ZIMMER MIS PERIARTICULAR LOCKING PLATE PROCEDURE UNIVERSITY OF WASHINGTON SEATTLE, WASHINGTON November 6, 2006

Transcription

1 ZIMMER MIS PERIARTICULAR LOCKING PLATE PROCEDURE UNIVERSITY OF WASHINGTON SEATTLE, WASHINGTON November 6, :00:04 PAUL J. DUWEILIUS, MD: We re live from Seattle. I m Dr. Paul Duweilius, orthopedic surgeon at the Orthopedic and Fracture Clinic in Portland, Oregon. Dr. Robert Winquist is with me here. He s clinical professor at the Department of Orthopedic Surgery at the University of Washington Medical School. 00:00:26 ROBERT A. WINQUIST, MD: This is Dr. Robert Winquist, and I d like to introduce my assistant, Tom Hummer. And also, Tony is kind enough, from the Zeem Corporation, to bring a machine and help us with the fluoroscopy. 00:00:41 PAUL J. DUWEILIUS, MD: I would just -- for the participants, feel free to questions throughout the webcast. Dr. Winquist, could you introduce you ve introduced our OR team? 00:00:49 ROBERT A. WINQUIST, MD: Yes. 00:00:51 PAUL J. DUWEILIUS, MD: All right, so we are set to go. We re going to do the plating principles and the rationale of the plating and lock plating, basically how we got here. Predynamic compression plate. Lambotte in the late 1800s described these clamps and actually came up with an initial plate concept. Sherman in 1912 furthered up on these ideas, and these were made popular later by the AO Group. George Bagby at the Mayo Clinic in 1958 actually came up with these diagrams and with this concept, and this was adopted by the AO and popularized by Muller s group. The new concepts, and we ve worked with these up at the University of Washington and come up with a bone scanning technique, and the plate actually fits the bone. And you can see here on the left side a contoured plate for the proximal tibia, as opposed to one which really isn t contoured. And how we got there was scanning technology and utilizing the bones up at the University of Washington Medical School. And this is what s evolved, and then the next step basically is the locking plates. So Bob s going to give an example of a supracondylar femur fracture with a locked plating. Bob? 00:02:25 ROBERT A. WINQUIST, MD: We actually are doing this on a cadaver, and we want to demonstrate the techniques and show you how to do the percutaneous minimally invasive, and then I ll show you how to open it up wider to see what you need to see to reduce the fracture and to put the plate on properly. So I m going to use a marking pen here just to orient you. And the patella is here in front, and we then have the tendon coming here. And you can see this specimen is thinner than a lot that you see down in the Midwest. I m going to come from down by the tubercle, and our incision potentially would come mid-condyle, and then if needed would continue up proximally right along the mid-femoral shaft. We ll start with a small incision and show you how to slide the plate in with the percutaneous jig, and we ll then extend that so you can see this process a little bit better. I m palpating the

2 join line just at the point you d put a scope in the knee, and we ll make an opening incision. Right up at the top. I m going to open the fascia a little more. And we ll place a rake in anteriorly. And now I m going through the fascia. And this will take me down to the femoral condyle. So that s taken us down to the femur. And I think you can just see the anterior border as it goes into the joint right here. And just a little look into the joint. And it s really important that you see this edge to be sure you properly position your plate. We ll then open this fascia just a little more because I also want to get the plate posterior enough so it isn t misplaced anteriorly, and so I m just freeing it up posteriorly a little bit. To do this percutaneously, if I could have camera one widen up. Zoom out with thank you. So then I have a chauve [sp?] elevator, and I ll slide that down to bone. And I think it s nice to pass it first. So I put it in this direction to start, and once I get on the bone I m going to turn it around the other direction to slide it up the shaft. 00:05:52 PAUL J. DUWEILIUS, MD: So you really recounter very little resistance there, Bob. 00:05:55 ROBERT A. WINQUIST, MD: There s very little resistance, and this is pre really easy to do on a routine basis, so -- in the femur and the tibia. Once you get the fascia open so you saw how I opened the fascia right here to be able to get it started, and after that it goes really pretty nicely. We re then going to look at this jig, which allows you to do it in a minimally invasive pattern and percutaneously. And obviously you have to have the fracture reduced to do this, so it s important that the fracture be reduced. It s all-important, and if you have to open it more, keep opening it until you get the fracture reduced. And it s important to get the intraarticular portion reduced but not necessarily the metaphyseal area where we try to preserve that. So I m going to slide this plate in. And if I may have a C-arm image. Can you see that okay? 00:07:04 PAUL J. DUWEILIUS, MD: That looks great, Bob. 00:07:06 ROBERT A. WINQUIST, MD: If we can go proximal with the C-arm. And we ll see the tip of the plate. And I ll go up a little higher with the C-arm. And right there. And if I may have live fluoroscopy. Tell me when you re ready. And we just continue to slide do you have live fluoro, Tony? There we go. Okay. So now you can see that sliding on up. And we ll go back to camera one. And on camera one you can see the jig here and you can see the plate sliding up under the skin. And I m going to slide that to a point. And I want you to come back no, that s fine, camera one s okay. It s important to make sure this fascia is free and that you re inside the fascia. So I was on top of it a little bit, which will give you problems. And Matt, I need this light adjusted. I need a little better light down here. Thanks. Good. Thank you. Okay, so I got underneath the fascia, which is critical to make sure that your positioning is okay. And up at the top again, if we can see that with the fluoro. 00:08:35 PAUL J. DUWEILIUS, MD: Bob, can you show them where you are in relationship to the anterior border of the distal femur? 00:08:41 ROBERT A. WINQUIST, MD: To the distal femur 00:08:42 PAUL J. DUWEILIUS, MD: Just with the rake. Right. 00:08:43 Sorry. The distal femur, camera one, is right here. Is that what you want to see? 00:08:48 PAUL J. DUWEILIUS, MD: Well, just if you can put a rake so that you can see the actual plate. 00:08:54

