|Year : 2018 | Volume
| Issue : 3 | Page : 142-146
Distal femoral fractures fixed by distal femoral locking compression plate: Functional outcomes and complications
KC Kapil Mani1, Raju Vaishya2, RC Dirgha Raj1
1 Department of Orthopedics, Civil Service Hospital, Kathmandu, Nepal
2 Indraprastha Apolllo Hospital, New Delhi, India
|Date of Web Publication||10-Sep-2018|
K C Kapil Mani
Civil Service Hospital, Minbhawan, Kathmandu
Source of Support: None, Conflict of Interest: None
Background: Fractures of distal femur are complex type of injuries that are difficult to manage and produce long-term disability if not treated appropriately. Anatomical reduction of articular fracture fragments, restoration of limb length, and early mobilization exercises are key factors for optimal outcomes of involved limb after surgical treatment. Distal femoral locking compression plate (DFLCP) is a relatively newly designed implant in which screws are locked into the plate to create fixed angle construct. Materials and Methods: This was a prospective analytical study of 40 patients with distal femoral fractures fixed by DFLCP. Demographic profiles, time to unite the fractures, functional outcomes as well as complications related to this surgery were noted. Results: Time to unite the fracture was 19.32 ± 5.48 weeks (range 14–32 weeks). There were one case of nonunion, one case of malunion (varus union <10°), four case of delayed union, two cases of superficial infection, one case of deep infections, one case of implant failure, and two cases of extensor lag of more than 15°. Based on Neer's scores, there were 30% excellent, 45% satisfactory, 20% unsatisfactory, and 5% failure rates. Conclusion: Distal femoral locking plate is the treatment of choice in the management of comminuted distal femoral fractures both in Type A and Type C varieties. It not only maintains the biological environment of bone but also prevents metaphyseal collapse and provides the stable construct for fracture union with good functional outcomes.
Keywords: Complications, distal femoral fracture, functional outcomes, locking compression plates
|How to cite this article:|
Kapil Mani K C, Vaishya R, Dirgha Raj R C. Distal femoral fractures fixed by distal femoral locking compression plate: Functional outcomes and complications. Apollo Med 2018;15:142-6
|How to cite this URL:|
Kapil Mani K C, Vaishya R, Dirgha Raj R C. Distal femoral fractures fixed by distal femoral locking compression plate: Functional outcomes and complications. Apollo Med [serial online] 2018 [cited 2021 Sep 24];15:142-6. Available from: https://www.apollomedicine.org/text.asp?2018/15/3/142/240935
| Introduction|| |
Distal femoral fractures accounts for 7% of all femoral fractures and while excluding hip fractures number increases to 30%. Fractures of distal femur are complex type of injuries that are difficult to manage and produce long-term disability if not treated appropriately. These fractures often occur either in elderly or multiply injured patients and have tendency of being unstable and intra-articular comminution. These fractures usually occur either in males between 15–24 years or elderly females over 60 years of age. To achieve full range of knee motion and functions may be difficult because of proximity of fracture to knee joint. Probability of long-term disability further increases when these fractures are associated with marked comminution, extensive articular damage, and severe soft tissue injury. Anatomical reduction of articular fracture fragments, restoration of limb length, and early mobilization exercises are key factors for optimal outcomes of involved limb after surgical treatment.
Despite the use of improvised implants and advanced surgical techniques, management of distal femoral fractures remains a great challenge to orthopedic surgeon. Different surgical implants are available for treatment of these fractures such as dynamic condylar screw (DCS), GSH (Green Seligson Henry) nail, and fixed-angle locking plates. As the complexity of fractures increases from the simple extra-articular supracondylar types to intra-articular comminuted types, nails or DCS may not be sufficient enough to hold the construct firmly. Hence, there is a need for different types of implant which overcomes the limitations of earlier implants mentioned above. Distal femoral locking compression plate (DFLCP) is a relatively newly designed implant in which screws are locked into the plate to create fixed angle construct. We prospectively evaluated functional outcomes including fracture union, range of movement of knee joint as well as complication related to this surgery for distal femoral fractures (both supracondylar and inter-condylar varieties) fixed with DFLCP.
