Training by Publishing

Vol 2 | Issue 1 | Jan – April 2016 | page:1-2 |  Dr. Ashok Shyam.


Author:  Dr. Ashok Shyam [1,2].

[1] Indian Orthopaedic Research Group, Thane, India
[2] Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India

Address of Correspondence
Dr. Ashok Shyam
IORG House, A-203, Manthan Apts, Shreesh, CHS, Hajuri Road, Thane, India. 400604
Email: drashokshyam@yahoo.co.uk


Editorial: Training by Publishing

This is a digital world we live in. In last 20 years technology has changed the face of this world specially the way in which the data is shared and interaction is improved. This has accelerated things especially scientific inquiry and distribution of scientific concepts. In field of orthopaedics this has led to better implants and more literature. Increased numbers of journals and articles have led to increased awareness about the results of particular surgery and implant. Also it has improved the propagation of awareness about a new technique / implant and its results. In last century, a new technique would simply remain with a single surgeon or country for a long time [Ilizarov ring fixator for example], but now with advent of the online tools and websites, distribution of knowledge is simply amazing.
One of the areas where technology can be successfully used is area of Training in surgical skills. We are currently having video websites like Vu-medi and many more videos on you tube etc, however I believe journals can play a very active part in this area. Surgical training of highest quality can reach each and every corner of the world simply by combining a format which will include text, pictures as well as videos. We all have basic surgical skill sets and to step up our training we would simply need to conceptualise and visualise different methods. This can easily be gained from the above format. Of course the learning curve for such training would be much longer and at times there will be unforeseen complications and difficulties. For this reason such articles should have a continued thread of comment and discussions which can be compiled over a period of time and better a list of frequently asked questions. This can provide answers to queries for a new trainee or even for an experienced surgeon. I believe the techniques should be open peer reviewed and not undergo a blinded peer review. The reviewers should be openly allowed to ask the surgeons questions and doubts that the reader will have. A post publication review of the technique is one of the most important part of this initiative where readers and peers can comment on the published technique. The goal of this entire exercise should be improvement of technique and to impart correct surgical principles to the trainees.
Trauma International wants to pioneer in this area of surgical training by publishing and will be inviting several surgeons on our special editorial board where techniques can be invited and published. I believe this will help surgeons from all across the world to learn new techniques and also improve older techniques. Innovations and tricks and tops in older techniques can easily be demonstrated by using the online tools. Open access will allow much better outreach and more audience for the author too. I sincerely hope that this idea will take firm root and will grow over a period of time. Although this will not be without challenges but with help of our editorial board and our authors we will definitely be able to achieve this goal
If you have any further opinions about this idea, please write to me. With this I leave you to enjoy this issue with symposium on distal femur fracture
Dr Ashok Shyam
Editor – Trauma International


How to Cite the article: Shyam AK. Training by Publishing. Trauma International Jan-April 2016;2(1):1-2

Dr Ashok Shyam

Dr Ashok Shyam


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Hip Instability following DHS Fixation Surgery for Unstable Four Part Per-Trochanteric Fracture Femur

 Volume 2 | Issue 1 | Jan-Apr 2016 | Page 37-41|Yashwant J. Mahale, Vikram V. Kadu, Abhijeet Deshmukh


Author: Yashwant J. Mahale[1], Vikram V. Kadu [1], Abhijeet Deshmukh[1]

[1] ACPM Medical College , Dhule – 424001 , Maharashtra India.
[2] Mahale Accident Hospital , Dhule, Maharashtra India.

Address of Correspondence

Dr. Vikram V Kadu
C/O Vilas Shamrao Kadu, Plot no. 20, Kadu House, Barde layout, Katol Road, Nagpur – 440013
Email: vikram1065@gmail.com


Abstract

Background: In an ageing population, with resultant osteoporosis hip fractures are common indication for per-trochanteric fracture hip repairs. Various modalities of surgical treatment basically emphasis fracture reduction, fracture immobilization, and rehabilitation as a guide to treatment. Subluxation or dislocation following operative treatment of four part unstable per-trochanteric fracture with Sliding Hip Screw is rare and occasional cases have been reported.
Material and Methods: An observational prospective study carried out at tertiary care hospital from Jan 1997 – Dec 2014. Our operative experience of total 510 patients of which 480 underwent DHS fixation surgery for unstable four part per-trochanteric fracture showed 6 cases of instability as subluxation and dislocation.
Results: We report 6 cases out of 480 DHS fixation showing instability in 3 cases and subluxation and dislocation in 3 cases after 6 weeks of follow-up. These patients were offered arthroplasty and the follow-up results were evaluated after 8 months. Among 6 cases, four had instability after six weeks and remaining two developed dislocation after eight months which were associated with infection. 1 patient refused further investigations & treatment, 3 other died with due course of time, 1 lost to follow -up and One patient with infection underwent excision arthroplasty.
Conclusion: Hip instability following DHS fixation surgery for four part Per-trochanteric fracture femur is a rare complication. Cause of this complication could be mechanical factors (excessive collapse, rotational torque) and infection (superficial or deep) may serve as a contributing factor. Diagnosis was done mainly on the basis of clinical examination and investigations such as X-rays, USG and blood tests. Treatment for such complications consists of Hip arthroplasty. These complications can be prevented with the use of TFN or cemented bipolar prosthesis primarily for treating these type of fractures.
Keywords: Intertrochanteric fracture, hip instability, surgical fixation


Introduction

Per-trochanteric (4 Part) fractures of femur are commonest in elderly people. The incidence is expected to increase in the coming years, with an ageing population resulting in a greater number of traumatic injuries in patients with osteoporotic bone.
DHS fixation is gold standard modality for treatment of such fractures. Various implants used for such fractures are 1) DHS Sliding compression screw and plate devices 2) Intra-medullary devices such as TFN and PFN 3) Enders Nail, 4) Bi-axial plate, 5) External fixator 6) Jewett nail and SP nail. Various Complications of DHS implant are as follows: 1) Implant Failure: a) Cut out of screw b) Proximal or distal migration of screw c) Breaking of plate and screws, 2) Uncontrolled Medialisation of distal fragment and collapse at fracture site, 3) AVN with collapse of head , 4) Infection: Superficial or Deep infection [1)]. However, Hip Instability: Subluxation and Dislocation is very rare [2]. We report, six cases of Hip instability following 480 cases of DHS fixation surgeries for unstable four part Inter- trochanteric fracture.

Materials and Methods
This is a prospective study conducted at our hospital since 1997. We reviewed patients with inter-trochanteric fracture femur treated with various implants. We performed 510 surgeries for Pertrochanteric fracture femur with different modalities DHS (n=480), TFN (n=13), Biaxial Plate (n=15), SP nail (n=1), and Enders Nail (n=1). We found six cases who developed hip instability only after DHS fixation. All available clinical notes and X-rays of these patients were studied to get the relevant information. Of the six cases three were male and two female patients, four had right sided fracture and one had left sided fracture, 4 had infection and 2 had mechanical problems, 1 patient refused further investigations & treatment, 3 other died in due course of time due to unrelated disease complications. 1 lost to follow –up and 1 patient with deep infection underwent excision arthroplasty. Radiological findings of these patients are shown in table 1 and 2.

Table 1: Table showing radiological findings at the diagnosis of instability.

Table 1: Table showing radiological findings at the diagnosis of instability.

 

Table 2: Table showing radiological of collapse *Pre-op measurement was done by drawing a straight line from Greater to lesser trochanter n then from the mid point upto the head of femur. * Collapse of the fragment was calculated from lateral blade plate upto the screw that has back-out. * The average collapse in the above mentioned cases was 9 mm which was found to be excessive as compared to the distance of lag screw backout with a mean length 8.8 mm.(11)

Table 2: Table showing radiology of collapse
*Pre-op measurement was done by drawing a straight line from Greater to lesser trochanter n then from the mid point upto the head of femur.
* Collapse of the fragment was calculated from lateral blade plate upto the screw that has back-out.
* The average collapse in the above mentioned cases was 9 mm which was found to be excessive as compared to the distance of lag screw backout with a mean length 8.8 mm.(11)

Case 1:
A 60 yrs old male was admitted to our hospital with history of domestic fall on Right hip. X-Ray Pelvis with both Hips AP View showed four part pertrochanteric fracture of femur (Fig. 1). Patient had previous history of myocardial infarction. He was treated with DHS and 135 degree 5 hole plate. Early post-operative period was uneventful. Immediate Post-operative X-Ray (Fig. 2) showed relatively acceptable valgus fixation , greater trochanter fragment was not fixed . At 6 weeks follow-up, patient complaint of gradual onset deep pain and difficulty in mobilising right hip. There was no history of recent fall, trauma, fever. On examination, limb was shortened, adducted and internally rotated. Patient had no evidence of infection, movements were limited and painful in all direction . X-Ray Pelvis with both Hips AP View (Fig. 3) showed subluxation of hip joint with DHS implant in situ, excessive collapse at fracture site, rotated femoral head, medialisation of shaft with displaced greater trochanter. The dislocation was reduced and abduction brace was given. Routine Blood examination reports WBC counts – 8300 , ESR – 12 , CRP – Non-Reactive. Patient was medically & financially restrained for further management. Hence immobilisation was continued with brace (Fig. 4). Patient died at the end of 3 months at home.

Figure 1: pre-operative X-ray showing IT fracture femur right side

Figure 1: pre-operative X-ray showing IT fracture femur right side

Figure 2: immediate post-operative X-ray showing good, stable fixation

Figure 2: immediate post-operative X-ray showing good, stable fixation

Figure 3: At 6 weeks follow-up, X-ray showed subluxation of hip joint

Figure 3: At 6 weeks follow-up, X-ray showed subluxation of hip joint

Figure 4: fracture reduced and Abduction brace was provided to maintain the reduction

Figure 4: fracture reduced and Abduction brace was provided to maintain the reduction

Case 2:
70 yr old diabetic male referred to our hospital with gradual onset deep pain, difficulty in mobilization since 15 days. He had history of domestic fall on Right hip 8 weeks back. X-Ray right Hip AP View showed four part pertrochanteric fracture of femur. He was treated with DHS and 135 degree 5 hole plate. Immediate Post-operative X-Ray showed stable fixation with DHS implant in situ. Now the patient complained of pain and limp while walking. On examination, limb was shortened, adducted and internally rotated. Patient had infection at operative site and bed sore. Movements were limited and painful in all direction. X-Ray Pelvis with both Hips Ap View showed dislocation of hip joint with DHS implant in situ, excessive collapse at fracture site, rotated femoral head, medialisation of shaft with displaced greater trochanter. Routine Blood examination reports WBC counts – 17,000 , ESR – 88 , CRP – 1:32 (Reactive). Patient was admitted for further investigations and management but Patient developed Septicaemia and diabetic keto-acidosis and died.

Case 3:
70 year old female, known case of hypertension, presented to our hospital with gradual onset deep pain, difficulty in mobilization, discharging sinus from operative site in left hip since last two months. She suffered a domestic fall on Left hip 6 months back. X-Ray left Hip Ap View showed Unstable four part pertrochanteric fracture of femur. She was treated with DHS and 135 degree 5 hole plate. Immediate post -operative X-Ray was satisfactory. Early post-operative period was uneventful. She was mobilised with walker and then full weight bearing at 4 months. After 6 months, She had discharging sinus and limitation of range of movement of left hip for which she was referred to our hospital. On examination, limb was shortened, adducted and internally rotated, local temperature was raised, operative site was discharging pus with granulation tissue. X-Ray left Hip Ap showed dislocation of hip joint with widely displaced greater trochanter and excessive collapse at fracture site with medialisation of distal fragment. Routine Blood examination reports WBC counts – 13,500, ESR – 70, CRP – 1:32 Reactive. Patient was not willing for further treatment and lost to follow up.

Case 4:
70 years old female known hypertensive presented to our hospital with history of domestic fall on Right hip. X-Ray Pelvis with both Hips AP View showed Unstable four part pertrochanteric fracture of femur. She was treated with DHS and 135 degree 5 hole plate. Intra-operatively, femoral head was found to be rotating during reaming and screw insertion. Early post-operative period was uneventful. At 6 weeks follow up Patient presented with gradual onset deep pain and difficulty in mobilising right hip. There was no history of recent fall, trauma, fever, discharging sinus. On examination, patient had no superficial or deep tenderness, movements limited and painful in all direction. X-Ray Rt. hip AP showed dislocated hip with DHS implant in situ, excessive collapse at fracture site, rotated femoral head and medialisation of shaft. Routine Blood examination reports WBC counts – 8300, ESR- 22, CRP – Non-Reactive. Patient was admitted for further management but died due to Cerebrovascular accident.

Case 5:
65 years old male, came to our hospital with history of fall over right hip. X-Ray Pelvis with both Hips AP View showed Unstable four part inter-trochanteric fracture of femur (Fig. 5). He was treated with 135 degree DHS with 5 hole plate. Immediate post – operative X-Ray was satisfactory (Fig. 6). The patient came regularly for follow-up. Weight bearing was started at 6 weeks. At 10 months follow-up, the patient presented with discharging sinus. On examination, limb was shortened, adducted and internally rotated. Patient had superficial and deep tenderness, movements were restricted and painful in all direction. X-Ray Pelvis with both Hips AP View at 10 months showed subluxation of femoral head with DHS implant in situ, excessive collapse at fracture site, rotated femoral head, with subluxation of the femoral head (Fig. 7). Routine Blood examination reports WBC counts – 9,800, ESR – 80, CRP – Reactive (1:32).USG was done which reported collection in proximal thigh with extension into the hip joint S/O Joint effusion. Hip aspirate was done and pus aspirated was sent for culture. Patient underwent implant removal and excision arthroplasty. Intra operatively large amount of pus was found (Fig. 8), which was drained and infected soft tissue debridement was done to remove all infected and nonviable tissue. Pus and infected deep soft tissues were sent for immediate Gram’s stain, culture and antibiotic sensitivity tests and the head was sent for histopathology which confirmed the diagnosis of pyogenic infection. A skeletal traction system through proximal tibia was applied. Two staged Total Hip Replacement was planned but the patient refused due to financial restraints and ended up with excision arthroplasty (Fig. 9).


Figure 5: pre-operative X-ray showing IT fracture femur right side

Figure 5: pre-operative X-ray showing IT
fracture femur right side

Figure 6: immediate post-operative X-ray showing good, stable fixation

Figure 6: immediate post-operative X-ray showing good, stable fixation


Figure 7: At 10 months follow-up, X-ray showed subluxation of hip joint

Figure 7: At 10 months follow-up, X-ray showed subluxation of hip joint


Figure 8: intra-operatively pus was present at the operative site and the head was completely deformed

Figure 8: intra-operatively pus was present at the operative site and the head was completely deformed


Figure 9: At 6 weeks follow-up after excision arthroplasty

Figure 9: At 6 weeks follow-up after excision arthroplasty

Case 6:
55 years old male k/c/o diabetes and hypertension, came to our hospital with history of fall over right hip. X-Ray Pelvis with both Hips AP View showed Unstable four part inter-trochanteric fracture of left femur (Fig. 10). He was treated with 135 degree DHS with 5 hole plate. Immediate post – operative X-Ray was satisfactory (Fig. 11). The patient came regularly for follow-up. At 6 weeks follow-up, the patient presented with discharging sinus. On examination, limb was shortened, adducted and internally rotated. Patient had superficial and deep tenderness, movements were restricted and painful in all direction. X-Ray Pelvis with both Hips AP View at 6 weeks showed subluxation of femoral head left with DHS implant in situ, excessive collapse at fracture site, rotated femoral head, with subluxation of the femoral head (Fig. 12). Routine Blood examination reports WBC counts – 11,800, ESR – 67, CRP – Reactive (1:32). USG was done which reported collection in proximal thigh with extension into the hip joint S/O Joint effusion. Hip aspirate was done and pus aspirated was sent for culture. The hip was reduced. Patient was not willing for further treatment so was treated by giving abduction brace. The patient died with due course of time due to comorbid conditions.