3 ROBERT A. WINQUIST, MD: Down here? Sure. We ll put a rake back in. And then here s our femur 00:09:01 PAUL J. DUWEILIUS, MD: That s beautiful. 00:09:02 ROBERT A. WINQUIST, MD: -- right along here. And pull just a little, Tom. There you go. And come over my shoulder just a little more here if we can with camera one. 00:09:15 PAUL J. DUWEILIUS, MD: Yeah, that s great. 00:09:16 ROBERT A. WINQUIST, MD: And I m going to show you that even better as we go to the other plate that s open a little more. So here s the border right here. You can see my plates just lined up with it. Can you see that wall, Paul? 00:09:28 PAUL J. DUWEILIUS, MD: Yes, perfect. And with that small an incision, you you re where you want to be. 00:09:32 ROBERT A. WINQUIST, MD: Exactly. So if you have a supercondylar fracture without an intraarticular extension, this is enough. If the intraarticular portion needs to be fixed first, you obviously have to open it more. And now take the rake out again. And you can see proximally with the C-arm that our plate looks pretty good. And now we re going to go to the lateral view. Just one second. Go to the lateral view. I m going to I m going to put a bump under the distal femur. May I have camera one? And move up proximal. I m going to put a bump here which actually helps reduce the fracture, and it also will help us see a little better here proximally. Now, may I have an image lateral? And we ll probably have to flex the femur a little more to see this. No, you can see it there. Go just a little further proximal, and let s see that. You see how I m off posterior a little bit? And now I m going to move it up and shoot. See how nicely it s placed? So this is a really critical step. And the other thing is that I have almost a pier lateral. So you can see the holes are round in the plate. It s just like targeting a nail: you want round holes to tell you that you have a true lateral picture of the plate. And I m going to do live fluoro for a moment. Tell me when you re on. And you can see how nicely you can see it. And now when I do this, you see the jig, and the jig you can see through really well also, which is really important doing these percutaneous techniques. Come down distal a little bit. And I ll move my hand out of the way. And then shoot that. And again, you can see that all the way down. Come down a little more. And shoot there. Okay? So now, other view, AP, and back to camera one. Now, I m going to go to a different plate in a moment here, or a different jig, but if we were using this jig through the whole procedure, we d go ahead and put a pin at each end, check fluoro again. May I have an AP fluoro down distally? Single shot. And on this view I would slide and tell me when you have live fluoro you d move this up and down until it has the best possible fit. And Tony, will you rotate this way just a little? That s probably enough. Shoot. A little bit more. See how he s rotating that C-arm? He s trying to show me the worst possible picture, and that s a really critical step. Is this camera over here live? Is this camera two over there? 00:12:57 PAUL J. DUWEILIUS, MD: Yes, that s camera two. 00:12:58 ROBERT A. WINQUIST, MD: Let s see if we can capture that on camera two. This is really an important step. You re going to look at this angle. Pardon? Right here. Show the C-arm. And you have that on camera two? There you go. Okay, rotate the C-arm, Tony. Up and down a little bit. Other way. He s rotating that to try to get a true picture so we can see the worst possible alignment to move this plate up and down. Thank you. Okay, we ll go back to the C-arm image. And now -- tell me when you re live, Tony rotate a little. There. Stop. See how that image? Little worse. I m going to move this up a little. Shoot. And shoot. And you

4 can see how nice a fit I have now. So these precontoured plates, a lot of work went into making a good fit. And you can see this bone that we ve never seen before, it fits very nicely. And we ll see how the tibia fits, but it ll probably fit very well, too. Okay, let s go back to camera one. And straight up and down, Tony. And back up just a little bit, Tony. 00:14:15 PAUL J. DUWEILIUS, MD: Bob, are you going to take that out? Before you take that out 00:14:16 ROBERT A. WINQUIST, MD: Yes. 00:14:17 PAUL J. DUWEILIUS, MD: Can you can you show me your tricks for the minimally invasive technique when you want to get your proximal pin in and what s your ideas on that? 00:14:28 ROBERT A. WINQUIST, MD: When I want to get a proximal pin in? 00:14:30 PAUL J. DUWEILIUS, MD: Yeah. How s easy it for I can I have trouble struggling doing it just through a stab wound. 00:14:36 ROBERT A. WINQUIST, MD: Well, I m going to come to that with the other plate. So what he s saying is let me have a sleeve up here. So here s a sleeve. And I need to widen up camera one. Bring some light here. Here we go. So here s a sleeve, and that goes down to bone. There s a trocar, and it s going to come into the sleeve so I can use it to get through the fascia after I make an incision, and then I can get a pin in that way and check it with fluoro. But I ve seen so many mistakes with this. I would really encourage you to make a short incision, be absolutely sure the plate is on bone proximally, or at the end of any locking plate before you proceed. So you can do this through a stab, but I think you re smarter to open it up, and we ll do that in a minute on a regular plate. Be absolutely sure it s on bone before you proceed. Did that answer that, Paul? 00:15:43 PAUL J. DUWEILIUS, MD: Thanks a lot, Bob. Yeah. 00:15:46 ROBERT A. WINQUIST, MD: I m going to take this plate out. And I ll take one with a metaphyseal jig. So here s one if you re doing an open technique is this metaphyseal jig, and it just goes right on the plate and it makes you a little easier to find the holes. I frequently don t use this because it s a little hard to see and it s a little bigger. And I usually put it on a second plate on the back table so if I m having any trouble with an angle May I have a sleeve, outers? Stay here. What happened? I need camera one back -- if I m having trouble with an angle, I can put this in on the back table and I can look at that and see what the angle is. And so I don t use the metaphyseal jig in surgery as much; I use it more on the back table to find an alignment if I m struggling. Any questions about that, Paul? 00:16:48 PAUL J. DUWEILIUS, MD: No, I like that idea. I mean, the jig works great, but if you don t need it and you just use it as a template on the back, that s that s nice. 00:16:55 ROBERT A. WINQUIST, MD: I m going to open this a little more now so you can see better. 00:17:05 PAUL J. DUWEILIUS, MD: So if it s intraarticular, Bob, while you re getting your exposure, do you just use lag screws and try to get the T-condylar or the Y-condylar fragment reduced and then put the plate on? 00:17:15 ROBERT A. WINQUIST, MD: Yes, and in a second when I open this I ll even show you that a little better, I think. 00:17:23

