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 Table of Contents  
ORIGINAL ARTICLE
Year : 2023  |  Volume : 6  |  Issue : 1  |  Page : 96-100

Functional outcome of distal femur fractures managed by open reduction and internal fixation with locking compression plate


1 Department of Orthopaedics, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, Guntur, Andhra Pradesh, India
2 Student, Guntur Medical College, Guntur, Andhra Pradesh, India

Date of Submission28-Aug-2022
Date of Decision29-Sep-2022
Date of Acceptance29-Sep-2022
Date of Web Publication27-Dec-2022

Correspondence Address:
Surapaneni Suresh Babu
Suresh Ortho and Multi Speciality Clinic, 56-2-18, Koneru Satyanarayana Street, Canara Bank Road, Patamata, Vijayawada - 520 010, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_74_22

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  Abstract 


Background: Distal femur fractures are one of the most frequent fractures seen in high-velocity trauma, and they are associated with substantial morbidity if not treated properly. Stiffness, secondary arthritis, shortening, and disturbance in the activity of daily living can occur as a result of this fracture. Open reduction and internal fixation with locking compression plates (LCPs) is the preferred treatment. The anatomic contoured LCP for the distal femur has been found to provide one of the best outcomes in terms of anatomical reduction with joint congruity, soft-tissue healing, fracture union, and functional ability. This study was done to evaluate the functional outcome of distal femur fractures managed with LCP. Materials and Methods: Thirty patients with distal femur fractures were treated at our institute using LCP were analyzed for the outcome in terms of clinical, radiological union, and functional results. Results: Twenty-one patients were male and nine were female. The average age was 41.55 years with a range of 21–60 years. In 22 patients, cause of fracture was road traffic accidents and in eight were fall at various occasions. Twenty-one patients had right-side fractures. The average time for radiological union was 14.2 weeks. The average flexion of the knee was 107.16°. Functional outcome was assessed using Sanders' Functional Evolution Scale. The outcome was excellent in 30%, good in 40%, fair in 17%, and poor in 13%. Conclusion: Locking compression plating is an excellent internal fixation option for both extra- articular and intra-articular distal femur fractures, and it is particularly helpful in osteoporotic metaphyseal fractures.

Keywords: Distal femur fracture, locking compression plate, Sanders' Functional Evaluation Scale


How to cite this article:
Babu SS, Velagapudi NG, Gani SA, Surapaneni S. Functional outcome of distal femur fractures managed by open reduction and internal fixation with locking compression plate. J Orthop Dis Traumatol 2023;6:96-100

How to cite this URL:
Babu SS, Velagapudi NG, Gani SA, Surapaneni S. Functional outcome of distal femur fractures managed by open reduction and internal fixation with locking compression plate. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jan 30];6:96-100. Available from: https://jodt.org/text.asp?2023/6/1/96/365291




  Introduction Top


Science advances at a rapid pace, and orthopedic science is no exception. During the Hippocratic era, fractures were treated with external wooden splints and prolonged rest of the injured limb. In today's world, fractures are repaired as soon as feasible following trauma, and patients are moved within hours and days. Distal femur fractures occur in about 37 people out of every 100,000.[1] Distal femur fractures are most commonly caused by low-energy injury in osteoporotic bone in the elderly or high-energy injury in the young. These fractures have a bimodal distribution in both elderly and young osteoporotic patients.[2]

It may be difficult to regain full knee mobility and functioning due to the closeness of these injuries to the knee joint. Many documented series had high rates of malunion, nonunion, and infection. Plating procedures such as blade plate, dynamic condylar screw, nonlocking condylar buttress plate, antegrade nailing, retrograde nailing, submuscular locked internal fixation, and external fixation are some of the operative management options.[3] External fixator can only be used as a temporary modality and not as a definitive fixation and we found better results when external fixation was converted early to definite stable internal fixation. The less invasive stabilization system and locking compression condylar plates are two recent technological developments in the management of distal femoral fractures.[4],[5] The locking compression plate (LCP) is a single-beam structure where bone contacts rather than axial stiffness provided by a single screw. When it is mended using a minimally invasive procedure, it provides for quick healing, low infection rates, and less bone resorption because the blood supply is kept open.[6]

An LCP reduces screw-plate toggling and ensures more secure fixation, which is among the most important factors in treating these fractures successfully. These mechanisms produce a set angle at each bolt hole, and a locking mechanism secures the particular screw head to the plate.[7],[8],[9] The advantage of an LCP is that it combines traditional compression plating and locking plating procedures to improve plate osteosynthesis. The precontoured design reduces soft tissue issues and serves as an internal–external fixator. Even if the bone quality is poor, locking plates provide several points of attachment since the screws, once secured to the plate, do not draw the fragments toward the implant.[10] The study was done to evaluate the functional outcome of distal femur fractures managed by open reduction and internal fixation (ORIF) with LCP and also analyzed for the outcome in terms of clinical and radiological union.