Discussion
Hip subluxation / dislocation is very rare complication after DHS surgery for four part inter-trochanteric fracture. The present series revealed incidence of 1.04% of 480 DHS suegeries performed. On review of literature occasional case reports of hip instability have been reported [1,2,3,4,5]. Our patients did not undergo further management after making diagnosis of instability for various reasons (3 died, 1 lost to follow up, 1 refused for further management, 1 underwent Excision arthroplasty); (see table no. 3). Various etiopathologies of dislocation / subluxation are on the basis of clinical examination, X-ray, Investigations and review of literature. In these cases it appeared that the factors responsible for instability could be mechanical factors but in some cases presence of pyogenic infection states that infection can be a major contributing factor.

Table 3: Patients demographics indicating age, sex, type of fracture, associated injuries, causative factors and fixation used.

Table 3: Patients demographics indicating age, sex, type of fracture, associated injuries, causative factors and fixation used.

Four part per-trochanteric fracture is generally caused by direct fall on the greater trochanter. This direct force as well as the muscular avulsion force leads to the damage of the capsule, surrounding soft tissues and ligaments and also greater and lesser trochanter are separated making the head rotate freely without any attachment left to it. It is well accepted practice of extraction of femoral head during hemi-arthroplasty procedures. While doing DHS we found out that the femoral head undergoes rotational torque atleast three times (during reaming, tapping and screw insertion ) specially when derotation wire is not used. In all the above mentioned cases the derotation wire was not used. This may cause damage to the remaining soft tissue attachments leading to instability. In right-sided fractures, the screw insertion causes the head fragment to rotate clockwise causing the head fragment to rotate into an extended position at the hip joint. Whereas, in left-sided fractures, the screw insertion causes the head to rotate clockwise leading to head and neck fragment into flexion at the hip and extension of the fracture site leading to potentially unstable construct [8], thereby increasing the soft tissue damage.
Lateral wall plays a key role in stabilisation of unstable pertrochanteric fractures by providing buttress for proximal fragment and its deficiency leads to excessive collapse [6], (table no.2) almost complete resorption of neck causing head to be stabilised against most lateral support which may force femoral head out of acetabulum . Therefore, maintaining the integrity should be important objective in all stabilisation procedures. In patients with four part pertrochanteric fracture femur, if there is gross comminution of posterior & medial cortex , in such patients, femoral head may go into retroversion and varus after fixation due to excessive collapse which may lead to posterior & lateral subluxation of head with progressive weight bearing or stress , finally resulting into dislocation of such hip. Thus lateral wall deficiency, excessive collapse, valgus fixation and postero-medial comminution plays a vital role in determining the instability of the femoral head. All the above mentioned factors are seen in our case series. (table no. 1 and 2).
Patient factors such as mental retardation, poor patient compliance, alcoholic patients, infection and neurogenic causes may lead to dislocation [7]
In our study, 3 cases had infection of which 2 had early and 1 late infection. In early stages of acute infection [4] instability of femoral head may be accounted because of destruction of soft tissue, such as capsule, ligaments and spasm of the adductors. In late stages i.e. chronic infection, the head is damaged asymmetrically in addition to above mentioned factors leading to instability [3] as seen in case 5.
This complication has not been reported with SP nail plate, Jewett nail, TFN, Biaxial plate etc. This may be because rotational torque is not required in fixation of fractures with these implants. However, in case of enders nailing 1 case report has been found leading to dislocation which they claimed was because of perforation of the capsule due to migration of nails in the posterior joint capsule(2). And the other case in which internal fixation of femoral neck fracture was done, concluded that possibly some rotation of the proximal fragment was inadvertently caused, when the fracture was reduced, resulting in twisting of capsule previously torn by trauma [1] suggesting that capsular damage also plays a vital role in instability of hip.
Once dislocation develops; clinical examination of patients, and investigations such as X-rays, CBC, ESR, CRP should be carried out to find out the causes. MRI / CT [10] is not advisable due to implant in situ and may not give the desired result. USG may help to show collection followed by aspiration leading to the diagnosis of infection. Hip arthroplasty would be appropriate option for such complications (Partial, Total, Excisional) depending upon the willingness, associated medical co-morbidities and financial status of the patients.
All the 6 cases who suffered complication were treated with DHS. Mechanical problem during fixation of DHS, loss of lateral femoral wall integrity are definite indicator of DHS implant failure with infection playing a major contributing role. With such fractures, role of DHS must be guarded, augmented with trochanteric stabilisation plate or intra medullary fixation such as TFN or cemented bipolar prosthesis should be considered. While reaming, tapping and screw insertion, additional derotation guide wire must always be used. Greater trochanter should be fixed and head should not rotate intra-operatively after fixation.

 


References

1. Melton JT, Yates P, Middleton RG. Dislocation of hip following valgus fixation of unstable peri-trochanteric fractures : A complication. Injury Extra 2006,
2. Iwegbu CG. Dislocation of the hip following Ender nailing. A case report. J Bone Joint Surg [Am] 1981;63:839-41.
3. Munjal S, Krikler SJ. Dislocation of the hip following intertrochanteric fracture. Injury 1995;26(9):645-6.
4. Infective Failure of Internal Fixation for Intertrochanteric Femoral Neck Fracture Presenting as Hip Joint Subluxation: A Case Report Rohit Rambania, c, Helen Ribeeb, Peter Bobakb; J Med Cases 2010;1(2):51-54.
5. Derek Younge, MD, FRCSC; Patrick A. Loisel, MD, FRCSC. A rare case of hip dislocation after internal fixation of femoral neck fracture without infection; JCC, Vol. 40, No1, février 1997.
6. Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction ofunstable pertrochanteric hip fractures. Clin Orthop Relat Res 2004;425:82–86,
7. Mahoney CR, Pellicci PM. Complications in total hip arthroplasty: avoidance and management of dislocations. Instr Course Lect 2003;52;247-55.
8. Mohan R, Karthikeyan R, Sonanis SV.Dynamic hip screw: does side make a difference? Effects of clockwise torque on right and left DHS. Injury. 2000 Nov;31(9):697-9.
9. Speed JS, Knight RA. Postoperative infections following internal fixation for fractures of the hip. Ann Surg 1956;143(5):651-657; discussion, 657-659.
10. Moorman CT 3rd, Warren RF, Hershman EB, et al. Traumatic posterior hip subluxation in American football. J Bone Joint Surg Am 2003;85A(7):1190-1196.
11. T6-10 APOA 2009 Trauma & Infection,Taipei : The Average Distance of Lag Screw Backout in Unstable Intertrochanteric Fracture After DHS Fixation with Trochanteric Stabilizing.


How to Cite this article: Yashwant J. MahaleYJ, KaduVV, Deshmukh A. Hip Instability  Following Dhs Fixation Surgery for Unstable Four Part Per- Trochanteric Fracture Femur. Trauma International Jan-April 2016;2(1):37-41.

Dr Yashwant Mahale

Dr Yashwant Mahale

Dr. Vikram V. Kadu

Dr. Vikram V. Kadu

Dr. Abhijeet deshmukh

Dr. Abhijeet deshmukh


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Frequency of Motor Bike Injuries, Helmet Vs Non Helmet Wearing in Karachi Pakistan

 Volume 2 | Issue 1 | Jan-Apr 2016 | Page 34-36|Ranjeet Kumar, Muhamad Muzamil,  Kashif Mahmood,  Prof Anisuddin Bhatti, Prof Saeedi Minhas, Vinod Kumar


Author: Ranjeet Kumar[1], Muhamad Muzamil[1],  Kashif Mahmood[1],  Prof Anisuddin Bhatti[1], Prof Saeedi Minhas[1], Vinod Kumar[1]

[1]  Department of Orthopedics, Jinnah Post Graduate Medical center, Karachi, Pakistan.

Address of Correspondence

Dr. Ranjeet Kumar
Jinnah Post Graduate Medical center, Karachi, Pakistan.
Email: ranjeetkumartalib@yahoo.com


 

Abstract

Purpose: To assess the frequency of motor bike injuries in Karachi, Pakistan’s largest city, and frequency of helmet and non helmet wearing among motorcyclist.
Design: cross-sectional study.
Place and duration of study: Accident& emergency department of Jinnah Post Graduate Medical Center, Civil hospital, Abbasi Shaheed Hospital, Aga Khan hospital and Liaqat Hospital Karachi. Pakistan from Jan 2014 to December 2014.
Patients and Methods: A descriptive cross-sectional study was carried out by ROAD TRAFFIC INJURY RESEARCH AND PREVENTION CENTRE “RTIR&PC” in the five tertiary care hospitals (Civil Hospital ,Jinnah Postgraduate Medical Center, Abbasi Shaheed Hospital and Aga Khan Hospital) of Karachi, Pakistan. All male motorbike accident victims presented to the emergency department of the selected hospital, were included in the study. A pretested trauma registry form was completed for all patients.
Results: Total numbers of accidents were 24360 and total number of injured were 30274. Minor injury 23825 approximately 78.6%, around 65 per day, serious were 5382 approximately 17%,around 15 per day and fatal were 1067 approximately 3.5%, 3 per day. Bike rider injuries were 25855 approximately 85% of all injuries and fatal bike rider accident were 506 approximately 47% of all fatalities. Helmet wearing bike riders were 1123 approximately 4.3% and non helmet wearing were 16681 approximately 64.5%. Injuries related to body part were , head and neck 23% ,fatal were 53%, face 17% ,fatal were 16%, chest 1% fatal 1%, abdomen, pelvic contents 1% fatal 1%, extremity, pelvic girdle 29% fatal 17% external injuries 28% fatal 12%.
Conclusion: Injuries in city of Karachi are an important public health problem and contribute to major bulk of Emergency facilities. Motorbike riders are known to be more vulnerable to road accidents and became victims of severe form of injuries even death by road traffic accidents, this unfortunately also becomes a socio economic problem. Non helmet wearing is the major risk factor in fatality for motor bike accidents. By putting into effect laws that enforce road safety measures and helmet usage can prevent these injuries.
Key Words: Motor bike , Helmet and Karachi.


Introduction

The Global status report on road safety 2013 presents information Worldwide, the number of people killed in road traffic crashes each year is estimated at almost 1.24 million, while the number injured could be as high as 50 million – the combined population of five of the world’s large cities. It was the 2nd leading cause of deaths among 15 – 44 years of age and 80%
of these deaths occurred in developing countries[1]. By 2020 road traffic accidents are expected to be the 3rd leading cause of death and disability worldwide[2]. According to the World Health Organization (WHO) 2011 fact sheet, “over 90% of the world’s fatalities on the roads occur in low-income and middle-income countries, even though these countries have less than half of the world’s vehicles.”1 In a 2009 report, WHO estimated that in Pakistan road traffic injuries result in 25.3 deaths per 100,000,2 which is high by the international organization’s standards. Currently it is the 9th leading cause of disability and adjusted life year lost globally, moreover 90% of the disability and adjusted life year lost occurs in developing countries worldwide due to road traffic accidents[3]. Being economical and convenient city traffic the use of motorbikes has increased tremendously during the last few years.
Almost percentage of the inhabitants of Karachi belongs to lower middle class and relies on motor bikes as the main mode of transportation in Karachi. In 2010 the number is estimated to climb to 3.6 million by According to an article published in Dawn, there were about 1 million motorbikes the year 2030. Unfortunately motorcyclists also contribute to a significant number in the mortality and morbidity in road traffic accidents. Even in developed countries, the accident risk of motorcycles is 20 times more per kilometer than drivers of other vehicles[4-6] .non helmet wearing is one of the most important factor in fatality in bike riders.

Methods:
It is cross sectional study conducted by ROAD TRAFFIC INJURY RESEARCH AND PREVENTION CENTRE “RTIR&PC” in emergency department of all five major hospitals in Karachi including Jinnah Postgraduate Medical Center, Civil hospital, Abbasi Shaheed Hospital, Aga Khan Hospital and Liaqat Hospital Karachi. . All male motorbike accident victims presented to the emergency department of the selected hospital, were included in the study. Inclusion criteria were injured patients of any age or sex presenting to the Accident, Emergency . A pretested trauma registry form was completed for all patients. If the patient was brought unconscious, an attempt was made to collect the information from the patient’s attendant. Basic demographic characteristics, time and date, nature and cause of injury, vital signs and outcome data were recorded. Type of vehicle and mode of collision was recorded in cases of road traffic accident.

Chart 1: Distribution of total injuries and sub classifications

Chart 1: Distribution of total injuries and sub classifications


 

Chart 2: Distribution of fatalities and anatomical injuries

Chart 2: Distribution of fatalities and anatomical injuries

 

Results:
Total numbers of accidents were 24360 and total number of injured were 30274. Minor injury 23825 (approximately 78.6%, around 65 per day), serious were 5382 (approximately 17%, around 15 per day) and fatal were 1067 (approximately 3.5%, around 3 per day). Bike rider injuries were most common around 25855 (approximately 85% of all injuries) and fatal bike rider accident were 506 (approximately 47% of all fatalities) (Chart 1). Helmet wearing bike riders were only 1123 (approximately 4.3%) and non helmet wearing were 16681 (approximately 64.5%). Injuries related to body part were , head and neck- 23%, fatal were 53%; face -17% ,fatal were 16%; chest -1% fatal 1%; abdomen, pelvic contents -1% fatal 1%; extremity & pelvic girdle- 29% fatal 17%; external injuries -28% fatal 12%. The most common mortality is due head and neck injuries which are due to not helmet wearing among bike riders (Chart 2).

Discussion:
Trauma is increasingly recognized as a global public health epidemic. WHO has predicted that trauma will rise from 9th leading burden of disease in 1990 to third leading cause in 2020 worldwide 8. In present study we found that annual incidence of trauma in road traffic accidents are commonly affecting bike rider which also have the highest fatality percentage among all road traffic accidents. We also found out that head and neck injuries are the commonest cause of fatality in these incidences and non helmet wearing is the commonest cause.
A study on An autopsy-based study of death due to road traffic accidents in metropolis of Karachi found out that Death were due to injury to the head (66.4%) victims, to the chest (14.5%) cases, multiple traumatic injuries in (8.6%) and pelvis (2.9%) cases.9
It is estimated that 45% of road traffic fatalities in low income countries are among pedestrians, whereas an estimated 29% in middle-income and 18% in high income countries are among pedestrians[24]. In Hong Kong, pedestrians accounted for 70% of RTA fatalities. On the other hand, in China, Malaysia and Thailand, pedestrian deaths are between 10-15% but over 50% of deaths due to RTA involved motorcyclists[10].
Unsurprisingly, the non-compliance of motorcyclists to wear helmets and the vulnerability of pedestrians accounts for head injuries proving fatal in 47% of the cases.: In a study in Nigeria, the most common cause of death was head injury 48.3%11 while in Singapore the second most common cause of death was head injuries 30.9%[12].

Conclusion:
Injuries in city of Karachi are an important public health problem and contribute to major bulk of Emergency facilities. Motorbike riders are known to be more vulnerable to road accidents and became victims of severe form of injuries even death by road traffic accidents, this unfortunately also becomes a socio economic problem. Non helmet wearing is the major risk factor in fatality for motor bike accidents. By putting into effect laws that enforce road safety measures and helmet usage can prevent these injuries.


