Evaluation of Results of Locking Compression Plate in Distal Femur Fractures

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1 Originl Article Print ISSN: Online ISSN: X DOI: /ijss/2018/110 Evlution of Results of Locking Compression Plte in Distl Femur Frctures Anuj Kumr Ll 1, S K Kushik 2, Utkl Gupt 3, Vivek Agrwl 4, Shuhm Annt 1 1 Post Grdute Student, Deprtment of Orthopedics, Shri Rm Murti Smrk Institute of Medicl Sciences, Breilly, Uttr Prdesh, Indi, 2 Associte Professor, Deprtment of Orthopedics, Shri Rm Murti Smrk Institute of Medicl Sciences, Breilly, Uttr Prdesh, Indi, 3 Professor, Deprtment of Orthopedics, Shri Rm Murti Smrk Institute of Medicl Sciences, Breilly, Uttr Prdesh, Indi, 4 Assistnt Professor, Deprtment of Orthopedics, Shri Rm Murti Smrk Institute of Medicl Sciences, Breilly, Uttr Prdesh, Indi Astrct Aim of Study: The im of this study is to tret distl femur frctures with locking compression plte (LCP) in 30 cses nd to evlute their functionl nd rdiologicl outcome. Mterils nd Methods: The present study ws conducted in the Deprtment of Orthopedics Surgery of SRMS-IMS, Breilly, from Novemer 2015 to July A totl of 30 cses with 22 mles nd 8 femles, fulfilling the inclusion criteri, with distl femur frctures were treted surgiclly with distl femorl-lcp using direct lterl pproch. 4.5 mm LCP, either of titnium or stinless steel, ws used. All surgeries were done in supine position with knee olster under the ffected lim nd tourniquet ws used in ll cses. Mnul trction ws used to reduce the frcture. Post-opertively, Oxford Knee Score ws used to ssess the functionl outcome. Results: At 6 months finl follow-up, 10 ptients (33.33%) chieved rnge of motion etween 120 nd 140, 17 cses (56.67%) chieved red-only memory etween 100 nd out of 30 cses (72.67%) showed rdiologicl union t 3 months follow-up. 7 cses (23.33%) hd rdiologicl union t 6 months (24 weeks) of follow-up. In the present study, 56.67% of cses tht is 17 of 30 cses hd Oxford Knee Score of more thn 41, 12 cses tht is 40% hd score etween 34 nd 40, nd only 1 hd score etween 27 nd 33. In the present study, 17 cses, i.e., 56.67% showed excellent functionl outcome, while 12 cses showed good nd 1 cse hd fir outcome. Conclusion: LCP in distl femorl frctures promotes erly rdiologicl union, good knee rnge of motion, decresed the post-opertive hospitl sty, with lesser infection rte s there is miniml soft tissue dissection. Finlly, it cn e concluded tht the use of LCP provides good functionl nd rdiologicl outcome in distl femur frctures. Key words: Direct lterl pproch, Distl femur frcture, Locking compression plte INTRODUCTION Distl femur frctures ccount for n estimted 6% of ll femur frctures. The nnul incidence of distl femur frctures is round 37/1,00,000 people. [1] Two different mechnisms re responsile for such trum, where high energy trum is seen commonly in young dults nd low energy or trivil trum in osteoporotic popultion. The Access this rticle online Month of Sumission : Month of Peer Review : Month of Acceptnce : Month of Pulishing : tretment of these frctures hs evolved over the pst 50 yers from closed tretment to open reduction nd internl fixtion with locked plting. In the 1990s, it ecme well estlished tht n internl fixtion construct with flexiility leds to secondry one heling. The method of plting using miniml invsive technique lso preserved frgment vsculrity nd primry one grfting ws not required. [2] The gol of surgicl mngement of these frctures is ntomic reduction, mintining the rticulr congruity nd restoring lim lignment nd erly moiliztion. [3] There re different surgicl options ville: Antegrde niling, retrogrde niling, lde-plte fixtion, isolted screw fixtion, locked plting, nd s prt of dmge Corresponding Author: Dr. Anuj Kumr Ll, Deprtment of Orthopedics, Shri Rm Murti Smrk Institute of Medicl Sciences, Breilly, Uttr Prdesh, Indi. Moile: / E-mil: ll.drnuj@gmil.com 41 Interntionl Journl of Scientific Study April 2018 Vol 6 Issue 1

