WIROC 2025 : Complex Distal Femur Fractures - Dr Sangeet Gawhale

[00:00:08]Right.

[00:00:09]The actors >> are these.

[00:00:18]Can you recognize any one of them?

[00:00:22]This is Raman.

[00:00:26]Uh he practices in Tan.

[00:00:30]He fires his short arms all around Tane with its short guns and missiles which is restricted to uh giving the accurate results in trauma.

[00:00:45]The second is a g is a dawn from Kune who heads the trauma unit in Sanetti hospital and is known for his special secret techniques.

[00:01:01]Harshad >> again from Bombay. He's expert in long arm missiles and captures entire north Mumbai with his trauma skills.

[00:01:14]The next one is Avin Date who practices in Dubai Amani Andheri and uh his firing a range is restricted only to his hospital as he is not allowed practice outside and being in Amani hospital he has modern gadgets which are needful for trauma care and lastly uh I invite all of them on the stage Can anybody recognize >> that is Dr. Praep Kotaria who is from Shapur and moves all around with his special intraarticular work.

[00:02:06]I need not introduce myself.

[00:02:10]So the symposium was on complex distal femur crack fractures. It is a case-based discussion and this dialogue was only for Dr. Muki but he is not here.

[00:02:25]>> Peter what indirectly you're trying to say this was only for Muki. No sir, it is coming.

[00:02:38]That was only for Dr. Muki but unfortunately he's not here. So we start with a case interactive case based discussion. Uh there is contribution from all the faculty. We have summarized the conclusion and we would be giving in between uh what is available in the current literature and what is a current practice. This is a 23-year-old who met with a motor vehicular accident had a compound distal femur and has sustained this communated fracture that is his CT uh significant communication in the supraondiler level. The intra articular doesn't look like except two major fragments of the two condile. There is a sagittital plane patellar fracture.

[00:03:25]Uh can you all see? Yes. Yes. Right.

[00:03:29]And [clears throat] this is the bone as expected you will do all of you will uh do the same anything different.

[00:03:39]So there was some bone loss uh in at the supraondola level through the wound and he came within 6 hours of his injury and uh once investigated he was taken up for debridement where all the vascular muscle was uh excised skin loose fragments were excised and then we were left with this clean wound. At this stage how will you proceed?

[00:04:09]You'll go for a fixator. You'll go for a plate. The wound is clean. So primarily Dr. Sangeit for this after the debridement. If your wound is clean, I would do a lateral plating and a >> speak on the mic. Speak in the mic.

[00:04:24]>> So I would do a lateral plate internal fixation with a cement spacer, an antibiotic delivery system and get your plastic surgeon to cover that skin as soon as possible.

[00:04:34]>> Right. Anything different?

[00:04:37]>> I think I'll have to put a whack initially get the wounds to >> that he don't repeat the same thing otherwise we won't proceed.

[00:04:46]>> Anything different? Fixator.

[00:04:48]>> Fixator. Yeah.

[00:04:49]>> Okay. And uh how will you address the condile? You'll put a pin in the condile.

[00:04:55]>> No, first uh or you'll be doing a knee spanning. Yeah. Yeah. Put multiple KY articular blockide the wound. Send a swab. Put a fixator. when the swap comes negative then the further plan.

[00:05:06]>> Okay. So uh literature wise is there any difference as what uh Harshad has advocated and a fixator in the presence of clean wound is there a difference?

[00:05:21]>> Yes Chetan.

[00:05:23]Yes, there there is [clears throat] a uh recent publication and uh that is pertaining to floating knee injuries actually but then we can extrapolate it to combinated open distal femur fractures. So if you have a clean closable wound what Harshett said gives you a better outcome than doing a knee- spanning external fixator >> right >> primarily because of two reasons. One is more damage to the quadriceps with your fixator and even if you are careful you do get some pin track infections etc. But then yes primary fixation with a mascula like procedure if it is a closable wound and a clean wound gives a better result over an Xfix.

[00:06:11]>> So the message from all of them is preference to the lateral plate as against a fixator unless the wound is contaminated which Dr. Raman has suggested. So uh we followed the plan which Dr. Harshad has agreed for or suggested where the primary fixation was with a lateral plate. The intercondiler was reduced with a clamp assisted reduction K wire and then there was a lateral plate which was fixed by opening distally and proximally it was locked with some screws perccutaneously.