References

1. World Health Organization. WHO: Road traffic injuries. Fact sheet N°358. (Online). September 2011 (Cited 2012 Feb 28). Available from URL: http://www.who.int/mediacentre/factsheets/ fs358/en/index.html.
2. World Health Organization. Global status report on road safety: Time for action. (Online). 2010 (Cited 2012 Feb 28). Available from URL: http://whqlibdoc.who.int/publications/2009/9789241563840_eng. pdf
3. Nantulya VM, Reich MR. The neglected epidemic: road traffic injuries in developing countries. British Med J 2002;324:1139-41.
4. Dischinger PC, Ryb GE, Ho SM, Braver RE. Injury patterns and severity among hospitalized motorcyclists: a comparison of younger and older riders. Annu Proc Assoc Adv Automot Med 2006;50: 237-49.
5. Solagberu BA, Ofoegbu CK, Nasir AA, Ogundipe O, Adekanye A, Abdur-Rahman A. Motorcycle injuries in a developing country and the vulnerability of riders, passengers, and pedestrians. Inj Prev 2006;12:226-8.
6. Peden MM, Scurfield R, Sleet D ,Mohan D,Hyder AA.World report on road traffic injury prevention. Geneva:
World Health Organization; 2004.11p.
7. Ilyas , F. (2014, July 2). Loose dresses and dupattas major cause of road traffic injuries: study. Daily Dawn. Retrieved from http://www.dawn.com/news/1116432
8 Murray, C.J. and A.D. Lopez, Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study.Lancet,1997. 349(9064): p.1498-504.
9 An autopsy-based study of death due to road traffic accidents in metropolis of Karachi Farhat Hussain Mirza, Qudsia Hassan, Nadia Jajja
Vol. 63, No.2, February 2013 JPMA page 156-160
10 Jacobs GD, Thomas AA. A review of global road accident fatalities. (Online) 2000 (Cited 2012 March 2). Available from URL: http://www.transport-links.org/transport_links/filearea/ publications/1_771_Pa3568.pdf
11 Osime OC, Elusoji SO, Eboreime O. Pattern and outcome of road traffic accidents in a suburban community in Nigeria. Annals of Biomedical Sci 2009; 8(1)
12. Wong ZH, Chong CK, Tai BC, Lau G. A review of fatal road traffic accidents in Singapore from 2000 to 2004. Ann Acad Med Singapore 2009; 38: 594-9.


How to Cite this article: Kumar R , Muzzamml M, Minhas MS. Frequency of motor bike injuries, helmet vs non helmet wearing in Karachi Pakistan. Trauma International Oct-Dec 2015;1(2):12-16.

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Dr. Ranjeet Kumar

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Distal Femoral Fractures: Complications and How to Avoid them?

 Volume 2 | Issue 1 | Jan-Apr 2016 | Page 24-27|Vaibhav Bagaria1, Smit Shah1, Gaurav Sharma1


Author: Vaibhav Bagaria[1], Smit Shah[1], Gaurav Sharma[1]

Dept. of Orthopedics, Sir HN Reliance Foundation Hospital, Girgaum, Mumbai.

Address of Correspondence

Dr. Vaibhav Bagaria
Dept. of Orthopedics
Sir HN Reliance Foundation Hospital,
Girgaum, Mumbai
Email: drbagaria@gmail.com


Abstract

Distal femur fractures are common but complex fractures and often are associated with complications. The cases of failure may be secondary to mechanical failure or biological failure. The current review offers overview of these complications and tips and tricks on how to manage these complications.
Keywords: Distal Femur Fractures, Complications, Surgical management


Introduction

Distal femoral fractures are severe injuries which are technically challenging to treat surgically. The incidence is between 4% to 6% of femur fractures and 1% of all orthopedic trauma. The numbers are going to increase with advent of rising geriatric population and also a secondary fallout of replacement surgeries that are giving rise to peri-prosthetic fractures [1]. Trauma can be low energy as seen with geriatric population or high-energy. It is imperative to know distal femoral anatomy, fracture characteristics, bone quality, patient goals and implant design to treat this fracture optimally and avoid complications. In olden days, these fractures were treated conservatively using traction and bracing. [REF]However, with new minimally invasive surgical techniques and implants, better understanding of distal femoral anatomy and fracture biology, surgical stabilization and early mobilization is favored.
Deforming Forces around distal femur: The distal femur is encompassed by several group of muscles that lead to different deformities at fracture site. In coronal plane, adductor and IT band causes varus /valgus deformity [2]. Apex posterior angulation is typical deformity imparted by two heads of gastrocnemius which also poses difficulty in reduction in sagittal plane. On the other hand, quadriceps causes shortening in communited fracture.

Classification
The most commonly followed classification system is AO/Orthopedic Trauma Association (OTA) system. This system classifies fracture into A, B and C corresponding to extra-articular, partial articular and intra-articular injuries. Further sub-classified from 1to 3 according to degree of comminution and fracture pattern. (Fig 1)
Type B1 depicts sagittal split of lateral condyle whereas B2 is split of medial condyle. B3 is coronal fractures known as Hoffa fractures.
Type C are further divided into C1- simple articular, simple metaphyseal, C2- simple articular, multi-fragmentary metaphyseal, C3- multi-fragmentary.

Figure 1: OTA Classification of Distal Femoral Fractures

Figure 1: OTA Classification of Distal Femoral Fractures

Complications of Distal Femur
Frcature: The failure can be broadly classified as mechanical failure or biological failures.

Fixation Modalities for distal femur fractures: Different fixation modalities are
External fixation
Angled blade plate
Dynamic condylar screw
Plating (locked or unlocked)
Distal femoral nailing
Distal femoral replacement.

External fixators: In patients with severe soft tissue injury and loss of skin or muscle cover, knee spanning external fixation is a temporary method of stabilization as per damage control protocol. Careful pin placement reduces risk of infection and maintains soft tissue cover for future definitive fixation [3]. Communited fractures can be treated definitively in Illizarov ring fixator. However, definitive treatment with ring fixator is associated with delayed union, pin-tract infection and knee stiffness owing to quadriceps scarring. [REF]

Avoiding failures with Ex Fix:
a. Right Indication: Open fractures/ Extreme communition, Poor Skin condition and as an adjunct fixation or as a part of damage control orthopedics.
b. Good Reduction: Wires can be used to joystick and accurately reduce the fracture. Ensuring a good reduction is the key to a definitive fixation.
c. Biology: Can be enhanced distraction osteogenesis or supplemental bone grafting
d. Supplementary Fixation: Occasionally it is used with Enders nail or other IM Devices so as to enhance the stability and improve reduction.

Fixed Angle devices and dynamic condylar Screw: The 95 degree angled blade plate provides rigid fixation owing to angled side plate which could be impacted into distal femur and held rigidly. Disadvantages are that this fixation modality needs large exposure., provides inadequate fixation in osteoporotic bone and it cannot be used to address all types of fracture for e.g. Hoffa fracture. Compared to locking plates, these devices are weaker construct leading to early failure and more subsidence on weight bearing.
Dynamic condylar screw, which is variant of fixed angled device, allows compression across inter-condylar area. Even it is not capable of addressing coronal fractures and it removes lot of bone while inserting screw. It also bends at plate barrel junction on loading leading to varus at fracture site. It is weaker construct in view of axial stiffness compared to locking devices, but similar in torsional stiffness[4].
Avoiding failures with Fixed angle plate:
a. Right Indication : Simple intra-articular with metaphyseal extension, no communition in intra-articular area. Contraindicated in type C3 fractures.
b. Good Reduction and Placement: Angled blade plate should be placed precisely 1.5cm from joint surface and condylar screw at 2cm. Also 95 degree angled blade plate needs precise sagittal placement. (Fig.2)
c. Biology: can be supplemented with lag screws, avoid excessive periosteal stripping, cement augmentation for blade or screw placement.
d. Supplementary Fixation: Medial communition requires Ender’s nail from medial condyle going up to shaft or medial plate.

Figure 2: Hoffa's fracture –B3.

Figure 2: Hoffa’s fracture –B3.

Figure 3: Precise placement of fixed angled device in distal femur.

Figure 3: Precise placement of fixed angled device in distal femur.

Locking and Non Locking Plates: Locking plates preserves periosteal blood supply by abolishing tight plate-bone interface leading to flexible construct which allows micro-motion at fracture site resulting in callus formation. If same locking plate is applied in a rigid way, it is bound to fail in communited fractures as rigid construct doesn’t allow secondary bone healing (callus formation) [5]. Screw placement also plays important role in the biomechanics. Locking screws at proximal most hole of plate leads to thigh pain and periprosthetic fracture due to stress concentration. Filling of all screw holes, especially near the fracture site makes he construct rigid and hampers callus formation [6]. Excessive periosteal stripping also lead to loss of vascularity and eventually failure of fixation. Locking devices though more stable axially and torsionally compared to other rigid implats, it fails when there is severe medial communition. Medial endosteal plate in case of medial communition is a good adjunct to lateral locked plate [7]. But it poses difficulty with future implant removal and arthroplasty.

Figure 4: Fixed angled device (DCS) done in A2 type fracture

Figure 4: Fixed angled device (DCS) done in A2 type fracture

Figure 5: Open distal femoral fracture –C3 type.

Figure 5: Open distal femoral fracture –C3 type.

Figure 6: Locking plate done in biological way.

Figure 6: Locking plate done in biological way.

Avoiding failures with Plates:
a. Right Indication : Severe intra-articular communition, very short distal femoral block available for fixation, Periprosthetic fractures.
b. Good Reduction: correct hyperextension deformity at fracture site using bolster underneath knee or Homan’s retractor elevating fracture. Failure to achieve this lead to malreduction. (Fig. 8)
c. Biology: Plate need not to be flush to bone, choose plate long enough to have empty holes same as holes with screws.
d. Supplementary Fixation: Endosteal plate in case of medial communition.

Retrograde Femoral nails: Other option is retrograde femoral nail which is biological means of fixing distal femoral fractures. As a load sharing device it offers advantages like early weight bearing and prevents deconditioning due to prolonged immobilization. Complications associated with nailing are knee joint stiffness, fat embolism, inadequate fixation in distal fragment leading to failure and fracture at the tipoff the nail proximally due to stress riser effect, if nail is not long enough to engage isthmus [8].

Figure 7: Locking plate used for rigid construct.

Figure 7: Locking plate used for rigid construct.

Figure 8: Malreduction of distal femur fracture.

Figure 8: Malreduction of distal femur fracture.

Figure 9: Combination of C3 type with Hoffa's, showing malreduction.

Figure 9: Combination of C3 type with Hoffa’s, showing malreduction.

 

Avoiding failures with retrograde nails:
a. Right Indication: Implant of choice for supracondylar fracture without communition, for simple Supracondylar periprosthetic fracture where box is open to receive nail.
b. Good Reduction: nullify deforming gastrocnemius muscle force by flexing knee to 30 degree.
c. Biology: reaming gives local endosteal bone graft. Avoid damaging cartilage or Metallic femoral component while taking entry.
d. Supplementary Fixation: Locking plate on lateral surface, combination of both these implants gives axial as well as torsional stability [9].

Biological Failures: Biology plays a very vital role in any fracture healing and same is true for distal femur fractures. Any construct no matter how rigid and sound it is, is likely to eventually fail in the event of non union. Fracture healing depends on an interplay of healing cascade and the important players in ensuring the smooth running of this cascades are: Stem cells, Optimal mileu with presence of growth factor and scaffold. In lines with these in absence of any one or all of this, fracture healing will not occur.

Loss of Stem cells: This happen when the fracture is open, patient is old or nutritionally challenged. Certain comorbidity also contributes to lack of these cells at the site and also their subsequent recruitment. It is thus vital to identify the responsible condition/ at risk individual and have a low threshold for primary bone grafting in these patients.

Optimal Milieu: Stem cell also known as inducible osteoprogenitor cells differentiate into osteoblast only when given the right stimulus. These stimuli are in fact the growth factors, the most important of which are transforming growth factor and vascular endothelial growth factors. These may be lost in case of open wounds, lack of blood supply as in case of vascular injuries and iatrogenically secondary to poor tissue handling and periosteal stripping.

Loss of Scaffold: New bone will best form over or with existing bones. If there is huge bone loss then it is difficult for bone to heal and form a weight bearing structure. Failure to recognize this may lead to early biomechanical failure. Bone defects thus must be filled with the bone graft or bone graft substitutes that allow the natural new bone to form and organize.

Figure 10: Plate breakage in non-union.

Figure 10: Plate breakage in non-union.

Figure 11: Another case of malreduced femur resulting in failure of implants

Figure 11: Another case of malreduced femur resulting in failure of implants

Figure 12: a. Distal femoral periprosthetic fracture salvaged by bilateral distal femur replacement AP view b. lateral View

Figure 12: a. Distal femoral periprosthetic fracture salvaged by bilateral distal femur replacement AP view b. lateral View

Reducing Chances of Failures:
1. Understanding the fracture type and forces in the area
2. Choosing the right Implant
3. Preserving Biology
4. Enhancing Biology when needed
5. Timely mobilization – not early y not too late
6. Identifying delayed unions and treating them at opportune time.

Managing Failures: Failures should be tackled Biologically and mechanically irrespective of the cause of failures.

Biomechanical: A careful assessment of the cause of failure will often guide us to the correct choice of implants. If one implant has failed, it is usually advised that it be replaced by an alternative type of fixation, for eg if the locking plates have failed and the fracture pattern is amenable to intramedullary fixation, these should be used as the mode of fixation. A supplemental fixation may also be a good idea along with combination of two modalities in case of difficult scenarios. It is very important to exactly understand the fracture pattern, mode of failure of previous implant and patients healing capacity apart form the local skin condition and milieu. A thorough assessment with additional modalities such as CT scan may also be warranted in certain cases [10]. Planning well is the key in ensuring optimal outcome.

Biological: Almost all failed cases require to be supplemented by some form of biological enhancers. The most common of these is the autologous bone grafting, Autologous bone grafts are excellent source of stem cells, containg growth factors and act as a scaffold for bone formation. Alternatives to bone grfat that also be used as supplements include Allografts, de mineralized bone matrix ( DBM) or synthetic bone usually ceramics.( Beta tricalcium phosphates and Hydroxy appatite combinations). Certain case may also require growth factors such as BMP for enhancing the healing and success of fixation.


References

1.Gwathmey FW Jr, Jones-Quaidoo SM, Kahler D, et al. Distal femoral fractures: current concepts. Re- view. J Am Acad Orthop Surg 2010;18(10):597–607
2.Agarwal A. Open reduction and internal fixation of the distal femur. In: Wiesel SW, editor. Operative techniques in orthopaedic surgery, vol. 1. Philadel- phia: Lippincott Williams & Wilkins; 2011. p. 582–4.
3.Haidukewych GJ. Temporary external fixation for the management of complex intra- and periarticular fractures of the lower extremity. J Orthop Trauma 2002;16(9):678–85.
4.SinghAK,RastogiA,SinghV.Biomechanicalcompar- ison of dynamic condylar screw and locking compres- sion plate fixation in unstable distal femoral fractures: an in vitro study. Indian J Orthop 2013;47(6):615–20.
5.Henderson CE, Lujan TJ, Kuhl LL, et al. 2010 mid- America Orthopaedic Association Physician in Training Award: healing complications are common after locked plating for distal femur fractures. Clin Orthop Relat Res 2011;469(6):1757–65.
6.Stoffel K, Dieter U, Stachowiak G, et al. Biomechanical testing of the LCP–how can stability in locked internal fixators be controlled? Injury 2003;34(Suppl 2):B11–9.
7.Prayson MJ, Datta DK, Marshall MP. Mechanical comparison of endosteal substitution and lateral plate fixation in supracondylar fractures of the femur. J Orthop Trauma 2001;15(2):96–100.
8.Beltran MJ, Gary JL, Collinge CA. Management of distal femur fractures with modern plates and nails: state of the art. J Orthop Trauma 2015;29(4):165–72.
9.Basci O, Karakaslı A, Kumtepe E, et al. Combination of anatomical locking plate and retrograde intrame- dullary nail in distal femoral fractures: comparison of mechanical stability. Eklem Hastalik Cerrahisi 2015; 26(1):21–6.
10.Suk M, Desai P. Supracondylar femur fractures. In: Archdeacon MT, editor. Prevention and manage- ment of common fracture complications. Thorofare (NJ): Slack; 2012. p. 236.