| Materials and Methods|| |
This was a prospective analytical study performed in Civil Service Hospital, Kathmandu, Nepal from November 2012 to October 2016. All patients were initially managed by ATLS protocol. The anteroposterior and lateral X-rays of the distal femur with knee joint were performed. In case of intra-articular fractures computed tomography scan of the knee joint was performed to further assess the fracture fragments. All the femoral fractures enrolled in the study were classified according to the Muller's classification. The patients with distal femoral fractures (Muller's Type A and Type C), age between 18 and 80 years and those with closed as well as Grade I and II compound fractures were included in the study. The patients with all Muller's Type B fractures and those with other associated injuries such as tibial plateau fractures, patella and femoral shaft fractures, pathological fractures, Grade III compound fractures, congenital, and acquired deformities of involved limb and pre-operative neurovascular involvement were excluded from the study.
The patients were positioned supine on a radiolucent table that allowed unimpeded fluoroscopic imaging in both planes. A small bump was placed beneath the involved hip to ensure that the femur remained in neutral rotation. The knee was placed in slight flexion over a custom ramp with an additional small rolled bump at the fracture site. This position facilitates intra-operative, lateral fluoroscopic imaging of the proximal thigh without obstruction from the contralateral extremity and also relaxes gastro-soleus muscle. A sterile tourniquet was applied proximally if desired. Direct lateral around 10–15 cm long was given starting from the level of the distal thigh to the knee joint. After incision of deep fascia and muscle fracture site was exposed. In case of extra-articular fractures [Figure 1] reduction was done under vision by applying the traction with bone holding clamps. After reduction was complete, distal femoral locking plate was fixed to the bone with as much as screws distally and 4–6 screws proximal to the fracture site [Figure 2] and [Figure 3]. In case of Muller's Type C fractures [Figure 4] and [Figure 5], intra-articular fracture fragments were first reduced and temporarily fixed with K wires to convert inter-condylar fractures to supracondylar fractures. When K wires were not sufficient to hold the fracture fragments properly, 6.5 mm cannulated screw was used to fix the inter-condylar fragments. Now fracture was reduced to the main fragment and fixed with the distal femoral locking plate. The drain was put before closure of soft tissue and continued until 48 h after surgery. Postoperatively, knee was immobilized with a long knee brace for 6 weeks. Active knee bending exercise as tolerated as well as quadriceps muscle strengthening exercise was started next day after surgery. After attaining sufficient quadriceps power, the patient was mobilized with the help of nonweight bearing crutch walking. Depending on the type of fractures, partial weight bearing was started 6 weeks to 2 months after surgery.
|Figure 1: Antero-posterior and lateral views of knee showing supracondylar fracture of distal femur|
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|Figure 2: Antero-posterior and lateral views of immediate postoperative X-ray of distal femur showing fixation with distal femoral locking compression plate|
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|Figure 3: Distal femoral fracture (supracondylar type) fixed with distal femoral locking compression plate 2 months after surgery|
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|Figure 4: Antero-posterior and lateral views of knee showing Muller's Type C variety of distal femur fracture|
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|Figure 5: Immediate postoperative X-ray of distal femur showing fixation with distal femoral locking compression plate|
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Patients were followed up clinically at 1st, 3rd, 6th month, 1 year, and then yearly. Clinically, fracture was considered to be united when there was no pain on movement of fracture site and formation of callus at least in three out of four cortexes in roentgenogram. When fracture was anticipated as impending nonunion and gap of fracture fragment was prominent, bone grafting could be planned. Functional outcomes were assessed based on the Neer's Functional Scoring Systems which includes pain – 20 points, function – 20 points, motion – 20 points, work – 10 points, gross anatomy – 15 points, and roentgenograms – 15 points. The outcome is said to be excellent when the score is above 85, satisfactory when between 70 and 85, unsatisfactory when between 55 and 70 and failure when <55. All the data were tabulated in Microsoft Excel Programme and results were interpreted as mean ± standard deviation and simple percentage also.
