Double-Plating of Comminuted, Unstable Fractures of the Distal Part of the Femur*

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1 Copyright 1991 by The Journal ofbone and Joint Surgery. ncorporated Double-Plating of Comminuted, Unstable Fractures of the Distal Part of the Femur* BY ROY SANDERS, M.D.t, MARC SWONTKOWSK, M.D.t, NASHVLLE, TENNESSEE, HOWARD ROSEN, M.D., AND DAVD HELFET, M.D.L TAMPA, FLORDA From Vanderbilt University Medical Center, Nashville, and Tampa General Hospital, Tampa ABSTRACT: The cases of nine patients who had a complex fracture of the distal part of the femur and a deficient medial-cortical buttress were reviewed. Stable fixation was not achieved with the lateral condylar buttress plate alone. Collapse of the distal fragment into varus angulation was noted intraoperatively, with the axis of rotation being the junction of the distal screws and the plate. Additional stabilization with a medial plate and a bone graft from the iliac crest was applied in all nine patients: in six, at the time of the index operation and in the remaining three, after the open wound and open fracture were considered clean. At an average duration of follow-up of twenty-six months (range, twenty-one to thirty-four months), all of the fractures had healed. Evaluation of the functional outcome revealed five good and four fair results. n three patients, less than 90 degrees of flexion of the knee was present and in six, the arc of flexion was limited to between 90 and 100 degrees. Additionally, four patients had an extensor lag of 5 degrees. Fractures of the distal part of the femur may pose difficult therapeutic problems. Dissatisfaction with non-anatomical reduction, prolonged confinement to bed, and poor function ofthe knee, commonly encountered with traditional treatment with traction, led to the development of devices for improved fixation of implants, including the 95-degree blade-plate and the condylar screw Recently, the locked intramedullary nail has been used in selected supracondylar fractures of the femur7. The superior results that have been obtained with these devices in fractures of the distal part of the femur that do not have major condylar comminution have made them the standard of care for the management of these injuries. Several fracture patterns occur in the most distal part of the femur, however, for which these devices cannot be * No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject ofthis article. No funds were received in support of this study. t Florida Orthopaedic nstitute, 4175 East Fowler Avenue, Tampa, Florida :1:Department of Orthopedics, University of Washington, Seattle, Washington The Hospital for Joint Diseases Orthopedic nstitute, New York, N.Y #{182} Department of Orthopedics, University of South florida, Tampa, Florida effectively used. Ninety-five-degree blade-plates and screwplates necessitate a minimum of three to four centimeters of intact bone in the distal part of the femur for adequate purchase of the condylar fragment 3. nterlocking nails need a minimum of seven to nine centimeters of intact bone in the distal part of the femur and should be used principally in extra-articular fractures7. All of these implants are therefore contraindicated in patients who have a very distal supracondylar fracture of the femur or a fracture with marked comminution of the condyles. The condylar buttress plate has been widely used in such patients because of the surgeon s freedom to insert multiple cancellous-bone screws selectively into major condylar fragments for fixation of the fracture9. Unfortunately, the condylar buttress plate may provide insufficient fixation of certain comminuted fractures, especially distal fractures that have fragmentation of the medial cortex of the femur or segmental loss of bone. Muller et al. recommended the use of a supplemental medial plate in such cases. The purpose of this retrospective study was to review our results with use of the condylar buttress plate in combination with a medial plate for the treatment of comminuted, unstable fractures of the supracondylar region of the femur. Materials and Methods Between January 1985 and February 1988, we treated nine patients who had a comminuted fracture of the distal part of the femur with a condylar buttress plate and supplemental