  Materials and Methods Top


Thirty patients aged between 20 and 60 years with distal third femur fractures who attended to our institute were included in our study. Fractures of Müller's type A and type C fractures, all closed fractures, and compound fractures presenting within 6 h such as Gustilo Anderson's type 1, type 2, and type 3A were included in the study. Müller's type B fracture, compound fractures presenting beyond 6 h, Gustilo Anderson's type 3B and type 3C fractures, undisplaced fracture patterns needing only conservative management, pathological fractures, patients who undergone previous surgery to the knee, patients associated with ipsilateral lower limb fractures were excluded from the study. Mode of injury and the severity of trauma was noted, other injuries by systemic examination were if any noted. Local examination of the injured limb in all most all cases revealed swelling at the fracture site, abnormal mobility, crepitus, and shortening by 1 to 2 cm. Distal neurovascular status was assessed by palpating dorsalis pedis artery, posterior tibial artery, and asking the patient to evert and dorsiflex the foot. X-ray of distal thigh including knee joint was taken. Müller's classification was used to classify the fracture. Computed tomography was performed before surgery. The injured limb of the patients was immobilized by skin traction. Once the general condition of the patient is stabilized, medically and anesthetically fit, definitive treatment was planned. If required preoperative blood transfusion was given.

On a radiolucent table, under c-arm, the patient will be positioned supine with the same side sandbag under the buttock, will be given a lateral incision parallel to the femur shaft, starting at the lateral condyle of the femur, and continuing proximally further to facilitate plate placement with at least four holes just above the most proximal fracture line. If needed, the distal incision was extended as parapatellar incision. Appropriate closed reduction, if needed open reduction of both intra-articular and metaphyseal fracture was done, provisionally holded with K-wires. Based on fracture geometry, fracture was fixed either in compression method or bridging method if needed combined method. Anatomically designed and molded to meet the distal femur, obviating the need for intraoperative plate contouring LCP will be inserted into submuscular tunnel, and laid flat on the condyle surface. To lower the plate to the bone, a standard 4.5 mm bicortical screw is first put into the proximal portion. 6.5 mm screws for metaphyseal and intra-articular fragments and locking bolts to proximal fragment were used routinely. All the patients were advised to review at regular follow-up in regular intervals for suture removal, 6 weeks, 3 and 6 months visits to assess both clinically and radiologically for union and functional results. If the callus is noted at the fracture site, the patient is allowed partial weight bearing. After clinical and radiological union, full weight bearing was permitted. Functional outcome was assessed using Sanders' Functional Evolution Scale.


  Results Top


Results of 30 patients with distal femur fractures which include supracondylar and intercondylar fractures managed surgically by ORIF with LCP presenting to our institution were analyzed. The average age of the patients was 41.55 years with a range of 21–60 years. There were 21 male and nine female patients. The majority of the incident, around 73% were caused by road traffic accidents. Right side involvement was seen in 21 (70%) patients and left side involvement was seen in nine patients. The distribution of patients based on the type of fracture was A1 of 27%, A3 and C3 of 17% each, and A2, C1, and C2 of 13% each [Table 1]. The average time for the radiological union was 14.2 weeks [Figure 1] and [Figure 2]. The average flexion of the knee joint was 107.16° [Figure 3] and [Figure 4]. Functional results were evaluated using Sanders' Functional Evaluation Scale. Outcome was excellent in 30%, good in 40%, fair in 17%, and poor in 13% [Table 1].
Table 1: Distribution of age, sex, type of fracture, mode of injury, and results

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Figure 1: Preoperative radiograph

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Figure 2: Postoperative radiograph, 6-month follow-up

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Figure 3: Clinical photograph of knee flexion, 6-month follow-up

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Figure 4: Clinical photograph of knee extension, 6-month follow-up

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  Discussion Top


The average age of the patients was 41.55 years and fracture was more common in the age groups between 31 and 40 years. The age quoted by Jose's and Krishnan's study ranged from 24 to 72 years, and the patients between the age group 31 and 40 years comprise the majority. The average age of the patients was 39.4 years.[11] In Mahajan et al.'s study, the patient's age ranged from 20 to 77 years with a mean age of 40.7 years.[12] In Gyanendra et al.'s study, the patient's age ranged from 18 to 62 years, and the mean age of 30 treated patients was 34.97 years.[13] In this study, there were 21 male and nine female patients showing male predominance. In Jose's and Krishnan's study, Out of 20 patients, there were 12 (60%) males and 8 (40%) females.[11] In Mahajan et al.'s study, the total number of patients studied was 30 out of which 21 were males and nine were females.[12] In Gyanendra et al.'s study, 18 were males and 12 were females.[13] In our study, 73% of patients have sustained fractures due to road traffic accident which comprises the majority. In Jose's and Krishnan's study, 17 (85%) patients sustained injury due to road traffic accident which comprises the majority.[11] In Mahajan et al.'s study, road traffic accident was the mode of injury in 70% of cases, whereas 30% of patients reported fall. In our study, there are 21 (70%) patients with right-sided fracture and 9 (30%) patients with left-sided fracture.[12] In Jose's and Krishnan's study, the majority of the patients 13 (65%) sustained injury to the right side.[11] In Mahajan et al.'s study, right-sided fracture was seen in 60% of cases, whereas 40% of patients had left-sided fracture.[12]

