Highly unstable complex C3-type distal femur fracture: can double plating via a modified Olerud extensile approach be a standby solution?

Dual Plating of Distal Femoral Fractures

Background

Dual plating of the distal femur is indicated for the treatment of complex intra-articular fractures, supracondylar femoral fractures, low periprosthetic fractures, and nonunions. The aim of this procedure is anatomical alignment of the articular surface, restoration of the articular block, and prevention of varus collapse.

Description

Following preoperative planning, the patient is positioned supine with the knee flexed at 30°. The lateral incision is made first, with a mid-lateral incision that is in line with the femoral shaft. If intra-articular work is needed this incision can be extended by curving anteriorly over the lateral femoral condyle. Next, the iliotibial band is transected in line with its fibers. The vastus lateralis fascia is incised and elevated off the septum, working distal to proximal. Care should be taken to maintain hemostasis when encountering femoral artery perforating vessels. Once there is adequate exposure, several reduction aids can be utilized, including a bump under the knee, Schanz pins, Kirschner wires, and reduction clamps. A lateral precontoured plate is placed submuscularly, and the most proximal holes are filled percutaneously. The medial incision begins distally at the adductor tubercle and is a straight incision made proximally in line with the femoral shaft. The underlying fascia is transected in line with the skin incision, and the vastus medialis is elevated. Care should be taken to avoid the descending geniculate artery, as well as its articular branch and the muscular branch to the vastus medialis. A lateral tibial plateau plate is contoured and placed.

Alternatives

Nonoperative treatment of distal femoral fractures is rare, but relative indications for nonoperative treatment include frailty of the patient, lack of ambulatory status, a non-reconstructible fracture, or a stable fracture. These patients are placed in a long-leg cast followed by a hinged knee brace1. There are several other surgical fixation options, including lateral plating, retrograde intramedullary nailing, distal femoral replacement, and augmentation of a retrograde nail with a plate.

Rationale

Dual plating has several benefits, depending on the clinical scenario. Biomechanical studies have found that dual plating results in increased stiffness and construct strength2,3. Additional construct stability can be offered through the use of locking plates, particularly in osteoporotic bone. Taken together, this increased stability and construct strength can allow for earlier weight-bearing, which is particularly important for fractures in the geriatric population. Furthermore, the increased stiffness and construct strength make this procedure a favorable treatment option for nonunion, and it has been shown to result in lower rates of postoperative nonunion compared with lateral plating alone4-7. Adjunctive use of a medial plate also has been suggested to prevent varus collapse, particularly with metaphyseal comminution and poor bone quality2,3,8. Finally, in the periprosthetic fracture population, dual plating also removes the concern of incompatibility with a retrograde nail.

Expected Outcomes

The outcomes of dual plating are promising, given the severity of the injury. When comparing operative to nonoperative treatment outcomes, nonoperatively managed patients had worse functional outcomes and higher rates of complications related to immobility1. Dual plating of supracondylar fractures and intra-articular distal femoral fractures yields nonunion rates ranging from 0% to 12.5%, lower than the 18% to 20% reported with lateral locking plates4-7,9-12. This reduction in nonunions has been shown to lead to fewer revisions when compared with single-plating techniques7. In prior studies, 95% of nonunions treated with the dual-plating technique achieved union postoperatively11. One concern when utilizing the medial approach is critical damage to medial vascularity; however, this result has not been reported in the literature, and there is a safe operating window13. Despite the benefits of dual plating, there are relatively high rates of infection following dual plating (0% to 16.7%) compared with lateral plating alone (3.6% to 8.5%)5,14-17. However, many of these studies are small case series, highlighting that a surgeon's comfort and skill with these procedures is paramount to patient outcomes.

Important Tips

Meticulous placement and contouring of lateral and medial plates are required to prevent malreduction of the articular block that creates a "golf-club deformity."18,19During the medial approach, be aware of descending geniculate artery-particularly its muscular branch, which is ∼5 cm from the adductor tubercle/medial epicondyle, and its root, which enters the compartment at the adductor hiatus at ∼16 cm13.

Comparison of radiological and functional results in osteoporotic distal femur fractures operated with single plating, lateral incision, and double plating, anterior paramedial incision: A retrospective study

Treatment of osteoporotic distal femur fractures is often complicated by a high rate of nonunion and varus collapse. For such fractures, lateral plating with lateral incision and double plating with anterior paramedial incision have shown promising results in the recent literature. The hypothesis of this study was that bilateral plating of comminuted distal femur fractures in osteoporotic patients would result in higher union rates and lower revision rates compared to an isolated lateral locking plate. The study included 56 patients (23 males, 33 females) with supracondylar femur fracture. According to the OA/OTA classification, 9 were type A3, 8 were A2, 13 were C1, 16 were C2, and 10 were C3. The mean follow-up period was 12 months, with 29 patients treated using lateral mini-incision, lateral locking plate, and 27 patients treated with anterior paramedial incision, dual plating. The clinical and radiological results were evaluated. The mean duration of radiological union in the studied population was 15 ± 2.1 months (range, 11-21 months) in the single plate group (Group A), and 13.5 ± 2.6 months (range, 9-19 months) in the double plate group (Group B). Mean ROM was 112.3° and flexion contracture 4° in Group A, and ROM 108.3° and flexion contracture 6.7° in Group B. (P = .15). The average Western Ontario and McMaster Universities Arthritis Index (WOMAC) score was 85.6 points in Group A and 83.5 points in Group B (P = .2278). The postoperative anteversion measurement in the operated extremity ranged from -15 to 19 in Group A, and from 5 to 18 in Group B. When the anteversion degrees were compared between the injured and uninjured extremities in the postoperative period, a significant difference was observed within Group A (P = .0018), but no significant difference was observed in Group B (P = .2492). Dual plate fixation using the anterior paramedial approach is an effective operative method for osteoporotic distal femur fractures. This has many advantages such as precise exposure, easy manipulation, anatomic reduction, and stable fixation. However, for surgical indications and medial bone defects > 1 cm, grafting should be performed.

Does the type of medial plate fixation matter for supplemental fixation of distal femur fractures manage with a lateral pre-contoured locked plate? A Biomechanical study

INTRODUCTION

Fixation of distal femur fractures with a lateral pre-contoured locking plate provides stable fixation and is the standard treatment in most cases, allowing early range of motion with a high rate of union. However, in situations, the stability achieved with the lateral plate alone may be insufficient, predisposing to fixation failure. The objective of the study was to compare, in synthetic bone models, the biomechanical behaviour of the fixation with a distal femur lateral pre-contoured locking plate solely and associated with a 3.5 mm proximal humeral locking plate applied upside down or a 4.5 mm helical locking compression plate on the medial side.

MATERIAL AND METHODS

A total of 15 solid synthetic left femur samples were used. A metaphysical defect at the level of the medial cortex was simulated. The samples were randomly distributed into three groups equally. All groups received a 4.5/5.0 mm single lateral 9-hole distal femur lateral pre-contoured locking plate. Group 1 had no supplementary plate. Group 2 received a supplementary 6-hole 3.5 mm proximal humeral locking plate and Group 3 received a supplementary 4.5/5.0 mm helical 14-hole narrow locking compression plate.

RESULTS

Both supplementary plate types used in groups 2 and 3 contributed to increase the apparent stiffness of the construct, but pairwise comparison showed statically significant difference only between group 1 and 3. No significant difference was observed between groups 2 and 3.