2 Ll, et l.: Role of LCP in distl femur frctures control orthopedics, externl fixtor use. The current trend is towrd perirticulr distl femorl locking pltes used s minimlly invsive percutneous plte osteosynthesis (MIPPO) technique, using locking compression plte (LCP). The LCP ws developed to give surgeons the opportunity to comine principles of internl fixtion nd dynmic compression, depending on the frcture site, s it contins Comi holes. It is single-em construct where the strength of its fixtion is equl to the sum of ll screw one interfces rther thn single screw s xil stiffness or pullout strength s seen in unlocked pltes. [3] These pltes re ntomiclly contoured to fit the distl femorl flre, nd s they re used y MIPPO technique, they llow prompt heling, lower rte of infection, nd reduced one resorption s lood supply is preserved. The im of this study is to evlute the rdiologicl nd functionl outcome of distl femorl LCP used in these ptients. MATERIALS AND METHODS The present study ws conducted in the Deprtment of Orthopedics of SRMS-IMS, Breilly, from Novemer 2015 to July 2017, on totl of 30 cses of distl femur frctures treted with LCP, fter otining pprovl from the Hospitl Ethics Committee. 22 mle nd 8 femle ptients were tken in this study. The ptients were initilly evluted in the emergency deprtment ccording to the ATLS guidelines. Once other injuries were ruled out nd ptient ws hemodynmiclly stilized, nd then, the injured lim ws immoilized on Bohler-Brun frme. The ptients were then sent to the rdiology deprtment nd X-ry ws tken of the ffected lim, thigh with knee in nteroposterior (AP) nd lterl views, nd the frcture pttern ws decided. The frcture ws clssified ccording to the AO clssifiction of frctures. All ptients ove the ge of 18 yers of either sex with closed or compound frctures up to Grde II or ptients with osteoporotic ones were included in this study. Ptients with hed injury or chest injuries nd pthologicl frctures were excluded from this study. Similrly, ptients were mediclly not fit for surgeries, nd ptients with Gustilo Type III compound injuries or previously treted frctures were not tken into this study. 4.5 mm LCP ws used which hs 50 of longitudinl screw ngultion nd 14 of trnsverse screw ngultion with uniform hole spcing. 4.0 mm nd 5.0 mm self-tpping locking screws with 3.2 mm nd 4.3 mm drill its, respectively, long with threded sleeves re ville. Both titnium nd SS pltes were used ccording to the ptient ffordility. Surgicl Technique A ptient ws tken in supine position on the O.T. Tle. Frcture reduction ws done under direct vision using mnul trction. A knee roll or olster ws plced to ssist in procurement nd mintennce of reduction. A tourniquet ws pplied to get loodless surgicl field. The posterolterl mrgin of the lterl femorl condyle ws plpted. The incision given ws 5 cm for MIPPO technique. The vstus lterlis muscle ws lunty dissected from the lterl intermusculr septum. Using the periostel elevtor, the lterl femorl condyle clered of soft tissue. The plte length nd xil nd rottionl lignment were checked under imge intensifier. Provisionl use of K-wires ws done to uild the rticulr lock. Intercondylr type ws first converted to single condylr lock. The K-wires were plced in such wy tht they did not ostruct the prt of distl femur where plte hd to e fixed. Then, the plte ws inserted nd they were held in plce using K-wires through the slot given for the k-wires to pss. Position of the plte ws confirmed in oth AP nd lterl X-rys under imge intensifier. Then, the distl centrl cncellous screw ws plced first nd then other screws. Proximl screw insertion ws done using minimlly invsive technique. Compression screws were used to pproximte the plte to the femorl shft. Tourniquet ws removed, nd fter chieving hemostsis, closure ws done in lyers nd sterile dressing ws then pplied [Figures 