9. Classification
Type Su
I Fracture proximal to
prosthesis
II Fracture starts at
prosthesis & extend
proximally
III Fracture distal to flange
of prosthesis
10. Classification
Type Felix - Classification
I Fracture of tibial plateau involving implant bone interface
II Fractuer of meta / diaphyseal transition
III Fracture distal to tibial component
IV Fracture of tibial tuberosity
Subtype
A Stable implant
B Loose implant
C Intraoperative fracture
11. Classification
Type Goldberg Classification
I Fracture not involving implant bone interface or
ext mech.
II Fracture involving Implant bone interface or
extensor mech.
III A - Fracture inf pole of patella with patellar lig
rupture
B – Fracture inf pole patella without patellar lig
rupture
IV All Types of fracture Dislocations
14. Management
• Stable joint without significant malalignment
• Uneventful and complete fracture healing in
6 months
• Range of motion & Knee function prior to
trauma
16. Management
Surgical options – Conventional Plate & Screw
• Indication
• Technique
• Advantages
• Disadvantages
-Displaced
-Minimally Comminuted
-Good Bone Stock
-Lateral Approach
-Minimal periosteal stripping
-3 screws in distal fragment
3 screws in proximal fragment
Augment with bone graft /
cement
Anatomic
reconstruction
Rigid fixation
Early ROM
Osteopenic Bones
Do Not work
High incidence
Non union
Malunion
Mechanical failure
17. Management
Surgical options - Locking Plate
Mainstay of managing these fractures
Indication
Technique
Advantages
Disadvantages
Lateral approach
Anterior approach
Polyaxial locking screws
Internal fixator
Bicortical fixation
Pull out from osteoporotic bone
Fracture reduced independent of plate – mal-aligned
Osteoporotic bones
Biomechanically Superior
Better Distal Fixation
Far Cortical Fixation
Reduced Construct stiffness
Retain strength
Symmetric callus
Bottlang et JBJS 2010
18. Management
Surgical options - Supracondylar IM nail
• Indication
• Technique
• Advantages
• Disadvantages
-Displaced
-Markedly Comminuted
-Open Box implants
Med. Parapatellar app.
Open with awl
Minimal stripping
Fracture haematoma undisturbed
Load Sharing Device
Reaming stimulate healing
Closed Box implants
C/f – very distal fracture
19.
20. Evidence
Surgical options - Locking Plate
• Better ROM VS IM nail
Johnson et al Knee 2011
• Lower Malunion rate
Ristevski JOT 2011
• Lower Nonunion rate
Althausen etal JOA 2003
• Extreme distal Fracture
Streubal et al JBJS 2010
21. Evidence
Surgical options - Locking Plate
• Inconsistent and asymmetric Callus Formation
Lujan et al JOT 2010
• Nonunion rates – 28 %
Henderson et al CORR 2011
Boulton et al 2011
Gross etal 2011
22. Evidence
Compare locking plate & Nail
Case
reports/Series
No Trials
Large et al
Locking plate
better – ROM
No non union
No Difference
24. Management - Algorithm
Periprosthetic Femur fracture
Open Box Design Closed Box Design
Stable Implant Loose Implant Stable Implant Loose Implant
Type I - II Type III Type I - III Type I - II Type III Type I - III
ORIF/CRIF
Locked plate
/
Retrograde
nail
ORIF/CRIF
Locked plate
/
Revision
Revision
Arthroplasty
Revision
Arthroplasty
ORIF/CRIF
Locked Plate
ORIF/CRIF
Locked plate
/
Revision
25. Management - Algorithm
Periprosthetic Patellar Fracture
Type I
Type II Type III
Exten
Mech.
Exten Mech
Intact
Implant loose
Intact
Conservative
Component
Remove &
reimplant after
bone healing
Exten Mech
Rupture
Implant stable
ORIF
A
B
Loose Stable Loose Stable
Explant
& recon
Recon/
SOS ORIF
Explant Conserv
26. Management - Algorithm
Periprosthetic Tibial fracture
Type I Type II Type III
A B
B A A B
Conservative
Change
Component
ORIF/CRIF
Lock Plate
Change
Component
+ORIF