CONCLUSION

Both supplementary plates might be considered for improving the fixation in distal femur fracture in selected cases.

Biomechanical analysis of bridge combined fixation system as a novel treatment for the fixation of type A3 distal femoral fractures

Background

To compare the biomechanical parameters of AO/OTA type A3 distal femoral fractures fixed bilaterally with a bridge combined fixation system (BCFS) and lateral locking compression plate + locking reconstruction plate (LCP + LRP).

Methods

Twelve A3 distal femoral fracture models with medial cortical defects of the distal femur were created using synthetic femoral Sawbones. BCFS and LCP + LRP were used for bilateral fixation, with six in each group. Axial compression and torsion tests were performed on the two groups of fracture models to determine their stiffness during axial compression and the Torsional stiffness during torsion tests. Axial compression failure tests were performed to collect the vertical loads of the ultimate failure tests.

Results

In the test conducted on the fixed type A3 distal femoral fracture models, the axial stiffness in the BCFS group (group A) (1,072.61 ± 113.5 N/mm) was not significantly different from that in the LCP + LRP group (group B) (1,184.13 ± 110.24 N/mm) (t = 1.726, P = 0.115), the Torsional stiffness in group A (3.73 ± 0.12 N.m/deg) was higher than that in group B (3.37 ± 0.04 N.m/deg) (t = 6.825, P < 0.001),and the ultimate failure test of type A3 fracture model showed that the vertical load to destroy group A fixation (5,290.45 ± 109.63 N) was higher than that for group B (3,978.43 ± 17.1 N) (t = 23.28, P < 0.05). Notably, intertrochanteric fractures occurred in groups A and B.

Conclusions

In the fixation of type A3 distal femoral fractures, the anti-axial compression of the BCFS group was similar to that of the LCP + LRP group, but the anti-torsion was better.

The double-plate fixation technique prevents varus collapse in AO type C3 supra-intercondylar fracture of the distal femur

INTRODUCTION

Varus collapse followed by osteosynthesis for distal femoral fractures with conventional implants has been well documented but is seldom mentioned in fractures managed with locking plates. The purpose of this study was to assess the incidence of varus collapse after treating complex supra-intercondylar fractures of the distal femur (AO type C3) using a Single Plate (SP) or Double Plate (DP) fixation technique.

MATERIALS AND METHODS

We retrospectively reviewed 357 patients with distal femoral fractures who were treated at our hospital between 2006 and 2017. After excluding cases of infection, malignancy, periprosthetic fracture, revision surgery, pediatric fracture, and extra-articular fracture, 54 patients were included in the study. All demographic data and radiological and clinical outcomes were reviewed and analyzed.

RESULTS

There were 54 patients enrolled into this study with age from 15 to 85 years old (mean 41.6, SD = 19.9), and 32 of them were open fractures (59%). The patients were further divided into either an SP (n = 15) or a DP group (n = 39). Demographics, including age, sex, injury severity score, and open fracture type, were all compatible between the two groups. The overall nonunion rate was 25.9% (n = 14; 6 from the SP and 8 from the DP group; p = 0.175). The varus collapse rate was 9.3% (n = 5; 4 from the SP and 1 from the DP group (p = 0.018).

CONCLUSIONS

The varus collapse rate after osteosynthesis with a single lateral locking plate could be as high as 26.7% in AO type C3 fractures of the distal femur, which would be decreased to 2.6% by adding a medial buttress plate. Surgeons should consider DP fixation to avoid varus collapse in severely comminuted complete intra-articular fractures of the distal femur.

Double plating via anterolateral and posterolateral approach for distal femoral fracture

Although there are some reports highlighting the applicability of double plates in distal femoral fractures, there is no standard approach or fixation method for supracondylar fractures combined with posterior coronal shear fractures. We report a case of distal femoral fracture treated with a lateral locking plate and posterior buttress plate using anterolateral and posterolateral approaches from one incision. A 70-year-old man was hit by a motorcycle and had an intra-articular distal femoral fracture involving a long medial proximal spike and a single lateral condyle fragment, with the lateral condyle fragment posteriorly displaced. A 12-cm lateral skin incision was made, and the joint was developed using a para-patellar approach from the anterior to iliotibial band. Posterior buttress plate fixation was successfully performed from behind the iliotibial band using a posterolateral approach, followed by cannulated cancellous screw and lateral locking plate fixation from the anterolateral window. Combined anterolateral and posterolateral approaches from one incision enable intra-articular exposure and fixation based on fixation principles for lateral condyle fragments combined with supracondylar fracture.

Application of Cortical Bone Plate Allografts Combined with Less Invasive Stabilization System (LISS) Plates in Fixation of Comminuted Distal Femur Fractures

Background and Objectives: At present, the management of comminuted distal femur fractures remains challenging for orthopedic surgeons. The aim of this study is to report a surgical treatment for comminuted distal femur fractures using supplementary medial cortical bone plate allografts in conjunction with the lateral less invasive stabilization system (LISS) plates. Materials and Methods: From January 2009 to January 2014, the records of thirty-three patients who underwent supplementary medial cortical bone plate allografts combined with lateral LISS plates fixation were reviewed. Clinical and radiographic data were collected during regular postoperative follow-up visits. Functional outcomes were determined according to the special surgery knee rating scale (HSS) used at the hospital. Results: Thirty patients were followed for 13 to 73 months after surgery, with an average follow-up time of 31.3 months. The mean time to bone union was 5.4 months (range of 3-12 months) and the mean range of knee flexion was 105.6° (range of 80-130°). Of the remaining patients, 10 had a score of "Excellent", while 10 had a score of "Good". Three patients had superficial or deep infections, one patient had nonunion that required bone grafting, and one patient had post-traumatic knee arthritis. Conclusions: Based on these promising results, we propose that supplementary medial cortical bone plate allografts combined with lateral LISS plate fixation may be a good treatment option for comminuted distal femur fractures. This treatment choice not only resulted in markedly improved stability on the medial side of the femur, but also satisfactory outcomes for distal femoral fractures.

Medial and lateral dual plating of native distal femur fractures: a systematic literature review

Introduction

Lateral locked plating (LLP) development has improved outcomes for distal femur fractures. However, there is still a modest rate of nonunion in fractures treated with LLP alone, with higher nonunion risk in high-energy fractures, intra-articular involvement, poor bone quality, severe comminution, or bone loss. Several recent studies have demonstrated both the safety and the biomechanical advantage of dual medial and lateral plating (DP). The purpose of this study was to evaluate the clinical outcomes of DP for native distal femoral fractures by performing a systematic review of the literature.

Methods

Studies reporting clinical outcomes for DP of native distal femur fractures were identified and systematically reviewed. Publications without full-text manuscripts, those solely involving periprosthetic fractures, or fractures other than distal femur fractures were excluded. Fracture type, mean follow-up, open versus closed fracture, number of bone grafting procedures, nonunion, reoperation rates, and complication data were collected. Methodologic study quality was assessed using the Coleman methodology score.

