Double-plating approach in the management of isolated distal femoral fractures

INTRODUCTION

Following RTA, fall from height and high energy injuries, distal femoral fractures occur. Supracondylar femur fractures are commonly associated with severe comminution and significant soft tissue injury and fractures are often severely comminuted. Inspite of all the advances in orthopaedics, surgeon faces challenge in distal femur intraarticular fractures. Patients with comminuted fracture and complex articular damage faces disability. Geriatric population suffers with osteoporosis resulting in poor bone quality which complicates the fracture with non-union, mal-union and increased mortality. Supracondylar femur fractures treated with locking compression plate is considered as modern and best option with low failure rates. Fixation with only lateral plate resulted in comparatively high failure rates. Addition of medial plate along with lateral plate reduces chances of fixation failure. One case treated with only lateral single plate resulted in fixation failure, which was later treated with addition of medial plate and autologous bone grafting of iliac crest. On follow-up, there was no recurrence of fixation failure observed.

Objectives

Objective of current study was evaluating the functional and radiological outcome in distal femur fractures treated with dual locking compression plate.

METHODS

The retrospective research study of 35 cases of distal femoral fractures which were treated with lateral and medial plates (dual plates) in Post Graduate Institute Swasthiyog Pratishthan, Miraj (G. S. Kulkarni Hospital, Miraj). The study period was from September 2020 to May 2022.

Inclusion and exclusion criteria

Patients willing for consent of the study, patients with skeletally mature, above 18 years of age, majority of fractures with AO type C2-C3 wew included. Patients not willing for participation in study, patients with infected distal femur fracture in non union, compound grade 3 fracture with severe contamination, patient with severe osteoporosis in old age, patient with multiple co-morbidities like diabetes, hypertension, asthma, thyroid disorder, patient with polytrauma injuries with or without head injuries were excluded.

Procedure

The average follow-up was 8 months. Average procedure time was 143 minutes (126-189 minutes). Average time from hospitalisation to intervention was 4.3 days. Double incision approach (lateral, swashbuckler, medial incision) was used. The fracture fragments identified and were reduced and fixed with lateral and medial plates with screws. 12 hr before operation i.e., in pre operative phase, patient was given LMWH (low-molecular weight heparin). Intravenous antibiotics and LMWH was given for 2 days post operatively. Immediately next day after operation, knee mobilisation was started with non-weight bearing (NWB) walk. Follow up of patients were taken sequentially in 1 month, 3 months, 6 months and 1 year. Oxford Knee Score was used for assessment of follow-up patients. A score of more than 40 is scaled as excellent, 30 to 39 as good functional status, 20 to 29 as moderate and score less than 19 as poor functional result. Medical statistics software SPSS 21 was used for analysis of the data.

Pre-operative planning

Compound injury were examined for mainly soft tissue status and all the fractures were examined for any distal neurovascular deficit. Any other injuries over body must be ruled out. Proper radiographs in all planes are must. Proper planning before surgical fixation is important. For better visualisation of fractured fragments and to study the pattern of fracture, computed tomography of the distal femur in all views is necessary.

Proper pre-operative planning is must to understand the need of dual plating in distal femur fractures.¹ Swashbuckler, lateral parapatellar and medial incision approach were used. The fracture fragments identified and were reduced and fixed with lateral and medial plates with screws.

In case of Comminuted distal femur fractures (AO type C2 and C3). Dual plating gives you stable construct. With the help of Dual incision exposure of fracture fragment is good, manipulation is easy and anatomical reduction is achieved.² Steinberg et al has shown good union rates with dual plating in AO type C2 and C3 distal femur fractures.³ Medial supracondylar void and bone loss of more than 3 cm must be fixed with separate medial side plating. Functional loss of medial cortex occurs in distal femur fracture. So, the healing chances are less in such conditions. Inorder to achieve additional stability, addition of medial plate is must.^1,4 Rajasekaran et al found that additional medial plating and bone grafting was needed for non-union distal femur with medial bone loss more than 3 cm.⁵

Articular surface is lost in Hoffa’s fracture and anatomical restoration of the articular surface is necessary for it. So in medial Hoffa fragment along with medial void, the application of a medial neutralization plate is necessary to achieve stable fixation. Non-union after failed fixation with single lateral plate. If treated with single lateral plate there is increased risk of non-union in patients with comminuted distal femur fractures.⁶ Lujan et al and Henderson et al revealed that using of locking plate constructs with high stiffness achievement may limit the amount of callus, resulting in delayed healing or non-union. It requires non union site stabilization with addition of medial plate and bone grafting at same site.^7-9 Two anatomically contoured locking plates are used. Medially, T-buttress plate can also be used for fixation. 6.5 mm Cancellous screws are used for fractured intercondylar fragment fixation.¹⁰ Data in current study were analysed and calculated by the medical statistics software SPSS 21.2.

Postoperative management

LMWH (anticoagulation) for 2 days and Prevention of infection, analgesia for next 7-10 days were routinely performed. Active knee flexion and extension exercises were suggested, immediately next day after operation. Patients were advised non-weight bearing walking with the help of walker next day after operation. Continuous passive motion (CPM), contraction exercises of quadriceps of the knee were suggested immediately after surgery for rigid internal fixations.

