EVIDENCE BASED MEDICINE

Presenter: Dr. Saumya Agarwal

Dept of Orthopaedics, JNMC, KLE’S Dr. Prabhakar Kore Hospital, Belagavi

Evidence based medicine (EBM) was originally defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.

Evidence-based medicine (EBM) is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well designed and conducted research.

Evidence-based medicine (EBM) is the process of• Systematically reviewing,• appraising and using clinical research

findings to• aid the delivery of optimum clinical

care to patients.

History

Name :- XYZAge :- 30Sex :- MaleAddress :- BelagaviOccupation :- electrician

Chief Complaints

Pain on right lower thighSwelling on right lower thigh

History of Presenting Illness

H/O road traffic accident with a 4 wheeler and patient was on 2 wheeler, sustained injury over right lower thigh. After the fall, patient was conscious but unable to bend the right knee.

No h/o- loc/vomiting/ENT bleed

Personal history

Diet : Mixed

Appetite : Normal

Sleep : Undisturbed

Bowel & Bladder : Normal and regular

Habbit : no addiction

Past history• No h/o – DM2/HTN/Asthma/TB

Family history• Not significant

Vitals◦ BP: 130/80 mm Hg◦ Pulse: 90 /min◦ Respiratory rate: 26 cycles/min◦ SpO2: 100%

Examination Inspection7 x1 cm CLW present over right distal thighSwelling and deformity seen over right distal

thighNo muscle wastingNo visible scars or sinuses

PalpationAll inspectory findings were confirmedNo local rise of temperatureTenderness and bony deformity present7 x1 cm CLW present over right distal thighRestricted movements at right knee joint

◦Pelvic compression test was negative

◦Chest compression test was negative◦B/L Toe movements +◦Distal pulses were b/l and equally

felt◦Motor and sensory examination was

within normal limits

Pre-op x-rays AP and lateral view

CT- Scan

3-D Reconstruction CT

DIAGNOSIS

Right supracondylar femur fracture with intra-articular extension

CLASSIFICATION

CLASSIFICATION

Neer and associates Stewart and coworkers Schatzker and Tile Seinsheimer AO classification

AO/OTA Classification of distal Femur

AO/OTA 33C2

Internal Fixation Devices

Condylar Buttress Plate

Condylar Locking Compression Plate

Less Invasive Stabilization System(LISS)

Angled Blade plate and lag screws

Retrograde Nailing

Ilizarov fixator with minimal internal fixation

EVIDENCE 1

Option 1 : Small fragment fixation of articular surface+ IM nailing- Useful if the bones are osteoporotic.

Option 2: Small fragment fixation followed by Locking Compression plate. PREFERRED METHOD

Option 3: Condylar butress plate; but there is high incidence of varus collapse; hence not preferred

Current AO Recommendation

Choice of Implant

Article 1

“Stabilization of Distal Femur Fractures with Intramedullary Nails and Locking Plates: Differences in Callus Formation”

J. 2010; 30: 61–68.

Analysed 174 distal femur fractures and cases were then individually matched between IMIL group and Locking plate.

The peripheral callus was measured on lateral and antero-posterior radiographs at 12 weeks in all fractures using validated software.

Callus was measured in anterior, posterior, medial and lateral location

The NAIL group had 2.4 times more callus area than the PLATE group.

Compared to the PLATE group, the NAIL group had 3.4 times more callus anteriorly, 2.6 times more callus posteriorly, and 2.3 times more callus medially.

Significantly less periosteal callus formed in fractures stabilized with locking plates than with IM nails.  

High stiffness achieved with locking plates may limit the amount of callus, resulting in delayed healing or nonunion.

Article 2

RETROGRADE INTRAMEDULLARY NAILING VERSUS LISS PLATING FOR DISTAL FEMUR FRACTURES

Fracture type LISS Group IM Nailing GroupType A 5% 11%Type C 35% 7%

Rate of Non union

FRACTURE TYPE

LISS GROUP

IM Nailing group

Total

Type A 21 31 52

Type C 35 28 63

Fracture Type

Both, retrograde IM nailing and LISS plating are adequate treatment options for distal femur #

Locked plating can be utilized for all distal femur # including complex type C #, periprosthetic # and osteoporotic #

IM nailing provides favorable intramedullary stability and can be successfully implanted in bilateral or multisegmental # of distal femur as well as in extra-articular and type C1 to C2 #

CONCLUDED

Article 3

J Orthop Trauma Volume 26, No. 6, June 2012

“Comparison of the 95-Degree Angled Blade Plate and the Locking Condylar Plate for the Treatment of Distal Femoral Fractures”

Conclusion: Patients treated with locking plates had

more complications and nonunion, requiring more secondary procedures to treat complications and to remove prominent implants

There has been a dramatic increase in use of LCPs reasons being ease of application, ability to gain purchase in a small distal fragment, ability to apply despite metaphyseal comminution, and ability to apply with less soft tissue disruption

Articles 4 & 5

Journal of Orthopaedic Trauma Issue: Volume 25 Supplement 1, February 2011, pp S8-S14“Locking Plates for Distal Femur Fractures: Is There a

Problem With Fracture Healing?”

CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Volume 469 (2011), 1757-1765,“2010 Mid America Orthopaedic Association Physician in

training Award: Healing Complications are common after Locked plating

for distal femur fractures.”

Both articles reported that Nonunion presented late without hardware failure and with limited callus formation suggesting callus inhibition as the primary problem. They suggested that mechanical factors may play a role in the high rate of nonunion.

Titanium plates had a nonunion rate of 7% compared with 23% for the more rigid stainless steel locking plates . They concluded that the stiffer nature of the stainless plates may contribute to the increased nonunion rates observed.

Article 6 “Distal femoral fixation: a biomechanical

comparison of Trigen Retrograde Intramedullary (IM) nail, dynamic condylar screw (DCS), and locking compression plate (LCP) condylar plate.”

Journal of trauma 2009 Feb;66(2):443-9. Department of

Orthopaedic Surgery, Promedica Health System, USA

Retrograde intramedullary (IM) nail, dynamic condylar screw (DCS), and locked condylar plate (LCP) were tested using 33-cm long synthetic femurs.

A standardized supracondylar medial segmental defect was created in the distal femur bone models.

Peak displacements were measured, and analysis was done to determine construct stiffness and gap micromotion in axial loading.

The stiffness of the IM nail, DCS and LCP were 1,106, 750 and 625 N/mm, respectively.

The average total micromotion across the fracture gap for the IM nail, DCS, and LCP were 1.96, 10.55, and 17.74 mm, respectively.

CONCLUSION: When considering micromotion and

construct stiffness, the IM nail had statistically significant higher stiffness and significantly lower micromotion across the fracture gap with axial compression.

Outcome analysis of retrograde nailing and less invasive stabilization system in distal femoral fractures: A retrospective analysis

59 (RN) [28 C2#], 56 (LISS) [31 C2#]

Concluded: IM nailing may provide favorable IM stability, may promote formation of circular and stable callus, and may be successfully implanted in bilateral or multisegmental fractures of the lower extremity as well as in extra-articular and type C1& C2 fractures.

Christian Hierholzer et al 2011

Parameters  

Watanabe et al

 

Yeap et al

Gao K et al Gupta SKV et al Our patient

RN LCP RN LCP RN LCP RN

Average Knee flexion

115.3⁰ 112.2⁰ 103.4⁰ 98.2⁰ 110.3⁰ 115.4⁰ 115⁰

Average Full weight bearing

13.8 weeks

14.1 weeks

15.7 weeks

16.8 weeks

15.6 weeks

14.9 weeks

12 weeks

Average Radiological union time

15.4 weeks

15.8 weeks

14.8 weeks

16.1 weeks

16.8 weeks

15.2 weeks

14 weeks

Modified Neer’s Criteria Score

68% 70% 76% 65% 79% 85% 90%

What we have done???

Post-op X-rays AP and lateral view

Post-op x-rays at 6 months follow-up 

6-month follow-up

Benefits of RN VS LCPRETROGRADE NAILING LOCKED COMPRESSION

PLATING1. The Intramedullary device aligns the femoral shaft with condyles reducing the tendency to place varus movement at the fracture site.

1.Prompt healing

2.There will be decreased failure of fixation in osteoporotic bone as the bending movement of intramedullary device is substantially reduced.

2.Lower rate of infection

3.Preservation of fracture hematoma

3.Reduced bone resorption

4.Decreased blood loss 4.Creates a fixed angle construct

5.Minimal soft tissue dissection 5.Rigidity of fixation is better in osteoporotic bone

6.Less operative time 6.Angular as well as axial stability restored

7.Reduced rate of infection 7. Highly effective in comminuted and displaced fracture

Risks of RN VS LCPRETROGRADE NAILING LOCKED COMPRESSION

PLATING

1.Distal screw related local symptoms

1.Does not completely solve the age old problems of non-union and mal-union.

2.Shortening 2.Impossible to fix the bone fragment distant from plate.

3.Angulation disturbance 3.Simple fracture treated with locked compression plate are prone for non-union.

Take Home MessageRetrograde nailing is a better

fixation system for intra & extra articular fractures of distal femur with better outcome in terms of range of movements, early radiological union, early mobilization and less operative time and blood loss.

Surgeon preference