1-7]. Post-opertively, the foot end of the lim ws elevted using pillows. Antiiotics nd nlgesics were given ccording to the hospitl protocol. Knee moiliztion ws strted the next post-opertive dy. Stitch removl ws done on the 14 th post-opertive dy in ll cses. The ptient ws kept non-weight ering for weeks. Follow-up ws tken t 2 weeks, 6 weeks, 12 weeks, nd 6 months to ssess the functionl nd rdiologicl outcome. Rdiologicl outcome ws checked using X-rys in AP nd lterl views. Oxford Knee Score ws used to ssess the functionl outcome. It is questionnire consisting of 12 questions ssessing the functionl sttus of the ptient. Figure 1: Intropertive photogrphs showing the incision tken for MIPPO plting nd estimtion of length of the plte to e used Interntionl Journl of Scientific Study April 2018 Vol 6 Issue 1 42

3 Ll, et l.: Role of LCP in distl femur frctures Figure 2: Cse 1 - Pre-opertive X-ry Figure 3: Cse 1 - () Immedite post-opertive X-ry. () Postopertive t 6 months Figure 4: Cse 1 - ( nd ) Clinicl photo showing full extension nd flexion Mximum score given is 48. Score of >41 is excellent; is good functionl sttus; is fir; nd score of <27 is considered poor functionl result. RESULTS The present study consisted of totl of 30 ptients with n verge ge of 44.8 yers rnging from 18 to 82 yers. The mximum numer of cses (27%) ws in the ge group elow 30 yers owing to the high-velocity trum, wheres low-velocity trum ws seen in only 1 cse, where the ge of the ptient ws Figure 5: Cse 2 - Pre-opertive X-ry ove 70 yers. Right side ws commonly involved thn the left. Distl femur frctures due to rod trffic ccidents mde the ulk of this study, while only 2 cses were due to trivil fll t home. AO clssifiction hs een used in this study to clssify the frcture pttern, which helped in deciding the frcture pttern. Distl femur is numered 33 ccording to AO group. It is further divided into 3 types: Type A - extrrticulr frcture, Type B - prtil rticulr frcture, nd Type C - intrrticulr frctures, ech clss is then further divided into 3 types. In this study, there were 12 cses elonging to Type 33A, 2 cses in Type 33B, nd 16 cses elonging to Type 33C, which mde the mximum numer of cses in this study. The durtion etween injury nd surgery time rnged from 2 to 11 dys with n verge intervl of 4.3 dys. Mjority of the cses, tht is, 60%, were operted within the first 5 dys of the injury. Cses tht showed dely were due to either lte hospitl presenttion or ecuse the ptient hd other ssocited injuries. Some cses hd mssive swelling nd surgery ws postponed until skin showed signs of wrinkling. The min mode of injury ws high-velocity trum nd so the ptient lso hd ssocited injuries. Ptell frctures were seen in 4 cses, tii frcture in 2 cses, proximl femur in 1 cse, nd verterl frctures in 1 cse. The period of hospitl sty vried from 7 dys to 14 dys. The verge post-opertive hospitl sty ws 10.9 dys. 22 cses hd hospitl sty of 10 dys. The rdiologicl union time ws ssessed y getting X-rys on the follow-up visits. 23 of 30 cses (72.67%) showed rdiologicl union t 3 months follow-up. 7 cses (23.33%) hd rdiologicl union t 6 months (24 weeks) of followup. The men knee rnge of motion ws 113.8, with two ptients showing 10 of extension loss. Flexion of t lest 110 ws considered stisfctory, nd 2 cses hd unstisfctory knee rnge of motion. 43 Interntionl Journl of Scientific Study April 2018 Vol 6 Issue 1