How to Cite this article:. Bagaria V, Shah S, Sharma G. Distal Femoral Fractures: Complications and How to Avoid them?. Trauma International Jan-Apr 2016;1(2):12-16.a

Dr. Vaibhav Bagaria

Dr. Vaibhav Bagaria


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Distal Femur AO type 33 B – Surgical options, Results and Complications (including Hoffa’s fracture)

 Volume 2 | Issue 1 | Jan-Apr 2016 | Page 20-23 |Sachin Jain1


Author: Sachin Jain[1]

[1] Sancheti Institute for Orthopaedics and Rehabilitation, Shivajinagar Pune, India.

Address of Correspondence
Dr. Sachin Jain
Sancheti Institute for Orthopaedics and Rehabilitation, Shivajinagar Pune, India.
Email: dr.sachinrjain@gmail.com


Abstract

Background: Distal femur AO type 33 B fractures are partial articular fractures. It also includes Hoffa’s fracture which is a relatively rare injury and requires always operative management even with no displacement. Approach to these fracture depend on the condyle involved also various quadriceps sparing approach like swashbuckler approach has been described in the literature. Surgical treatment of these fractures involves anatomical reduction, compression, stable fixation and early mobilization. Treatment modalities such as cancellous screws, pre-contoured anatomical locked plate, posterior condylar buttress plating, distal retrograde interlocking nailing, angled blade plate fixation, dynamic condylar screw may be considered. Each implant is associated with advantages and disadvantages which is discussed here.
Keywords: .


Introduction

Distal femur AO type 33 B fractures consists partial articular fractures subdivided into 3 types namely sagittal lateral condyle fracture, medial condyle fracture and coronal split fracture  . Hoffa’s fracture is tangential unicondylar fracture of distal femoral condyle and is a relatively rare injury . Hoffa’s fracture and type 33 B fractures may affect either of the condyles but they have a preponderance to effect lateral condyle due to physiological valgus and the direction of force which is usually direct trauma to flexed knee with an element of slight abduction   . Hoffa’s fracture are usually missed on plain radiograph in approximately 30 % cases and the incidence of these fractures in type 33 B fractures is 38% . Non operative treatment in these fractures usually fails due to intraarticular involvement, multi-fragmentary morphology and muscular forces involved . Treatment of these fractures is varied with different modalities used such as cancellous screws, pre-contoured anatomical locked plate, posterior condylar buttress plating, distal retrograde interlocking nailing, angled blade plate fixation, dynamic condylar screw, external fixator and distal femoral replacement depending on the fracture configuration.
Anatomical basis for distal femoral condylar fracture
Fracture of distal femur depends on the velocity of injury or the amount of osteoporosis involved. It follows zone of weakness in the anatomic location of distal femur which leads to fracture in specific pattern. These are the transition from diaphysis to metaphysis, intercondylar notch where patella acts as a wedge and area between trochlear groove and medial or lateral condyle . The distal femur in cross section is trapezoid with anterior and posterior surfaces are not parallel to each other. Also, there is an inclination of 10 degrees on medial and 25 degrees on lateral aspect . Various muscles causes displacement of the fragments in different direction such as gastrocnemius causes displacement in posterior direction, overriding of the distal and proximal fragments can occur due to combined action of quadriceps and hamstrings, adductors can cause varus or valgus angulation depending on the fracture is proximal to or distal to adductor tubercle

AO Classification of type 33 B fractures
33-B Partial articular (unicondylar)
33-B1 Lateral condyle, sagittal
33-B2 Medial condyle
33-B3 Frontal — ”Hoffa fracture”.

Hoffa’s fracture are further classified according to Letenneur  into 3 types
Type I – Fracture line parallel to the posterior femoral cortex involving the entire posterior condyle.
Type II – Fracture occurs in the area behind the line parallel to the posterior femoral cortex. The posterior condyle is divided into 1/3rds and depending on the relationship of fracture line to the thirds the type II is sub-classified into A, B and C. Type II fragments lack soft tissue attachments and are prone for osteonecrosis and nonunion.
Type III – Fracture line runs obliquely, therefore respond poorly to conservative treatment.

Fig.1 AO/OTA classification for Type B distal femoral fractures.

Fig.1 AO/OTA classification for Type B distal femoral fractures.

Fig. 2 Letenneur classification of Hoffa's fracture

Fig. 2 Letenneur classification of Hoffa’s fracture

Approach to treat type 33 B fractures
Surgical approaches to these fractures depend upon the condyle involved, location of the fracture line and also the presence of comminution. Various approaches like medial parapatellar for medial condylar and hoffa’s fracture screw fixation, lateral parapatellar and lateral for lateral condylar fixation, posterior approach for open reduction of hoffa’s fracture with screw or buttress plate fixation. Another is swashbuckler approach  which is a modified anterior approach as it provides improved exposure and spares quadriceps muscle bellies. Also, surgical scar does not interfere with subsequent total knee arthroplasty if required at a later date. It is useful for fixation of distal femoral fractures with intraarticular involvement. Similarly, minimally invasive surgical stabilization is the norm to preserve the bone biology while fixation . It is achieved by preoperative planning by tracing the fractured fragments and planning the incisions intraoperatively. Under the fluoroscopic guidance, the different incisions are made for distal fixation and proximal fixation of screws. The ultimate goal is to be minimally invasive and also get appropriate alignment   .

Positioning
A standard operating table or fracture table can be used for positioning of the involved leg. The main technical difficulty in distal femoral fractures is recurvatum of the distal fragment, for which a bolster can be applied below it . Similarly, a radiolucent angle frame can be applied for better control of distal fragment manipulation for reduction. If a fracture table is used then pressure in the form of stirrup over the distal fragment can be applied. Tibial traction pin or calcaneal pin traction can also be applied to achieve reduction. In case of Hoffa’s fracture if a plate fixation is planned then prone or floppy lateral position may be required for ease of fixation and adequate exposure.

Surgical treatment and results of type 33 B fractures
Goals in treatment of all intraarticular fractures should be  :
1. Accurate anatomical reduction of the joint surface.
2. Accurate reduction of the metaphyseal component of fracture with restoration of normal axial alignment.
3. Stable internal fixation.
4. Early mobilization.

Blade Plate fixation
It is the earliest form of fixation in distal femoral fractures. the 95 degree angled Müller blade-plate, the Judet screw-plate and Strelitzia blade-plate, known as the Maconor device were the preferred fixation options for distal femoral fracture fixation before the advent of other fixation modalities. Vandenbussche et al. showed no differences between blade-plate fixation and other fixation methods regarding the complications, need for bone grafting, healing rate, final functional score, disassembly rate, or need for early revision surgery. The tibio-femoral axis was usually acceptable, with few cases of mal-union.

Dynamic condylar screw
It is technically less demanding as compared to blade plate construct as the position of the plate can be determined after the lag screw has been inserted between the fragments. Disadvantage of this constuct is that a large volume of bone is reamed out to accommodate the lag screw. Also after removal of implant chances of refracture also increases.

Intramedullary nail
Distal femoral nailing is one of the preferred methods of fixation for distal femoral fractures. Although, there is a risk of malalingment of 10% with this modality it can be significantly reduced by addition of poller screws to guide the trajectory of the reamers to appropriate position. Advantage is minimal invasive and also in cases with involvement of segmental femur fracture in proximal and distal segment it can be used very effectively.

Locked Plates
The benefits of the LISS (less invasive stabilization system) over condylar buttress plates or dynamic condylar screws as reduced blood loss, lower infection rates and an ability to bridge the supracondylar fracture zone as an internal fixator, without extensive dissection of the bone fragments and associated periosteal stripping required for conventional plate fixation . Periprosthetic fractures after total knee arthroplasty are very well treated with LISS due to availability unicortical and polyaxial configuration of screws. Cement augmented implants can be used to achieve better surgical outcomes in osteoporotic fractures . An axial deviation of less than 5 degrees on the frontal (coronal) or in profile (sagittal) plane is usually considered acceptable .
Cancellous screw fixation and posterior plating
Two 6.5mm partially threaded cannulated cancellous screw are the preferred modality especially in cases of undisplaced hoffa’s fracture to provide rotational stability. A medial parapatellar arthrotomy or a direct lateral approach between the iliotibial band and the biceps tendon may be required to expose the fracture. Arthroscopic evaluation and confirmation of reduction visually is advisable to prevent any step-off. Screw direction may be posterior to anterior or anterior to posterior depending on the surgical expertise. However, posterior to anterior screw placement is related with increased complications. Broad condylar buttress plate may be used as a treatment modality for displaced hoffa’s fracture associated with osteoporosis or associated with supracondylar component . Articular reductions were classified as anatomical, acceptable (<2 mm step) and poor (>2 mm) on the immediate post-operative radiographs .

Technical Pearls
In case of Hoffa’s fracture, a minimum of two screws is required to provide rotational stability. PA screw insertion should be performed with the knee was hyperflexed (>120 degrees) and they should be countersunk . Important factor LISS is that it should end 1.5 cm proximal of the articular line. K wires and lag screws can temporarily hold the fracture fragments before insertion of plate. After the plate insertion, a proximal and distal screw is inserted to fix it after confirming the correct alingnment in all planes . The cable method can be used to achieve the coorect mechanical axis . A temporary intrafocal pin can be used to reduce the overlapped condylar fragments especially in cases of type B fractures . If there is a < 2mm gap in the metaphysis due to communition, locked plate fixation provides better resistance to compression and torsion. Plastic deformation is significant if the gap exceeded 5mm  and primary iliac crest/fibula strut grafting should be considered.

Complications
Distal femoral nail may cause accidental injury to posterior cruciate ligament at its entry point . Interlocking screw displacement, migration of screws especially in osteoporotic bone and loss of distal fixation followed by malalignment can also occur . Other complications include anterior knee pain, iatrogenic fracture of the femoral shaft, injury to the deep femoral artery with proximal locking, stress fracture above the implant, fatigue failure of the nail
In case of LISS initial complication may be attributed to implant malpositioning with loss of reduction due to lack of technical expertise. But with improved skills the complication rate in this type of fracture is greatly reduced . Similarly, misplacement of the LISS plate on the shaft of the femur can lead to a tangential screw position causing poor screw hold and subequent pain . Another complication is proximal screw pullout if the working length of the plate is inadequate and also due to early weight bearing . Non union rates are reported to be between 17-21% in total which may be due to obesity, diabetes, open fracture, age, fracture comminution, alcoholism, post-operative smoking, as well as technical factors such as plate length and screw density of the fixation constructs, use of titanium vs. stainless steel, and cortical reduction . Cases of non union or delayed union may require subsequent secondary bone grafting . Infection rates in cases of open distal femur fracture managed with LISS is better than other fixation modalities primarily due to early debridement and minmal tissue handling during primary fixation.

Conclusion
Distal femoral type B fractures are common except for hoffa’s fracture which is relatively rare. Anatomical reduction and compression is the key to achieve fracture union irrespective of the surgical implant used. Expertise and experience of surgeon combined with fracture geometry play important role in deciding the implant selection.


References

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14. Letenneur J. Fractures de Hoffa : a prpos de 20 observations. Ann Chir. 1978;32:213–9.
15. Starr AJ, Jones AL RC. The “swashbuckler”: a modified approach for fractures of the distal femur. J Orthop Trauma. 1999;(13):138.
16. Smith TO, Hedges C, Macnair R, Schankat K, Wimhurst JA. The clinical and radiological outcomes of the LISS plate for distal femoral fractures : A systematic review. 2009;40:1049–63.
17. Ehlinger M, Adam P, Arlettaz Y, Moor BK, DiMarco A, Brinkert D, et al. Minimally-invasive fixation of distal extra-articular femur fractures with locking plates: Limitations and failures. Orthop Traumatol Surg Res [Internet]. 2011;97(6):668–74. Available from: http://dx.doi.org/10.1016/j.otsr.2011.05.004
18. Jae J, Keun H, Bae J, Wan J. Radiological assessment of the safe zone for medial minimally invasive plate osteosynthesis in the distal femur with computed tomography angiography. Injury [Internet]. Elsevier Ltd; 2014;45(12):1964–9. Available from: http://dx.doi.org/10.1016/j.injury.2014.09.023
19. Forster MC, Komarsamy B, Davison JN, Infirmary LR. Distal femoral fractures : A review of fixation methods. 2006;97–108.
20. Shahulhameed A, Roberts CS, Ojike NI. Technique for precise placement of poller screws with intramedullary nailing of metaphyseal fractures of the femur and the tibia. Injury [Internet]. Elsevier Ltd; 2011;42(2):136–9. Available from: http://dx.doi.org/10.1016/j.injury.2010.04.013
21. Rodriguez EK, Boulton C, Weaver MJ, Herder LM, Morgan JH, Chacko AT, et al. Predictive factors of distal femoral fracture nonunion after lateral locked plating: A retrospective multicenter case-control study of 283 fractures. Injury. 2014;45(3):554–9.
22. Partenheimer A, Koenemann B, Krettek C. Distal femoral fractures and LISS stabilization. Injury. 2001;32:55–63.
23. Lange JH, Schulze M, Lenschow S, Stange R, Raschke MJ, Wa D. The potential of implant augmentation in the treatment of osteoporotic distal femur fractures : A biomechanical study. 2013;44:808–12.
24. R. LS, P. G, Sahu RL, Gupta P, R. LS, P. G. Operative management of hoffa fracture of the femoral condyle. Acta Med Iran [Internet]. 2014;52(6):443–7. Available from: http://www.embase.com/search/results?subaction=viewrecord&from=export&id=L373522469\nhttp://sfx.library.uu.nl/utrecht?sid=EMBASE&issn=17359694&id=doi:&atitle=Operative+management+of+hoffa+fracture+of+the+femoral+condyle&stitle=Acta+Med.+Iran.&title=Acta+M.
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27. Chang JJ, Fan JC, Lam HY, Cheung KY, Chu VW FK. Treatment of an osteoporotic Hoffa fracture. Knee Surg Sport Traumatol Arthrosc. 2010;(18):784–6.
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How to Cite this article:. Distal Femur AO type 33 B – Surgical options, results and complications (including Hoffa’s fracture). Trauma International Oct-Dec 2015;1(2):12-16.

Dr. Sachin Jain

Dr. Sachin Jain


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Distal femur AO type A fractures – Surgical options, techniques, results and complications

Volume 1 | Issue 2 | Oct-Dec 2015 | Page 12-16|Anuj Agrawal


Author: Anuj Agrawal[1]

[1] Dept. of Orthopaedics, Sri Aurobindo Institute of Medical Sciences,
Indore (MP), India.

Address of Correspondence
Dr. Anuj Agrawal,
63, Moonpalace colony,
Indore (MP), India- 452009.
Email: anuj_aiims@yahoo.co.in


Abstract

Background: Distal femur fractures are challenging injuries, frequently resulting in complications like non-unions, malunions, knee stiffness and infections. This article reviews the current concepts in the surgical management of extra-articular (AO/OTA type A) fractures of the distal femur, with an evidence-based approach. The role of newer and emerging techniques is also briefly discussed.
Keywords: Supracondylar fractures of femur, AO type A fractures of distal femur, extra-articular fractures of distal femur, current concepts in distal femur fractures, recent advances in distal femur fractures.