fixation with a medial plate, either at Vanderbilt University Medical Center or at Tampa General Hospital. Although the exact number of condylar buttress plates used during this time at these institutions is unknown, we estimated that forty-eight supracondylar or supracondylar-intracondylar fractures had had application of a lateral condylar-buttress plate. All nine patients had a supracondylar fracture with intracondylar extension. Four fractures were type C2.3 (supracondylar-intracondylar fractures of the distal part of the femur with supracondylar comminution) and five were type C3.3 (supracondylar-intracondylar fractures of the distal part of the femur with both supracondylar and intracondylar comminution), according to the classification of Muller et al. (Table 1). Eight of the nine fractures had severe comminution of the condyles in both the sagittal and frontal VOL. 73-A, NO. 3, MARCH

2 342 ROY SANDERS, MARC SWONTKOWSK, HOWARD ROSEN, AND DAVD HELFET TABLE DATA ON THE PATENTS Range of Sex, Type of Soft-Tissue Operative Duration of Time to Motion of Deformity at Functional Result* Case Age Fracture njury Approach Follow-up Healing the Knee Follow-up Outcome Grade (Yrs.) (Mos.) (Mos.) (Degrees) (Points) 1 M, 30 C2.3 Grade Combined, immediate No 32/40 Good 2 F, 69 C2.3 Closed Combined, immediate No 28/40 Good 3 M, 32 C2.3 Grade B Combined, delayed No 27/40 Good 4 M, 29 C2.3 Grade C Combined, delayed No 27/40 Good 5 F, 2 1 C3.3 Closed Combined, immediate No 27/40 Good 6 F, 29 C3.3 Closed Combined, immediate degree ext. contracture 25/40 Fair 7 F, 75 C3.3 Grade B Extensile No 24/40 Fair 8 F, 24 C3.3 Closed Extensile No 22/40 Fair 9 F, 46 C3.3 Grade Combined, delayed No 20/40 Fair * See Table. planes (Figs. 1-A through 1-F). n one patient who had a minimally comminuted fracture, fixation had been attempted with a Zickel supracondylar device, which had resulted in additional comminution. Subsequent reoperation and application of a lateral condylar buttress plate and medial plate were needed. Four fractures were closed injuries with extensive comminution of the medial cortex of the distal part of the femur. Five fractures were open: two grade-l and three grade-ll injuries4. All five involved loss of a substantial amount of metaphyseal bone, either at the time of injury through the open wound or at the time of d#{233}bridement. After anatomical reduction of the condyles with lagscrews, fixation of the condyles to the shaft with a condylar buttress plate was performed. The placement of cancellousbone screws into the distal portion of the condylar buttress plate was highly variable and was based on the pattern of the fracture, the location ofthe lag-screws, and the adequacy of the bone stock. At least three screws were placed into the condyles, and more were placed if technically feasible. After fixation of the condylar buttress plate to the proximal and distal fragments, stability was tested intraoperatively by inspection of the site of the fracture during flexion and extension of the knee and during application of varus and valgus loads to the knee. f motion was present, with either the femoral condyles moving on the screws or the screws moving at the screw-plate junction, a medial plate and bone graft were applied. At least three cancellous-bone screws were used distally and three cortical-bone screws were used proximally for fixation of the medial plate. n three of the open fractures, medial plating and tightening of the lateral screws was delayed until the open wound was considered clean. Bone-grafting was delayed until the time of closure of the wound in all open fractures. The operative approach that was used for the medial plating varied. n two patients, an extensile approach with elevation of the tibial tuberosity was used8. A separate medial approach, as described by Henry, was used for the seven remaining patients6. This latter approach consisted of a longitudinal ten to fifteen-centimeter incision, extending from a point five centimeters distal to the adductor tubercle up the medial aspect of the thigh. The medial cortex of the femur was exposed by dissection of the plane anterior to the adductor magnus and posterior to the vastus medialis. The geniculate arteries were identified and were ligated as necessary. Because the dissection