4 Ll, et l.: Role of LCP in distl femur frctures Figure 6: Cse 2 - () Immedite post-opertive. () Post-opertive fter 6 months nd functionl outcome ws ssessed using Oxford Knee Score. The men Oxford Knee Score is The Oxford Knee Score is functionl knee score of consisting of 12 questions. Totl score is tken s 48. In the present study, 56.67% of cses tht is 17 of 30 cses hd score of more thn 41, 12 cses tht is 40% hd score etween 34 nd 40, nd only 1 hd score etween 27 nd 33. Grding is done ccording to the score. It is designted s follows: Excellent - more thn 41, good , fir , nd poor - <27. In the present study, 17 cses, i.e., 56.67% showed excellent functionl outcome, while 12 cses showed good nd 1 cse hd fir outcome. There ws no cse with poor functionl outcome. Of totl of 30 cses in the present study, 13 cses hd complictions. There were no cses of ny deep infection, mlunion, or skin necrosis. 2 cses hd superficil infection, 7 hd delyed union, i.e., union seen t 24 weeks of follow-up, 2 hd knee stiffness tht is 6.67%, nd 2 cses hd extension lg of 20 nd 10, respectively (6.67%) [Tles 1-3]. DISCUSSION Figure 7: Cse 2 - ( nd ) Clinicl photo showing full extension nd flexio The present study consisted of 30 ptients with distl femur frctures who were treted y LCP. The rdiologicl Distl femur frctures hve lwys shown imodl ge distriution. High-speed vehiculr ccidents re responsile for distl femur frctures commonly oserved in the young nd middle ged. Low energy mechnisms such s fll t home my e responsile for producing frctures of distl femur in elderly osteoporotic popultion, especilly post-menopusl women. Frctures of the distl prt of the femur re difficult to tret nd present considerle chllenges in mngement. Pin, decresed rnge of motion, nd compromised function of the knee joint re common prolem rising out of rticulr incongruity nd improper fixtion of rticulr frgments in such frctures. [4] A study done y Hoffmn et l. [5] did not show ny difference for non-union rtes or hrdwre filure etween titnium nd stinless steel. This result mtched to the present study where no cses of non-union were seen nd oth titnium nd stinless steel implnts hve een used. Axil stiffness nd torsionl rigidity of internl fixtion re minly influenced y working length. There is fine line etween flexile fixtion, which enhnces cllus formtion nd improves the heling process, nd rigid fixtion, which leds to non-union nd/or implnt filure. Short spnning segments concentrte the stress moment nd my led to filure of the construct. A 34% higher lod to filure in xil loding for the less invsive stilizing system (LISS) construct in comprison to the Amgen iosimilr cndidte ws demonstrted y Kregor et l. In the comprisons of the energy to filure in xil loding, the LISS constructs sored lmost 2.5 times s much energy s the ngled lde plte constructs nd more thn 5 times s much energy s the intr-medullry niling constructs efore filing. [6] Interntionl Journl of Scientific Study April 2018 Vol 6 Issue 1 44

5 Ll, et l.: Role of LCP in distl femur frctures Tle 1: Rdiologicl union in weeks Durtion in weeks Numer of cses (%) 12 weeks 23 (76.67) weeks 7 (23.33) Totl 30 (100) Tle 2: Rnge of motion t end of follow up Rnge of motion Numer of cses (%) Up to (10) (56.67) (33.33) Totl 30 (100) Tle 3: Grding ccording to the Oxford Knee Score t end of the follow up Grding Numer of cses (%) Excellent 17 (56.67) Good 12 (40) Fir 1 (3.33) Poor 0 (0) Totl 30 (100) In study on iomechnicl testing of the LCP y Ahmd M et l., [7] it ws stted y incresing the distnce from 2 to 6 mm nd oth torsionl rigidity nd xil stiffness decresed y s much s 10 15%. It ws found tht incresing the distnce etween the plte nd the one significntly ffected the construct stility. It ws concluded tht LCP ehved in mechniclly similr mnner when fixed either flush to the one or t 2 mm from the one. However, when the LCP is fixed t distnce of 5 mm from the one, oth xil stiffness nd torsionl rigidity re decresed significntly. In the present study, mjority of the ptients (72.67%) showed rdiologicl union t 12 weeks of follow-up nd delyed union seen in 7 cses tht is union seen t 24 weeks follow-up, which mtched the study done y Knr et l. of 12.5 weeks. The cllus formtion ws ssessed in oth lterl nd AP rdiogrphs. [8] The verge rnge of motion in this study ws 113.8, which ws similr to the men red-only memory in other studies mentioned in review of literte. In study done y Pushkr nd Bhn., [9] it