Introduction

Fractures of the distal femur are uncommon injuries, accounting for 0.4% of all fractures[1]. However, they continue to present a challenge to the treating surgeon, with frequent complications like non-union (6%), implant failure (3.3%) and deep infections (2.4%)[2], despite significant advances in reduction techniques (MIPO/biological plating) and implant technology (locking plates) in the last decade.
The extra-articular fractures (AO/OTA type A) of the distal femur have a better prognosis than the articular (type B/C) fractures, as the joint anatomy is preserved, allowing better knee function. However, their healing too can frequently be complicated. In the younger patients, distal femur fractures result from high-energy trauma, and are frequently associated with soft tissue injury and bony comminution, affecting patient rehabilitation and stability of fixation. Whereas, in the elderly, the fractures usually result from low-energy trauma, and are frequently complicated by poor bone quality and vascularity.
We have reviewed the current practices in the management of AO/OTA type 33A fractures, including the role of newer, emerging implants and techniques.

Fracture classification
The AO/OTA classification, which is currently the universally accepted classification for distal femur fractures, divides the extra-articular type A fractures into 3 further groups and 9 sub-groups, with further qualifications[3]. 33A3.1 fractures are apophyseal fractures of the medial or lateral epicondyles of the femur, and are usually a part of complex knee dislocations or complex intra-articular fractures. When present as an isolated injury, these can usually be managed conservatively with a good outcome.
Excluding the apophyseal fractures, type A fractures are further subclassified as simple (A1), wedge (type A2) and complex (A3) ones, according to the increasing severity of the injury. A1.2 (simple spiral/oblique), A1.3 (simple transverse) and A2.1 (intact wedge) fractures are amenable to open, anatomic reduction and compression plating, whereas the A2.2, A2.3 and A3 fractures are comminuted fractures, better suited for indirect (biological) reduction and nailing/bridge plating.
The term ‘supracondylar’ fracture of the femur has been variably used in the past, for fractures occurring within 7.5 cms4 to 9 cms5 from the articular surface of distal femur, giving rise to confusion. According to the AO/OTA classification, the ‘distal femur fractures’ are defined as those occurring within a length of bone, equivalent to the maximum condylar width, from the articular surface of distal femur. The term ‘supracondylar’ fracture of the femur is not currently favored, and should be used in a similar context, as ‘distal femur fractures’. It may be noted that, in the AO/OTA classification, any fracture extending to an end segment is classified as belonging to that segment, even if the centre of the fracture zone (which is otherwise used to define the location of the fracture) falls in the middle segment of the bone. For example, the fracture shown in Fig 1 would be classified as a 33A2.1, though the centre of the fracture falls above the distal femur region. The treatment principles of distal femur fractures described in this paper also apply to most distal femoral shaft fractures (32A2.3), the difference being nails are more commonly applicable for the latter than plates.

Surgical options and techniques
Surgical treatment is currently the standard treatment for distal femoral fractures, with the goal of providing a stable fixation to allow early mobilisation of the knee and the patient. Conservative management with a cast-brace or a prefabricated brace can be used in undisplaced or minimally displaced, simple fractures, with a high expected rate of union, and satisfactory anatomic and functional results[6]. Distal femur is the only part of the femur where brace management is still acceptable. Bracing, following a period of 4-6 weeks in cast/traction, was previously used in displaced fractures, but has now been abandoned, due to a high rate of complications like malunion and knee stiffness[7]. It may still be occasionally indicated in patients not willing/fit for surgery.
The following implants are indicated for displaced fractures of the distal femur in adults:

Table 1: Summary of the approach to extra-articular distal femur fractures according to the AO/OTA classification

Table 1: Summary of the approach to extra-articular distal femur fractures according to the AO/OTA classification

Condylar buttress plates (CBP)
Condylar plates fixed with conventional (non-locking) screws were used in the past for type A/C fractures. These needed to be supplemented with a medial plate to prevent varus collapse[8], in fractures with medial comminution (A2.3, A3.2 and A3.3), and have now been replaced by locking plates.

95o angled blade plate (ABP)
This was the first fixed angle implant devised by AO for distal femoral fractures, and revolutionised their management in the 1960s. It provides excellent stability for all type A fractures, and guides the reduction of comminuted fractures (both in coronal and sagittal planes), once the blade is inserted parallel to the joint. However, being a monobloc (non-modular) implant, it is not amenable to percutaneous fixation techniques (MIPO). It has waned in popularity in recent times, due to the demanding surgical technique and excessive force (hammering) required to insert the blade portion of the plate in young patients. Such a force may disrupt the condylar mass in complex articular (C3) fractures.

Dynamic condylar screw (DCS)
DCS was devised as a modular, fixed-angle implant for proximal/distal femur, simplifying the surgical technique, as it allowed insertion of a guidewire and reaming, prior to insertion of the lag screw. However, the cost of replacing the blade with a screw is that more bone needs to be sacrificed, and one more cancellous screw needs to be inserted in the distal fragment for rotational stability in the sagittal plane. Hence, the fracture line needs to be atleast 5 cm proximal to the knee joint to allow insertion of a DCS with derotation screw, whereas only 2-3 cm of intact bone is required distally to insert an ABP. However, a low (transcondylar) fracture line is rarely seen in extra-articular fractures, being more commonly associated with complex type C fractures. Hence, DCS is applicable for most type A fractures.
A recent comparative study[9] between DCS and LISS demonstrated better results in distal femur fractures fixed with a minimally invasive technique using DCS, with a higher healing rate and lower reoperation rate, as compared to LISS plates. DCS is cost-effective and can be the implant of choice for all type A fractures, unless the bone quality is poor, mandating the use of locked plates.

Locking plates (LISS, DF-LCP, condylar LCP)
Locking plates have been the greatest revolution in implant technology in recent times. These plates are increasingly being used in osteoporotic and peri-articular fractures, as locking screws provide greater resistance to pullout in osteoporotic and cancellous bones. Moreover, locking plates are technically easier to apply and slide percutaneously, than even a DCS.
However, over-enthusiasm of surgeons and over-reliance on the new technology has led to inappropriate application of locking plates in all fracture patterns, including simple ones in which a short working length can lead to an overstiff construct. Many recent papers have highlighted the problems of asymmetric callus formation[10] and callus inhibition[11] with the use of locked plates. High rates of complications (40%), particularly non-union (20%), have been reported with the use of locked plates in distal femur fractures, with the suggested causes being mechanical, like use of stainless steel plates and an insufficient bridge span (working length of the fracture)[11]. A long working length of the plate, two to three times the working length of the fracture, is desirable, with a screw density ratio of 0.4 to 0.5, to prevent the construct from becoming too stiff.
The locking compression plate (LCP) design amalgamates the principles of both conventional and locking plates in a single design, providing an option of compression of simple fracture patterns, with the subsequent use of locking screws in the articular and/or diaphyseal segments (hybrid fixation) for increased stability. The condylar LCP is based on the design of a condylar buttress plate, while a DF-LCP is based on the design of a LISS plate (Fig 2).

Figure 2: Treatment of simple spiral fracture of distal femur (33A2) in a 32 year old young male by open, compression plating with DF-LCP. DCS could have been used here, instead of DF-LCP. Fig 2A Pre-operative x-rays Fig 2B 3 month post-operative x-rays

Figure 1: Treatment of simple spiral fracture of distal femur (33A2) in a 32 year old young male by open, compression plating with DF-LCP. DCS could have been used here, instead of DF-LCP. Fig 1A Pre-operative x-rays Fig 1B 3 month post-operative x-rays

Figure 3: Designs of common locking compression plates (LCP) used for distal femur Fig 3A Distal femur Locking Compression Plate (DF-LCP) Fig 3B Condylar LCP

Figure 2: Designs of common locking compression plates (LCP) used for distal femur Fig 2A Distal femur Locking Compression Plate (DF-LCP) Fig 2B Condylar LCP

Antegrade/retrograde nails
Though intramedullary nails allow an indirect reduction and percutaneous fixation of distal femur fractures, providing similar advantages as MIPO, the stability provided by the nails is less than locked plates, particularly in osteoporotic bones. In a biomechanical comparison of locked plating and spiral blade retrograde nailing in 33A3 fractures, the nail constructs showed greater subsidence and reduced axial stiffness, and a higher risk of failure in osteoporotic bones[12]. In a meta-analysis, Zlowodzki et al reported a higher rate of secondary surgical procedures (23-24% versus 16%) required after nailing of distal femur fractures, with a slightly lower rate of infections (<1% versus 2%), as compared to submuscular LISS plates[2].
Antegrade nailing is applicable only for fractures more than 7-9 cm proximal to the knee joint[13], and provides a less stable construct than retrograde nailing, which provides an option to insert multiple, larger distal bolts/blade, and a thicker nail . Hence, antegrade nails are not favored in distal femur fractures, except in special situations like a stiff knee (precluding retrograde nailing), or segmental femur fractures (particularly where the proximal fracture is high in the trochanteric/subtrochanteric region).
Retrograde nails are preferred over plates for fixation of distal femur fractures by many surgeons, citing advantages like decreased blood loss, shorter operative time and reduced length of hospital stay[14]. However, they can lead to complications like anterior knee pain, malalignment, intra-articular impingement of the knee (due to incorrect technique), stress fracture at the tip of the nail, and injury to the deep femoral artery with proximal locking[15]. Malalignment is a common complication of retrograde nails, as an accurate reduction of the fracture requires a correct entry point and at times, the use of poller screws. Acharya et al[16] reported a high rate of complications like anterior knee pain (73%), knee instability (38%) and malunions (31%) after retrograde nailing of distal-third femur fracture. Thus, the use of retrograde nailing is gradually on the decline for distal femur fractures, and it should be reserved for special situations like a floating knee injury (wherein both femur and tibia can be nailed through a single incision) or a concomitant femoral neck fracture, wherein a DHS-retrograde nail ‘rendezvous’ construct[17] is advantageous (Fig 3).

Figure 4: Rendezvous fixation of ipsilateral femoral neck (31B2.3) and shaft (32B2.2) fractures with a DHS-retrograde nail combination Fig 4A Pre-operative x-rays Fig 4B Immediate post-operative x-rays

Figure 3: Rendezvous fixation of ipsilateral femoral neck (31B2.3) and shaft (32B2.2) fractures with a DHS-retrograde nail combination Fig 3A Pre-operative x-rays Fig 3B Immediate post-operative x-rays

External fixators
The use of monolateral external fixators (either spanning or non-spanning) is currently limited as a temporary fixation in polytrauma patients, fractures with vascular injury, fractures with extensive soft tissue loss and open fractures presenting late. Fractures with extensive bone loss can be definitively managed by an external fixator (a rail fixator or ring fixator) and bone transport through a subtrochanteric corticotomy (Fig 4).

Figure 5: Crush injury of left thigh in a 13 year old girl Fig 5A Clinical picture at presentation, showing extensive soft tissue injury, with loss of extensor mechanism Fig 5B Presenting x-rays, showing extensive bone loss Fig 5C Bone transport was done with application of a rail fixator primarily Fig 5D Final radiological picture after knee fusion at one year

Figure 4: Crush injury of left thigh in a 13 year old girl Fig 4A Clinical picture at presentation, showing extensive soft tissue injury, with loss of extensor mechanism Fig 4B Presenting x-rays, showing extensive bone loss Fig 4C Bone transport was done with application of a rail fixator primarily Fig 4D Final radiological picture after knee fusion at one year

Open versus closed reduction
There is an increasing attempt to preserve the fracture biology wherever feasible, with the use of minimally invasive plate osteosynthesis (MIPO) technique. MIPO technique has been shown to better preserve the bone circulation[18], when compared to traditional open plating, which may be particularly advantageous for callus formation with bridge plating. However, MIPO is a technically difficult procedure, involving a steep learning curve and increased radiation exposure. When done improperly, it may lead to a high rate of malalignment and malpositioning of the plate[19,20]. In a study of distal femur fractures fixed using LISS plates by MIPO technique, 38.5% of the femora were found to be malrotated >10o, as compared to the normal side, on CT scanograms.20 In an experimental study, a LISS plate, when malpositioned in external rotation to the lateral femoral surface, showed a significantly less axial stiffness and more failure rate with cyclic axial loading, as compared to a correctly positioned plate[21]. Hence, MIPO technique should be reserved for comminuted fractures (A2.2, A2.3 and A3) of the distal femur, where open reduction would be technically difficult, and endanger fragment devascularisation. Simple (A1.2, A1.3) or intact wedge (A2.1) fractures of distal femur can be anatomically reduced by an open technique, and the fracture compressed by lag screws (A1.2, A2.1) or dynamic hole compression (A1.3), using conventional plates or LCPs (hybrid fixation).
Compression plating can also be done by minimally invasive techniques (MIPO compression plating) in simple spiral/oblique fractures of the distal femur, by percutaneous reduction of the fracture with clamps, and percutaneous placement of lag screws, without opening of the fracture, followed by a neutralisation plate. However, closed reduction is usually difficult to achieve in spiral (particularly double spiral) fractures, and risks fracture of the spike(s). Moreover, the three-dimensional fracture configuration in spiral fractures requires an open approach for accurate positioning of the lag screws. Hence, we restrict the use of MIPO compression plating in long oblique fractures, favouring open compression plating for transverse, short oblique and spiral fractures. Table 1 shows our preferred approach to distal femur fractures, based on the AO/OTA fracture classification.

Locked versus hybrid plating
With the availability of locking compression plates (LCP), a locking plate can be used as a hybrid fixation (an amalgamation of traditional compression plating with locked plating). The term ‘hybrid’ construct is used in two contexts- the use of two different modes of fixation (compression and bridge techniques) in a single plate, as in segmental fractures, and secondly, the use of both locking and conventional screws in a single plate (fixing a single fracture), compressing the plate to the bone. Here, we have used the term ‘hybrid’ construct in the latter context.
Biomechanical studies have shown that only the locking screws placed in the distal segment are important for axial and torsional stiffness of the construct, with proximally unlocked (hybrid) plates showing equivalent axial and torsional stiffness, as fully locked plates[22]. Thus, the LCPs may be preferred over LISS plates in simple fracture configurations, where compression plating is required. Moreover, the use of less number of locking screws brings down the costs too. The use of plates compressed to the bone can potentially affect periosteal/cortical circulation, but this has not been proven to be detrimental for primary bone healing.

Surgical approach
The lateral approach to the distal femur is the standard surgical approach for the fixation of type A distal femur fractures. It involves a mid-lateral skin incision, incision of the iliotibial tract and atraumatic elevation of the vastus lateralis from the intermuscular septum (Fig 5A). Distal extension of the approach towards tibial tuberosity/ lateral knee arthrotomy is not required in type A fractures.
The approach can be extended proximally, if open compression plating of the fracture is planned. If a MIPO compression/bridge plating is planned, only the distal part of the approach is performed, with a minimal exposure of the lateral femoral shaft at the proximal end of the plate (to ensure proper positioning of the plate in coronal and sagittal planes) and multiple stab incisions for percutaneous screw placement (Fig 5B). There is a potential space beneath the vastus lateralis which allows percutaneous, submuscular sliding of the plate.
For retrograde nailing, a midline infra-patellar skin incision in 20-40o knee flexion is performed, with the patellar-tendon either split or retracted laterally (through a small medial arthrotomy). Some surgeons prefer to perform a complete medial parapatellar arthrotomy to ensure correct positioning of the entry point, but that is not required, except in type C fractures, where direct visualisation of the articular fracture reduction is essential.