In Gyanendra et al.'s study, 19 patients were with fracture on the right side and 11 on the left side. In this study, eight cases are type A1 fracture, four cases are type A2 fracture, five cases are type A3 fracture, four cases are type C1 fracture, four cases are type C2 fracture, and five cases are type C3 fracture.[13] In Jose's and Krishnan's study, seven cases are type A1 fracture, six cases are type A2 fracture, three cases are A3 fracture, three cases are type C1 fracture, and one case is type C2 fracture. In Mahajan et al.'s study, 15% patients had C1, 30% of patients had C2 type fracture, and 25% presented with C3, the remaining patients had 10% of B1 and B2 each.[12] In Gyanendra et al.'s study, type A1 with 8 (26.7%) patients, type A2 with 7 (23.4%) patients, type A3 with 2 (6.6%) patients, type C1 with 1 (3.3%) patient, type C2 with 6 (20%) patients, and type C3 with 6 (20%) patients.[13] In our study, shortening of 1 cm was seen in four patients postoperatively, shortening was mainly due to comminution. There were no cases of deformities, nonunion, implant failures, and neurovascular injuries. Similarly, in our study, there were two cases of infection. In Jose's and Krishnan's study, one case had a deep infection, three cases had a surface infection, one case had shortening, one case had an implant fracture, and four instances had knee stiffness.[11] In Mahajan et al.'s study, only one patient had immediate postoperative complications in the form of superficial infection which ultimately healed with appropriate antibiotics and antiseptics, knee stiffness in 2 (6.7%) cases, and malalignment in 2 (6.7%) cases. All the patients were observed to have limb length discrepancy within a range of 0–2 cm with the majority of patients in the range of 1–1.5 cm. 1.3 cm was found to be an average length discrepancy of the limb and no treatment was needed.[12]

This was similar to Kiran Kumar et al. where the average limb length discrepancy of <2 cm.[14]

The length of time it takes for a fracture to heal depends on the nature of fracture, the quality of the bone, and the rigidity of the fracture fixation. In my research, the average time for radiological union was 14.2 weeks [Figure 1] and [Figure 2]. In Jose's and Krishnan's study, five of the 20 cases had radiological union within 15 weeks, with the remaining 14 cases taking between 16 and 30 weeks. The average time for the union was 20.5 weeks.[11] In Mahajan et al.'s study, union was seen around 5 months in the majority of the cases (55%). The mean time for radiological union was 15 weeks. When the callous formation started, the patient was advised to start partial weight bearing.[12] Kanabar et al.'s study shows union ranges between 12 and 19 weeks which resembles our study.[15] In Gyanendra et al.'s study, radiological union attained an average of 17.83 weeks (range 16–22 weeks).[13] The average flexion of knee joint was 107.16° in our study [Figure 3] and [Figure 4]; the average flexion of the knee depends on type of fracture, fracture fixation, union of fracture, and postoperative mobilization. In Jose's and Krishnan's study, In 2 (10%) cases, <70° of knee flexion was achieved, 71°–100° of flexion of the knee in 10 (50%) cases, and more than 100° of flexion of the knee in 8 (40%) cases.[11] In Mahajan et al.'s study, the mean flexion at 1.5-month follow-up was 75.75 ± 13.50 which increased to 85.75 ± 12.28, and at 6 months follow-up and it was 106.6 ± 15.80.[12]

In Gyanendra et al.'s study, the average flexion of the knee achieved by the participants was 103.5° (range is 60°–120°).[13] In our study, functional outcome was assessed using Sanders' Functional Evaluation Scale, excellent results were seen in 30% (nine patients) patients, good results were seen in 40% (12 patients) patients, fair results were seen in 17% (five patients) patients and results were poor in 13% (four patients) patients. The functional outcomes of the Jose and Krishnan research were examined using Jose's and Krishnan's functional evaluation scale. One patient (5%) had excellent outcome, 13 (65%) had good outcome, 5 (25%) had fair outcome, and one (5%) had a poor outcome among 20 patients managed surgically.[11] In Mahajan et al.'s study, 10 cases had excellent scores (33%), 16 (52%) cases had satisfactory score, 3 (11%) cases had unsatisfactory scores and only one case had poor scores.[12] In Gyanendra et al.'s study, out of 30 patients, 16 had outstanding outcomes, 11 had good outcomes, two had acceptable outcomes, and one had a failed outcome.[13]