5 PAUL J. DUWEILIUS, MD: And I know you guys at Harbor View have written about how tough it is to identify a Hoffa fracture. 00:17:29 ROBERT A. WINQUIST, MD: I think that should all be CT-scanned to look for the Hoffa. The incidence is high and you d like to know that pre-op. And I m going to go proximal a little more, open the fascia. That ll probably give us enough of a view. A rake back in? Now you can see the front of the joint, and now we can see across get a blue towel here. We re inside the knee. I m just opening up the fat pad a little. And can we bring camera one over my shoulder just a little more? And as I open that up Do you have an Army retractor or a Sofield on the table? I don t see one. Army-Navy. One. 00:18:55 PAUL J. DUWEILIUS, MD: That s nice. 00:18:56 ROBERT A. WINQUIST, MD: Now you can see across to the other condyle. You can see a T- component. You can reduce that, you can clamp it. I didn t Do you still have the linear bone clamps around? I ll show you one of these that works nicely. Little wider on camera one. Wider angle on camera one. 00:19:30 PAUL J. DUWEILIUS, MD: He wants to see the clamp. There you go. 00:19:32 ROBERT A. WINQUIST, MD: This clamp works in a linear fashion, so it really reduces the fracture nicely. We just make a stab wound on the far side and compress it, and that will hold your fracture while you fix it. 00:19:48 PAUL J. DUWEILIUS, MD: That works great on the tibial plateau as well. 00:19:50 ROBERT A. WINQUIST, MD: Right. So here s our opposite condyle. We can reduce it, we can fix the T. And I actually use 4.0 screws with small heads and just bury them in the bone a little bit and put the plate right over them, so that way they re not in your way. Don t use large 6.5 screws. You don t need it. We ll take this out now. And now we re going to use the plate with just these sleeves on it. So I ve taken the metaphyseal jig off, I ve just put sleeves on, and that s the way I find I use it most often. And you can see we still have a fairly short incision, but it s not really truly percutaneous. We ll slide it in. We ll slide it up the femur. I m picking up that fascia again so I don t trap it under the plate. That s really important. And now I can get that plate right on the condyle, right where it needs to be. 00:20:52 PAUL J. DUWEILIUS, MD: Bob, can you kind of talk about a starting point if you were going to use a blade plate, because it really applies here. 00:20:58 ROBERT A. WINQUIST, MD: A blade plate starting point is right here. Can I have camera one? Right here. So here s a blade plate 1.5cm up from the joint right here, and this plate is going to come down in just the same region. And it ll be just a little distal to that with a distal end. 00:21:16 PAUL J. DUWEILIUS, MD: And if you were going to do a Hoffa fracture, you d be directing your screws right from front to back 00:21:22 ROBERT A. WINQUIST, MD: From anterior to posterior. I would have put those in before even putting the plate in the in the bone. 00:21:29 PAUL J. DUWEILIUS, MD: Same old 4.0 screws you use? 00:21:31 ROBERT A. WINQUIST, MD: Same.

6 00:21:32 PAUL J. DUWEILIUS, MD: Okay. 00:21:33 ROBERT A. WINQUIST, MD: Now I m wider on camera one I m palpating the top of my plate here, which you d normally just find with fluoro, to see where it s located, and I m going to make an incision up there to make sure it s in good position. And again, we ve been gifted with a thin individual here, and I understand that makes things a little better, but it does help you see. And we ll put a rake up there; this one s fine. And I m going to dissect my muscle off the fascia and go under the muscle. And come up on the bone. Didn t quite get it free. 00:22:37 PAUL J. DUWEILIUS, MD: So again, you ve checked it with x-ray, and you know you re lateral, and you re good on the AP and the lateral. And in this way, by making a little bigger incision, you can always visually verify it. 00:22:48 ROBERT A. WINQUIST, MD: Right, which I think is frequently a little safer. I m having a little trouble with my elevator, so I m going to do this with a knife. 00:23:05 PAUL J. DUWEILIUS, MD: Again, audience, feel free to any questions. 00:23:12 ROBERT A. WINQUIST, MD: Hohmann. Just placing a Hohmann. Hold that. Slide the plate up. And here it is. And now come up top with that camera. Let s see if the boom will show that to us. Here s our plate yes, very nice here s our plate on the bone. We re sure we re centered. I m off the front, I m off the back, and now we re centered. So I think that s an important step and I usually check that. Let s take this out for a minute, Tom. 00:23:59 PAUL J. DUWEILIUS, MD: I ve just seen cases where there s a stab wound and the plate s too anterior, off the cortex, or vice versa. 00:24:05 ROBERT A. WINQUIST, MD: Too often. You see it too often. I ll take a pin. And the technique I like to use I always say it s pin-pin-lag-lag-lock-lock. So I put a pin at each end and check it, and then I lag each end to bring the bone to the plate, and then locking screws are the very last thing. So Tony, if I can see down at the knee again. And may I have fluoro? 00:24:30 PAUL J. DUWEILIUS, MD: There s a couple comments here. The patient is not alive, okay, so we re working on a cadaver specimen. And Bob, they wanted some more definition of what a Hoffa fracture was. 00:24:47 ROBERT A. WINQUIST, MD: A Hoffa is when the condy just one second, let me look at this fluoro a second and make sure I m in a good position. And that looks pretty good. Rotate a little more, Tony. There, I think I m in pretty good position. A Hoffa is when the condyle is split in this plane, so instead of the T in this plane, it s split in the opposite plane and either the medial or lateral condylar is split in half. 00:25:16 PAUL J. DUWEILIUS, MD: So it s really what s really displaced is usually a posterior fragment. Twenty-five to thirty percent of the time they ve been missed, so it s a big thing to get a CT scan on these because if you miss them it s very poor prognosis for the patient. 00:25:35 ROBERT A. WINQUIST, MD: Okay, maybe I have camera two again? Or one, I mean. And widen up. There you go, thank you. I m going to put a pin in distally. So I m going to place this pin in the bone, through the sleeve. I m checking once more. My plate s in good position. And I m going to put a finger over here. And that feels just right. This driver is a D