[00:06:49]So there is a defect of about 7 cm here.

[00:06:53]So any opinion on uh the defect part we'll discuss later. Now in this situation you have excised a segment of those loose fragment. There is a significant defect. Now here there is a deformity which is called as a golf club deformity. Uh any reason why very often we end up in fixing these supracondular fracture where the distal fragment shifts medially when you plate it. Any reason for that?

[00:07:24]Is it because of the shortening or is it because of the external rotation? It the plate has to be lateral. If it stays lateral or postrolateral then you have this golf club uh deformity.

[00:07:37]>> It is rotational rotational. So two things they are commented one is your proper placement of the plate and second is the external rotation deformity the distal femur shifts medially when you're using anatomical plate even if you try to correct it with a clamp it does not sit well so the relevant anatomy we must understand when you see a profile of the distal femur laterally in your imaging you'll always see this there when the two condiles are overlapping you will always see two lines the one is a red line anteriorly and second is the white line posteriorly. So this is the area. This is the area where your plate has to be placed. When you are seeing a lateral view, it cannot be seen. If your condiles are overlapping that means you are seeing two shadows of the condile, you will not be able to see this. For that you must see this in a view, a lateral view where there is a overlap of both the condiles. Whether you're plating or even if you're nailing your entry point remains the same or your implant has to be in this zone. So what is this zone? The white arrows they represent the blue manset line that is the subcondral arc of the tleia and the red arrows they represent uh subcondral bone the femoral notch. So the plate has to be in between these two lines that is the footprint of the plate. So when you see it in actual view the medialization of the article block will happen if your plate is not placed like this which Dr. Raman has pointed out. The chances of mal reduction are almost 25%. If your plate is placed posteriorly and that is what has happened in this patient. You can see in the lateral view the plate is too posterior that may be because of the communition or that may be because of the rotation or there is a significant defect which led to placing the plate posteriorly and hence you can see the distal femur has shifted medially. So a posteriorly placed may lead to a medialization of the condiler segment.

[00:10:01]There is a inbuilt 16.5° poster anterior inclination in the plate itself which matches with that of the condile. Hence the plate has to come in that area to get uh to avoid this deformity.

[00:10:18]So anything different?

[00:10:21]Okay. So now we move from the deformity to the correction. How will you correct uh the length in such combination where there is a loss after debridement and uh there is a significant shortening sir.

[00:10:37]So if you are expecting or anticipating a shortening of such degree after your debridement ideally you should paint and drape both sides. Ideally you should paint and drape both sides so you get a direct comparison of both limbs. That would be your interrop way of judging the length properly.

[00:10:55]Anything different?

[00:10:57]Chaitan.

[00:10:58]>> No.

[00:10:59]>> Uh, >> anybody in the audience?

[00:11:04]So, in a situation where there is a significant bone loss, how do you correct the limb length?

[00:11:10]>> Draping both sides together and knowing the length pre-operatively from the normal side. So as you can see here uh since we have fixed the plate on the lateral side the lateral condile or the lateral part will look normal and on the medial side if you draw the line there will be a mismatch here. So one way which Dr. Harshad has suggested is a cery test where you put a cy wire on both the side and you screen uh both the limbs together.

[00:11:42]uh the distal femur is like a flute or a funnel where the two borders have to match.

[00:11:51]So the picture or the image on your right side you can see the step on the medial side. So you can go on achieving till go on lengthening or go on getting a traction till you see both of them matching like a flute the funnel of the flute here. So that will give you one way by which you can you have corrected and secondly now most of you are using a flat panel. The difference between the older CM and the newer flat panel CM is in the older CM we used to see round image and in the newer flat panel you are seeing a square image. So that means the area which can it can capture is larger. So now you can see in this and there are two types of either 8 in or 12 in CM. The newer CM are 12 in. So when you take a view if the patient is thin and you see the opposite side you can see that much is the shortening on the one which we have fixed screws in the femeral condile. I don't know whether I have to shorten lengthen or uh that is adequate. So what you can do is you can screen both the femurss both the femoral head you square the pelvis patient is on a supine position and you take a picture where you can bring both the knees together as you can see here the normal side is longer and the operated side is shorter. So you go on lengthening that till you get the joint line equal and that is possible in thin patient. If the patient is huge it will not be possible.

