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Distal Femur PDF
Distal Femur PDF
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REVIEW ARTICLE
Department of Orthopaedics and Trauma Surgery, Hautepierre Teaching Hospital Center, Strasbourg Academy Hospital Group, 1,
avenue Molière, 67098 Strasbourg cedex, France
KEYWORDS Summary Fractures of the distal femur are rare and severe. The estimated frequency is 0.4%
Distal femur; with an epidemiology that varies: there is a classic bimodal distribution, with a frequency peak
Fracture; for men in their 30s and a peak for elderly women; however, at present it is found predominantly
Supracondylar and in women and in the elderly with more than 50% of patients who are over 65. The most common
intercondylar mechanism is an indirect trauma on a bent knee, and more rarely direct trauma by crushing.
fracture; The anatomy of the distal femur explains the three major types of fracture. Because of the
Internal fixation; anatomy of the distal femur, only surgical treatment is indicated to stabilize the fracture. A
Biomechanics non-surgical treatment is a rare option. The aim of this report was to provide an update on the
existing surgical solutions for the management of these fractures and describe details of the
surgical technique applicable to these injuries. Recent radiological, clinical and biomechanical
data published in the literature are reported to compare different surgical options.
© 2013 Elsevier Masson SAS. All rights reserved.
1877-0568/$ – see front matter © 2013 Elsevier Masson SAS. All rights reserved.
http://dx.doi.org/10.1016/j.otsr.2012.10.014
354 M. Ehlinger et al.
Figure 1 Bilateral floating knee: a: clinical appearance; b: AP X-ray; c and d: postoperative X-ray, left side; e and f: postoperative
X-ray, right side.
Figure 2 Example of a bifocal fracture of the femur treated with anterograde intramedullary nailing: a, b, c: preoperative X-rays;
d, e, f: immediate postoperative X-rays.
Blade plate
band and creates medial compression. The 95◦ blade plate is of epiphyseal compression with locking screws, requiring
placed on a femur whose articular surface is in 1—3◦ valgus. prior placement of standard additional screws. These screws
In this way, the difference in angle between the plate and should not interfere with the plate. The rules for fixation of
the distal end of the femur results in medial compression this system must be strictly followed, in particular during
of the metaphyseal fracture site after diaphyseal fixation, mini-invasive surgery to prevent malunion and mechanical
thanks to the deformation of the blade plate. For an optimal failure [15]. The patient can be installed according to the
effect, the medial pillar must be perfectly reconstructed. surgeon’s preference. If the patient is installed on a traction
The diaphyseal position of the plate is determined by the table, traction should be moderate and a certain degree of
position of the blade which must be precisely defined. It impaction of the fragments should be preserved, especially
should be located 2 cm from the joint line (AP and lateral in elderly patients to promote union. The first step of the
view), along the axis of the femoral diaphysis and in the mid- mini-invasive surgery is to mark the skin with references
dle of the anterior half of the largest diameter of the condyle (fracture, joint line, patella, femoral stems of an existing
in profile. Thus the blade is inserted in front of the Blumen- implant, femoral axis, incision) which will help reduce the
satt line (avoiding the cruciate ligaments) and behind the amount of radiation to the patient, choose the length of the
groove of the trochlea (avoiding the patellofemoral joint plate and facilitate the procedure. The lateral paracondylar
line). The path is perpendicular to the lateral cortex, aimed approach is used. The length of the plate is chosen to leave
approximately a dozen degrees towards the back to prevent at least five holes above the fracture. The goal is to obtain
internal rotation and medial translation of the distal frag- coverage that is as long as possible to absorb and distribute
ment. The blade should not extend beyond the medial cortex strains and stresses. It is necessary to remain extra-articular
to prevent injuries of the medial collateral ligament. by raising the suprapatellar pouch. The beveled tip of the
plate allows minimally traumatic submuscular and extrape-
riosteal insertion. The plate should be parallel to the lateral
Dynamic compression plate
cortex in front, centered on the femoral diaphysis in profile,
with the racket of the distal femoral plate located behind
The indications are classic: extra-articular fractures,
the base of the trochlea and in front of the Blumensatt line.
sagittal unicondylar fractures or supra- and intercondylar
The anatomical plate can be used as a reduction mold if and
fractures.