7 driver, and tighten up here, if we can see this. Give me a little light here, Matt. This just lines up this arrow It s hard to see. There it is! it lines us with a flat on the pin, so it tells you how to put it onto the pin, and it makes it a lot easier to put it on and off. And now we ll put in our Hohmann. And I ll take a sleeve. And I ll take the boom camera. Come up straight, Tony. 00:26:41 PAUL J. DUWEILIUS, MD: Now while 00:26:43 ROBERT A. WINQUIST, MD: And I want the view with the boom up here. Light up here, Matt. 00:26:48 PAUL J. DUWEILIUS, MD: While he s getting the proximal pin, the fracture is going to be reduced, and there s instruments you can use to reduce the fracture before he commits himself to the proximal pin. 00:27:01 ROBERT A. WINQUIST, MD: Now, you can see my plate slid off the bone again, so I need to get it back up. And I have it right here. And now we re back on the bone. Straight up in the air. Give me the T. Yeah, thanks. Okay. I m going to put in a guide up proximal, and then find that center of the bone, and we re ready to put a pin proximally to make sure everything is good. And I usually just go through the near cortex in case I need to adjust something. Take the Hohmann out. Show that to us on fluoro. There s our proximal pin, unicortical in case we have to reduce the fracture, so we don t bend or break the pin. Come distally. Hand me a free pin. Free pin. Clear down at the knee, Tony. And shoot. You can see how nicely that pin parallels the joint. And this is what I like about fixed angle. I don t like variable-angled plates because this plate tells you if you re reduced properly, and it tells you if everything is lined up. We know the plate is correct, we know the pin is correct, we know that everything is where it s supposed to be before we proceed, and this is absolutely critical. So this is the pin-pin step, and if this isn t right, you re going to have problems. And redo it right now. Don t go ahead until you have this done. So we ve checked it proximally, we ve checked it distally. We would check in a lateral, and then we re ready to move on. So I m going to put a pin here, Matt. I m going to now put one more pin in. Leave these pins until the end so things don t come loose on you while you re working. And I m going to put a pin through here. X-ray, fluoro. Live fluoro. Good. So now we have a pin here and we re ready to measure. Camera one. And you can see the measuring device. I m sorry the light isn t too good, but it s going to measure 80. The T handle. I m going to take out the sleeve. This is the lag phase now. We re going to lag the plate to the bone. So we re not ready to put in locking screws yet. This screw is conical in shape. It has a con it s smooth, it s a cone, and it doesn t have threads, so it s simply a lag screw to lag the two fragments together and the plate to the bone. And always take the screw in your hand and put it on the pin instead of putting it on power first. It s just easier this way. And now it s ready to go. We ll slide the cannulated screwdriver over, we ll put the screw in, and watch this. As it goes down we stop short of the plate, I ll pull out the pin, and always finish it by hand. And this now is going to pull the plate down and give us stability. So now everything is nicely locked there. We ll then put our Hohmann back in. And Tony, if you can come way up high here just for a moment. And may I have a Sofield, small Sofield? I m going to put a lag screw at the top now, and I might put it closer to the fracture. I want to get a come down here, Tony. Take that out. Come down about here. And we usually put a lag screw down closer to the fracture to pull that shaft in if it s displaced. May I see the fluoro a moment? And there we go. So I can put a lag screw in there, and I ll choose to do it right Shoot. Shoot. -- And we ll do it right there. And I ll take a sleeve. And we ll just slide this here down to bone. And let me have a regular sharp sleeve for a 3.2 drill out of the standard set. 00:31:55 PAUL J. DUWEILIUS, MD: Yeah, the problem with the percutaneous technique is you do get a little tissue and it gunks up the threads.

8 00:32:03 ROBERT A. WINQUIST, MD: Find that. Instead of a green sleeve. Do you have the basic instruments up there or not? 00:32:07 ASSISTANT: No, sir. 00:32:09 ROBERT A. WINQUIST, MD: It doesn t matter. I m fine. I m sorry, he didn t have a basic set there, so I m just going to put this in. I d usually put a sleeve in to drill to make sure I m properly positioned. So we re going to drill this. And I m going to take a screw. And this is going to measure So now we re lagging the plate down to the bone. We haven t done any locking yet. We re going to lag this down to bone. And I m just going to put this standard 4.5 screw in, and the purpose of it is to stabilize everything before we start locking. If you wanted to compress a fracture, if you want to lag a fragment, that should all happen before you lock. 00:33:27 PAUL J. DUWEILIUS, MD: Bob, I have a question from the audience. 00:33:29 ROBERT A. WINQUIST, MD: Yes. 000:33:30 PAUL J. DUWEILIUS, MD: If you re using this system for the first time, could you have a Zimmer rep come to your OR and help you with the case to show you the instrumentation? 00:33:37 ROBERT A. WINQUIST, MD: I think it s better to have them for about the first ten times to help me, or if not, I like to have them help the scrub techs, so I think it s extremely helpful. 00:33:46 PAUL J. DUWEILIUS, MD: I echo that. To help them with the scrub the scrub tech so that I ve got a slide that shows a pile of junk on the back table and all of a sudden the Zimmer rep has it all assembled, ready to hand to the surgeon is invaluable. 00:34:03 ROBERT A. WINQUIST, MD: Camera one. I ve just put a sleeve in. Now I m ready to lock. I pinned it, I checked it with x-ray, I ve put in my lag screws, the plate and bone are together, and I m now ready to lock. And so this is I call the Indy 500 part, where we just start putting in locking screws. We ll drill. We ll measure. And 80, :34:32 PAUL J. DUWEILIUS, MD: See, Bob s really excited now because he knows the rest of the nation is watching the Seahawks on Monday night football down the road. 00:34:42 ROBERT A. WINQUIST, MD: And a lock screw. I didn t put it on power; I took it by hand. I slide it over the pin. It saves you a great amount of time. And we re then ready to lock it down. I m going to stop short. Don t put these in by power, don t finish them by power; you ll cross-thread, and particularly with titanium, which has a terrible problem with crossthreading. And I don t use titanium at all, but if you do, don t power it in all the way. 00:35:16 PAUL J. DUWEILIUS, MD: Yeah, the Minneapolis group has quite a series on problems. I know Dick Kyle and Dave Templeman have had problems removing titanium Caldwell screws on these locking plates. 00:35:29 ROBERT A. WINQUIST, MD: So I finished it by hand, it s tight, but when I finish the case I m going to come back and retighten everything. Now, I think in the interest of time what I normally would do now is put about four lock screws here. May I have a little wider on camera one? A wider shot. Thank you. I usually put a non-lock screw closest to the fracture, then a lock screw next, a lock screw at the very end of the plate so you want to spread your screws out and for good luck I add one more in the middle. So there s not full

