1. Articular fractures Principles of management Ram K Shah Fractures Around Knee Joint: Femur, Tibia, Patella.

2. Aims & objectives - Pathophysiology of articular healing after fracture - Indications for treatment - Treatment principles

3. Anatomy of articular cartilage - Articular cartilage: - resilient - elastic, avascular - Composition: - chondrocytes - proteoglycan - type II collagen - water - Roles: - distribute forces evenly - provide a frictionless surface to the joint - shock absorber

4. Nutrition of articular cartilage - Nutrition comes from synovial fluid - Flow of synovial fluid requires motion and load - To preserve injured articular cartilage: early motion and some load

5. Articular cartilage response to trauma - Very sensitive to injury - Poor healing potential - Early mobilization enhances healing (Salter et al 1980) - Anatomical reduction + interfragmentary compression + movement = healing with hyaline cartilage (Mitchell and Shepard 1980)

6. Clinical and experimental evidence—I - Immobilization results in joint stiffness - Immobilization of the articular fractures treated by ORIF (open reduction and internal fixation) results in much greater stiffness - Depressed osteochondral fragments which do not reduce by closed manipulation and traction are impacted and will not reduce by closed means

7. - Major depressions don’t fill with fibrocartilage, the resulting instability is permanent - Anatomical reduction and stable fixation of articular fragments is necessary to restore joint congruency - Metaphyseal defects must be filled with bone graft to prevent articular redisplacement Clinical and experimental evidence—II

8. - Metaphyseal and diaphyseal displacement must be reduced to prevent joint overload - Immediate motion is necessary to prevent joint stiffness and to ensure articular cartilage healing and recovery, this requires stable internal fixation Clinical and experimental evidence—III

9. Options of treatment—decision factors - Type of trauma- Magnitude of incongruency - Age- Profession/leisure activities - Affected joint- Goals of treatment - Patient’s expectations

10. Principles of treatment - Understand the injury - Preoperative planning - Timing - Surgical approach - Articular reduction - Buttress of the metaphysis - Postoperative care

11. Principles of treatment Understand the injury: - Evaluation of the soft tissues - Adequate imaging: x-rays, CT, MRI

12. Principles of treatment Preoperative planning: - Positioning - Approach - Implant selection - Reduction tactics - Sequence of fixation

13. Principles of treatment Primary: - Little edema, good skin, recent trauma Primary deferred: -Traction or external fixator - ORIF 1–2 weeks later In 2 sessions:-Assembling of the articular surface + transarticular external fixator - Bridging internal/external fixation Timing

14. Principles of treatment Surgical approach: - Soft- tissue condition - The least traumatic possible - Indirect reduction - Arthroscopy, C-arm, percutaneous

15. 1 year follow-up C-armIndirect reduction Percutaneous fixation

16. Principles of treatment Articular reduction: - Interfragmentary compression - Step-by-step K-wires - Bone graft into the defects - Gaps forgiving, step-offs dangerous

17. Principles of treatment - Articular reduction - Buttress of the metaphysis: - Usually with a bridging or a buttress plate

18. Principles of treatment Postoperative care: - Pain-free active mobilization - Isometrics in day 1 - Physiotherapist - Limited weight bearing (15–20 K)

19. Types of fixation Minimal osteosynthesis: - K-wires, cannulated screws - Buttress plate - Hybrid external fixator - Transarticular external fixator

21. 32-year-old male 41-B3

23. Immediate postoperative 1 year follow-up

24. 33-C2 33-year-old female, polytrauma, multiple fractures

26. Assembling of the joint surface

27. Bridging plate joining the condyles and diaphysis

29. 7 months

30. 31-year-old, male 41-C3

31. 8 days postoperative

32. First xRays

33. Tibial Condylar Fracture Treated by TRACTION

34. After Treatment

35. Evidence: Tibia: C onservative treatment is a valid option for fractures with minimal displacement and surgical treatment is justified for severely displaced or depressed fractures. Attention must be paid to the recognition and restoration of joint stability and articular surface congruency for a satisfactory outcome. ( Med J Malaysia. 2005 Jul;60 Suppl C:83-90 ) Femur: Regardless of treatment method, goals include restoration of articular congruity, anatomical length, rotation, and axial alignment while establishing adequate fixation to initiate early and unrestricted range of motion.( J Knee Surg. 2007 Jan;20(1):56-66. ) Calcaneum : The results of this 15-year follow-up of displaced intra- articular calcaneal fracture randomised controlled trial were equivalent between conservative and operative treatment and demonstrate similar findings to those at one year follow-up. ( Injury. 2007 Jul;38(7):848-55. Epub 2007 Apr 18. )

36. Take Home Message -Intra-articular Condylar Fracture of Tibia & Femur requires accurate reduction and early joint motion for good anatomical and functional recovery. -Conservative treatment with Traction or Hinged Brace is applied in selected patients for useful functional recovery. - Undisplaced Burst Fracture Patella is treated conservatively.