[00:13:31]So that way we can correct the limb length by these various ways a cauter test uh checking the other side and then by this two three ways by which I have suggested. Now the third issue here is the defect. So uh as hers has already pointed out it requires uh would it be different now hers?

[00:13:55]>> No.

[00:13:56]>> So we have fixed the plate on the lateral side. We have achieved the correct length and the rotation here.

[00:14:02]And then uh we have planned a two-stage reconstruction with a masculate technique where we are using antibiotic cement spacer.

[00:14:13]This is from the lateral side. We pack that in the defect and that is how uh it looks like at the end. So slightly different in the sense the cement rather than being in the cavity you can overlap it to the normal ends of the bone also so that when your membrane forms it forms from the normal bone to the normal bone.

[00:14:37]>> Okay. Okay.

[00:14:38]>> In fact it is recommended to overlap on either side because removal also becomes easier and there is a homogeneous membrane across. So see to it that there is at least a centimeter of cement going on cleaner edges of the board. So would you would you put a single bolus or multiple beads in in in the defect? Will that make a difference?

[00:15:00]>> No, I would probably in this case use a more quantity of cement 40 g or something addyin to it and use a single bolus.

[00:15:12]>> Okay. So single bolus does provide some structural stability also >> that will allow you to mobilize the knee because you're giving a structural strength to it.

[00:15:21]>> Right. So this is the wound at the end of uh your surgery and he was put on whack as Arshad has also suggested.

[00:15:33]>> The only difference is this works better if the wound is closable. Now if you have used cement with antibiotic and you have put a wack on it then it probably does not.

[00:15:44]>> So the illusion of the antibiotic through the open wound is very high.

[00:15:49]So uh a wack was put which was removed at about uh 2 to 3 weeks. This is the wound how it has shrked and we redepbride it with the help of a plastic surgeon we were able to close it. So this is uh at the end of 3 weeks there is no infection.

[00:16:07]He comes at 6 weeks with a stiffness where we cannot flex beyond 40°. Now here uh at this stage as we have planned we have to uh remove the cement and then address the defect again but before that he has landed up with this uh stiffness.

[00:16:27]So how do you address and manage that most of the time the stiffness is because the quadriceps get clustered or adherent. There is no intraarticular reason for stiffness. You've seen that during your first surgery that your intraarticular reduction is good. So when you do your removal of cement you do release the quadricep from the entire femur and you will get flexion uh better than what you have now.

[00:16:51]>> Sit he also said that he also had a fracture patella also initially. He had a patella also which was fixed with >> two medularal screws. Aim anything you want to add or say different >> uh stiffness at 6 weeks how will you address? You'll go for the full uh uh release.

[00:17:14]>> No, I will put the medial plate. Take out the cement bone graft.

[00:17:20]Take take out the cement media plate bone graft. And in the process whatever release is possible around the knee I will not do the whole off.

[00:17:29]>> Okay.

[00:17:30]>> And I'll get movement. I I'm sure at 6 weeks I'll get it full.

[00:17:33]>> So lateral side there was no wound. Uh the approach here was on from the medial side where we released the patella which was added because of the adjacent soft tissues healing and on the lateral side we had to just do a pie crusting with a needle. So there was no incision at any stage till now there was no infection as the markers were normal. So here now uh you can see the membrane after opening on the medial side you can see the thick membrane induced membrane on anterior as well as the posterior side. The cement could not be removed piece uh end mass.

[00:18:12]So it had to be broken and then it had to be removed like that. But there were the advantage was a thick induced membrane. Now we are at this stage after removing the uh cement. So you can see the lateral plate is still holding. This is from the medial side. What you are seeing the defect and um uh is this microotion enough to be acceptable by putting graft uh you address the defect or close the membrane. Is that enough or it requires additional metal work?