9 agreement on how everybody thinks you need two spread apart, and it s not clear if you need one more. You probably don t need two more. So if I could take any other questions on this, and then we ll move to Paul doing the tibia, and I think we re all set. Any other things you want me to show, Paul? 00:36:28 PAUL J. DUWEILIUS, MD: No, I think that s great, Bob, and I think time-wise, we ll just go ahead with the proximal tibia. And then if we have that ll give us question time. I ve got options for case reports, case examples. So, any questions from anybody, just keep ing them in. Bob s going to take that plate off. But I think the real indications are to, you know, for these plates are to prevent collapse, osteoporosis, and metaphyseal comminution. I mean, these are pretty pretty relative indications, or absolute indications for lock-plating now. An example of preventing collapse with a traditional plate, you don t get the fixed angle device, and you ve got problems like this. And these are the fractures that you have, the Hoffa fracture, and you can see posteriorly there s a lot of comminution, and so I know there was a person in the audience that had a question about that. And then metaphyseal comminution, again, you want to fix the joint. This was stabilized with an x fix and then addressed later in the OR with a graft. You can see a screw from front to back, a 3.5 screw. That would be the Hoffa fracture, and a small, very small screw that would be addressing a Hoffa fracture, again. So here you can see a proximal tibia fracture treated with a locking plate, and then a supercondylar fracture that ultimately healed because it was done relatively percutaneously, and the joint looks very nicely restored. So again, you don t have to anatomically fix all of the these fractures. And then osteoporosis, huge problem at our center, and we re certainly seeing more and more of these fractures. We re seeing periprosthetic fractures, so that s that s the deal here. I ve got some questions here. I guess the question that s the million-dollar question is when would you go this way, the open technique, I m assuming, versus the guided technique? I think it s nice to try to do the minimally invasive technique on a fairly straightforward fracture initially. And as you gain your confidence, your OR team gains these, you know, the equipment, they get familiar with it, then it s easier to do. And I see the Hey, Bob, there was a question on the whirlybird. Do we have that? 00:39:07 ROBERT A. WINQUIST, MD: We do. May I have that, Matt? 00:39:09 PAUL J. DUWEILIUS, MD: That s a great question. 00:39:10 ROBERT A. WINQUIST, MD: The reason this all went so nicely is because Matt Elliot, the Zimmer rep, is working behind me here, and I want to thank him for thank him for doing a great job. He s hooking up the whirlybird right now. 00:39:20 PAUL J. DUWEILIUS, MD: And then this is a case of an osteoporotic fracture. This is one of Bob s cases. So the changes that have evolved, I think, and in answer to that last question about when do you use the minimally invasive, I think that s an evolutionary thing. You ve got to have the reduction. If you re going to sacrifice skin incision for an inadequate reduction, that s a bad idea. The precontoured plates and the locking plates, I think this is a huge advantage over the variable-angled screws because you know that your screw positions are good if the plate fits, it s low-profile. And again, if you can do it percutaneously but not at the sacrifice of the reduction, it s great. And then here s just the percutaneous jig that Bob just illustrated. 00:40:07 ROBERT A. WINQUIST, MD: You ready for this, Paul? 00:40:09 PAUL J. DUWEILIUS, MD: Yes, the whirlybird. 00:40:10