Figure 6: Surgical approaches and reduction techniques for distal femur Fig 6A Standard open, lateral approach to distal femur Fig 6B MIPO approach to distal femur Fig 6C Use of intra-op distractor for indirect reduction Fig 6D Use of cautery cord intra-operatively to judge limb alignment

Figure 5: Surgical approaches and reduction techniques for distal femur Fig 5A Standard open, lateral approach to distal femur Fig 5B MIPO approach to distal femur Fig 5C Use of intra-op distractor for indirect reduction Fig 5D Use of cautery cord intra-operatively to judge limb alignment


Figure 7: 65 year old male with a distal femur fracture (33A2.1) occurring below a hip prosthesis, with pre-existing gonarthrosis Fig 7A,B Pre-operative x-rays, showing a spiral fracture line with a wedge fragment anterodistally Fig 7C,D Immediate post-operative x-rays after open, compression plating with DF-LCP, overlapping the plate over the hip stem

Figure 6: 65 year old male with a distal femur fracture (33A2.1) occurring below a hip prosthesis, with pre-existing gonarthrosis Fig 6A,B Pre-operative x-rays, showing a spiral fracture line with a wedge fragment anterodistally Fig 6C,D Immediate post-operative x-rays after open, compression plating with DF-LCP, overlapping the plate over the hip stem

Technical pearls for close reduction
All distal femur fractures should be reduced in a slightly flexed position of the knee to relax the gastrocnemius muscle complex, allowing correction of the apex posterior deformity in the sagittal plane. A bump may be placed posteriorly at the fracture site to correct the deformity. Conventional tables are usually preferred over fracture tables.
Application of traction is central to restore limb length and allow reduction of distal femur fractures. Traction can be applied directly (by an assistant), through a pin inserted in distal femur or proximal tibia, or more effectively by the use of a femoral distractor (Fig 5C) with Schanz screws inserted proximal and distal to the fracture.
Restoration of length is easy to judge in A1/2 fractures, where direct contact between the main fracture fragments provides an easy guide. In complex A3 fractures, the restoration of limb length can be difficult, and is facilitated by draping of the normal side too, to allow direct intra-operative comparison.
Restoration of alignment in the coronal plane is paramount for a good knee function, and reduce the incidence of secondary osteoarthritis of the knee. An anatomic femorotibial angle between 5 to 10o is desirable for a normal function. The restoration of alignment is usually facilitated by a plate, if the distal blade (blade plate), lag screw (DCS) or locking screws (locking plates) of the plate, are correctly placed parallel to the knee joint. The cautery cord method (Fig 5D) can be helpful in difficult fractures, ensuring the centre of the knee lying just medial to a cautery cord placed joining the centres of the hip and the ankle joints.
Restoration of alignment in the coronal and sagittal planes is trickier with a nail, than a plate. Unlike diaphyseal fractures, a retrograde nail does not facilitate reduction of metaphyseal fractures (due to the mismatch in diameters of the proximal and distal fragments), and fracture reduction has to achieved prior to reaming and passage of the nail. Indeed, an intramedullary nail can lead to malalignment, if the entry point is not correctly made in both the coronal (in line with the centre of canal) and sagittal (just anterior to the Blumensaat’s line) planes. Placement of poller screws at the concave side of the deformity (usually medial and anterior to the guidewire to correct the commonly seen varus and apex posterior angulation deformities) is frequently required to achieve a correct alignment.
Restoration of alignment in the axial plane, i.e. rotation, is the trickiest part in comminuted fractures. Unlike diaphyseal fractures, matching the diameters of the proximal and distal fragments is not helpful in comminuted distal femur fractures, due to the differing diameters of the proximal (diaphysis) and distal (epiphysis) segments. Again, draping the normal side is helpful to restore the correct rotational alignment intra-operatively. First, the rotational profile of the lesser trochanter of the fractured limb is noted, and the normal side is then rotated to assume a rotational profile of the trochanter similar to that of the injured side. Then, the rotational profile of the foot on the normal side is noted, and the foot of the injured side is then rotated to assume a position similar to that of the normal side.

Role of newer implants and techniques

Polyaxial locked plates
Polyaxial locking plates are newer locking constructs, which allow for variable angle screw insertion, which can then be secondarily locked into the plates. Biomechanical studies have shown conflicting evidence regarding the superiority of polyaxial locking plates over uniaxial locking plates, in terms of axial/torsional stiffness and fatigue strength[23,24]. Currently, the role of polyaxial locking plates seems limited in extra-articular distal femoral fractures, except in special situations, like peri-implant fractures (around a nail or stem of a hip/knee prosthesis), where the variability in angle of insertion of locked screws id advantageous to negotiate the intra-medullary implant.

Dynamic locked plates
With increasing reports of asymmetric/insufficient callus formation and delayed/non-union with locking plates, systems have been developed to make the locking constructs more dynamic by overdrilling the near cortex, use of far cortical locking (FCL) screws, or use of dynamic locking screws[25]. Biomechanical studies comparing the stiffness and strength of these constructs in distal femur fractures are awaited. Clinical studies using FCL constructs in distal femur fractures have shown excellent rates of union with no implant failures[26,27] This technique seems to be prevent the healing problems seen with locked plates.

Implant augmentation
Even locking plates can fail in severely osteoporotic bones, due to decreased strength of the construct. Attempts to augment the fixation of locked screws by cement injection, either prior or following (through perforated cannulated screws) screw insertion, have shown success in biomechanical studies[28,29]. Implant augmentation seems a viable option for severely osteoporotic fractures, though reports of its successful clinical use are awaited.

Distal femur replacement
In low-demand elderly patients (eg. nursing home residents) with severe osteoporosis, there has been a recent trend to opt for prosthetic replacement, instead of osteosynthesis, in comminuted metaphyseal fractures, to allow earlier pain relief and immediate, full weight-bearing. However, distal femur replacement is a costly and technically challenging surgery, associated with greater morbidity/mortality, and a high rate of complications[30] (upto 50%), like peri-prosthetic fractures, infections and aseptic loosening. Hence, it needs to be cautiously used, only as a salvage procedure in low-demand patients with poor bone stock and comminuted peri-prosthetic fractures, complex intra-articular (C3) fractures, comminuted extra-articular fractures with pre-existing gonarthrosis, and resistant non-unions. Patients with relatively simple fracture patterns and pre-existing gonarthrosis can be managed with a standard total knee prosthesis with femoral stem extension (eg. the case illustrated in Fig 6 could have been managed by a primary TKR, but osteosynthesis was chosen as the patient could not afford a total knee prosthesis)[31].

Conclusion
Distal femur fractures are challenging injuries, though an excellent outcome can be expected in most extra-articular fractures with current techniques. The treating surgeon should understand the regional anatomy, fracture morphology, implant biomechanics and patient characteristics (age, functional status, bone quality) to formulate a suitable plan for an individual case.


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16. Acharya KN, Rao MR. Retrograde nailing for distal third femoral shaft fractures: a prospective study. J Orthop Surg (Hong Kong). 2006 Dec;14(3):253-8.
17. von Rüden C, Tauber M, Woltmann A, et al. Surgical treatment of ipsilateral multi-level femoral fractures. J Orthop Surg Res. 2015 Jan 24;10:7.
18. Farouk O, Krettek C, Miclau T, Schandelmaier P, Guy P, Tscherne H. Minimally invasive plate osteosynthesis: does percutaneous plating disrupt femoral blood supply less than the traditional technique? J Orthop Trauma. 1999 Aug;13(6):401-6.
19. Pakuła G, Wodzisławski W, Fudalej P, Wodzisławski J. Errors in Treatment of Fractures of Distal Femur by LISS Method (Less Invasive Stabilization System) – Single-centre Experience. Ortop Traumatol Rehabil. 2014 May-Jun;16(3):275-84.
20. Buckley R, Mohanty K, Malish D. Lower limb malrotation following MIPO technique of distal femoral and proximal tibial fractures. Injury. 2011 Feb;42(2):194-9.
21. Khalafi A, Curtiss S, Hazelwood S, Wolinsky P. The effect of plate rotation on the stiffness of femoral LISS: a mechanical study. J Orthop Trauma. 2006 Sep;20(8):542-6.
22. Cui S, Bledsoe JG, Israel H, Watson JT, Cannada LK. Locked plating of comminuted distal femur fractures: does unlocked screw placement affect stability and failure? J Orthop Trauma. 2014 Feb;28(2):90-6.
23. Wilkens KJ, Curtiss S, Lee MA. Polyaxial locking plate fixation in distal femur fractures: a biomechanical comparison. J Orthop Trauma. 2008 Oct;22(9):624-8.
24. Otto RJ, Moed BR, Bledsoe JG. Biomechanical comparison of polyaxial-type locking plates and a fixed-angle locking plate for internal fixation of distal femur fractures. J Orthop Trauma. 2009 Oct;23(9):645-52.
25. Nikhil N, Marcus W. Current concepts to reduce mechanical stiffness in locked plating constructs: a review article. Orthopaedic Research & Reviews. 2014;6:91-6.
26. Adams JD Jr, Tanner SL, Jeray KJ. Far cortical locking screws in distal femur fractures. Orthopedics. 2015 Mar;38(3):e153-6.
27. Bottlang M, Fitzpatrick DC, Sheerin D, et al. Dynamic fixation of distal femur fractures using far cortical locking screws: a prospective observational study. J Orthop Trauma. 2014 Apr;28(4):181-8.
28. Wähnert D, Hofmann-Fliri L, Richards RG, Gueorguiev B, Raschke MJ, Windolf M. Implant augmentation: adding bone cement to improve the treatment of osteoporotic distal femur fractures: a biomechanical study using human cadaver bones. Medicine (Baltimore). 2014 Nov;93(23):e166.
29. Wähnert D, Lange JH, Schulze M, Lenschow S, Stange R, Raschke MJ. The potential of implant augmentation in the treatment of osteoporotic distal femur fractures: a biomechanical study. Injury. 2013 Jun;44(6):808-12.
30. Fakler JK, Hepp P, Marquaß B, von Dercks N, Josten C. [Is distal femoral replacement an adequate therapeutic option after complexfractures of the distal femur?]. Z Orthop Unfall. 2013 Apr;151(2):173-9.
31. Choi N-Y, Sohn J-M, Cho S-G, Kim S-C, In Y. Primary Total Knee Arthroplasty for Simple Distal Femoral Fractures in Elderly Patients with Knee Osteoarthritis. Knee Surg Relat Res. 2013;25(3):141-6.


How to Cite this article: Agrawal A. Distal femur AO type A fractures – Surgical options, techniques, results and complications. Trauma International Oct-Dec 2015;1(2):12-16.

Dr. Anuj Agrawal

Dr. Anuj Agrawal


(Abstract)      (Full Text HTML)      (Download PDF)


Management options and Decision making algorithm for Distal Femur fractures

 Volume 2 | Issue 1 | Jan-Apr 2016 | Page 7-12|Mohsin e Azam


Author: Mohsin-e-Azam[1]

[1] iCare Clinics, Dubai UAE.

Address of Correspondence

Dr. Mohsin e Azam,
.Dr Mohsin-e-Azam
MBBS, MCPS, FCPS, Dip IT, Dip Bioethics
Specialist Orthopaedic Surgeon
iCare Clinics, Dubai UAE
Email:  mohsindoc@gmail.com


Abstract

Distal femur is a complex fractures and most of times a personalized approach is needed for these fractures. Over a period of time variety of approaches and implants have been used for these fractures. The guiding principles for achieving good prognosis is meticulous surgical technique, preservation of fracture biology, restoration of articular surface and overall alignment of the limb. In case of geriatric fractures factors like long terms health and functional goals also need to be taken into consideration in planning treatment. This review focusses on providing an overview of the management options and lay down the premise for the symposium
Keywords: .Distal femur fractures, surgical management, decision making


Introduction

Distal femur fractures have been reported to account for between 4% and 6% of all femoral fractures[1, 2]. The distribution of fractures of this region is bimodal both in terms of age and mechanism. Distal femur fractures can result from either high-energy trauma or low-energy trauma. High-energy trauma such as road traffic accidents and sports accidents are more likely in men ages 15–50, whereas low-energy trauma such as falls from standing height at home are more likely to lead to distal femur fractures in women aged 50 and above. There is also the addition of the peri-prosthetic fracture group in the geriatric population with osteoporosis. In both cases axial loading of the leg is the most common mechanism of injury[2]. The fractures can be open or closed, due to their peri-articular location, can also have associated injuries of the patella and tibia. Proper antibiotic prophylaxis is essential to reduce the rate of infection in open fractures[3]. In cases of high energy trauma there can be associated neurovascular injury. Hence the neurovascular status of the extremity should be monitored closely in the perioperative and postoperative period. For evaluation of the fractures AP and Lateral X-Rays are obtained. Where articular comminution is present CT (computerized tomography) can aid in better understanding of the fracture geometry. 3D reconstruction images can further clarify complex articular injuries and coronal plane fractures[4]. As for all peri-articular fractures the restoration of articular surface and joint alignment requires thorough assessment of the fracture character and proper preoperative planning. Failing to do so can result into severe permanent disability specially if there is loss of knee stability and function[5].
Classically, the treatment of choice for management of femoral fractures, including supracondylar fractures, was with different types of splints. In 1907 and 1909, Steinmann and Kirschner, respectively, developed the first traction treatment modalities with the use of pins or wires under tension. A single pin is usually placed in proximal tibia when applying skeletal traction for treating these fractures[6].
Retrospective reports during the 1960’s by Stewart et al. (1966) and Neer et al. (1967) favored simple non-operative methods of treatment. However, in the next decade the pendulum started to shift as new surgical methods and materials improved the results of surgery according to Miiller et al[1].
Progressively with time better understanding of anatomy and fracture characteristics led to improved implant designs and improved outcomes. The modalities for fixation of distal femoral fractures can be broadly classified into external fixation, Conventional plating (sliding screws, blade plates and Dynamic compression plates), Locked plate fixation, Intramedullary nailing and arthroplasty.

Non Operative Management

The options of non-operative management are splint, cast and traction. Thomas and Meggit compared different non operative modalities and observed that there was no significant difference in the malunion rates between the splint versus the cast brace treatment. Although there was delayed union associated with splints[7]. Butt et al. evaluated operative (dynamic condylar screw) versus conservative (skeletal traction) treatment in a randomized control trial for displaced distal femur fracture in elderly patients. Good or excellent results were obtained in 53% of the operative patients versus 31% in the conservative group. The non-operative group had an increased risk for deep vein thrombosis (despite anticoagulation therapy), pulmonary and urinary tract infections, non-unions, mal-unions, knee joint stiffness, skin related complications and pin tract infections[8]. Therefore the application of the non-operative treatment is limited to only certain conditions like non-displaced fractures, bed bound patients, patients unfit to undergo surgery due to comorbidities[9].

Operative Management
Fractures of the distal femur can be managed successfully with surgery. A good result depends on identification of all fragments, adequate repair of soft tissue, appropriate bone grafting, meticulous inter-fragmentary compression, and complete reduction of the joint space[10].
Indications for operative management include open fractures, displaced fractures, intra-articular fractures, fractures associated with neurovascular compromise, ipsilateral lower extremity fractures, irreducible fractures, pathologic fractures and non-unions.
The implant and technique used is determined by fracture pattern, bone quality, the hemodynamic stability of the patient, and the skill and experience of the surgeon[11].

Surgical Techniques

ORIF Approaches
Surgical approach usually depends upon the character of the fracture and the choice of the implant. Most commonly performed approach is the lateral approach.

Lateral Approach
This approach is employed for fractures without articular involvement or simple articular extension. It is performed in the supine position with the knee flexed to 30 degrees. Flexing the knee releases the traction caused by gastrocnemius muscle and prevents extension of the distal fragment. This approach can be extended as required proximally to mid-thigh and to the lateral parapatellar region distally. The approach relies on an atraumatic elevation of the vastus lateralis from the lateral aspect of the distal femur, and a lateral arthrotomy for joint access. Articular reduction and lateral plate placement can both be achieved with the same approach. When extended proximally this approach can provide access to the entire length of the femoral shaft. Fractures of the medial femoral condyle and more complex fractures can also be handled with a lateral approach[12]. Occasionally a medial para-patellar approach may be utilized to provide good view of the articular surface of the distal femur.

