AO Articular Fractures

Articular fractures Principles of management management

Fractures Around Knee Joint: Femur, Tibia, Patella.

Ram K Shah

Aims & objectives

- Pathophysiology of articular healing after fracture - Indications for treatment - Treatment principles

Aims & objectives

- Pathophysiology of articular healing after fracture - Indications for treatment - Treatment principles

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

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

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)

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

Clinical and experimental evidence—II - 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—III

- 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

Options of treatment—decision factors - Type of trauma

- Magnitude of incongruency

- Age

- Profession/leisure activities

- Affected joint

- Goals of treatment

- Patient’s expectations

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

- Postoperative care

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

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

Principles of treatment Timing 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

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

C-arm

Percutaneous fixation

Indirect reduction

1 year follow-up

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

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

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

Types of fixation Minimal osteosynthesis:

- K-wires, cannulated screws - Buttress plate - Hybrid external fixator - Transarticular external fixator

32-year-old male

41-B3

Immediate postoperative

1 year follow-up

33-year-old female, polytrauma, multiple fractures

33-C2

Assembling of the joint surface

Bridging plate joining the condyles and diaphysis

7 months

31-year-old, male

41-C3

8 days postoperative

First xRays

Tibial Condylar Fracture Treated by TRACTION

After Treatment

Evidence: • Tibia: Conservative 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 intraarticular 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. )