10 ROBERT A. WINQUIST, MD: This is the whirlybird. If I could have camera one. So the whirlybird: you first put a sleeve into the plate. Tighten up a little bit and zoom in. Matt, help with light a little. No problem. Okay, zoom in tighter. All right. Thank you. I m going to screw this into the plate, then I m going to drill and put this threaded pin it s a little hard to see into the far cortex. And then yes, there s the threaded pin and I will have put this into the plate. This goes through it. I lost some light here, just got bumped. Thank you. This goes through it, and then we put this across the bone, and then widen up your shot a little I just tighten this handle down and it just pulls the bone through the plate. So that s called the whirlybird; it s another way to lag the plate to the bone. Thanks. So Paul, are you ready to come and do 00:41:24 PAUL J. DUWEILIUS, MD: That s actually an example of the whirlybird on the screen there that Bob s pulling right to it. 00:41:31 ROBERT A. WINQUIST, MD: Are you ready to come over and do the tibia? 00:41:32 PAUL J. DUWEILIUS, MD: I am. Nice job, Bob. 00:41:34 ROBERT A. WINQUIST, MD: Well, thanks. I got lucky. We re lucky to have Tony here, who s an x-ray tech extraordinaire, and the Zeem company was kind enough to bring that along. 00:41:59 PAUL J. DUWEILIUS, MD: And glasses or gloves? 00:42:01 ROBERT A. WINQUIST, MD: So, are there other questions? 00:42:09 PAUL J. DUWEILIUS, MD: Thanks, Matt. So now we re going to the proximal tibia. And this is a different little bit different beast. So the vast majority of tibia fractures the I s, II s, and III s that just involve the lateral condyle -- would be done open, but the Schatzker V s and VI s, or the ones that extend down into the shaft, I think the minimally invasive percutaneous technique is really, really helpful because you just have so much soft tissue dissection that it just really is vascularly a detriment. So I m going to take the marking pen here, and we re going to dodge Bob s incision here. And I need camera two. Perfect. And the overhead. That s good. So I like to make a hockey stitch incision, so a little bit lateral. I feel the crest, which is very easy in this slender individual, and I come just about 5 to 10 mm to the lateral side of the crest. I don t like to be right on the crest. And then here s the joint that you can clearly see from the earlier incision, and I just hockey-stick it a little bit. Now, if this is an extensive fracture, then you can take it and make it extensile and come all the way up, and it d be just a little bit more posteriorly directed behind Bob s incision. And if you re going to do this percutaneous, we really only need this much of the incision. But again, for most of them we d come all the way down to where you could put your graft in. So we ll go ahead. You re coming right off Gerdy s tubercle. Got a knife here. 00:44:17 ROBERT A. WINQUIST, MD: I m going to take a question while he exposes that. One question is, Do you tend to lean towards unicortical screws or bicortical screws? And in osteoporosis, I think that you should always use bicortical screws. In really hard bone, unicortical is sufficient. Still, probably want to use four screws instead of three if you re going unicortical. Another question is a 3.5 small-plate system exists. And actually, not for the femur but for the tibia, and that s what Paul is going to show you here. So go ahead, Paul. 00:44:51 PAUL J. DUWEILIUS, MD: And a pair of pickups. There we go. Thank you. So I m right here on Gerdy s tubercle, and I m taking the fascia right off of that. This is a very slender patient. And there, you can feel there s the anterior compartment. Thank you. So we ve got

11 camera two looking right at that, cleaning off the muscle. Just coming back here. So. That s really all I need for the small incision. I m going to expose a little bit more up here, get the fascia out of the way because the plate is going to want to fit up here. Just back a little bit. 00:45:57 ROBERT A. WINQUIST, MD: I m going to answer another question while he s working. One is, When would you use the minimally invasive guide, that jig I showed you at first, versus the plate by itself? And I think if you don t have to open things up, you can use the percutaneous guide, but if you have to open it to reduce it anyway, then I frequently use the other guide with an incision up at the end. 00:46:24 PAUL J. DUWEILIUS, MD: Okay, so now, just like Bob showed proximally, I m just going to take this osteotome, come right down along the bone. I m just gently elevating, and I can take it both directions and come down quite a ways. So there s the end of the osteotome, or the elevator. Camera two s got this. So this is the the jig, proximal lateral tibial percutaneous jig. This is the 3.5 jig. We also have a 5.5 jig, so if you prefer to use 3.5 screws or if you prefer to use larger screws, it s dealer s choice. So then just come down here, and that slides on very nice. Everybody see that? So I ve just got to get around the posterior, and like Bob had problems with the fascia, we re going to look. Now, I want to see how this fits with an AP of the fluoro, so fluoro shot? Okay, so I m too low, so I m going to just take a periosteal elevator. I may slide this out to make that easier. I ve got periostium in the way that s And that s important. That was what Bob was 00:47:54 ASSISTANT: Tilt. Yeah. 00:48:04 PAUL J. DUWEILIUS, MD: And I m going to come up just a little bit with the skin incision because I m fighting that. So I took a few more millimeters up here to get proximal. Because again, if the plate s not fitting, then I m going to worry about the fracture reduction. So what I d do right now is come in here, and I d make a little square-centimeter bone opening. There d be an open-book fracture. Typically I don t like to open that; I like to just come in from below and with an osteotome use any kind of an osteo-conductive material to elevate the tibial plateau and get that reduced. And once that s reduced, then I like to come in here with the plate. And I think that ll give us a little bit better on the x-ray. Yeah, see how that fits better? Now we re going to rotate. Another AP. Can still be a little bit. Okay, spot. Yeah, I like that better. 00:49:22 ROBERT A. WINQUIST, MD: Can you show the fluoro on the screen, please? Thanks. 00:49:27 PAUL J. DUWEILIUS, MD: Perfect. 00:49:28 ROBERT A. WINQUIST, MD: Now do it live for a second. 00:49:29 PAUL J. DUWEILIUS, MD: Okay. Go ahead and fluoro. 00:49:32 ROBERT A. WINQUIST, MD: Leave it on fluoro. 00:4(:35 PAUL J. DUWEILIUS, MD: I want to come up a little bit more. And I m going to Yeah, see now I m coming off distally. 00:49:40 ROBERT A. WINQUIST, MD: There you go. 00:49:42 PAUL J. DUWEILIUS, MD: There we go. And I also like using that wide clamp. I find this really helpful. You can come in here and reduce it like that. 00:49:56