[00:18:48]>> This is this is not micro motion. This is microotion. If you see it that mean it is mobile. So microotion is something where you actually shouldn't be able to see any motion. It's it's a physiological uh activity. So this obviously requires a medial support also. So you would put in either a graft and a medial plate whether the graph be allograph autograph mix or whether it be fibula or whatever you wish to but there should be some uh um small graft component not just the fibula there should also be autoalobics >> what I would put a plate also on the medial side yes >> see [clears throat] I if you have u this would require a huge amount of graft so I would use a allograph. I usually use a complete femoral head or two if required. But once you put a medial plate long enough that macro motion will be gone unless there is some loosening also which has happened on the lateral side conccommittently which uh you must have seen probably.

[00:19:54]But once you do a bicondelar plating usually that motion goes away and uh the fracture heals with only allograph also.

[00:20:04]>> Okay. So uh what >> no fibular no fibrillar strut or uh autograph is required if you are adding a medial plate and adequate allograph.

[00:20:15]So what type of graph to be used in presence of such defects is uh questionable and uh what we have done was a mixture of aloe and autograph and additional plate on the medial side and that is how it looks like. Is it okay?

[00:20:33]And we were able to close the membrane over the graft and uh uh all the graft are contained inside the membrane. So uh the debate here is what type of graft and u after compiling literature from all of them uh those who are sitting in front of you we have come to a conclusion if the defect size is 3 to 4 cm less than 3 to 4 cm the recommendations are autologus cancellous graft and internal fixation in the presence of defect.

[00:21:09]>> Why no fibula? What is the what is the contra indication of that? It will give you a good stability on the medial side.

[00:21:15]>> Sir, I'm using a plate to add to the stability and I would not like to harvest the fibula unnecessarily if I have a source of alograph.

[00:21:22]>> Then you are using an allograph. Use a fibula allocraft.

[00:21:26]>> Okay. Fibular alo. Yeah, that that's fine. So if your defect is more than 5 cm within 15 cm a mascul stage technique with autograph and or fibular graft and titanium cages. The last paper in 23 is about uh uh the recommendation of using titanium cage fill that with graft and fix it in between the screws.

[00:21:53]>> I must give a compliment to Dr. Muki who has been using these cages for a long time. But >> he has presented it quite often.

[00:22:01]>> But the recommendation is not in all cases sir.

[00:22:05]>> 5 to 15 cm >> is where the size of defect dictates what graft you would use.

[00:22:13]He uses in uh many of cases which the he uses is in the areas in which like it is a fairly big gap.

[00:22:22]>> So the length I'm talking about sir.

[00:22:25]So if the defect is more than 15 cm then a vascularized fibular graft or modified capanas technique where you use a vascularized fibula along with aloraft and or bone transport and when the situation is bad where there is an intraarticular involvement which is not reconstructable probably in a elderly a distal femoral replacement would be ideal. So this is his uh x-ray at 8 months where you can see the graft are getting incorporated. He's doing full activities. His range of movement is almost complete. He's doing rigorous quadriceps training as he's a uh gym trainer and he could do all possible activities which are required for praying also he can do normally. And he comes after 14 months where uh you can see the grafts are getting incorporated completely. But you can see there is a fluffy area just proximal to the medial plate and there is that excessive newborn which has formed which was not there earlier. If you see here >> the sangeit >> it was not as much as it was earlier over 6 months.

[00:23:45]>> Yes sir. Sangeit with such a big gap the cancellous bone graft unless and until it is ctified unless it is stabilized this is going to give you a weakness at one stage that's the reason the strut graft or or a cage is going to be the more important thing in order to give you a stability >> so the second plate on the medial side will it not address the >> I think it is a but the bone which is there in between cancellous bone it has to become strong it will not become strong in a 5 years also.

[00:24:18]>> Okay. So the faculty uh what is the reason why you are seeing this? Uh Amit you have seen the case.

[00:24:27]>> No no no but I have a question. I know I have seen the case.

[00:24:30]>> So before before you uh any reason why you have that excessive newborn proximal to the medial plate.

[00:24:38]>> So there is a little bit of motion at the proximal end of the medial plate. So it's a normal biological the screws are not broken.

[00:24:45]>> What when you what do you mean by little bit it is a little bit pregnant?