Results

The initial electronic review and reverse inclusion protocol identified 1484 publications. After removal of duplicates and abstract review to exclude studies that did not discuss clinical treatment of femur fractures with dual plating, 101 potential manuscripts were identified and manually reviewed. After final review, 12 studies were included in this study. There were 199 fractures with average follow-up time of 13.72 months. Unplanned reoperations and nonunion occurred in 19 (8.5%) and 9 (4.5%) cases, respectively. The most frequently reported complications were superficial infection (n = 6, 3%) and deep infection (n = 5, 2.5%) postoperatively. Other complications included delayed union (n = 6, 3%) not requiring additional surgical treatment and knee stiffness in four patients (2%) necessitating manipulation under anesthesia or lysis of adhesions. The average Coleman score was 50.5 (range 13.5-72), suggesting that included studies were of moderate-to-poor quality.

Conclusions

Clinical research interest in DP of distal femoral fractures has markedly increased in the past few decades. The current data suggest that DP of native distal femoral fractures is associated with favorable nonunion and reoperation rates compared with previously published rates associated with LLP alone. In the current review, DP of distal femoral fractures was associated with acceptable rates of complications and generally good functional outcomes. More high-quality, directly comparable research is necessary to validate the conclusions of this review.

Primary fibular grafting combined with double plating in distal femur fractures in elderly patients

PURPOSE

To report functional and radiological outcomes of using primary fibular graft together with double plating in distal femoral fractures in the elderly.

METHODS

A retrospective study on 30 elderly patients with comminuted distal femoral fractures managed by primary fibular grafting and double plating through an anterior midline approach has been conducted. Only isolated distal femoral fractures type 33-A3, 33-C2, and 33-C3 were included. The patient's mean age was 75.3 years. Evaluation included operative time, blood loss, time to union, knee range of motion, Sanders scoring, and presence of complications.

RESULTS

The average follow-up period was 26.6 months. Mean intraoperative blood loss was 401 ml, and mean operative time was 216 min. All patients had a knee range of motion (90-120°) during follow-up. Time for union ranged from 16 to 23 weeks with a mean of 18.4 weeks, with no cases of non-union. A total of 22 patients (73.3%) showed excellent functional outcomes, and the remaining eight (26.7%) showed good functional outcomes according to the Sanders scoring system. Only two cases (6.6%) had superficial wound infections managed conservatively. No post-operative deformity, loss of reduction, or implant failure was observed until the end of follow-up period.

CONCLUSION

Primary fibular grafting combined with double plating of comminuted distal femur fractures in patients above 70 years is an effective technique with higher rates of union and lower re-operation rates compared to other fixation modalities.

Double fixation for complex distal femoral fractures

For complex distal femoral fractures, a single lateral locking compression plate or retrograde intramedullary nail may not achieve a stable environment for fracture healing.

Various types of double fixation constructs have been featured in the current literature. Double-plate construct and nail-and-plate construct are two common double fixation constructs for distal femoral fractures.

Double fixation constructs have been featured in studies on comminuted distal femoral fractures, distal femoral fracture with medial bone defects, periprosthetic fractures, and distal femoral non-union.

A number of case series reported a generally high union rate and satisfactory functional outcomes for double fixation of distal femoral fractures.

In this review, we present the state of the art of double fixation constructs for distal femoral fractures with a focus on double-plate and plate-and-nail constructs.

Stable internal fixation with dual plate technique for osteoporotic distal femur fractures

Background

Material and methods

Results

Conclusion

•

Osteoporotic distal femur fractures are difficult in terms of fracture treatment and recovery.

•

The minimally invasive plate osteosynthesis (MIPO) with the dual plate technique can provide rigid fixation for osteoporotic distal femur fractures.

•

This stable and rigid fixation may allow early mobilization and return to pre-fracture activity in elderly patients.

•

The MIPO with the dual plate technique could be useful treatment option for osteoporotic distal femur fractures.

Dual-Plating in Distal Femur Fracture: A Systematic Review and Limited Meta-analysis

INTRODUCTION

Although lateral locking plate has shown promising results in distal femur fracture, there are high rates of varus collapse and implant failure in comminuted metaphyseal and articular fractures. This systematic review evaluates the functional outcomes and complications of dual plating in the distal femur fracture.

MATERIALS AND METHODS

Manual and electronic search of databases (PubMed, Medline Embase and Cochrane Central Register of Controlled Trials) was performed to retrieve studies on dual plate fixation in the distal femur fracture. Of the retrieved 925 articles, 12 were included after screening.

RESULTS

There were one randomized-controlled, four prospective and seven retrospective studies. A total of 287 patients with 292 knees were evaluated (dual plating 213, single plating 76, lost to follow-up 3). The nonunion and delayed union rates following dual plate fixations were up to 12.5% and 33.3%, respectively. The mean healing time ranged from 11 weeks to 18 months. Good to excellent outcome was observed in 55-75% patients. There was no difference between the single plate and dual plate fixation with regards to the functional outcomes (VAS score, Neer Score and Kolmert's standard) and complications. Pooled analysis of the studies revealed a longer surgical duration (MD - 16.84, 95% CI - 25.34, - 8.35, p = 0.0001) and faster healing (MD 5.43, 95% CI 2.60, 8.26, p = 0.0002) in the double plate fixation group, but there was no difference in nonunion rate (9.2% vs. 0%, OR 4.95, p = 0.13) and blood loss (MD - 9.86, 95% CI - 44.97, 25.26, p = 0.58).

CONCLUSION

Dual plating leads to a satisfactory union in the comminuted metaphyseal and articular fractures of the distal femur. There is no difference between the single plate and dual plate with regards to nonunion rate, blood loss, functional outcomes and complications. However, dual fixation leads to faster fracture healing at the cost of a longer surgical duration.

Fractures of the distal femur in elderly patients: retrospective analysis of a case series treated with single or double plate

Introduction

We evaluated the radiologic and clinical outcomes of a lateral incision single plate with and a single-incision double plating in elderly patients with osteoporotic distal femoral fractures.

Materials and methods

We performed a retrospective study of 82 cases of distal femoral fractures from May 2004 to June 2018. Group A consisted of 42 patients who underwent single-plate fixation. Group B consisted of 40 patients who underwent double-plate fixation. The mean patient age was 77 years (67–87 years) and 76 years (64–86 years) in groups A and B, respectively. All patients were evaluated for procedure duration, time to union, range of knee motion, Lysholm knee score, and presence of complications.

Results

The average procedure time was 81 min (66–92 min) and 110 min (95–120 min) in groups A and B, respectively (p = 0.33). One case in group B required bone grafting after 5 months. The average time to union was 14 weeks (9–19 weeks) and 12.2 weeks (8–19 weeks) (p = 0.63), and the mean range of knee motion was 105° (90–125°) and 110.7° (90°–130°) (p = 0.37) in groups A and B, respectively. There was no significant statistical difference between the two groups in the Lysholm knee score (p = 0.44) and knee society score (p = 0.53).

Conclusion

The clinical and radiological outcomes were similar in the 2 groups. In elderly patients, double plate fixation for distal femoral fractures is an useful method for several advantages such as adequate exposure, easy manipulation, anatomical reduction and stable fixation.

A modified anterolateral swashbuckler approach for distal femoral fractures: description and outcomes

BACKGROUND

The treatment of distal femur fractures represents a challenging task. General and local factors, including bone quality, articular surface involvement, fracture comminution, associated soft tissue injuries and ultimately fixation system, all play a role in the final clinical outcome. Current surgical approaches often undermine patellar vascularization and integrity of the extensor apparatus, not guaranteeing sufficient visualization of the medial condyle. This technical note presents the efficacy and safety a new surgical technique to address distal femoral fractures.

