Supracondylar fracture of femur: our experience of treatment with locking compression plate from rural Maharashtra

INTRODUCTION

Surgical treatment of supracondylar or intercondylar distal femoral fractures (AO/OTA types 33-A To 33-C) remains a significant surgical challenge with significant complication rates.^1–7 Adverse events include infection, decreased range of motion, need for bone grafting, malunion, and nonunion.^1,2,4–7

Emphasis on preservation of osseous vascularity utilizing indirect reduction techniques has led to increased union rates without bone grafting.^8,9 Recent advances in submuscular plate applications using existing plate constructs seem to offer the advantages of a lower infection rate and need for bone grafting.^10–13 A problem unique to these fractures is loss of fixation of the distal femoral fragment, however, especially in osteoporotic bone when using the condylar buttress plate.^4,14–16

Many internal fixation devices have been used for the treatment of distal femoral fractures. Implants consisting of plates and screws include devices such as the dynamic condylar screw (DCS), or angled blade plate (ABP) (Synthes, Paoli, PA), along with flexible and rigid intramedullary (IM) nail designs.¹⁷ Studies have shown that internal fixation devices provide superior outcome as compared with closed methods by providing stability that allows early mobilization.¹⁸

Schutz et al described new internal fixation systems such as LISS (less invasive stabilization system) and LCP (locking compression plate) as new approaches to treat metaphyseal fractures.¹⁹ These implants improve fracture healing, especially in osteoporotic bone due to better holding capacity. Also, percutaneous plating becomes easier since screws once locked to the plate do not pull the fracture towards the implant and hence there is no displacement of fracture once reduced.

Objective of the study was to assess the efficacy of LCP in maintenance of post-operative distal femoral alignment and in preventing post-operative varus collapse in supracondylar fracture of femur.

METHODS

Study setting: Post Graduate Institute of Swasthiyog Pratishthan, Miraj, Maharashtra.

Study design: Prospective longitudinal observational study.

Sample size: 50 patients with supracondylar fracture.

Study period: August 2007 to September 2009.

Sampling method: All patients with confirmed diagnosis of supracondylar fracture femur reported to our institution during above-mentioned period.

Selection criteria

This study involved 50 patients who sustained fractures of AO/OTA type 33 (A to C) both closed and compound according to Gustilo and Anderson classification were chosen. Age group ranging from 20-80 yrs who were treated using (LCP) locking compression plate in post graduate institute of Swasthiyog Pratishthan Miraj operated between August 2007 to September 2009. All fractures were classified according to the AO/OTA classification system.

Fracture demographics

The fractures were classified as supracondylar femur fracture (AO/OTA type 33) (A-C). Fractures that were supracondylar with significant proximal fracture extension were classified as an AO/OTA type 33 fracture unless there was a separate diaphyseal fracture.

Statistical analysis

Data was collected by using a structure proforma. Data entered in MS excel sheet and analysed by using SPSS 16.0 version IBM USA. Qualitative data was expressed in terms of percentages. Quantitative data was expressed in terms of Mean and Standard deviation

Association between two qualitative variables was seen by using Chi square/Fischers exact test. Comparison of mean and SD between two groups was done by using unpaired t test to assess whether the mean difference between groups is significant or not. A p value of <0.05 was considered as statistically significant whereas a p<0.001 was considered as highly significant.

RESULTS

In our study majority of patients with supracondylar fracture were from 30-39 years age group i.e. 32% and 24% from 20-29 years as well as 40-49 years age group each.

Majority of patients were males i.e. 46 (92%) and remaining were females i.e. 8%. In our study we found preponderance of male population with male to female ratio as 11.5:1

The cases were classified according to AO/OTA classification. 8 (16%) patients had type A fractures. 1 (2%) patient had type B fractures and 41 (82%) patients had type C fractures.

Out of the total number of cases, majority of them i.e. 52% cases had ROM between 70-100 degree followed by 28% between 0-70 degree. 20% had more than 100 degrees. 7 (14%) patients had healing time <4 months. 24 (48%) patients had healing time between 4-6 months. 19 (38%) patients had healing time more than 6 months. The average healing time was 5.9 months with range between 4 to 8 months.

The immediate post-operative and 8 months post-operative LDFA (lateral distal femoral angle) was assessed and by applying the paired t test and finding the P value there is no significant difference in the lateral distal femoral angle immediate postoperatively and 8 months postoperatively. This shows that the post-operative alignment is well maintained in cases treated with LCP. To assess the overall results, we used Knee society score. In 38% of patients, we found excellent results. Good and fair results were seen in 32% and 26% of patients.

DISCUSSION

Our study using LCP was compared with other study groups using different modalities for treatment for supracondylar fractures of the femur.

Average time for union in our study was 23 weeks. Siliski et al in his study stated the average time of union as 13.6 weeks. Stewart et al observed it as 17.6 weeks.^23,24 In our study average time for union was more as compared to other studies.

Age group was compared with other studies. Mean age in our study was found to be 37.8 years. Siliski et al found the mean age of their study population as 42.2 years. It is almost comparable with our study findings.²³

Outcome score was assessed as per the Knee society score. In our study it was found excellent in 32%, good in 28%, fair in 34% and poor in 6%. Almost more than 50% cases our outcome results are satisfactory. Dunlop in his study found outcome score (Neer) as 22 (85%) excellent and satisfactory 2 (7.5%) unsatisfactory 2 (7.5%) failures. Bolhofner discovered outcome score (Schatzker) as 84% good and excellent, 11% fair, 5% poor. ^20,21 Ostrum also found outcome score (Neer) as 16 (86.6%) excellent.²² Our study findings are less comparable to above mentioned study findings.

Improvements in implants have increased the ability to effectively stabilise these fractures and operative treatment results in a significant reduction in poor results compared with nailing and other plates. Locking plate fixation has become one standard method of treatment for comminuted distal femoral fracture.

A desire to preserve the blood supply to the bone by eliminating or at least reducing plate contact with the periosteum provided the impetus for development of the early fixed angle plate systems. The fundamental principles of external fixators apply to locked plates The stiffness provided by external fixators increases as the connecting bar is moved closer to the bone and the amount of pin spread is increased, locked plates are thus comparable with extremely rigid external fixators and run the risk of becoming non-union generators.

CONCLUSION

Locking compression plate is an ideal implant for fixation of supracondylar fracture of femur 33 (A-C) especially in C3 type where articular comminution is present. Post-operative distal femoral alignment is well maintained and there is no collapse of articular surface. LCP provides stable construct especially in cases with metaphyseal comminution and enables early mobilization.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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