[00:24:49]>> No no no. So what I what what the point which you made was that there is no uh intramedularary weightbearing axis. So there is more stresses on the medial side and there >> on the plate >> on the plate. Therefore there is callus.

[00:25:05]So there is there may be loosening of the screws there at that point. So your point of putting something intrammedularary to avoid precisely this situation >> whether the long plate on the medial side would have been >> longer plate than this would have been a little better solution.

[00:25:21]>> But I wouldn't worry about this callus has to be a sign of failure or something. I would say it's a sign of healing. It's a positive sign.

[00:25:29]>> But why there only in that particular area? It is not seen anywhere distally.

[00:25:35]Uh Amit put a bone there.

[00:25:39]>> No, it wasn't there before in last uh six prior 6 months X-ray.

[00:25:45]>> Sangeit after removing the the uh cement from there before suturing and putting the graft you showed the macro or micro motion according to you. So that means your plate the lateral plate was not fixing well as it is. You you also said that your lateral plate does not have a good hold or it's not in alignment on the lateral uh condile. So why didn't >> No, I never said that.

[00:26:08]>> Yeah, but you can see it is uh you didn't correct your uh think of correcting your >> is corrected the length is corrected the rotation lateral plate. No, no, that was a point which before fixing the plate permanently.

[00:26:22]>> That was during the surgery. Those were the slides which has shown that just for information that was not the final picture.

[00:26:31]>> Okay. Another main question for me as since I'm doing the nailings why not a nail in this case primarily before while putting the plate just just a question.

[00:26:42]>> Should you have done it? Um so >> nailing in this setting is extremely difficult especially we if you don't have if you don't have control over the dist fragment enough control over the dist fragment in this particular situation you don't have enough control over the distal fragment >> probably Amit you'll get the answer in my talk >> no but uh in the distal fragment is big enough you can have easily a control over that >> first of all it was an intraarticular fracture and there are enough problems in nailing when you are nailing I mean I know you are an expert nailer you could have nailed this but when we talking of uh average orthopedic surgeons like me >> it's not that just hold on Chaitan Amit this is unrelated to the present situation we can discuss later sir one more thing is that your proximal medial plate is fixed only with two screws >> I think the third one may have prevented this toggling >> slight medial instability.

[00:27:45]>> See if you have put only allographs and that two also cancel as alographs.

[00:27:51]The literature shows that for the allographs to >> so it was a mixture of aloe and autograph in equal volume 50/50 >> but it takes almost 1 year >> yes >> for the allographs to get incorporated.

[00:28:05]>> Till that time you are putting the stress on the implants when you are giving this kind of an exercise to the patient. So I'm sure it is likely to cause loosening of the implant you.

[00:28:17]>> So this is at 16 months following the surgery. You can see the lateral plate has broken exactly at the area where there was a defect. You can see that on the medial side and that excessive movement has produced a callus just proximal to the medial plate. So there was some instability which was happening. Medial screw is also broken.

[00:28:40]Proximal medial screw >> proximal most medial screw.

[00:28:46]>> Yeah. So this is what is a picture now.

[00:28:50]So how will you proceed?

[00:28:53]>> I think that was the instability even after the fixation. That was the problem.

[00:28:57]>> Micro micro >> correct yourself. [laughter] >> Invisible invisible.

[00:29:03]>> Sorry.

[00:29:09]So maybe this lateral plate breakage could have been prevented had you had a longer plate area.

[00:29:15]>> Oh doubt very much. I doubt very much.

[00:29:17]Even if it is a longer plate which is there you because even that plate is not broken. It's the lateral plate which is broken.

[00:29:24]>> So I'm not talking the medial plate. I'm talking the lateral plate would have been longer.

[00:29:35]not denying would have helped. Yes, >> Jayan. For that reason, I'm telling you a nail would have been much much of a better implant.

[00:29:42]>> Now, I would think of a nail augmented with a plate.

[00:29:45]>> Okay. So, >> and bone grafts also addition.

[00:29:48]>> So, that is what was done. So, when we cleaned everything, uh there was no the bone here had absorbed and there was a defect. exactly at the area where uh as you can see here that area.