METHODS

The original "swashbuckler" surgical approach was modified in order to obtain a better visualization of the lateral and medial femoral condyles without affecting the knee extensor mechanism and the anastomotic arterial supply of the patella. This modified surgical approach was utilized in a consecutive series of patients presenting with an AO Foundation/Orthopaedic Trauma Association (AO/OTA) 33 distal femur or periprosthetic fracture of the knee. The final outcome was recorded according to a functional evaluation scoring system.

RESULTS

Twelve patients (2 males and 10 females) with a mean age of 67,8 years were included in this series. The same, modified "swashbuckler" surgical approach was applied in all cases. Multiple internal fixation techniques, including a single lateral plate, a combination of a lateral and medial plate, a single lateral plate associated with lag screws, were used to obtain a satisfactory stabilization of the fracture site. All patients were reviewed at a minimum one-year follow up (median 15 months): all patients regained their level of activities of daily living. No major intraoperative or postoperative complications were recorded.

CONCLUSIONS

The modified swashbuckler approach allows anatomical reduction and appropriate fixation without sacrificing the blood supply to the patella and ensures rapid weight bearing resumption thanks to an intact extensor mechanism.

Union rates and functional outcome of double plating of the femur: systematic review of the literature

BACKGROUND

The optimal treatment strategy for the surgical management of femur fractures and non-unions remains unknown. The aim of this study is to assess union rates, complications and outcome after femoral double plating. Treatment of shaft, distal, periprosthetic fractures and pathological proximal femur fractures as well as femoral non-unions with double plating were evaluated.

METHODS

A systematic review according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement was conducted. Published literature reporting on the treatment and clinical outcome of femoral fractures and non-unions with double plating was identified. In total, 24 studies with 436 cases of double plating, 64 cases of single plating, 84 cases of intramedullary nailing (IM), and 1 interfragmentary screw treatment met the inclusion criteria of this systematic review. The evaluated literature was published between 1991 and 2020.

RESULTS

Double plating of femoral fractures achieved high healing rates and few complications were reported. It displayed significantly less intraoperative haemorrhage, shorter surgery time reduced risk of malunion in polytraumatised patients when compared to IM. Fracture healing rate of double-plating distal femoral fractures was 88.0%. However, there were no significant differences regarding fracture healing, complication or functional outcome when compared to single plating. Treatment of periprosthetic fractures with double plating displayed high healing rates (88.5%). Double plating of non-unions achieved excellent osseous union rates (98.5%).

CONCLUSIONS

The literature provides evidence for superior outcomes when using double plating in distal femoral fractures, periprosthetic fractures and femoral non-unions. Some evidence suggests that the use of double plating of femoral fractures in polytraumatised patients may be beneficial over other types of fracture fixation.

LEVEL OF EVIDENCE

IV.

Impact on periosteal vasculature after dual plating of the distal femur: a cadaveric study

Although dual plating of distal femur fractures has been described for injuries at risk of varus displacement, the vascular insult to the medial distal femur utilizing this technique is unknown. The aim of this study was to evaluate the perfusion of the medial distal femoral periosteal arteries after supplemental medial plating of the distal femur.

Methods

Fifteen human fresh-frozen cadaveric femora were thawed and randomized to lateral locked plating alone or with supplemental medial plate fixation. Conventional submuscular medial plating was performed using a 12-hole small fragment plate and multiple cortical screws. The superficial femoral artery was injected with latex dye. Specimens were dissected. The patency of the medial distal femoral periosteal vessels was evaluated.

Results

Four vessels were consistently observed traversing the distal medial femur: the transverse and descending (d-MMPA) branches of the medial metaphyseal periosteal artery, and the transverse and longitudinal branches of the descending geniculate artery. The anterior longitudinal arch (ALA) was present in 13 of 15 specimens and was fed by the d-MMPA. The median number of periosteal arteries occluded by the medial plate was 2 (6 out of 8 specimens). The d-MMPA was occluded in 6 of 8 medially plated femurs, resulting in a complete lack of perfusion of the ALA.

Conclusions

Submuscular medial plating of the distal femur compressed the d-MMPA in the majority of specimens. This vessel gives rise to the ALA, which lacked perfusion in these specimens. This vascular insult could affect the healing of metaphyseal distal femur fractures treated with dual plating.

The Olerud Extensile Anterior Approach for Complex Distal Femoral Fractures: A Systematic Review

The management of AO/OTA (AO Foundation/Orthopaedic Trauma Association) 33-C3 complex distal femoral fractures presents challenges for orthopaedic surgeons. The extensile anterior approach may be an appropriate alternative treatment technique. The purpose of this systematic review is to (1) evaluate the Olerud approach (extensile anterior approach) for the treatment of 33-C3 complex distal femoral fractures and (2) evaluate postoperative patient outcomes. A systematic literature search was performed to retrieve studies that evaluated the treatment of 33-C3 complex distal femoral fractures. The PubMed database query resulted in 429 studies. Two reviewers independently reviewed the studies, of which six were identified. Patient demographics, AO/OTA fracture, surgical intervention, follow-up duration, clinical outcomes, and postoperative complications were collected and analyzed. The systematic review included six studies reporting on 85 patients (43 males and 42 females); the mean patient age was 45 years (range: 16-101 years). The most common cause of injury was road/traffic accident (51 patients). The mean follow-up time was 26 months (range: 3-72 months). In five studies, the mean time for union was 5.8 months (range: 2-9 months). The three most commonly reported complications were infection (seven [8.2%] patients), failure/malunion (three [3.5%] patients), and delayed tibial tuberosity osteotomy healing (three [3.5%] patients). Seventy (82.4%) patients did not suffer any postoperative complications. Out of 72 patients, 7 (9.7%) had resultant varus/valgus deformity. Overall, 57.1% had excellent/good functional outcomes. Based on the systematic literature review, the extensile anterior approach may be a viable alternative surgical option for 33-C3 complex distal femoral fractures. Given the current literature, more comprehensive and extensive studies need to be performed to ensure the best possible outcome.

Supplemental medial small fragment fixation adds stability to distal femur fixation: A biomechanical study

INTRODUCTION

Bridge plating of distal femur fractures with lateral locking plates is susceptible to varus collapse, fixation failure, and nonunion. While medial and lateral dual plating has been described in clinical series, the biomechanical effects of dual plating of distal femur fractures have yet to be clearly defined. The purpose of this study was to compare dual plating to lateral locked bridge plating alone in a cadaveric distal femur gap osteotomy model.

MATERIALS AND METHODS

Gap osteotomies were created in eight matched pairs of cadaveric female distal femurs (average age: 64 yrs (standard deviation ± 4.4 yrs); age range: 57-68 yrs;) to simulate comminuted extraarticular distal femur fractures (AO/OTA 33A). Eight femurs underwent fixation with lateral locked plates alone and were matched with eight femurs treated with dual plating: lateral locked plates with supplemental medial small fragment non-locking fixation. Mechanical testing was performed on an ElectroPuls E10000 materials testing system using a 10 kN/100 Nm biaxial load cell. Specimens were subject to 25,000 cycles of cyclic loading from 100-1000 N at 2 Hz.