12 ROBERT A. WINQUIST, MD: Take camera one. 00:50:00 PAUL J. DUWEILIUS, MD: Everybody see that? Can you widen the overhead boom camera one? Okay. Excellent. So just a stab wound over on the medial side, and I like to put this right up next against the plate. It s basically like having a resident for the case and it doesn t talk back. Because residents always know what s going on and all that stuff. Okay. So now what I want to do is feel, and I can just lift up so everybody can see that moving on the wide shot. Come down, pan out a little bit more. Everybody see me moving that? So I shouldn t need image for this right now, but I would like to make an incision to know exactly where I am in relationship to the bone. And I ve tried to do this 00:50:58 ROBERT A. WINQUIST, MD: Can we have some light down there, please? 00:50:59 PAUL J. DUWEILIUS, MD: I ve tried to do this percutaneously, and I just look stupid. 00:51:06 ROBERT A. WINQUIST, MD: I m going to take one more question while he s working on that exposure at the bottom, and it says, How many locations minimum on the plate you recommend lagging before locking? And I usually lag one screw distally that s in the center of the plate so I can rotate around it, then I lag one just above the fracture site to pull the fracture in, to pull the diaphysis in, and then if the far end of the plate is pulling off bone, I ll put one more lag up at the end of the bone. So two lags at least, one in each end, and a third one, if necessary. And if you want to lag fragments through the plate, you would add as many as you want. Also, if you re going to lag an independent fragment or if you re going to compress the fracture, that should all happen before locking. So go ahead, Paul. 00:51:58 PAUL J. DUWEILIUS, MD: So here I am down here. And everybody can see the end of the plate. So now it s tending to go posterior. So I ve got a little narrow Hohmann in here, so I m not doing too much damage. I made an inch incision. I just don t think that s going to matter for vascularity, and the ideal situation now as I can see it. And with is, it s not as critical. Tibial plateau fracture, unless you ve got a Schatzker VI fracture that goes down, which would be the ideal indication for the percutaneous technique. And we ve seen, you know, two or three of these in the last six weeks at our place, and we really like this plate, so I m going to go ahead and Can I have x-ray again? Okay, now that plate s off a tiny bit distally, but I m going to bring it up. Let s give me let s give it that rotation again to get my maximum live. I like that better. I could be up a tiny bit. 00:53:03 ROBERT A. WINQUIST, MD: Do you want fluoro? 00:53:04 PAUL J. DUWEILIUS, MD: Yeah, fluoro. 00:53:05 ROBERT A. WINQUIST, MD: Can we have fluoro on the screen, please? 00:53:10 PAUL J. DUWEILIUS, MD: There we go. That s pretty nice there. 00:53:11 ROBERT A. WINQUIST, MD: So there he s getting lined up now. 00:53:12 PAUL J. DUWEILIUS, MD: I like that. So I m going to go ahead and put a guide pin in proximally. I m not squeezing hard enough. Here we go. Is that tight enough? There we go. Fluoro. 00:53:43 ROBERT A. WINQUIST, MD: So fluoro on the screen. 00:53:44 PAUL J. DUWEILIUS, MD: Just a little bit higher. Spot.

13 00:53:55 ROBERT A. WINQUIST, MD: So he just moved his plate up a little. 00:53:57 PAUL J. DUWEILIUS, MD: Spot. Yeah, I like that. Spot. Okay. One more. Perfect. And I m going to Now, the nice thing about this is I m only committed on one, so I still got rotation, and you can see now distally can you zoom in distally? you can see that I m nicely centered on the bone. So I ll take a cannula 00:54:24 ROBERT A. WINQUIST, MD: So if we could have camera one on the distal end of the plate, please? Thank you. 00:54:31 PAUL J. DUWEILIUS, MD: Yeah. Well, I don t really need that trocar because I ve already got exposure. Normally a trocar d be nice, but I made the incision, so I want to get this thing out of my way. Okay, so this is too long on this plate. 00:54:50 ROBERT A. WINQUIST, MD: That goes in that next hole up. 00:54:52 PAUL J. DUWEILIUS, MD: Yeah, I m about to go to that next hole up. There we go. 00:54:58 ROBERT A. WINQUIST, MD: So while he puts that in, I m going to take one more question here, and the question: Is there a contraindication to bending a locking plate? And usually we don t like to bend them, and they usually fit awfully well. And if you re thinking of bending it, it usually means you didn t reduce the fracture properly. But if you absolutely have to, it s okay, but if you bend through a locking hole, the threads won t work, so just don t lock that hole. 00:55:27 PAUL J. DUWEILIUS, MD: Okay, so now I got my distal pin in, I did not go by cortical. If you can fluoro that. Okay, so now you can see that my plate s not right up against the bone. And what I d like to do is if you can zoom in here on the jig with camera two, you can see that these slots are oblong, and that s going to allow me to put in just a regular compression screw, and I d like to do that right now because I haven t locked up top or distally, I ve just got pin-pin technique. So I want to lag it, but I want to lag it in the center of the plate because I ve got a 3 or 4-mm gap. If you can come up just a little bit with fluoro, and I want to see ideally which lag screw I d like to put in. Anywhere in the middle there will suck that plate down. And I don t need a whole bunch of screws, and the only reason I with the trocar. So now we re doing this percutaneously. 00:56:25 ROBERT A. WINQUIST, MD: Can we have camera one? Thanks. 00:56:27 PAUL J. DUWEILIUS, MD: So now we re coming in. Can everybody see that from camera two? Sorry, camera one. I m not seeing them. Thank you. Knife. What are we doing for standard screws? 00:56:50 ROBERT A. WINQUIST, MD: Matt, will you switch knives? That knife s gotten a little dull. 00:56:55 PAUL J. DUWEILIUS, MD: Thanks. Beautiful. Just a regular cortical screw would be great. Want to take a little spot of that, okay? That looks seated nicely. Matt, do you have one more sleeve? I ve got to have a 3.2 sleeve in here. That s too big. I ll just drill it. It ll be okay. Depth gauge? Fluoro? Okay, fluoro. Yeah, I didn t have the exact cannula. It s one size bigger, but this will work. And I d like, like, a 38. Okay. So anyway, then the idea is to get you ve got proximal control, distal control. You can bring the plate down now without you know, before you ve done any kind of lagging. Spot. I m just outside. Hold on. All