[00:30:06]So this is that defect >> and since all of you have suggested we used again a combination where we packed that defect with the callus the amount of callus was quite significant with that graft. Uh we added a lateral plate and that is how he is at 8 months. He's doing all his activities and the consolidation is still not complete on the medial side. Uh you can see a callus. So hopefully we wait uh uh in in almost 2 years >> again. It is the same thing.

[00:30:44]>> You put in a nail in between which is giving you a little more stability but still there is a gap in the bone there.

[00:30:51]>> Yes.

[00:30:51]>> Which cannot be compensated by a nail or a plate. So I'm coming to the conclusion of this. So u from this case what we can conclude are three four points.

[00:31:04]Achieving limb length in such defect defects is difficult. A ideal graph for such large defect is what we have discussed. If the defect is small you can use this type of combination allo or auto or only autograph. But when you have a graft as big as this probably uh auto and allograph is not enough. You have to use either intramalorate device or additional cage or a fibular graft to support the ideal implant construct in the presence of such defect is a nail and a plate as it improves the axial and the torsional stiffness biomechanically. And if you are able to link them uh it is the best construct as of today and you have to load them as early as possible. The problem with dual plate is that is it gives a higher construct stiffness and the callus is not seen in them almost up to 2 years. It takes a longer time to heal. This defect in most of the available literatures have taken 2 years 3 years to see a good consolidation. But if you use a nail plate combination, the callus is much more earlier.

[00:32:21]>> But that nail plate which you showed, you have the end result.

[00:32:25]>> So he's just 2 months. That X-ray was 2 months.

[00:32:29]>> You will need a third surgery.

[00:32:30]>> He has not healed completely. But he's doing all the activities.

[00:32:34]>> That was [laughter] you said he was jumping around. He was doing everything.

[00:32:40]>> He's still he's still doing the same sir.

[00:32:44]So the choice of implant when you have such communated fracture is a lateral lock plate in all fracture patterns a retrograde multilock intramillary nail for extra articular fracture and partial intraarticular fracture I mean partial intraarticular fractures fracture fixation failures in spite of all this in the presence of communated fracture are almost 19 to 20% a robot First construct such as nail plate or a double plate construct aim to improve the construct strength and to minimize the failure. However, in searching all the literature, what is a ideal stiffness required? Nobody has been clear about that and we are yet to find a solution in such difficult fractures. Sange.

[00:33:36]>> So meanit.

[00:33:37]>> Yeah.

[00:33:38]>> Can tense nail can be used from the medial side long tense nail. It would have advised this >> with graft.

[00:33:48]Today probably a femoral graft along with the cancellorous bone is going to be the solution. You put a femoral alograph. So it's a good strut graft.

[00:34:02]So we move to the next case. He is a fifth.

[00:34:08]Navin privilege since you are a vice president. [laughter] Sorry sun sorry so we need a city scan now here then and then we'll able to judge the uh [clears throat] trajectory of the fixation >> so with the artifacts you'll be able to find out >> yeah uh so [clears throat] you have a advantage being in that position you you can read the CT scan which have so many artifacts I appreciate that So this is a 53 year old >> who had a vehicular accident and that is the hofas fracture uh lateral hoofas uh 2D sequence where you can see that is the extent of that fragment and that is a sagittital cut where you can see that fragment is tilted and that is CT where you can see some combination in the supraondellar area. This is a part of the head of the fibula which has evulsed and uh there is the communition here as you can see. So uh if you have to classify as per this letter neck classification where would you grade them this type of fracture? You have seen the X-rays, you have seen the CTS.

[00:35:39]Uh, hers.

[00:35:43]>> So, I don't know. It won't fall into the typical classification because there's a combination at the cortex that isn't figured out. But I would say it's more of type one rather than anything else.

[00:35:54]But that combination is a matter of concern. We should address that area also. So when I'm fixing it, I'm thinking of having a butress plate ready because I want to butress it from the back in addition to an interfragmentaryary screw. Antro, posterior, posterior, anterior.

[00:36:09]>> The screw will be from posterior to anterior side through the plate. If I can get it through the plate, there will be a plate on the posterior side. If I if the plate is impinging on the articular surface, it'll just be a butress plate and the screws will be outside the plate.