RESULTS

Two (2/8) specimens in the lateral only group failed catastrophically prior to completion of testing. All dual plated specimens survived the testing regimen. Dual plated specimens demonstrated significantly less coronal plane displacement (median 0.2 degrees, interquartile range [IQR], 0.0-0.5 degrees) compared to 2.0 degrees (IQR 1.9-3.3, p = 0.02) in the lateral plate only group. Dual plated specimens demonstrated greater bending stiffness compared to the lateral plated group (median 29.0 kN/degree, IQR 1.5-68.2 kN/degree vs median 0.50 kN/degree, IQR 0.23-2.28 kN/degree, p = 0.03).

CONCLUSION

Contemporary fixation methods with a distal femur fractures are susceptible to mechanical failure and nonunion with lateral plates alone. Dual plate fixation in a cadaveric model of distal femur fractures underwent significantly less displacement under simulated weight bearing conditions and demonstrated greater stiffness than lateral plating alone. Given the significant clinical failure rates of lateral bridge plating in distal femur fractures, supplemental fixation should be considered, and dual plating of distal femurs augments mechanical stability in a clinically relevant magnitude.

Excellent outcomes after double-locked plating in very low periprosthetic distal femoral fractures

INTRODUCTION

Very low periprosthetic distal femur fractures (PPDFFs) are rare injuries and often have a relatively high failure rate after single lateral locked plating. The double plating technique yields good outcomes in osteoporotic fractures of the distal femur. To date, there is limited information on double-locked plate fixation of very low PPDFFs. This study aimed to evaluate the outcomes and complications of surgically treated very low PPDFFs using double-locked plate fixation.

MATERIALS AND METHODS

Between January 2013 and December 2018, sixty-one consecutive patients with PPDFFs have been conducted. Only Su type III PPDFFs with double-locked plate fixation through a lateral minimally invasive approach and a medial subvastus approach to the distal femur were analyzed. Patients were encouraged to perform straight leg raising exercises and active knee motion on the second postoperative day. Assisted weight bearing from the early postoperative days was supported, and full weight-bearing was allowed after healing the fracture site. All patients were evaluated according to the time to union, limb alignment, range of knee motion, Knee Society Score, and presence of complications.

RESULTS

Twenty one patients (17 females and 4 males, mean age 76 years, range 56-90) were included in the study. There were 10 of 33-A1, 6 of 33-A2 and 5 of 33 A3 fractures, according to the AO classification. Of 21 patients, 20 achieved union at an average of 14 weeks postoperatively. Postoperative limb alignment was satisfactory in all cases, with an average mechanical distal lateral femur angle of 89° and average mechanical posterior distal femur angle of 86°. All patients recovered the knee joint motion similar to that of the contralateral side, and daily life pre-injury. The average knee and function scores were 94 and 89, respectively. There were one case of non-union and three cases of superficial wound infection, which resolved after intravenous antibiotic therapy.

CONCLUSIONS

Double locked plating showed excellent radiographic and functional outcomes with few complications in patients with very low PPDFFs. Based on these promising results, we propose the consideration of double-locked plate fixation in the treatment of very low PPDFFs.

Early fixation failure of locked plating in complex distal femoral fractures: Root causes analysis

BACKGROUND/PURPOSE

Orthopaedic Trauma Association (OTA) C-type distal femoral fractures can be very challenging to treat effectively. While locked plating is widely used in the complex distal femoral fracture, failure of locked plate fixation is not uncommon. First, we tried to determine the risk factor related to early failure of multiplanar OTA C-type fracture in the distal femur after fixation with lateral locked plate. Second, we tried to provide a strategy for surgeons to prevent pitfalls of early failure in the complex distal femoral fractures treated with lateral locked plating.

METHODS

We retrospectively reviewed 44 adults with OTA C-type fractures of the distal femur treated with locked plate fixation between 2010 and 2016 at Tri-Service General Hospital. Average length of follow-up was 27.6 months (range, 12-54 months). Univariate and multivariate logistic regression were used to determine the association of variables on early failure of fixation. A p-value < 0.05 in univariate and multivariate analyses were considered significant.

RESULTS

There were six patients experiencing early failure, and the early failure rate was 13.6%. The risk factors associated with early failure of complex distal femoral fracture identified by univariate analysis included sagittal oblique fracture pattern, longer working length and post-operative sagittal malalignment (odds ratio [OR] and 95% confidence intervals [CI]: 90.00 (6.85-1183.33), 0.55 (0.31-0.98) and 8.63 (1.077-69.075) respectively). The multivariate analysis showed only sagittal oblique fracture pattern was associated with early failure [OR: 52.348 (3.06-895.23)].

CONCLUSION

Sagittal oblique fracture was more likely to result in early postoperative failure. Early recognition of the fracture pattern should be considered to avoid catastrophic results.

The effects of dual plating on the vascularity of the distal femur

AIMS

Dual plating of distal femoral fractures with medial and lateral implants has been performed to improve construct mechanics and alignment, in cases where isolated lateral plating would be insufficient. This may potentially compromise vascularity, paradoxically impairing healing. This study investigates effects of single versus dual plating on distal femoral vascularity.

METHODS

A total of eight cadaveric lower limb pairs were arbitrarily assigned to either 1) isolated lateral plating, or 2) lateral and medial plating of the distal femur, with four specimens per group. Contralateral limbs served as matched controls. Pre- and post-contrast MRI was performed to quantify signal intensity enhancement in the distal femur. Further evaluation of intraosseous vascularity was done with barium sulphate infusion with CT scan imaging. Specimens were then injected with latex medium and dissection was completed to assess extraosseous vasculature.

RESULTS

Quantitative MRI revealed a mean reduction of 21.2% (SD 1.3%) of arterial contribution in the lateral plating group and 25.4% (SD 3.2%) in the dual plating group (p = 0.051); representing a mean decrease in arterial contribution of 4.2%. The only significant difference found between both experimental groups was regionally, at the lateral aspect of the distal femur with a mean drop in arterial contribution in the lateral plating group of 18.9% (SD 2.6%) versus 24.0% (SD 3.2%) in the dual plating group (p = 0.048), representing a mean decrease in arterial contribution of 5.1%. Gross dissection revealed complete destruction of periosteal vessels underneath either medial or lateral plates in both groups. The network of genicular branches contributing to the posterior and distal femoral condyles was preserved in all specimens. A medial vascular pedicle was found dividing from the superficial femoral artery at a mean 12.7 cm (SD 1.7) proximal to the medial epicondyle and was undisrupted in the dual plating group.

CONCLUSION

Lateral locking-plate application resulted in mean 21.2% reduction in distal femur vascularity. Addition of medial plates did not further markedly decrease vascularity. As such, the majority of the vascular insult occurred with lateral plating alone. Supplemental medially based fixation did not lead to marked devascularization of the distal femur, and should therefore be considered in the setting of comminution and poor bone stock in distal femoral fractures. Further clinical research is required to confirm the results of this study. Cite this article: Bone Joint J 2020;102-B(4):530-538.

Supplementation of Lateral Locked Plating for Distal Femur Fractures: A Biomechanical Study

OBJECTIVES

To investigate the biomechanical properties of a lateral locked plate alone or in combination with a supplemental medial plate or an intramedullary nail (IMN).

METHODS

Intra-articular distal femur fractures with metaphyseal comminution (OTA/AO 33-C) were simulated with a standardized model in 28 synthetic femora and divided into 4 groups. Group I was instrumented with a 4.5-mm lateral locked distal femoral plate alone, group II with a lateral locked plate plus a low-profile precontoured 3.5-mm medial distal tibial plate, group III with a lateral locked plate plus a medial 3.5-mm reconstruction plate, and group IV with a lateral locked plate plus a retrograde IMN. Specimens were then axially loaded and cycled to failure or runout. Outcomes of interest were baseline stiffness, survivability, and cycles to failure.