Medial parapatellar
A medial approach to the distal femur may be used for a medial distal femoral fracture or in case of a coronal split (Hoffa-type fracture) of the femoral condyles. It can also be used in conjunction with lateral exposure when double plating of the distal end of the femur is indicated for severe supracondylar comminution or for bone defects requiring additional medial stabilization and in patients with complex combined supracondylar and intracondylar fractures. The vastus medialis is reflected anteriorly to expose the distal medial shaft of the femur. Structures to be protected in this approach are medial collateral ligament, the medial meniscus and the femoral artery and vein as they leave the adductor canal[13].

Surgical Algorithm
For extra articular distal femur fractures a minimally invasive surgical approach can be utilized, this approach preserves the fracture biology. This can be achieved by minimal invasive plate osteosynthesis or retrograde intramedullary nailing. Either approach allows for bridging of the fracture. This approach is superior to open reduction and internal fixation of intermediate fragments where blood supply may be impaired. Compression mode plating has been found superior to bridging mode and should be performed where feasible[14].
For simple articular fractures open reduction of the affected femoral condyle is required to achieve anatomic reduction. Lag screws can be used to reduce the articular fragments followed by a plate for osteosynthesis.
In case of the comminuted articular fractures visualization of the knee joint is required in order to reduce and anatomically reconstruct the articular surface. Temporary k-wire fixation can be performed followed by placement of lag screws using 3.5 mm screws. Afterwards the articular bloc is fixed to the femoral shaft. No matter which kind of fixation is performed it is imperative to restore axial alignment, length and rotation of the lower limb for good functional recovery[15].
In severely comminuted fractures a spanning external fixator may be used as a salvage procedure. The external fixator may be applied for several weeks in order to achieve adequate conditions for later total knee arthroplasty[16].

External Fixation
External fixation is commonly used as a temporary measure of these fractures, in particular for displaced intra-articular fractures. Mainly used when there is an open fracture, significant comminution, bone loss, vascular compromise or extensive soft tissue damage. A bilateral fracture or a floating knee are also examples of complex fractures requiring external fixation. Proper placement of pins away from the zone of injury will reduce the risk of infection and maintain the integrity of the soft tissue for definitive management at a later stage[17].
With Monolateral fixators, it is difficult to control alignment, the stability is often poor, there is no fixation of the articular component and stabilization of the fracture requires bridging the knee, which increases the risk of stiffness. As a damage control measure external fixation provides opportunity for medical management, reduction in pain and facilitates nursing care till definitive treatment can be performed. Severely comminuted fractures can also be treated definitively with tensioned external fixation devices such as the Ilizarov fixator.
Oh et al. reported results of a series of 59 complex intra-articular fractures with temporary bridging external fixation. There were seven complications including four that developed in distal femoral fractures which were infection and the unsuccessful control of leg length[18]. Parekh et al. reported good results in staged management of complex intra-articular fractures around the knee, with 16 distal femoral fractures in a series of 47 cases[19]. Zlowodzki et al. reported an average 7.2% nonunion rate, 1.5% rate of fixation failure, 4.3% rate of deep infection, and 30.6% need for secondary surgical procedures when distal femoral fractures were treated with external fixation[20]. Arazi et al. evaluated 14 complex fractures treated with Ilizarov external fixator and found that union occurs around 16 weeks with a mean ROM of 105 degrees at the knee. With the only complication being an infected nonunion, they concluded that the fixator is a safe option that provides adequate stability[21]. Kumar and colleagues examined the outcomes of the Ilizarov fixator in open supracondylar fractures and found that union occurred much later at 39 weeks, with at least 4 cm of shortening noted in 40% of fractures and pin-track infections in 21% of patients[22].

Conventional Plate Systems
After the 70s, better results to support ORIF in fractures of the distal femur were reported in literature[1, 23] Shahcheraghi et. al. compared ORIF with closed reduction directly, preferred ORIF with good or excellent clinical results registered, 81% open versus 42% closed and a significantly reduced malunion rate, 3% open versus 37% closed[15]. With the availability of the fixed angle blade plate the care for the distal femur fracture got transformed. This construct provided polyaxial stability and inherent rigidity. Earlier designs constituted an angled side plate that could be impacted into the distal femur and fixed to the distal femur by the precontured region of the plate across the metaphyseal flare. The angle of the blade was commonly 95 degrees and careful implantation ensured that length and alignment could be restored even in injuries with metaphyseal comminution. The major drawback of this design was that it required a large exposure. Furthermore, it could not be used in cases of osteoporosis and was unable to address the coronal plane fractures[5]. Later another implant was designed on the fixed angle concept with a sliding screw and was called the Dynamic Condylar Screw (DCS). This implant provided the ability to compress the intercondylar fragments. This design was adopted for the ease of application and smaller exposure. But it still did not address the coronal fracture limitation of the angled blade plate and also resulted in more bone loss upon insertion which made revisions difficult[24].
In general open reduction and internal fixation requires extensive dissection and can therefore lead to devascularization of fracture fragments, hence there is an increased risk of delayed union, non-union and infection[25]. To decrease these complications, concepts evolved applying indirect reduction techniques to restore length, rotation, and the mechanical axis without direct exposure of the fracture site and therefore maintaining the blood supply to the fracture region. Indirect reduction techniques were shown to have a biological advantage. Bolhofner et al. treated 57 patients with distal femoral fractures with conventional plates using only indirect reduction techniques. The average time to fracture union and full weight bearing was 10.7 weeks with no non-unions or hardware failures reported. These results could be achieved although 11 patients with open fractures were included[26].
Keeping in view the problems with open reduction and internal fixation and advantages of indirect reduction and preservation of vascularity of fracture fragments evolution occurred to wards minimally invasive surgery[27]. Studies have shown the preservation of soft tissue perforators and specially of the periosteal blood supply while using minimally invasive plate osteosynthesis (MIPO) techniques. Furthermore it decreased the incidence of infection, implant failure and led to earlier callus formation and decreased the need for subsequent bone grafting[20].

Locked Plate Fixation
With the development of different options in plate osteosynthesis, the locked pre-contoured plates have become widely used in orthopedics for many different fractures. Unlike the previously used (conventional) plates, which required friction between the plate bone interface for stability, the locking plates have mechanisms to secure the screw heads to the plate. This allows for the screws to be placed at different angles. The major advantage is that the plate doesn’t not have to be in contact with the bone. This allows for preservation of the periosteal blood supply[27].
Locking plate can be used in an open reduction and internal fixation procedure when the fracture is intraarticular, or with minimally invasive surgery using the less invasive stabilization system (LISS) in case of an extra-articular fracture or a simple non- displaced fracture[28]. One of the disadvantages of locking plate is the lack of interfragmentary compression with locking screws, this requires fixation of fragments with placement of lag screws prior to plate fixation. Extra care while insertion is required to prevent the interference of lag screws with the locked screws. There is a learning curve associated specially when using LISS in order to achieve union and prevent malunion and mechanical failure[29].
Although locking plates provide the biological advantage, at the same time they create rigid constructs which can suppress fracture union. As micro motion across the fracture site has been long known to cause stimulation of healing across the fracture fragments. Making the construct too rigid can affect the callus formation[30]. Choice of material also affects rigidity, stainless steel being more rigid, whereas titanium and associated alloys provide more flexibility[31].
In locking plates there are variations that exist based on the locking mechanism of the screws. One type has the unidirectional screws and the other has polyaxial screws. Polyaxaial system allows for more accurate screw placement, especially in the peri-articular regions. As a further development, a hybrid locking plate was made known as the Locked compression plate (LCP) which contains holes for both locking screws and cortrical screws. This system allowed for interfragmentry compression similar to a dynamic compression plate (DCP)[32].
In the literature there are many biomechanical studies that evaluate locking plate fixation systems. Beingessner et al. compared titanium plates to steel plates as well as unicortical to bicortial screws. They concluded that strength under torsion is reduced in titanium plates and strength is improved with bicortical screws. Whereas there is no difference for axial compression strains and plastic deformity[33].
Lujan et al. demonstrated that titanium plates favor the formation of callus due to elasticity in fixation material[31]. Stoeffel et al. when comparing LCP, DCP and Hybrid fixation showed that locking system results in less loss of reduction under axial compression with less plastic deformity and the DCP system provides better strength under torsion. The conclusion was that Hybrid fixation is preferred[34]. Wilkens et al. showed that the placement of polyaxial screws increased strength under axial compression and torsion and reduces deformation when loaded[35]. Freeman et al. compared load to failure, axial stiffness, and screw extraction torque for distal femoral locking plates with locked or cortical screws. Results demonstrated that locked fixation was superior in the osteoporotic model only[36]. Buckley et al. brought forward the issue of mal-rotation following MIPO if careful intra operative assessment is not done[37].
Recently, Tank et. al. concluded that early mechanical failure with the variable angle distal femoral locking plate is higher than traditional locking plates (LCP and LISS) for comminuted intraarticular distal femur fractures. They advised against use of this plate for metaphyseal fragmented distal femur fractures[38].
In a randomized prospective multicenter controlled trial comparing the Less Invasive Stabilization System (LISS) with the minimally invasive Dynamic Condylar Screw System (DCS) published by the Canadian orthopedic trauma society, they concluded that there was no statistically significant difference between LISS and DCS in terms of the number of fractures healed, time to union, or functional scores. Complications and revisions were more common in the LISS group. Only 52% of the LISS group healed without intervention by 12 months compared with 91% in the DCS group[39].

Interlocked IM nail
Intramedullary nailing is a good surgical option for distal femur fracture. It helps avoid extensive soft tissue dissection and minimize secondary damage of devascularization of fracture fragments[40]. This method has been recommended for non-comminuted fractures with intact distal femur to allow for interlocking. Both ante- and retrograde nailing have successfully been applied in the treatment of even comminuted and intraarticular fractures, but antegrade nailing has lost appeal[41]. Antegrade nailing has now been reserved for extraarticular fractures with fracture line > 5 cm proximal to the articular surface to allow for adequate distal fixation. The only advantage of antegrade nailing is the avoidance of an arthrotomy[32]. Retrograde nailing prevailed due to availability more options of distal fragment fixation. As with minimally invasive plate osteosynthesis, indirect fracture reduction and a minimally invasive approach were adopted for nailing as well.
Handolin et. al. reported in a series of 44 patients with 46 distal femur fractures with retrograde nailing, that the final union rate was 95% and a mean union time was 17.5 weeks. However, there were three patients with a loss of reduction and two of them had to undergo a re-operation[42]. Henry et al. compared open versus percutaneous reduction techniques for retrograde nailing of distal femoral fractures. The authors concluded improved post-operative knee function with decreased operative time, blood loss, bone grafting, and non-union rates without differences in malunion rate[43]. Hartin et. al. compared nailing vs plate fixation in fractures of the distal femur. They demonstrated high union rates in both groups without any statistically significant difference between groups. They observed that the deep infection rate, knee range of motion and healing time was better in the nailing group but was not statistically significant[44].
Disadvantages of the nailing technique may be a lack of alignment control, posterior angulation, perforation of joint cartilage and intra-articular distribution of reaming debris. Stability is limited if small diameter and short nails are inserted[45].

Arthroplasty
Complex peri-articular fractures can be a challenging to treat especially in the elderly. Even after achieving anatomic reconstruction and rehabilitation, posttraumatic arthritis and knee pain are complaints that commonly arise in addition to any baseline osteoarthritis. In younger patients the use of primary arthroplasty or distal femoral replacement may not be a viable option but in elderly it can be a valuable consideration, especially in the presence of primary osteoarthritis and comminution of the femoral condyles. Thin cortices, wide intramedullary canal and osteoporosis can make stable primary fixation difficulty to achieve, especially in the presence of multiple medical co-morbids[46]. Preservation of knee function and early weight bearing should be the objectives of management in the geriatric population[47]. Careful pre-operative planning and imaging is required to gauge the extent of injury. Radiography of the contralateral limb can act as a template in planning. Depending on the extent of the fracture and its pattern implant choice can be made. Primary total knee arthroplasty implants for non-comminuted fractures, revision TKA implants in the presence of metaphyseal extension, distal femoral replacement in cases of significant metaphyseal comminution and hinged implants where there is ligamentous instability. Addition of plates, lag screws, cables and cement can be done to achieve the required stability[48]. Choi et. al. performed TKA with the Medial Pivot prosthesis in 8 patients with ages between 65 and 89 who had primary osteoarthritis along with a distal femur fracture. They reported a mean time of 15 weeks to union and a good clinical result for all patients. They concluded that primary TKA can be considered as an option for the treatment of minimally comminuted distal femoral fractures in elderly patients who have advanced osteoarthritis of the knee with appropriate bone stock[49]. Appleton et. al. reported results of hinged total knee replacement in treatment of 54 fractures in 52 patients with a mean age of 82 years. Within the first year after implantation 22 of the 54 patients had died, six required further operation and two required revision surgery. They concluded that hinged total knee is useful alternative treatment to internal fixation in elderly patients and has a high probability of surviving as long as the patient[50]. Arthroplasty for peri articular fracture may not be seen as a paradigm shift but instead as a good alternative, for a certain patient group, that requires a strict indication and an experienced surgeon[51].

:Conclusion 
With the evolution of techniques and implants over time the treatment of the distal femoral fracture has improved. Although the advantage of one system of fixation over the other cannot be absolutely concluded, the main dependence of the surgical decision remains more on the fracture pattern and familiarity of the surgeon with the use of a certain implant and technique. The guiding principles for achieving good prognosis is meticulous surgical technique, preservation of fracture biology, restoration of articular surface and overall alignment of the limb. In case of geriatric fractures factors like long terms health and functional goals also need to be taken into consideration in planning treatment.


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39. Society COT. Are Locking Constructs in Distal Femoral Fractures Always Best? A Prospective Multicenter Randomized Controlled Trial Comparing the Less Invasive Stabilization System With the Minimally Invasive Dynamic Condylar Screw System. Journal of orthopaedic trauma. 2016;30(1):e1-e6.
40. Kim J, Kang SB, Nam K, Rhee SH, Won JW, Han HS. Retrograde intramedullary nailing for distal femur fracture with osteoporosis. Clinics in orthopedic surgery. 2012;4(4):307-12.
41. Butler MS, Brumback RJ, Ellison TS, Poka A, Bathon GH, Burgess AR. Interlocking intramedullary nailing for ipsilateral fractures of the femoral shaft and distal part of the femur. The Journal of bone and joint surgery American volume. 1991;73(10):1492-502.
42. Handolin L, Pajarinen J, Lindahl J, Hirvensalo E. Retrograde intramedullary nailing in distal femoral fractures–results in a series of 46 consecutive operations. Injury. 2004;35(5):517-22.
43. Henry SL. Supracondylar femur fractures treated percutaneously. Clinical orthopaedics and related research. 2000(375):51-9.
44. Hartin NL, Harris I, Hazratwala K. Retrograde nailing versus fixed-angle blade plating for supracondylar femoral fractures: a randomized controlled trial. ANZ journal of surgery. 2006;76(5):290-4.
45. Hierholzer C, von Rüden C, Pötzel T, Woltmann A, Bühren V. Outcome analysis of retrograde nailing and less invasive stabilization system in distal femoral fractures: A retrospective analysis. Indian Journal of Orthopaedics. 2011;45(3):243-50.
46. Bell KM, Johnstone AJ, Court-Brown CM, Hughes SP. Primary knee arthroplasty for distal femoral fractures in elderly patients. The Journal of bone and joint surgery British volume. 1992;74(3):400-2.
47. Mounasamy V, Cui Q, Brown TE, Saleh KJ, Mihalko WM. Primary total knee arthroplasty for a complex distal femur fracture in the elderly: a case report. European Journal of Orthopaedic Surgery & Traumatology. 2007;17(5):491-4.
48. Gangavalli AK, Nwachuku CO. Management of Distal Femur Fractures in Adults: An Overview of Options. The Orthopedic clinics of North America. 2016;47(1):85-96.
49. Choi NY, Sohn JM, Cho SG, Kim SC, In Y. Primary Total Knee Arthroplasty for Simple Distal Femoral Fractures in Elderly Patients with Knee Osteoarthritis. Knee surgery & related research. 2013;25(3):141-6.
50. Appleton P, Moran M, Houshian S, Robinson CM. Distal femoral fractures treated by hinged total knee replacement in elderly patients. The Journal of bone and joint surgery British volume. 2006;88(8):1065-70.
51. Thomas Haufe SF, Peter Müller, Johannes Plath, Edgar Mayr. The Role of a Primary Arthroplasty in the Treatment of Proximal Tibia Fractures in Orthogeriatric Patients. BioMed research international. 2016;2016:5.