only if the plate is, firstly, parallel to the lateral cortex of
This solution includes dynamic epiphyseal screw fixation
the femur (parallel to the cortex does not mean in contact
(lag screw) for compression of the fracture site. Epiphy-
with bone), secondly, the epiphyseal screws are parallel to
seal fixation is obtained by a single screw which the plate
the joint line. The second part of the procedure includes
pivots upon for sagittal adjustment. The 95◦ angle between
placing a 2 mm pin along the path of the central screw of
the plate and the screw facilitates frontal placement and
the LISS system which should be parallel to the joint line.
positions the ephiphyseal screw parallel to the joint. This
The bone can then be pulled towards the plate with a trac-
system has the advantage of being fairly easy to position,
tion screw or by using the LISS system. To obtain a perfect
because the screw is cannulated, to limit bone trauma and
reduction, different technical tricks can be used (lag screw
to have good resistance to screw failure. However the screw
from the bone to the plate, temporary intrafocal pinning,
hole is large, there may be rotational instability in the dis-
temporary screws, joystick pin) [13—15].
tal screw before diaphyseal fixation and the insertion site of
Numerous biomechanical studies have been performed
the screw may be located near a frontal fracture. The inser-
to evaluate and define locking plate fixation systems.
tion guide is positioned according to the same criteria as the
The LCP® (Synthes, Etupes, France) system is usually the
blade plate, and its direction on the axial plane is parallel to
reference and is compared to classic internal fixation sys-
the anterior trochlear rims, or 10◦ downwards and inwards.
tems. Dougherty et al. [16] suggest that bicortical screws
should be systematically used to provide three points of
Locking compression plate fixation (2 cortical + the plate) to limit breakage. The posi-
tion of the screw in relation to the fracture line depends on
The classic indications are extra-articular fractures, sagittal the type of fracture. If the fracture is unstable (long frac-
unicondylar fractures or supra- and intercondylar fractures. ture line, comminutive fracture) locking screws are placed
The goal of locking plate is to provide better stability in near the fracture line to stabilize the fracture site. If it is
fragile bone. Primary stability of the plate is independent a simple fracture, locking screws are placed further away
of the friction effect as the screw presses the plate, and is with an open hole on each side of the fracture to create
obtained by locking the screw into the plate. Plate design is elasticity in the system, which will promote union [17]. For
usually anatomical which allows it to be used as a ‘‘reduction Ahmad et al. [18], the internal fixation system should be
mold’’, molding the bone to the plate. close to the fracture. A distance of less than 2 mm provides
The locking plate can be used during an open procedure better resistance to compression and torsion, while there
when there is intra-articular involvement, or with mini- is significant plastic deformity with more than 5 mm. LCP
invasive surgery using the ancillary less invasive stabilization plates have combination screw holes making it possible to
system (LISS) in case of an extra-articular fracture or in the use a ‘‘locked system’’, a dynamic compression plate (DCP)
presence of a simple non- displaced fracture [13]. Combina- system or a ‘‘combination’’ system. Stoeffel et al. [19] com-
tion use is possible, with mini-invasive proximal diaphyseal pared these three systems. The locking system results in
fixation combined with open distal internal fixation. Mini- less loss of reduction under axial compression with less plas-
invasive surgery reduces postoperative pain, and facilitates tic deformity and the DCP system provides better strength
functional recovery [14]. Its main disadvantage is the lack under torsion. The authors propose combination fixation.
358 M. Ehlinger et al.
Bottlang et al. [20] propose the use of a standard screw at was increased in locking plates, however failures were more
the end of the plate in case of a fracture in osteoporotic bone severe with opening of the proximal femoral fragment.
to limit strains and prevent a stress fracture. This type of Zlowodzki et al. [29] compared LCP, blade plates, and ret-
system increases strength during bending without changing rograde nailing in extra-articular fractures. Strength under
strength under compression or torsion. The implant must be axial compression was better with the LCP system than with
parallel at a 10◦ angle to the cortex and the lateral condyle. the blade plate or nailing, by 34 and 13% respectively, but
Indeed Khalafi et al. [21] have shown that these parallel sys- strength under torsion was reduced. The authors observed
tems are stronger under axial compression and cyclic loading better distal fixation with the LCP system with loss of dis-
than systems in which the plate is not parallel to the lateral tal fixation in only one LCP plate (6%), three blade plates
cortex. Beingessner et al. [22] compared ‘‘titanium’’ plates (38%) and eight losses with retrograde intramedullary nail-
to steel plates as well as unicortical to bicortial screws in ing (100%). These same authors compared the blade plate to
these indications. They showed that strength under torsion the LCP system in cadavers with high bone density and did
is reduced in ‘‘titanium’’ plates and strength is improved not find any significant difference in compression strength
with bicortical screws. On the other hand, there is no dif- [30]. Finally, Hingins et al. [31] concluded that the locking
ference for axial compression strains and plastic deformity. plate system was better than the blade plate with increased
Lujan et al. [23] concluded that ‘‘titanium’’ plates favor strength under axial compression and cyclic loading what-
the formation of calluses by increasing elasticity in fixation ever the quality of cadaveric bone. To our knowledge, no
material. Finally, for Wilkens et al. [24], the placement of studies have been performed to compare anteretrograde
polyaxial screws increases strength under axial compression intramedullary nailing to locking plates. Overall, biome-
and torsion and reduces deformation observed under cyclic chanical results showed that locking plates are better.
