1st step: traction bone graft soft tissue cover Staged procedures joint bridging external fixator: - per se - combined with screws/ wires/ plates ORIF / MIS 2nd step :

29. Delayed definitive surgery: „safer“ soft tissue conditions ? reduction more difficult ! cartilage damage? slower return of function heterotopic bone formation e.g. upper extremity in polytrauma calcaneus fx, complex pilon fx ? acetabulum no later than 3 weeks

30. Reduction techniques: You need a good view of the articular surface!! by direct inspection through arthroscope (???) Impacted articular components are reduced exactly and supported by bone graft or substitute - Joint bridging distractor to keep the alignment - but articular fragments must be handled directly, - percutaneous insertion of buttress plate

31. Reduction under arthroscopic control & percutaneous fixation For rare indications only

32. Choice of implant: For articular fractures screws & plates More adequate than im-nails 3.5 implants best dimension tubular, LC DCP, LCP new: special form plates LCP prox.Tibia pilon Distal humerus...but special plates are no garantee for a good reconstruction and result !!

33. G. N, 25 y old lady, skiing accident on 27 Jan.1959 : Pilon 43-C3 only plain x-rays no Tomogr, no CT emergency surgery by M. Allgöwer limited implants & instruments Jan 27th 1959

34. 3 different types of implants: - straigth non AO malleolar screw - Rush pin - AO 6.5mm Cancellous bone screw satisfactory reduction, but „horrible“, unstable fixation by today‘s standards, mix of implant & materials G.N 25y Jan 27th 1959 post-op

35. G. N. same patient in 2007, 48 y later, Aug 28th 2007 No discomfort Good function No signs of osteo- arthitis even after 48 years !! do we really need LCP Pilon plates etc.?? or just a good surgeon ?

36. How to handle bony defects ? Depends on purpose: - providing mechanical support? - filling up defect? Bone substitute: - resorbable - non- resorbable - BMP etc. Autologous graft: - cancellous - cortico- cancellous

37. Conclusions: displaced articular fractures are an absolute indication for surgery, provided: anatomical reconstruction and rigid fixation is obtained correct timing and planning are crucial staged surgery may be advisable early postoperative mobilisation of injured joint is mandatory (CPM)

38. Post-operative care:“compliant“ pat. CPM continuous passive motion for 5 - 6 days Immediate toe-touch (15kg) weightbearing No external splint 6 - 8 weeks: 30 - 40 kg

39. Results after ORIF in articular fractures: are in general quite good, provided there is anatomical reconstruction and rigid fixation an experienced surgeon early rehabilitation* 70-80% good or excellent 10-15% moderate 5-10% poor *Dammaged cartilage never „heals“ completely, but also normal cartilage „depends“ on early joint motion

40. .....however secondary reconstructions may be worth the effort ! even the best surgery has its limits !! there is no cure against bad surgery !! not every joint incongruency means clinical impairment

41. Thank you !!

42. B.F. 39y.m MD, 6mo ago, malleolar fx and ORIF elsewhere painful, disabling valgus position of foot, due to short fibula, tibial impaction (?), circumscribed osteoarthitis plan to lengthen fibula by 7 mm, anterolateral tibial osteotomy intraoperative view after exposure of involved area

43. B.F. 39y.m MD, 6mo ago, malleolar fx and ORIF elsewhere anterolat. block of tibia is removed, view into ankle joint the block has been moved distally + graft appearance on intraoperative x- rays

44. B.F. 39y.m MD, 6mo ago, malleolar fx and ORIF elsewhere buttressing of the reduced anterolateral tibia by 1/3 tubular plate fibula is lengthened and fixed with 3.5 LCP, transfixion to tibia 1 year follow up, with good joint space, walks for several hours function 0- 0- 20, no pain 36mo

45. 51y female, Skiing injury 8 mo ago, still knee pain & instability Not recognized, neglected Hoffa fracture of lateral femoral condyle original x-ray

46. 51y female, Skiing injury 8 mo ago, still knee pain & instability Osteotomy in original fracture plane and fixation with 3 screws Post-op 27 weeks