ws stted tht norml knee flexion is 140. Luethl et l. hve demonstrted tht verge motion required for: Norml - 93, sitting - 100, nd squtting The functionl outcome in this study ws ssessed using the Oxford Knee Scoring system. The men score in this study ws Gnesh et l. [10] in their study of LISS in tretment of distl femur frctures showed 8% good nd 92% excellent result using the Oxford Knee Score. In our study, there excellent result ws seen in 50% of cses, while hd good results. Philips et l. [11] stted tht the possile disdvntges of the use of the LISS fixtor for distl femorl frctures include reduction difficulties of the metphysel-diphysel component of the frcture nd ccurte fixtor plcement. In ddition, its use is techniclly demnding ecuse frcture reduction nd fixtion must e otined nd performed simultneously. In the present study, there were 2 cses of superficil cteril infection, 7 cse of delyed union where rdiologicl union ws seen t round 24 weeks, nd 2 hd extensor lg of 10. CONCLUSION From the present study, it ws concluded tht LCP in distl femorl frctures promotes erly rdiologicl union, good knee rnge of motion, decresed the post-opertive hospitl sty, with lesser infection rte s there is miniml soft tissue dissection. Mximum of the ptients were le to rech ner norml joint motion y the end of 6 months nd were ssessed using Oxford Knee Score. Finlly, it cn e concluded tht the use of LCP provides good functionl nd rdiologicl outcome in distl femur frctures. REFERENCES 1. Zlowodzki M, Bhndri M, Mrek DJ, Cole PA, Kregor PJ. Opertive tretment of cute distl femur frctures: Systemtic review of 2 comprtive studies nd 45 cse series (1989 to 2005). J Orthop Trum 2006;20: Henderson CE, Kuhl LL, Fitzptrick DC, Mrsh JL. Locking pltes for distl femur frctures: Is there prolem with frcture heling? J Orthop Trum 2011;25 Suppl 1:S Hnschen M, Aschenrenner IM, Fehske K, Kirchhoff S, Keil L, Holzpfel BM, et l. Mono- versus polyxil locking pltes in distl femur frctures: A prospective rndomized multicentre clinicl tril. Int Orthop 2014;38: Moloney GB, Pn T, Vn Eck CF, Ptel D, Trkin I. Geritric distl femur frcture: Are we underestimting the rte of locl nd systemic complictions? Injury 2016;47: Hoffmnn MF, Jones CB, Sietsem DL, Tornett P 3 rd, Koenig SJ. Clinicl outcomes of locked plting of distl femorl frctures in retrospective cohort. J Orthop Surg Res 2013;8: Kregor PJ, Stnnrd JA, Zlowodzki M, Cole PA. Tretment of distl femur frctures using the less invsive stiliztion system: Surgicl experience nd erly clinicl results in 103 frctures. J Orthop Trum 2004;18: Ahmd M, Nnd R, Bjw AS, Cndl-Couto J. Biomechnicl testing of locking compression plte: When does the distnce etween one nd implnt significntly reduce construct stility. Injury,Int.J.Cre Injured. 2007;38: Schütz M, Müller M, Regzzoni P, Höntzsch D, Krettek C, Vn der Werken C, et l. Use of the less invsive stiliztion system (LISS) in ptients with distl femorl (AO33) frctures: A prospective multicenter study. Arch Orthop Trum Surg 2005;125: Interntionl Journl of Scientific Study April 2018 Vol 6 Issue 1

6 Ll, et l.: Role of LCP in distl femur frctures 9. Pushkr D, Bhn N. Comprsion of results of distl femorl frctures treted y internl fixtion with locking compression plte nd retrogrde femorl nil. J Cont Med A Dent 2016;4: Wilkens KJ, Curtiss S, Lee MA. Polyxil locking plte fixtion in distl femur frctures: A iomechnicl comprison. J Orthop Trum 2008;22: Nsr AM, Mc Leod I, Soueh A, Mffulli N. Conservtive or surgicl mngement of distl femorl frctures. A retrospective study with minimum five yer follow-up. Act Orthop Belg 2000;66: How to cite this rticle: Ll AK, Kushik SK, Gupt ZU, Agrwl V, Annt S. Evlution of Results of Locking Compression Plte in Distl Femur Frctures. Int J Sci Stud 2018;6(1): Source of Support: Nil, Conflict of Interest: None declred. Interntionl Journl of Scientific Study April 2018 Vol 6 Issue 1 46