loading.
As in complex fractures of the proximal humerus, the dis- Vallier and Immler [32] compared the 95◦ blade plate
tal humerus and fractures of the femoral neck, total knee and LCP locking plates in a retrospective series of 71
arthroplasties can be included as a therapeutic option in intra-articular and extra-articular fractures. The rates of
elderly patients. complications, surgical revisions and nonunion were statisti-
This is a difficult procedure in a fragile population requir- cally higher with LCP plates. On the other hand, Nayak et al.
ing extensive expertise in arthroplasty. The main technical [33] support the use of LCP locking plates for extra-articular
point is to restore the height of the joint line when there fractures, reporting union in all cases, good recovery of
is no longer any possibility of reduction. An intact lateral alignment and high quality function. An autologous graft was
or medial pillar facilitates adjustment of the replacements. not necessary with the mini-invasive technique, postopera-
A constrained knee replacement is usually chosen and even tive pain was reduced and the rate of union was high. Kolb
in certain cases a megaprosthesis such as that used after et al. [34] confirmed these results in a retrospective series
tumor resection. Postoperative morbidity-mortality is high. of 50 fractures. Functional recovery was found to be very
In a series of 54 fractures in patients in their 80s, Apple- good with 80% of good and very good results. They concluded
ton et al. [25] reported a mortality of 40% and a morbidity that the locking plate system allows early mobility, rapid
of 15% at 1 year with 11% of surgical revisions and 4% of functional recovery and good radiological results with low
implant revisions. Patient selection is essential to guarantee morbidity, even though these were intra-articular fractures.
the best results. Finally, certain authors propose a hinged Kanabar et al. [35] and Kavali et al. [36] proposed fixation of
prosthesis to treat nonunion of the distal femur in elderly complex fractures of the distal femur with locking plates by
patients. After a mean follow-up of 4 years in a series of 10 mini-invasive approach emphasizing the limited blood loss
patients mean age 74 years old, Vaishya et al. [26] reported and low rate of complications. Kavali et al. [36] did not find
satisfactory functional results with a very low morbidity in any statistical difference in functional recovery between
eight patients. Haidukewych et al. [27] proposed a total patients treated for single or multiple fractures. Compar-
knee replacement for nonunion of the distal femur as well as isons in the literature between retrograde intramedullary
for early failure of internal fixation. Survival was 91%, after nailing and blade plate by a mini-invasive approach have
5 years in 15 patients with perioperative complications in not shown any difference between intra-articular or extra-
29%, postoperative complications in 29%, and poorer results articular fractures. Markmiller et al. [37] did not report
than for primary replacements. improved results for any particular implant for identical
indications. Hierholzer et al. [38] confirmed these results
in a retrospective series of 115 fractures comparing retro-
Results in the literature grade nailing (n = 59) and mini-invasive locking plate (n = 56).
The authors describe the indications for each technique:
Biomechanical data the plate can be adapted to all fractures, while retrograde
nailing is better adapted to extra-articular fractures. They
Several biomechanical studies have shown that locking sys- emphasize that high quality results are more dependent
tems are better than classic internal fixation (DCP plate, upon the surgical technique than the choice of implant.
retrograde nailing, blade plate) [28—30]. Fulkerson et al. On the other hand, results comparing retrograde nailing
[28] compared locking plates to classic large fragment plates and classic open internal fixation are clear. For Thomp-
with cables. Strength under axial compression and torsion son et al. [39], statistical results for the rate of surgical
Treatment of distal femur fractures in adults 359
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