RESULTS

Groups III and IV have a significantly higher baseline stiffness (P < 0.001) when compared with groups I and II. Furthermore, groups III and IV had a higher max load to failure (P < 0.01) when compared with groups I and II. The survivability in groups III and IV was 71% and 100%, respectively, while no specimens in group I or II survived maximum loading. There was no significant difference between group III and IV regarding stiffness, survivability, and cycles to failure.

CONCLUSION

When considering fixation for intra-articular distal femur fractures with metaphyseal comminution (OTA/AO 33-C), we found that supplementation of a lateral locked plate with a medial plate or an IMN to be biomechanically superior to lateral locked plating alone regarding stiffness, survivability, and cycles to failure. A low-profile precontoured plate did not add significantly to the construct stiffness in this study.

Additional fixation of medial plate over the unstable lateral locked plating of distal femur fractures: A biomechanical study

INTRODUCTION

Lateral locked plating is a standard treatment option for distal femur fractures. However, the unstable conditions after lateral locked plating are increasing. The objective of this study was to investigate the biomechanical strength of additional medial plate fixation over the unstable lateral locked plating of distal femur fractures.

MATERIALS AND METHODS

A distal femur fracture model (AO/OTA 33-A3) was created with osteotomies in the composite femur. Three study groups consisting of 6 specimens each were created for single-side lateral locked plating with 6 distal locking screws (LP-6), single-side lateral locked plating with 4 distal locking screws (LP-4), and additional medial locked plating on LP-4 construct (DP-4). A compressive axial load (10 mm/min) was applied in the failure test. Mode of failure, load to failure, and ultimate displacement were documented.

RESULTS

All single-side lateral locked plating (LP-4 and LP-6) showed plate bending at the fracture gap, while none of the DP-4 showed plate bending at the fracture gap. Load to failure of DP-4 (mean 5522 N) was 17.1% greater than that of LP-6 (mean 4713.3 N, p < 0.05) and 29.2% greater than that of LP-4 (mean 4273.2 N, p < 0.05). Ultimate displacement of DP-4 (mean 5.6 mm) was significantly lower than that of LP-6 (mean 8.8 mm, p < 0.05) and LP-4 (mean 9.1 mm, p < 0.05).

CONCLUSIONS

Additional fixation of medial plate significantly increased the fracture stability in distal femur fractures fixed with the lateral locked plating. Especially in the clinical situations where sufficient stability cannot be provided at the distal segment, the medial plate may be considered as a useful biomechanical solution to obtain adequate stability for fracture healing.

Dual plate fixation results in improved union rates in comminuted distal femur fractures compared to single plate fixation

Purpose

The treatment of distal femur fractures with extensive metaphyseal comminution is frequently complicated by high rates of nonunion and varus collapse. Dual plating with lateral and medial locking plates for these types of fractures has shown promising results in the recent literature. We hypothesize that dual plating of comminuted distal femur fractures leads to higher union rates and lower revision rates compared to an isolated lateral locking plate.

Methods

A retrospective medical chart review between January 2015 and December 2017 was conducted. Inclusion criteria included patients 18 years of age and older who sustained a complex distal femur fracture (AO/OTA 33-C2/33-C3 or periprosthetic fracture with significant metaphyseal comminution) and at least 6 months of follow up. Patients with simple fracture patterns, alternative fixation methods, and inadequate follow up were excluded. All patients in the single plating group were treated with a lateral distal femoral locking plate using a lateral approach. In the patients treated with dual plating, an extensile parapatellar approach was utilized for fracture reduction and placement of an adjunctive medial plate. Demographic information, fracture types, injury severity score (ISS), medical comorbidities, type of surgical fixation, union rates, complications, knee range of motion, time to follow up, and need for revision surgery were extrapolated from the medical charts for analysis.

Results

Twenty-one patients were included in the study. Thirteen patients underwent single plate fixation and 8 underwent dual plate fixation. There were no significant differences in demographics, number of co-morbidities, fracture classification, or ISS between single and dual plate groups (p > 0.05 for all). There was a statistically significant difference in union rates between the single plate group (6 nonunions, 4 unions, and 3 delayed unions) and the dual plate group, with no nonunions or delayed unions (p = 0.0049). Although not statistically significant, 4 patients treated with single plating underwent revision ORIF, compared to none in the dual plating group (p = 0.13). There were no significant differences in time to follow up, time to full weight bearing, or infection rates (p > 0.1 for all).

Conclusion

Based on these results, the medial and lateral locked plating technique demonstrates a higher union rate, with possible lower rates of revision surgery, compared to a single lateral plate in highly comminuted distal femur fractures.

Level of evidence

Level 3. Retrospective Cohort Study.

Challenges in the management of floating knee injuries: Results of treatment and outcomes of 224 consecutive cases in 10 years

INTRODUCTION

Floating knee is a flail knee joint resulting from fractures of the shafts or adjacent metaphyses of the femur and the ipsilateral tibia. It is usually associated with several complications and mortality. This study was designed to present our experience with the treatment of this injury.

MATERIAL AND METHOD

This study was performed between January 2004 and December 2014. 224 cases of floating knee injuries gathered from the 34,480 lower extremities trauma files were studied, and the target information recorded. The injuries most frequently occurred in subjects between 16 and 35 years of age (60.71%), and in male subjects (85.71%). The most frequent mechanism of injury was traffic accident (92.85%). External fixation was the common type of treatment (82.14%) in emergency or as a definitive treatment. The treatment was performed within 24 h of the trauma. We performed a 36-month follow up with clinical examination, radiographs, assessing the complications, and using the Modified Cincinnati Rating System Questionnaire (MCRSQ) and the Karlström/Olerud Score (KOS) to evaluate the progression of the outcomes.

RESULTS

Early complications included 8 cases of compartment syndrome, 60 open fractures and 24 partially amputated limbs. A total amputation was performed in 3 patients. The most common late complication was heterotopic calcifications of the knee (n = 68, 30.6%). Good scores for MCRSQ and KOS were obtained only after patients were sent to a reference center for knee surgery.

CONCLUSIONS

Our experience revealed that the complication rate associated with floatingknee injuries remains high, regardless of the performed treatment. Surgeons should focus on reducing complications while treating these severe injuries.

Medial Open-wedge Osteotomy with Double-plate Fixation for Varus Malunion of the Distal Femur

Objective

To present our clinical experience of treating varus malunion of the distal femur through a medial open‐wedge osteotomy with double‐plate fixation.

Methods

A prospective cohort study was performed. From January 2005 to February 2015, 15 consecutive patients with varus malunion following distal femur fractures were surgically treated at a single level I trauma center. The coronal and sagittal deformity were corrected by a medial open‐wedge osteotomy of the distal femur. A medial buttress plate was used to maintain the realignment. A lateral locking plate was additionally used as a protection plate. The mean age of patients at the time of the surgery was 35.5 years (range, 22–58 years). The radiographical evaluation included the mechanical femorotibial angle, the mechanical lateral distal femoral angle, the anatomic posterior distal femoral angle, and the leg length discrepancy. Clinical outcome evaluation consisted of the range of motion (ROM) and Hospital for Special Surgery (HSS) score.