was anterior to the adductor canal and always remained distal to the mid-part of the thigh, the superficial femoral artery was not encountered. Postoperatively, the limb was placed in an above-theknee brace with knee-hinges. The hinges were unlocked to allow full range of motion, and a continuous-passive-motion machine was applied in the recovery room. The range of motion started at 30 degrees and was then advanced on a daily basis. Use of the machine at night was variable. The patients who had an open fracture had the same postoperative regimen, but only after medial plating, bonegrafting, and closure of the wound. Physical therapy was begun in the hospital and continued for an average of four and one-half months after the patient was discharged. Walking was progressive, with full weight-bearing being postponed until there was radiographic evidence of union (a minimum of twelve weeks postoperatively). The brace was discontinued at this time. All patients were interviewed and examined at follow-up by us. Hospital charts, physician records, radiographs, and physical therapy notes were reviewed, and functional results were evaluated (Table ). Results The average duration of follow-up was twenty-six months (range, twenty-one to thirty-four months). All fractures healed without additional procedures at an average of 6.7 months (range, five to nine months). No loosening or failure of the plates occurred. There were no wound complications, neurovascular injuries, or infections associated with the plating procedures. The average duration of the operation for the extensile procedure was six hours and twenty-five minutes and for the operations involving separate medial and lateral mcisions, six hours. n the three patients who needed delayed medial plating, the average duration for the lateral plating was three hours and thirty minutes and for the medial ap- THE JOURNAL OF BONE AND JONT SURGERY

3 DOUBLE-PLATNG OF COMMNUTED, UNSTABLE FRACTURES OF THE DSTAL PART OF THE FEMUR 343 proach, two hours and thirty minutes. Estimated loss of blood was not recorded in a consistent manner. No intraoperative complications were encountered in any procedure. Evaluation of the functional outcomes revealed five good and four fair results (Tables and ). The loss of range of motion of the knee was the most important limitation in these patients. Three patients had less than 90 degrees of flexion of the knee and five, between 90 and 100 degrees. Only one patient had flexion beyond 100 degrees, and no patient had flexion beyond 1 10 degrees. Four patients had a flexion contracture of 5 degrees. Only one patient was pain-free. Six patients complained of occasional pain about the plates. Two patients had pain with walking, but none had pain at rest. All patients were able to walk, although only one (Case 1) was able to do so without limitation. Seven patients were able to walk for more than thirty mmutes but less than one hour, and one patient could walk for only fifteen minutes. Of these eight patients, three needed a cane for support. Only one patient was able to return to the job that he had held before the injury. Five patients changed jobs, and two patients who were retired needed assistance at home. One patient who was a nurse had a neurological impairment secondary to a head injury; this limited her over-all recovery and prevented her return to work. Radiographic evaluation revealed that all fractures had healed with full incorporation of the bone grafts. The joint surface was anatomically restored in seven of the nine patients. n one patient, an incongruous reduction of the joint was accepted at the operation. The other non-anatomical reduction was in a seventy-three-year-old woman who had pre-existing osteoarthrosis; at the time of the injury, she lost most of the lateral femoral condyle through the grade-ll open wound4. The osseous defect was reconstructed with a tricortical iliac-crest graft and healed uneventfully. Although the range of motion of the knee was limited to 5 to 65 degrees, she complained of little pain, needed only mild analgesics for the discomfort, and was capable of performing all of the activities of daily living without difficulty. Shortening of the femur of more than 2.5 centimeters was not evident in any patient, despite major traumatic loss