| Results|| |
Demographic profiles as well as the mechanism of injuries for fracture were mentioned in [Table 1]. The incidence of different varieties of fracture according to Muller's classification was mentioned in [Table 2]. The average age of patients in our study was 40.75 ± 19.18 years (range 18–73 years). Average time interval between the injury and surgical intervention was 5.65 ± 2.73 days (range 2–14 days). An average hospital stay of patients in our study was 8.47 ± 2.21 days (range 6–16 days). Time to unite the fracture was 19.32 ± 5.48 weeks (range 14–32 weeks). Similarly, average flexion movement of the knee was 111.4° ±17.8° (range 58°–150°). All the complications after fracture fixation were mentioned in [Table 3]. Functional outcomes of the involved limb at latest follow up visit were expressed based on Neer's scores. According to this scoring system, there were 30% excellent, 45% satisfactory, 20% unsatisfactory, and 5% failure rates [Figure 6].
|Table 2: Incidence of different fractures based on Muller's classification|
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|Figure 6: Bar diagram showing the functional outcomes based on Neer's criteria with distal femoral locking plates|
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| Discussion|| |
Distal femoral fractures have presented considerable therapeutic challenges throughout treatment. Most of the failures are because of inadequate fixation of fracture fragments. The prognostic factors for distal femur fractures include the age of patients, intra-articular extension, comminution, quality of bone, methods of treatment, selection of implants, and timing of physiotherapy. The goal of treatment is to achieve the painless stable joint with a normal or near normal range of motion. This can be achieved by the use of an implant which allows rigid fixation of articular fragments, preserves as much as the soft tissue around the bones, does not hamper the vascular supply and allows early weight bearing. DFLCP is a single beam construct where the total strength of fixation is equal to the sum of all screw-bone interfaces rather than single screw's pull-out strength and axial stiffness. Locking plates have considerable advantages over the standard normal plates. Standard plate firmly holds the bone by compression of the plate against the bone surfaces with screws that lead impaired blood supply of bone, the decreased cortical thickness and cancellous transformation of bone while locking plates maintains the biological environment.
In the present study, the mean age of the patients was 40.75 ± 19.18 years (range 18–73 years). A total number of patients below 40 years, 40–60 years, and more than 60 years were 25 (62.5%), 5 (12.5%), and 10 (25%), respectively. As in other studies, this study showed the bimodal age distribution in case of distal femoral fractures. The peak age is either young patients of <40 years or elder patients of more than 60 years of age. Young patients sustained fractures because of high-grade injuries while older patients sustained fractures due to low-grade injuries like simple fall on the ground while walking. There were 26 (65%) males and 14 (35%) females in our study. Increased incidence of male patients as compared to the female is due to the involvement of the male population in outdoor activities and sustained injuries to cause the fractures. Most of the injuries were caused by road traffic accidents 22 (55%) and fall from height 8 (20%). In our study, 16 (40%) patients belonged to Muller's Type A group and 24 (60%) patients belonged to Type C group. Of 16 patients in Type A subgroup 4 in A1, 5 in A2 and 7 in A3 subgroups, whereas out of 24 patients in Type C group, 5 in C1, 11 in C2, and 8 in C3 subgroups. This showed that majority of fractures were included in Type C group of Muller's classification because many fractures in our study was caused by high-grade injuries.