Results

Mean follow‐up was 7.4 years (range, 4–11.5 years). Varus and flexion malalignment and limb discrepancy were adequately corrected in all patients. The mechanical femorotibial angle, the mechanical lateral distal femoral angle, and the anatomic posterior distal femoral angle were restored from 17.5° (range, 13°–25°) to 2.3° (range, − 2°–7°), 102.3° (range, 95°–112°) to 85.2° (range, 81°–92°), and 77.1° (range, 65°–87°) to 82.7° (range, 76°–88°), respectively. The leg length discrepancy was diminished from 3.4 cm (range, 2.4–4.5 cm) to 0.8 cm (range, 0–1.7 cm). The average bone healing time was 4.1 months (range, 2.5–6 months). The average ROM of the affected knees at 24‐month follow‐up was 3.4°–112.55°. The score of HSS at 4‐years follow‐up was 76.1 (range, 64–88). No internal fixation failure or secondary operation was noted until the last follow‐up.

Conclusion

Medial open‐wedge osteotomy can adequately correct the posttraumatic varus malunion of the distal femur. With fixation of the double plate, non‐displaced bone healing and good functional outcome are expected.

WITHDRAWN: Challenges in the management of floating knee injuries: Results of treatment and outcomes of 224 consecutive cases in 10 years

The Publisher regrets that this article is an accidental duplication of an article that has already been published in Injury, 50(2) (2019) 453–461, https://doi.org/https://doi.org/10.1016/j.injury.2018.12.009. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Transient retrograde interfragmentary compression technique in AO/OTA type 33-C distal femur fractures: A surgical technique and short-term radiographic follow up results

Surgical treatment of AO/OTA type 33-C fractures is a therapeutic challenge despite advances in surgical instruments and techniques. We introduce a novel surgical technique named transient retrograde interfragmentary compression (TRIC) to help intraarticular fragment reduction in AO/OTA type 33-C fracture. We inserted a partial threaded 7.0-cannulated screw with a washer along the transepicondylar axis from the medial femoral epicondyle during the articular block reduction process of AO/OTA type 33-C fractures to strengthen the compressive force between the condylar fragments and to enhance the handling of the articular block fragment in the alignmental correction stage. Following the provisional reduction and fixation using lateral distal femur locking compression plate, TRIC screw was removed. Fifteen AO/OTA type 33-C distal femoral intraarticular fractures of thirteen patients were surgically treated using the TRIC technique. We analyzed the radiographic result of the patients by measuring the horizontal gap and vertical step-off in the postoperative radiographs. Mean horizontal fracture gap was 0.34 mm and mean vertical step-off between bicondylar fragments was 0.63 mm. The median value of the horizontal fracture gap and vertical step off was 0 and 0.46 mm, respectively. Mean time to union in the bicondylar fracture fragment was 9 week. TRIC is considered to be a valuable surgical reduction technique in the treatment of the AO/OTA 33-C type fractures.

[Current status and progress of clinical research on distal femoral fractures]

Objective

To investigate current status and latest progress of clinical research on distal femoral fractures.

Methods

The related literature was extensively reviewed to summarize the trend of the researches and their clinical application in the treatment of distal femoral fractures.

Results

Distal femoral fractures are likely to occur in young people who suffer from high-energy damage and the elderly with osteoporosis, which is always comminuted and unstable fractures, and often involved in the articular surface and combined with serious soft tissue injury. Therefore, the treatment faces many challenges. External fixation is now used as a temporary means of controlling injury. The vast majority of patients are feasible to internal fixation, including plates system and intramedullary nail system. Different internal fixator also has its own characteristics, such as double plates can strengthen the medial support of the femur, less invasive stabilization system protects the blood supply of fractures, distal cortial locking plate is theoretically more fit for the requirements of bone healing, retrograde intramedullary nail can resist varus and valgus.

Conclusion

The treatment of distal femoral fractures should be based on the type of fracture and the characteristics of internal fixators.

Orthogonal plating of Vancouver B1 and C-type periprosthetic femur fracture nonunions

BACKGROUND

Periprosthetic femoral shaft fractures are a significant complication after total hip arthroplasty (THA). Plate osteosynthesis has been the mainstay of treatment around well-fixed stems. Nonunions are a rare and challenging complication of this fixation method. We report the outcomes of a novel orthogonal plating surgical technique for Vancouver B1 and C-type periprosthetic fractures that previously failed open reduction internal fixation (ORIF).

METHODS

A retrospective review identified all patients with Vancouver B1/C THA periprosthetic femoral nonunions from 2010 to 2015. Exclusion criteria included open fractures and periprosthetic infections. The technique utilised a mechanobiologic strategy of atraumatic exposure, resection of necrotic tissue, bone grafting with adjuvant bone morphogenetic protein (BMP) and revision open reduction internal fixation with orthogonal plate osteosynthesis.

RESULTS

6 Vancouver B1/C periprosthetic femoral nonunions were treated. 5 patients were female with an average age of 80.3 years (range 72-91 years). The fractures occurred at a mean of 5.8 years (range 1-10 years) from their initial arthroplasty procedure. No patients underwent further revision surgery; there were no perioperative complications. All patients had a minimum of 11 months follow-up (mean 18.6, range 11-36 months). All fractures achieved osseous union, defined as solid bridging callus over at least 2 cortices and pain free, independent ambulation, at an average of 24.4 weeks (range 6.1-39.7 weeks).

CONCLUSIONS

This is the 1st series describing orthogonal locked compression plating using modern implants for periprosthetic femoral nonunions. This technique should be considered in periprosthetic femur fracture nonunions around a well-fixed stem.

A double-plating approach to distal femur fracture: A clinical study

BACKGROUND

Locked plating is one of the latest innovative options for treating supracondylar femur fractures with relatively low failure rates. Single lateral plating was often found to have a relative higher failure rate. No clinical studies of double-plating distal femur fixation have thus far been reported. The aim of this study is to present our clinical experience with this surgical approach.

PATIENTS AND METHODS

Thirty-two patients (26 females and 6 males, mean age 76 years, range 44-101) were included in the study. Eight of them patients had a periprosthetic stable implant fracture and two patients were treated for a nonunion.

RESULTS

All fractures, excluding one that needed bone grafting and one refracture, healed within 12 weeks. One patient needed bone grafting for delayed union and one patient needed fixation exchange due to femur re-fracture at the site of the most proximal screw. Two patients developed superficial wound infection and one patient required medial plate removal after union due to deep infection.

CONCLUSIONS

Based on these promising results, we propose that the double-plating technique should be considered in the surgeon's armamentarium for the treatment of supracondylar femur fractures, particularly in patients with poor bone quality, comminuted fractures and very low periprosthetic fractures.

Double plating of intra-articular multifragmentary C3-type distal femoral fractures through the anterior approach

INTRODUCTION

In this prospective case series, we report a mean of 12-month follow-up of the utilization of a dual plating of distal femoral fractures. Our technique included a lateral distal femoral locked plate with a low-contact-locked medial plate and bone graft through an extended medial parapatellar anterior approach for the fixation of C3-type distal femoral fractures.

PATIENTS AND METHODS

Sixteen patients (11 males and 5 females) presented with supracondylar femoral fracture type C3, according to Müller long-bone classification system and its revision OA/OTA classification. These were treated using dual plating through extended anterior approach and bone grafting. Our outcomes included clinical and radiological outcomes. Secondary outcomes included postoperative complications.