[00:36:23]>> Avin, anything do you feel any any of the classification? Yes sir very much.

[00:36:28]It >> really helps you >> very much sir. I'm coming to the conclusion. Very important.

[00:36:32]>> I feel it is the ego trip of a >> No sir. No no no no no. I disagree with you.

[00:36:39]So this probably was a type two falling in type two.

[00:36:44]>> Uh surgical approach and how will you fix it? Partly Harshad has answered that. Raman anything different from what he has spoken. A plate and screws. No.

[00:36:56]Okay.

[00:36:58]So this is what was done as Harshad has suggested. Is it all right? Uh your comments on fixation.

[00:37:06]>> Yes.

[00:37:08]>> So I would have been happier from posterior to anterior screw rather than anter to posterior because now you're having a kind of a uh canty liver effect and the screws can still toggle there.

[00:37:19]The distal fragment plate is good. It would have come a little more distal and whether it's holding that fragment the only the surgeon will know.

[00:37:26]>> So is it but tracing that fragment or not?

[00:37:29]>> The surgeon will know. It's very difficult for me.

[00:37:31]>> The plate is doing nothing.

[00:37:32]>> You can see that in the X-ray here >> it has lifted off and that usually happens when you're using thin plate when you tighten the cortical screw which is uh closer to the fracture the plate tilts. That means it lifts off from the distal uh uh distal end.

[00:37:50]Actually the uh the approach he has taken is antilateral antrateral approach which is not a good approach. It has to be a posteralateral approach >> and then only you can actually have the proper trajectory of the screws as well as the proper sitting of the plate.

[00:38:06]>> Right. And this is what is his five years x-ray. He has uh flexion only up to 90°. He has limp and he has started having lateral side pain, lateral knee pain.

[00:38:21]Is it a non-union or it has united completely?

[00:38:29]>> Is there an element of avascularity here?

[00:38:31]>> Yes.

[00:38:32]>> Yes.

[00:38:35]So it is due to the collapse of the articular surface and it is probably heading for a early osteoarthritis and the reason is the superior lateral genicular artery.

[00:38:49]It it doesn't supply the posterior area of the lateral condi. It is through the nutrient artery uh where it deres its perfusion and that is the reason uh you have to handle the soft tissues particularly as one the approach was wrong. So the dissection was extensive and to reach that area was difficult and hence these uh intraarticular fractures which do not have any soft tissues they likely to have uh avascular necrosis the key is limiting the stripping of the soft tissue. Second is what is the direction of your screwdriver.

[00:39:34]So your direction should be perpendicular to the fracture and you can see here in this the direction is all lateral that means the fragment is not fixed well with the screws they are not perpendicular to the fracture and hence it has ended up in this complication.

[00:39:56]Sir this is the significance of that classification where they recommend in type one your position of the screw has to be anterior to the posterior.

[00:40:06]>> You you do not know okay when there is a vertical fracture you got to be at 90° to it. You need a classification for that.

[00:40:12]>> So CT based classification carry on.

[00:40:15]>> So for type two your position of the screws has to be posterior to anterior.

[00:40:21]And in type three you require a additional plate apart from screws. You can pass it anterior to the posterior or posterior to the anterior. Now what happens or what has happened in this particular case is if the hoofas fragment is less than 10% of the AP diameter then you cannot reach with even with the postrolateral approach.

[00:40:47]If it is 20% probably you may reach that hofas fragment and if you're not able to reach then you must use a combined approach. So this is the surgical approach which one must practice. A medial parapetellular approach will give you a exposure lateral and medial parapateral approach will give you exposure of the condile in this area. A medial subvastus up to this area. And for the the type two fractures you have to do either a direct medial approach or a direct posterior approach. Then only you will be able to hold the screw hold that fragment and fix it. Well, the direct lateral approach what was required for this patient was uh a direct incision identify the lateral poplial nerve retract them and you are directly on the lateral condile to have that fixation.

[00:41:48]So my time is up and that those are the conclusions which we could derive from all the literature what was available.

[00:41:54]Thank you very much.

[00:41:55]>> Thank you. [applause] >> [music]