14 right. Something s not right. I ve got tissue in here. Hemostat. Or this ll work. And that trocar again. Thanks a lot. Fluoro. All right, so I m just a little Can I have that drill back? 00:59:36 ROBERT A. WINQUIST, MD: While he puts that in I m going to take another question here. And one question is, Now that we have locking and nonlocking plates, what s the percentage of using locking plates versus using nonlocking? And I find that routinely in the femoral fractures I use locking fractures virtually all the time, and in the tibia with a split or a split depression, I use nonlocking plates, and then if there s osteoporosis, comminution, bicondylar plateau and shaft, proximal tibia, then I use a locking plate in those indications. 01:00:14 PAUL J. DUWEILIUS, MD: Spot. So now you can see how that sucked the plate down. 01:00:18 ROBERT A. WINQUIST, MD: Can we see the fluoro on the screen? 001:00:20 PAUL J. DUWEILIUS, MD: So everybody see that? Okay. That s good. So now we can go ahead and do the drill. I can take that screw out later if I need to. So I need another screw because I want to leave this one intact. Somehow I m off up here. I want to come back proximally, take a look at that. X-ray. Make sure that I haven t. Okay, so I m good there. Can I have a I ve got to Can I have a rake here? Can somebody hold a rake right here? Thanks, Tom. And if you can just hold a rake, Tom, right up here. Do you have a smaller one? I ll go ahead and drill. I just need the skin out of the way where I put this because of the fascia s in the way here. And we ll go ahead and Matt, do you have another cannula? So I ll go ahead and put another cannula in here. Thank you. And I put that in on the posterior, so it really shouldn t be in the way, and I m ready to drill. Because I like to leave that other pin like Bob did. And Matt, do you have a 70 screw? Yeah. There we go. And I ll put that on. 3.5 s are a little harder to thread. And this is the first time that I ll commit to locking. 01:02:38 ROBERT A. WINQUIST, MD: So what kind of screw are you putting in now, Paul? 01:02:40 PAUL J. DUWEILIUS, MD: Just a 3.5, conical. 01:02:42 ROBERT A. WINQUIST, MD: 3.5 conical. Why are you using a conical? 01:02:45 PAUL J. DUWEILIUS, MD: Well, I ve got I ve got tissue in here, sorry. I ve got to have that backed out. You know, I don t think it s that important for I just want to get a lag right now because I would probably have compression. I want to get I don t want to commit to a locking screw yet, and then I ll put in a locking screw. Knife, please. And then I don t know if we re going to get this through on a compression. Yeah, that s driver, driver. Let s see. I might have tissue in there. If not, we ll just go to a front screw. Okay. Spot. 01:03:55 ROBERT A. WINQUIST, MD: Go to fluoro on the screen. 01:03:56 PAUL J. DUWEILIUS, MD: Yeah. Now I can take this screw out and I ll put that underhand. Because again, I don t want to get a 01:04:03 ROBERT A. WINQUIST, MD: Tony, tilt a little bit so we can see that better. 01:04:10 PAUL J. DUWEILIUS, MD: See that going on? Perfect. And I ll get that other thread out of the way. Thank you. Is that threading in? Is that going in? Okay. Then I can take this one out. I ll take another 70. Now I ll go with the locking so that if I wanted any compression across the the fracture site, I d get it now that I have compression. Thank you. There we

15 go. Take it out with the T handle; I was struggling. So here you go. Just like this. You got that. Okay. Then you can take it out by hand. These are the screws, about a 70 or :05:07 ROBERT A. WINQUIST, MD: Can you speak up just a little? 01:05:08 PAUL J. DUWEILIUS, MD: Oh, the screws are usually about 70 or 75 in length for a slender patient. 01:05:15 ROBERT A. WINQUIST, MD: So is this a locking screw now? 01:05:17 PAUL J. DUWEILIUS, MD: Yes. 01:05:20 ROBERT A. WINQUIST, MD: And how many are you going to normally put in proximally? 01:05:22 PAUL J. DUWEILIUS, MD: I like to use the raft construct, so three or four. Now, I ve got a mark here, if you can see it, so that I know not to use power. So I can go to there safely without stripping the screws like Bob talked about on the last case, come out, and then insert it by hand. Nice little ratchet screwdriver. Now, x-ray. 01:06:03 ROBERT A. WINQUIST, MD: And we ll take fluoro on the screen. 01:06:05 PAUL J. DUWEILIUS, MD: Fluoro. Okay. There we go. Right there. Now, I would put in two more up here. I have the option for putting in two more up here, Bob, and I also have the option for putting in a screw. I d like to show one like this, if I wanted to, that could come in this way. Do you have the lag? Yeah. 01:06:50 ROBERT A. WINQUIST, MD: So this is a strut screw you re putting in? 01:06:52 PAUL J. DUWEILIUS, MD: Yeah, I can put in a strut screw this way. 01:06:54 ROBERT A. WINQUIST, MD: And that greatly enhances your fixation. 01:06:58 PAUL J. DUWEILIUS, MD: I can put it in that way. That s the one for the locking screw. So right here, and then I just assemble that the same way. And actually, that would be right where I d want to put my that s where I usually would be the hole for my bone graft, Bob. And then the debate is whether to put another and I don t know the exact answer for number of screws down here. I ve got a lag screw down here to try to suck the plate down, I put a lag screw up here initially to reduce the fracture if it s a Schatzker I, II, or III. Or if there s any kind of split component, I like to get my compression first, and I can either do that with a lag screw or with that clamp. And I like to use that clamp directly against the plate. I really feel the tibial plateau fracture is the work horse for this. 01:07:46 ROBERT A. WINQUIST, MD: Could we have the boom camera? 01:07:48 PAUL J. DUWEILIUS, MD: Because I can put it right in the plate right here, and I can get rigid compression of that plate against the bone. I could also put it right here, again, through the same stab wound -- this jig s a little bit in the way, the percutaneous jig and clamp it that way. Can everybody see that from the overhead? And that ll put compression on the plate. Generally I just use it up here. Bob, you got any other ideas for how you use the And the nice thing is that this ll spin Like, if it s like this, then you can rotate it right out of the way, so you can actually see your reduction. So if you have to come in up here to see the joint and again, I use fluoroscopy to evaluate my reduction. And I think that the only I think this is limited. I think the percutaneous jig would be limited to very