RESULTS

The mean time of complete radiological union in the studied population was 6.0 ± 3.5 months with a range of 3-14 months. We have not observed postoperative varus or valgus deformity in our cohort. The majority (68.75%) of the studied patients showed significant improvement in range of motion (90°-120°) during follow-up. Eleven out of sixteen patients (68.75%) had well-to-excellent functional outcome. Poor outcome was reported in only two patients (12.50%).

CONCLUSIONS

Dual plating fixation using anterior approach for type C3 distal femoral fractures is an efficient method of management. It has several advantages such as precise exposure, easy manipulation, anatomical reduction and stable fixation. However, operative indications and instructions should be strictly followed. The surgical technique must be rigorous, and the biomechanical qualities of these implants must be understood to prevent the development of major complications.

Complex AO type C3 distal femur fractures: Results after fixation with a lateral locked plate using modified swashbuckler approach

BACKGROUND

Complex AO type C3 fractures of the distal femur are challenging injuries, fraught with complications such as malunion and stiffness. We prospectively evaluated a consecutive series of patients with complex AO type C3 distal femur fractures to determine the clinicoradiological outcome after fixation with a single locked plate using modified swashbuckler approach.

MATERIALS AND METHODS

12 patients with C3 type distal femur fractures treated with a lateral locked plate, using a modified swashbuckler approach, were included in the study. The extraarticular component was managed either by compression plating or bridge plating (transarticular approach and retrograde plate osteosynthesis) depending on the fracture pattern. Primary bone grafting was not done in any case. The clinical outcome at 1 year was determined using the Knee Society Score (KSS). The presence of any secondary osteoarthritis in the knee joint was noted at final followup.

RESULTS

All fractures united at a mean of 14.3 ± 4.7 weeks (range 6-26 weeks). There were no significant complications such as nonunion, deep infection, and implant failure. One of the patients underwent secondary bone grafting at 3 months. The mean range of motion of the knee was 120° ± 14.8° (range 105°-150°). Seven patients had excellent, three patients had good and two patients had a fair outcome according to the KSS at 1 year. At a mean followup of 17.6 months, three patients showed radiological evidence of secondary osteoarthritis of the knee joint. However, only one of these patients was symptomatic.

CONCLUSION

The results of complex C3 type distal femur fractures, fixed with a single lateral locked plate using a modified swashbuckler approach, are encouraging, with a majority of patients achieving good to excellent outcome at 1 year.

The safety and feasibility of minimally invasive plate osteosynthesis (MIPO) on the medial side of the femur: A cadaveric injection study

INTRODUCTION

Minimally invasive plate osteosynthesis (MIPO) on the medial side of the femur appears to be a dangerous procedure due to possible femoral artery injury.

OBJECTIVE

This study aims to determine the feasibility of applying MIPO of the femur via the medial approach, and to determine the anatomical relationship and structures at risk between the artery and the implant using computed tomography angiography.

MATERIALS AND METHODS

A descriptive study of ten fresh cadavers was done. Two separate incisions were made, creating a submuscular tunnel close to the medial side of the femur. An 11- or 13-hole LCP lateral proximal tibial plate (5.0mm) was inserted through the distal incision into the submuscular tunnel and fixed. A CT angiogram with 3D reconstruction was made to determine the distance from and location of the plate relative to the femoral artery and surgical dissection was done to identify the structures at risk.

RESULTS

No disruptions of superficial or deep femoral arteries were found. The closest distances from the superficial femoral artery and deep femoral artery to the plate were 8.3-27.2mm (average 16.3mm) (99% CI: 12.7-19.9) at the level 3 and 4.5-20.0mm (average 8.6mm) (99% CI: 6.4-10.9) at the level 2 in the proximal part of femur, respectively. The location where the SFA crossed the anterior cortex of the femur in the sagittal plane was 9.7-36.0% of the femoral length (average 20.1%) (99% CI: 15.0-25.3%) and the posterior cortex of the femur was 24.7-55.3% of the femoral length (average 40.8%) (99% CI: 35.0-46.7%). The location where the DFA crossed the anterior cortex of the femur in the sagittal plane was 7.9-25.3% of the femoral length (average 13.4%) (99% CI: 10.6-16.3%) and where it crossed the posterior cortex of the femur was 21.7-39.4% of the femoral length (average 31.2%) (99% CI: 27.1-33.3%).

CONCLUSION

MIPO of the femur via medial approach is a feasible option for treatment of femoral fractures when the lateral approach is contraindicated. The distal 60% of the femoral length is safe for this approach.

Peri-implant failure in dual plating of the distal humerus-A biomechanical analysis with regard to screw and plate positioning

PURPOSE

The aim of this biomechanical study was to analyse the influence of plate and screw positioning on peri-implant failure in dual plate osteosynthesis. We hypothesized that screw positioning rather than plate configuration influences the risk of peri-implant fractures.

METHODS

Twenty macerated humerus specimens were available. 5 groups of 4 were built according to specimen size. Locking dual plates (Medartis, Switzerland) were randomly applied to the distal humerus of the specimens in 4 types of configuration: Bending forces were applied using a universal testing machine until peri-implant fracture occurred.

RESULTS

Mean failure loads for respective configuration types were as follows: P1: 428.7 (±84.2) N, A1: 410.0 (±54.7) N, A0: 297.8 (±48.3) N, P0: 261.0 (±65.0) N. Configurations with positioning of the most proximal screws at different levels (P1, A1) reached significantly higher failure loads when compared to screw placement at the same level (P0, A0) (0.01≤p≤0.03). Altering the plate configuration did not significantly influence failure loads (0.34≤p≤0.58).

CONCLUSIONS

The results of this study suggest that placement of the most proximal screws rather than the configuration of the plates is critical regarding the predetermined risk of peri-implant failure in dual plate osteosynthesis of the distal humerus. Varying levels of the outermost screws of corresponding double plates seem to be crucial to avoid complications related to the osteosynthesis.

Comminuted distal femur closed fractures: a new application of the Ilizarov concept of compression-distraction

INTRODUCTION

The treatment of intra-articular distal femur fractures with severe metaphyseal comminution is challenging. It is important to choose a technique that provides secure fixation, minimum tissue handling, and early ambulation. The aim of this work was to evaluate the outcomes of application of Ilizarov concept as an early definitive treatment of comminuted distal femur closed fractures.

PATIENTS AND METHODS

A total of 17 male patients (mean age 28.53±6.33 years) presented with comminuted distal femur fractures (with 10 type C2 and 7 type C3-2 fractures according to AO/ASIF system) were included in this prospective study. Initial fixation of the articular fragments was done by inter-fragmentary screws, percutaneously through a limited open approach, and stabilization was completed by Ilizarov fixator. The procedure included acute shortening, through the comminution, followed by gradual re-distraction to compensate the created shortening. Radiological and functional results were assessed according to ASAMI evaluation system.

RESULTS

The mean amount of intra-operative shortening was 3.68±0.53 cm. The mean external fixation index was 37.24±2.53 days/cm. The mean follow-up period was 18.18±1.91 months. All fractures united primarily in an average 137.65±4.12 days, with no evident angular deformity or limb-length discrepancy. None of the cases required a second major procedure or bone graft. The functional results were excellent in three cases, good in 12, and fair in two patients.

CONCLUSIONS

The Ilizarov concept of acute compression-distraction is a valuable alternative for the treatment of distal femur fractures with severe metaphyseal comminution.