of bone in five patients. One fracture healed with a posterior angulation of 5 degrees. Discussion Complex C2 and C3 fractures of the distal part of the femur are distinguished from simpler fractures by their metaphyseal comminution, associated femoral shortening, and, in the case of C3 fractures, severe articular comminution9. n such fractures, rigid stabilization is difficult. The use of intramedullary nails is rarely indicated. Ninety-five-degree blade-plates and condylar screws can be used after interfragmentary fixation of the condylar fragment. The insertion of a blade-plate may, however, loosen the condylar fixation because of the pounding that is needed for insertion. The use of a condylar screw necessitates that at least four centimeters of intact condyle be available for purchase, because Range of motion (degrees) Flexion > <90 Extension >10 TABLE Pain None Occasional or with changes in weather, or both With fatigue Constant Deformity Angulation (degrees) 0 <10 10 to 15 >15 Shortening (cm) 0 < to 2.5 >2.5 FUNCTONAL EvALUATON* Walking ability Walking Unrestricted >30 mins. to <60 mins. <30 mins. Walks at home, is confined to wheelchair, or is bedridden Stair-climbing No limitation Holds rail One stair at a time Elevator only Return to work (either A or B) A. Employed before injury Returned to preinjury job Returned to preinjury job with difficulty Altered full-time job Part-time job or unemployed B. Retired before injury Returned to preinjury life-style Needs occasional help with shopping or laundry Needs assistance at home with activities of daily living Moved in with family or moved to nursing home Result Points Fair Exc. 10 Good 7 Fair 5 Fair Fair 1 Fair * Excellent = points, good = points, fair = points, and poor = 0-15 points. of the large diameter of the screw 3. The condylar buttress plate is the accepted alternative when these implants cannot be used. The design of this implant, however, necessitates a stable medial buttress. Methods of creation of this buttress include direct anatomical reduction, techniques of indirect reduction, or use of external support, such as a cast-brace. n most fractures, stable fixation can be achieved with use of the condylar buttress plate alone, with good results, and a second plate is unnecessary. VOL. 73-A, NO. 3, MARCH 1991

4 344 ROY SANDERS, MARC SWONTKOWSK, HOWARD ROSEN, AND DAVD HELFET FG. 1-A FG. 1-B Figs. -A through 1-F: Case 3. Figs. -A and 1-B: Anteroposterior and lateral radiographs showing a C2.3 supracondylar fracture of the femur with a grade-b open wound. The patient had had a previous fracture of the femoral shaft, but he denied any loss of motion of the knee from that injury. FG. -C FG. l-d Fig. 1-C: Radiograph made after treatment with a condylar buttress plate, irrigation, and d#{233}bndement. No brace was used. Fig. l-d: Radiograph made four days postoperatively, showing instability of the lateral fixation. This necessitated reduction, medial plating, bonegrafting, and retightening of the lateral screws. THE JOURNAL OF BONE AND JONT SURGERY

5 DOUBLE-PLATNG OF COMMNUTED, UNSTABLE FRACTURES OF THE DSTAL PART OF THE FEMUR 345 FG. l-e FG. -F Anteropostenor and lateral radiographs made ten months after the reoperation, demonstrating anatomical alignment as well as consolidation of the bone graft. The results of our study suggest that, for the treatment of patients who have a difficult fracture in whom stable fixation of the distal part of the femur cannot be achieved with a condylar buttress plate because of medial cortical comminution, a short distal condylar fragment, or loss of metaphyseal bone, double-plating is indicated. The distal screw-holes of the condylar buttress plate, while allowing the surgeon to place the screws in the condyles selectively and accurately, lack a locking mechanism for the screwheads to prevent shifting at the screw-platejunction. f there is an inadequate medial buttress, collapse of the distal fragment of the fracture can occur with loading of the extremity. Stability of the fracture must therefore be assessed after application of the lateral plate. This can best be accom-,.. plished by inspection of the interface of the bone and the screw-plate for motion during flexion and extension of the knee and during varus and valgus stress on the distal part