  Conclusion Top


Locking compression plating is an excellent internal fixation option for both extra-articular and intra-articular distal femur fractures, and it is particularly helpful in metaphyseal fractures. Osteoporosis, which causes the loss of cancellous bone material in metaphyseal fractures, causes the screws to loosen, which can be prevented using an LCP. With the use of an LCP, combining methods such as compression, and bridging in heavily comminuted metaphyseal fractures is also achievable. Due to its flexibility and fixed angle features, this device looks to be a viable alternative to conventional implants for the treatment of a variety of distal femur fractures, comprising comminuted intra-articular fractures and osteopenic bone. The most common complication is knee stiffness, which occurs more frequently in intra-articular distal femur fractures, and infection is a significant problem in compound fractures.

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Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Arneson TJ, Melton LJ 3rd, Lewallen DG, O'Fallon WM. Epidemiology of diaphyseal and distal femoral fractures in Rochester, Minnesota, 1965-1984. Clin Orthop Relat Res 1988;188-94.  Back to cited text no. 1
    
2.
Martinet O, Cordey J, Harder Y, Maier A, Bühler M, Barraud GE. The epidemiology of fractures of the distal femur. Injury 2000;31 Suppl 3:C62-3.  Back to cited text no. 2
    
3.
Zlowodzki M, Bhandari M, Marek DJ, Cole PA, Kregor PJ. Operative treatment of acute distal femur fractures: Systematic review of 2 comparative studies and 45 case series (1989 to 2005). J Orthop Trauma 2006;20:366-71.  Back to cited text no. 3
    
4.
Ricci AR, Yue JJ, Taffet R, Catalano JB, DeFalco RA, Wilkens KJ. Less invasive stabilization system for treatment of distal femur fractures. Am J Orthop (Belle Mead NJ) 2004;33:250-5.  Back to cited text no. 4
    
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Markmiller M, Konrad G, Südkamp N. Femur-LISS and distal femoral nail for fixation of distal femoral fractures: Are there differences in outcome and complications? Clin Orthop Relat Res 2004;252-7.  Back to cited text no. 5
    
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Kregor PJ, Stannard JA, Zlowodzki M, Cole PA. Treatment of distal femur fractures using the less invasive stabilization system: Surgical experience and early clinical results in 103 fractures. J Orthop Trauma 2004;18:509-20.  Back to cited text no. 6
    
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Greiwe RM, Archdeacon MT. Locking plate technology: Current concepts. J Knee Surg 2007;20:50-5.  Back to cited text no. 7
    
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Cantu RV, Koval KJ. The use of locking plates in fracture care. J Am Acad Orthop Surg 2006;14:183-90.  Back to cited text no. 8
    
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Egol KA, Kubiak EN, Fulkerson E, Kummer FJ, Koval KJ. Biomechanics of locked plates and screws. J Orthop Trauma 2004;18:488-93.  Back to cited text no. 9
    
10.
Virk JS, Garg SK, Gupta P, Jangira V, Singh J, Rana S. Distal femur locking plate: The answer to all distal femoral fractures. J Clin Diagn Res 2016;10:C01-5.  Back to cited text no. 10
    
11.
Jose RS, Krishnan NG. Study of functional outcome of distal femur fractures treated by open reduction and internal fixation with locking compression plate. J Evol Med Dent Sci 2016;5:1984-91. [doi: http://doi.org/10.14260/jemds/2016/469].  Back to cited text no. 11
    
12.
Mahajan NP, Ravesh VA, Prasanna Kumar GS, Chandanwale A, Gadod L. Assessment of functional outcome of distal femur intra-articular fractures treated with locking compression plate. Int J Res Orthop 2020;6:145-50.  Back to cited text no. 12
    
13.
Gyanendra KJ, Deepesh KY, Pravin T. Outcome of supracondylar femur fracture in adults managed by distal femur locking compression plate. Biomed J Sci Tech Res 2018;3:1-7.  Back to cited text no. 13
    
14.
Kiran Kumar GN, Sharma G, Farooque K, Sharma V, Ratan R, Yadav S, et al. Locking compression plate in distal femoral intra-articular fractures: Our experience. Int Sch Res Notices 2014;2014:372916.  Back to cited text no. 14
    
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Kanabar P, Kumar V, Owen PJ, Rushton N. Less invasive stabilisation system plating for distal femoral fractures. J Orthop Surg (Hong Kong) 2007;15:299-302.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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