The average time interval between injury and surgery in our study was 5.65 ± 2.73 days (range 2–14 days). Delay in surgery is because of referral of patients from peripheral area to our hospital as well as the association of other injuries along with this fracture that needed some time to prepare the patients for surgical intervention. Delay in surgery sometimes resulted to poor functional outcomes. The average duration of hospitalization in our study was 8.47 ± 2.21 days (range 6–16 days). Even though this time duration seemed slightly longer, this was comparable to the other type of fractures treated in our hospital. Increased time for hospitalization was due to other associated injuries and the need for the strict postoperative physiotherapy which affected the course of treatment and rehabilitation. Postoperatively, bed-side physiotherapy was started on the on the next day after surgery based on the tolerance of patient and associated injuries. The average time to unite the fracture was 19.32 ± 5.48 weeks (range 14–32 weeks). Kregor et al. in his study in 2004 showed that fracture united in 12 weeks. Weight and Collinge et al. in 2004 also showed in their study that fractures united in 13 weeks. The longer time duration for fracture union in the current study was because of the high incidence of intra-articular comminution, osteoporosis and a significant number of elderly patients in our patients that required much time for the bony union. The average range of motion in our study was 111.4° ±17.8° (range 58°–150°). The range of motion of knee joint depends on the stable fixation and early mobilization of joint after surgery. The average knee flexion in Type C fractures was less as compared to the Type A fractures in our study. It showed that intra articular fractures lead to intra articular stiffness and decreased range of motion. We conclude that locking plates are a useful option in patients with intra-articular comminution of distal femur fractures with osteoporotic bones and those with poor bone stock. Markmiller et al. reported average range of movement of knee joint of 110°. Range of motion in distal femur intra-articular fractures as in any other intra-articular fractures depends on the early rehabilitation program.
In this study, complications such as one case of nonunion, one case of malunion (varus union <10°), four case of delayed union, two cases of superficial infection, one case of deep infections, one case of implant failure, and two cases of extensor lag of more than 15° were noted. There was no obvious limb length discrepancy in any case. Kregor et al., in 2001 and 2004 and Schultz et al. in 2005 showed that deep infection occurred in 3% of their patients.
The sequence of screw placement has to be well planned to avoid fracture malreduction. Distal screws are inserted perfectly parallel to the distal femoral joint line. Any angulation of screws in projection to the joint line may result in increased valgus or more detrimentally, in varus deviation. The concept of bridging osteosynthesis implicates that the final fracture construct should be elastic and not too stiff to prevent nonunion. Indication for DF-LCP plate osteosynthesis are periprosthetic femur fracture, open injury, short distal fragment, C2 and C3 fracture configuration, failed closed reduction with IM nailing, salvage implant for revision surgery and complicated situations.,, The ideal treatment for such fractures will include anatomical reduction and rigid fixation of articular surface and early function of knee joint. This can only be provided by such an implant which holds the metaphyseal bone strongly and at the same time provides stable fixation in the shaft to promote callus formation.
Distal femoral alignment is one of main concern for treatment of distal femoral fractures. The femoral shaft is oriented 7° of valgus in relation to the knee joint. Maintaining this alignment is critical for optimal function of knee joint. Coronal plane alignment has been shown to be the most difficult factor to control and the most crucial to overall outcome. Malalignment in the axial and sagittal planes also affects knee kinematics and range of motion. When comminution is present, supracondylar femoral fractures are especially prone to varus collapse. The current study supports the reduced rate of fixation loss due to the utilization of locked plating and shows that additional lag screws do not influence varus collapse. Previous studies stated that open fractures are common in the setting of distal femur fractures (19%–54%). Open fractures were related to high-energy injury mechanism and a greater prevalence of infection. Therefore, the outcome of distal femoral fractures, similar to other major injuries, not only depends on bony reconstruction but also on soft tissue management. The locking compression plate (LCP) system offers a number of advantages in fracture fixation combining angular stability through the use of locking screws with traditional fixation techniques., However, the system is complex, requiring careful attention to biomechanical principles, and good surgical technique. The angular stability provided by LCP at the plate-screw interface, allows extra periosteal fixation of the plate to bone. By preserving periosteal blood supply to the bone, it addresses the importance of the biological factors involved in fracture healing. Although the LCP system offers a number of advantages in fracture management, its successful use requires careful preoperative planning, consideration of biomechanical principles, and the use of the appropriate plate and screws combined with good surgical technique.
| Conclusion|| |
The DFLCP is the treatment of choice in the management of comminuted distal femoral fractures both in Type A and Type C varieties. It not only maintains the biological environment of bone but also prevents metaphyseal collapse and provides the stable construct for fracture union with good functional outcomes. However, careful selection of patients and strict adherence to the basic principles of fracture fixation are key factors in reducing the complications of fracture fixation using LCPs.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]