Outpatient follow-up

Plain film was performed every 1 month, 3-months, 6 month and 1 year after operation for monitoring the fracture healing and whether there was loss of reduction and failure of implant placement. Every patient was followed up till the union of fracture. Partial weight bearing was advised depending on sequential follow up of radiographs and condition of patients. Knee function was evaluated by Oxford knee score, one year after surgery.

RESULTS

In our study, total 35 patients were selected which were admitted to our hospital. All patients undergone operative surgical procedure in the form of open reduction internal fixation with dual plating. Out of 35 patients, 25 patients (71.42%) were male patients categorically falling more in age group of 30-49 years.

Remaining 10 patients (28.57%) belonged to female group. Among 35, all patients treated with dual plating showed excellent results with good range of motion of knee. Among 35, maximum 31 patients (88.57%) had less than 5 days stay at hospital (i.e., short post operative stay). In all 35 patients, we had good union of fracture site. Swashbuckler, lateral parapatellar and medial incision approach were used. The fracture fragments identified and were reduced and fixed with lateral and medial plates with screws. Functionally the mean oxford knee score was 41.53±1.69, of which 24 were excellent (36.6%), 10 were good (8.6%), 1 was moderate (2.8%) and none show poor results. Mean EQ-5D-5 L score was 83.8 (72-82). No loss of reduction in any of the cases was evident. After 6 months, 22 patients had no pain and 13 had mild pain (Table 2). 30 patients without aids and 5 patients with crutches. Functionally the mean oxford knee score was 41.53±1.69. Mean EQ-5D-5 L score was 83.8 (72-82). No loss of reduction in any of the cases was evident (Table 2). Post operative complications was included in 3 patients accounted 8.6% (Table 3). One patient was superficial infection and two others were pulmonary infection. All of them were treated well before being discharged from the hospital.

DISCUSSION

The aim of the study is to evaluate the result of dual plating in distal femoral fractures. Complication faced are time required for union, reduction quality, radiological outcome and functional too. MIPPO technique using locking compression plates shown better results with higher union rates and are used widely now.^6-11 Early stabilization in open fractures benefits the patient. By considering factors like restoration of skeletal length, preventing further soft tissue injury by mobile fracture fragments, the compound open fractures, Multiple injuries, bad skin conditions were treated with debridement and external fixation.^12-14 4-6 months was the average recorded time for healing of the fracture with 92.3% of union rate. Soft tissue tethering, pin tract infection and higher inconvenience of patient were major drawbacks of using these methods of fixation.^15-17 Due to all these complications, this method of fixation were decreased in popularity.^15-17

In fractures type 33-C3, intra-articular element should be stabilised first by interfragmentary screws and so intramedullary nails are not recommended.^18-22 If treated with intramedullary nail, axial loading causes loss of distal fixation leading to nail failure resulting in catastrophic nail penetration of nail in knee joint. Other complications were knee stiffness in about 48% of the cases; anterior knee pain (22%), loss of reduction (7%), breakage of the locking screws (8%).^18-22 Lateral locked plates in management of distal femur fractures are used but single plate resulted into other complications like non-union, mal-union, loss of reduction, rotational deformity and breakage of plate resulting into revision surgery in a rate of 20% to 23%.^22-27 With unique geometry of the distal femoral condyles with a 25⁰ of inclination in the medial femoral condyle and 10⁰ of the lateral femoral condyle, risk increases with MIPPO technique causing Rotational mal-alignment. This mal-rotation alignment affects mainly patella-femoral articulation leading to anterior knee pain and aggravates osteoarthritic changes.^18,28

In current study, we implicated the column theory that was described in different intra-articular fractures with double plating techniques like in distal humerus, acetabulum, tibial plateau, and plafond fractures. Addition of medial plate to lateral plate in management of distal femur fractures provides better stability for fracture fixation.²⁹ The average union rate was 9 months (6-12 months). Bone grafting was needed in 10 patients. Surgical debridement was done for 1 case which had superficial skin infection. The majority had good to excellent functional and radiological outcomes. In a biomechanical study done by Prayson et al it was found that the supplementation of the medial column by medial plate must be considered to prevent varus collapse, especially in highly comminuted meta-physeal fractures with bone loss.³⁰

Limitations

Sample size was smaller and follow up period was shorter are the factors taken into consideration as limitations. Larger study of population and Meta analysis are needed for verification of data. Besides this, all patients were selected without randomization which can cause bias and confounding factors. Inspite of this, our study provides statistically significant data regarding outcome of patients with distal femur fractures treated with dual plating.

CONCLUSION

High incidences of distal femur fractures are seen in young patients with high velocity injuries and accidental falls in older patients. The new concept of Dual Plating with option of locked screws has provided the means to increase the rigidity of fixation and is a reliable and effective modality of treatment. Dual 4.5 anatomically contoured locking plates is a good implant to use for fractures of the distal femur. Properly placed accurate positioning and fixation are required to produce good results. It improvises the fracture stability and patients achieve early rehabilitation with good range of motion, strengthening muscle exercises, early weight bearing and mobilisation of patients. Single lateral plating of distal femur fractures was associated with relatively higher failure rate. Addition of medial plate along with lateral plate reduces chances of fixation failure. It must be emphasized that if no signs of radiological healing noticed within 6 months postoperatively and every 3 months afterward, autologous bone graft shall be considered.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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