of the femur. Any noticeable motion at the interface mdicates unstable fixation, with the need for a medial plate and bone graft. The specific type of medial plate appeared Unimportant in our series, provided it was sufficiently strong to buttress the distal part of the femur during healing and consolidation of the bone graft. The efficacy of a medial plate and bone graft in maintenence of reduction during the loading of early active motion is demonstrated by the fact that all nine fractures healed without loss of reduction and without breakage and loosening of the implant. Despite the achievement of union in satisfactory alignment, motion of the knee was uniformly limited in our patients. The fractures of the distal part of the femur that are reported here are the most severe and are caused by high-velocity trauma with resultant muscular and capsular injury. Comminuted fractures about the distal part of the femur cause extensive adhesions of the quadriceps mechanism Several investigators have recommended the early use of a continuous-passive-motion machine to lessen the formation of adhesions and improve the range of motion 2 3. Despite its use in this series, excellent motion of the knee and restoration of normal function could not be achieved. Decreased flexion of the knee occurred regardless VOL. 73.A, NO. 3, MARCH 1991

6 346 ROY SANDERS, MARC SWONTKOWSK, HOWARD ROSEN, AND DAVD HELFET of the operative approach that was used. These results are medial plate, which necessitated additional dissection of the probably attributable to the high-energy nature of these in- soft tissues, contributed to the contractures about the knee. juries and their attendant damage to the soft tissues. t is We are unaware, however, of any other types of fixation also possible that the need for additional stability with a that can adequately stabilize these severe injuries. References 1. CHRON, H. S. ; TREMouurr, JEAN; CASEY, PATRCK; and MOuJaR, MAURCE: Fractures of the Distal Third of the Femur Treated by nternal Fixation. Clin. Orthop., 100: , CONNOLLY, J. F. ; DEHNE, ERNST; and LAFOLLETE, BRUCE: Closed Reduction and Early Cast-Brace Ambulation in the Treatment of Femoral Fractures. Part : Results in One Hundred and Forty-three Fractures. J. Bone and Joint Surg., 55-A: , Dec GLES, J. B. ; DELEE, J. C. ; HECKMAN, J. D.; and KEEVER, J. E.: Supracondylar-ntercondylar Fractures of the Femur Treated with a Supracondylar Plate and Lag Screw. J. Bone and Joint Surg., 64-A: , July GUSTLO, R. B., and ANDERSON, J. T. : Prevention of nfection in the Treatment of One Thousand and Twenty-five Open Fractures of the Long Bones. Retrospective and Prospective Analysis. J. Bone and Joint Surg., 58-A: , June , HALL, M. F.: Two-Plane Fixation of Acute Supracondylar and ntracondylar Fractures of the Femur. Southern Med. J., 71: , 1481, HENRY, A. K.: Extensile Exposure. Ed. 2. New York, Churchill Livingstone, JOHNSON, K. D., and HCKEN, GREG: Distal Femoral Fractures. Orthop. Clin. North America, 18: , MzE, R. D. ; BUCHOLZ, R. W. ; and GROGAN, D. P. : Surgical Treatment of Displaced, Comminuted Fractures of the Distal End of the Femur. An Extensile Approach. J. Bone and Joint Surg., 64-A: , July MULLER, M. E.; ALLGOWER, M.; and WLLENEGGER, J.: Technique of nternal Fixation of Fractures. Revised for the American edition by G. SegmUller. New York, Springer, NEER, C. S., ; GRANTHAM, S. A.; and SHELTON, M. L.: Supracondylar Fracture of the Adult Femur. A Study of One Hundred and Ten Cases. J. Bone and Joint Surg., 49-A: , June OLERUD, SVEN: Operative Treatment of Supracondylar-Condylar Fractures of the Femur. Technique and Results in Fifteen Cases. J. Bone and Joint Surg., 54-A: , July SALTER, R. B. ; SMMONDS, D. F. ; MALCOLM, B. W. ; RUMBLE, E. J. ; MACMCHAEL, DOUGLAS; and CLEMENTS, N. D. : The Biological Effect of Continuous Passive Motion on the Healing of Full-Thickness Defects in Articular Cartilage. An Experimental nvestigation in the Rabbit. J. Bone and Joint Surg., 62-A: , Dec SANDERS, R.; REGAZZON, P. ; and RUED!, T. P. : Treatment of Supracondylar-ntracondylar Fractures of the Femur Using the Dynamic Condylar Screw. J. Orthop. Trauma, 3: , SCHATZKER, JOSEPH, and LAMBERT, D. C.: Supracondylar Fractures of the Femur. Clin. Orthop., 138: 77-83, ThE JOURNAL OF BONE AND JONT SURGERY