How to Cite this article: Azam M. Management options and Decision making algorithm for Distal Femur fractures. Trauma International Jan-Apr 2016;2(1):12-16.

Dr. Mohsin e Azam

Dr. Mohsin e Azam


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Classification of Distal Femur Fractures and Their Clinical Relevance

Volume 2 | Issue 1 | Jan-Apr 2016 | Page3-6 |Raja Bhaskara Kanakeshwar, Arun Kamal C, Dheenadayalan J


Author: Raja Bhaskara Kanakeshwar[1], Arun Kamal C[1], Dheenadayalan J[1]

[1]Ganga Hospital, 313, MTP road, Coimbatore , Tamilnadu, India Pin code – 641043

Address of Correspondence
Dr Raja Bhaskara Kanakeshwara
Ganga hospital,313, MTP road, Coimbatore , Tamilnadu, India, Pin code – 641043
Email id – rajalibra299@gmail.com


Abstract

Introduction: Analysis and classifying distal femur fractures is one of the important steps for an orthopaedic surgeon towards a successful outcome in treating these fractures. Few surgeons tried to classify these fractures and we discuss in detail those systems and their clinical relevance . Three classification systems have been discussed below and it has shown the Müller AO classification system remains the ideal classification for these fractures as it is user friendly, easy to document and gives an idea on the prognosis .
Keywords : Distal femur fracture, classification, Müller, AO, Hoffa.


Introduction

To treat a fracture better, we need to understand it better. To understand them better, we need to analyse them better and classify them . Distal femur fractures are often comminuted and intra-articular, and they frequently involve osteoporotic bone, which makes it difficult to reduce them while maintaining joint function and overall limb alignment [1,2]. Hence, classifying them in an appropriate manner which would help surgeons to give a better outcome is of utmost impotance. Unlike proximal femur fractures – which have numerous classifications to describe them – there are only a few systems proposed for distal femur fractures mainly due to the less complex muscular anatomy and vascular anatomy involved between both these regions[3,4,5].
For a classification system to have clinical significance, it must be able to :
1) allow adequate documentation so that a common language is possible to discuss these injuries
2) be ‘user friendly’
3) help in clinical decision making
4) prognosticate the outcome depending on the treatment option [3] .
We shall discuss about the various classification systems described for distal femur fractures and their clinical significance .

Classification of distal femur fractures and their clinical relevance
Classification systems in distal femur fractures :
The various classification systems described for distal femur fractures are (Table 1,2) :
1) Neer and associates ( 1967 )
2) Seinsheimer classification ( 1980 )
3) AO Classification – Müller ( 1990 )

Table 1: Basic algorithm – Distal femur fracture classification – Müller AO :

Table 1: Basic algorithm – Distal femur fracture classification – Müller AO :

Table 2: Summary of Classification systems for distal femur fractures and their significance.

Table 2: Summary of Classification systems for distal femur fractures and their significance.

Neer and associates classification [ 8 ] :
One of the simpler classification systems of supracondylar femur fractures was that of Neer and associateswhich was described early in 1967 . They subdivided supracondylar- intracondylar femur fractures into three primary categories . The 2nd category had two subdivisions[ 8 ] .
Category I : Minimal displacement
Category II : Displacement of the condyles
A) Medial condyle displacement
B ) Lateral condyle displacement
Category III : Concomitant supracondylar and shaft fractures [Fig 1]

Figure1: Neer and associates classification

Figure1: Neer and associates classification

Clinical relevance :
This classification was very basic and did not give much clinical information to the surgeon . No light was thrown upon coronal plane fractures . Moreover , there was no information on the prognosis of these injuries[3]. Hence, this system did not gain much popularity and is seldom used anywhere now among trauma surgeons worldwide .

Seinsheimer classification [9] :
In 1980, Seinsheimer published his system where he classified the fractures of the distal 3.5 inches of the femur into 4 types [9].
Type I : Non-displaced fractures ( less than 2mm displacement )
Type II : Distal metaphyseal fractures ( Extra-articular )
II-A : 2 part fractures
II-B : Communited fractures
Type III : Fractures involving the intercondylar notch in which one or both condyles are separate fragments
Type IV : Intra-articular fractures
IV-A : Medial condyle fracture
IV-B : Lateral condyle fracture
IV-C : Comminuted fractures
Clinical relevance :
Seinsheimer found that the type I and II fracture patients had osteoporosis prior to the injury and they were usually following low energy trauma . On the other end of the spectrum , he found that type IV fractures resulted from high energy trauma[9]. This classification system though it had a better descriptive detail about the fracture pattern , did not become popular as it was not user friendly and provided minimal information on prognosis[3].

AO Classification system – Müller and associates [6,7,80] :
The “Schweizer Arbitsgemenischaft fur Oseosysthesesfragen” Group ( SWISS AO ) , chaired by Müller, through its documentation data centre in Davos brought forward their classification system on distal femur fractures after analysing thousands of these fractures . This system has been found to be easy to use and satisfies all the criteria for an ideal classification [3,8] .
Müller and his colleagues divided these fractures into 3 primary groups [6,8] . Based on the common principles of the AO classification, type A fractures include extra-articular fractures and type B fractures are partial articular fractures, meaning parts of the articular surface remains in contact with the diaphysis of the femur [Fig 2]. Type C fractures include complete articular fractures with both condyles being detached from the diaphysis. The fracture types are further subdivided describing the degree of comminution and other characteristics. Further subdivision of type B fractures includes Bl (sagittal, lateral condyle), B2 (sagittal, medial condyle) and B3 (frontal, Hoffa type). Fracture type C is divided in C1 (articular simple, metaphyseal simple), C2 (articular simple, metaphyseal multifragmentary) and C3 (multifragmentary)[8].

Figure 2: The Müller Classification

Figure 2: The Müller Classification

The B3 type fracture – popularly known as ‘Hoffa’s fracture’- has immense clinical signifcance in the outcome following treatment and has been further subdivided into three types [3,8,10] . This type of cornoal fractures of he distal femur are further classified into :
B3.1 – Anterior and lateral flake fracture
B3.2 – Unicondylar Hoffa’s fracture
B3.3 – Bicondylar Hoffa’s fracture

Clinical relevance :
This classification also states that progressing from type A to type C , the severity of the trauma and injury increases whereas the prognosis for a good outcome decreases [3,10,14] . This relation also holds true for the progression from type 1 to type 3 in each group . Communication among surgeons worldwide regarding distal fractures using this system was easy and it was unanimously accepted as the gold standard classification woldwide [3,9].
Regarding the appropriate treatment or surgical option for any particular type of fracture based on the AO Müller classification system , there have been many articles published[11-16] (Table 3) . The final treatment for the patient anyhow needs to be taken by the treating surgeon depending upon many factors including the soft tissue status and the general condition of the patient [16]. A variety of surgical exposures, reduction techniques and various new implants have been developed to treat such fractures and these include intramedullary nailing, screw fixation ,periarticular locked plating and also the LISS ( Less Invasive Stabilization System ) technique [15,16] .
However, in simple fractures compression osteosynthesis should be favoured over bridging osteosynthesis since higher rates of non-unions have been reported for using locking plating for treatment of simple fractures[12].

Table 3: The recommended Surgical treatment option based upon the type of the Muller's classification is[ 12,13 ]

Table 3: The recommended Surgical treatment option based upon the type of the Muller’s classification is[ 12,13 ]

Conclusion :
Among all the classifications described for distal femur fractures, the Müller AO classification system is the most widely accepted system and is being used worldwide. This classification takes into account the involvement of anatomic region of the distal femur, the energy of the injury and also prognosticates the outcome . It has a high inter-observer reliability and validity. Being user friendly and also serving as a common language among surgeons worldwide to discuss distal femur fractures, this classification is the one of choice for treating these fractures.


References

1. Gwathmey FW Jr, Jones-Quaidoo SM, Kahler D, Hurwitz S, Cui Q. Distal femoral fractures: current concepts. J Am Acad Orthop Surg. 2010 Oct;18(10):597-607.
2. Everhart JS, Chaudhari AM, Flanigan DC. Creation of a simple distal femur morphology classification system. J Orthop Res. 2015 Nov 17.
3. Krettek C, Schandelmaier P, Richter M, Tscherne H. [Distal femoral fractures].Swiss Surg. 1998;(6):263-78.
4. Martinet O, Cordey J, Harder Y, Maier A, Bühler M, Barraud GE. The epidemiology of fractures of the distal femur. Injury. 2000 Sep;31 Suppl 3:C62-3.
5. Mu¨ller, M.E.; Allgo¨wer, M.; Schneider, R.; Willenegger, H. Manual of Internal Fixation, 3rd ed. New York, Springer-Verlag, 1991.
6. Mu¨ller, M.E.; Nazarian, S.; Koch, P. 1987. Classification AO des Fractures. Springer-Verlag New York,
7. Mu¨ller, M.E.; Nazarian, S.; Koch, P.; Schatzker, J. The Comprehensive Classification of Fractures of Long Bones. New York, Springer-Verlag, 1990.
8. Neer, C.S.; Grantham, S.A.; Shelton, M.L. Supracondylar fracture of the adult femur. A study of one hundred and ten cases. J Bone Joint Surg Am 49:591–613, 1967.
9. Seinsheimer, F. Fractures of the distal femur. Clin Orthop 153:169–179, 1980.
10. Stover M.: Distal femoral fractures: current treatment, results and problems. Injury, 32 (Suppl. 3): SC3-13, 2001
11. ZLOWODZKI M, BHANDARI M, MAREK DJ, COLE PA, KREGOR PJ. Operative treatment of acute distal femur fractures: systematic review of 2 comparative studies and 45 case series (1989 to 2005). J. Orthop. Trauma, 20: 366-371, 2006
12. LIU, E., TAO, R., CAO, Y., WANG, Y., ZHOU, Z., WANG, H., et al.: The role of LISS (less invasive stabilisation system) in the treatment of peri-knee fractures. Injury, 40: 1187-1194, 2009.
13. SHAHCHERAGHI, G. H., DOROODCHI, H. R.: Supracondylar fracture of the femur: closed or open reduction? J. Trauma, 34: 499-502, 1993.
14. Bel JC, Court C, Cogan A, Chantelot C, Piétu G, Vandenbussche E; SoFCOT. Unicondylar fractures of the distal femur. Orthop Traumatol Surg Res. 2014 Dec;100(8):873-7.
15. Arastu MH, Kokke MC, Duffy PJ, Korley RE, Buckley RE. Coronal plane partial articular fractures of the distal femoral condyle: current concepts in management. Bone Joint J. 2013 Sep;95-B(9):1165-71.
16. Pritchett, J.W. Supracondylar fractures of the femur. Clin Orthop 184:173–177, 1984.


How to Cite this article: Raja BK, Arun KC, Dheenadayalan J. Classification of distal femur fractures and their clinical relevance. Trauma International Jan-Apr 2016;2(1):3-6.

Dr. Raja Bhaskara Kanakeshwara

Dr. Raja Bhaskara Kanakeshwara

Dr. Arun Kamal C

Dr. Arun Kamal C

Dr. Dheendalayan J

Dr. Dheendalayan J


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Non Union Distal Femur Fracture: Causes and Management Options

Volume 2 | Issue 1 | Jan-April 2016 | Page 28-33|Puneet Maheshwari, Pramod Maheshwari


Author: Puneet Maheshwari[1], Pramod Maheshwari[1]

[1] Maheshwari Nursing Home, 163, Bhagat Singh Marg
Dewas M.P. 455001, India

Address of Correspondence
Dr. Puneet Maheshwari
Maheshwari Nursing Home, 163, Bhagat Singh Marg
Dewas M.P. 455001, India
Email: puneet1984@gmail.com


Abstract

Distal femur fractures are common but complex fractures and often are associated with complications. The cases of failure may be secondary to mechanical failure or biological failure. The current review offers overview of these complications and tips and tricks on how to manage these complications.
Keywords: Distal Femur Fractures, Complications, Surgical management


Introduction

Distal femoral fractures are a common orthopaedic problem in all age groups of patients with and incidence of about 37 per 100,000 person years.(1) Distal femoral fractures since a long time has been considered difficult to treat using traditional implants due to high failure rate and secondary varus collapse. (2)
Distal femoral fractures in young age group is most commonly due to high energy trauma while in older age group it is mostly associated with fall from height or walking along with osteoporosis of bones. Treatment of these fractures can be successfully done with variety of plates(3-6) and retrograde intramedullary nails(7-10).
Early studies of treating distal femoral fractures with locked plates reported excellent out come with non-union rates of 0-14% (mostly less than 6%) (4, 11-21).
However, with the recent data being analyzed and reported the non-union rates are now as high has 17-21% (11, 22, 23). This can be partially attributed to wider variety of fracture morphology and in patients prone for development of non-union.
Definition of Non-union
Non-union definition is based on three factors namely, duration of time since injury, characteristics of fracture on serial x-rays and lastly clinical parameters assessed by the treating surgeon.
Presently, US FDA defines non-union as fracture bone that has not completely healed in 9 months since injury and which has not shown any signs of healing over 3 consecutive months on serial x-rays.(24)
Multiple literatures indicates that optimal time for healing is in between 4 to 12 months, taking into account the type of bone fractured, nature of injury and quality of the soft tissues around the fractured bone. (25-33)
Along with these factors one more important factor is the physiologic capability of the individual in mounting a healing response.

Classification
Distal femur fractures (AO classification)
As per the AO classification the distal femur (33) can be classified in to 3 types namely extra-articular, partial articular and complete articular factures, which are further classified.
Distal femur fractures are:
Type 33A: extraarticular fracture
o A1: simple
o A2: metaphyseal wedge and/or fragmented wedge
o A3: metaphyseal complex
Type 33B: partial articular fracture
o B1: lateral condyle, sagittal
o B2: medial condyle, sagittal
o B3: frontal
Type 33C: complete articular fracture
o C1: articular simple, metaphyseal simple
o C2: articular simple, metaphyseal multifragmentary
o C3: articular multifragmentary

Weber and Cech have classified femoral non-union based on the viability or blood supply of the fracture into two broad groups viable and non-viable types. (24)
Viable type of non-union has an intact blood supply to the fracture area and thus body can mount a healing response to injury. Viable type is further divided into hypertrophic and oligo-trophic non-union.
Non-viable type of non-union is also called as atrophic or avascular non-union. The vascularity of the fracture area is absent and thus it cannot mount a healing response to injury. Type of non-union can be determined on plain x-ray in AP and lateral view or more accurately on bone scans.
Classification of non-union is important not just for documentation purposes but also for management point. In a viable non-union minimally invasive or non-invasive treatment can lead to union and thus saving the patient from another major surgical procedure.
These procedures would be give a questionable healing response in case of atrophic non-union and there the surgeon need to be more aggressive and has to plan a more extensive treatment.

Diagnosis and Evaluation
It is extremely important for the treating surgeon to timely diagnose, evaluate and document a non-union both for management as well as for legal purpose.
Diagnosis begins with a detailed history and examination of the patient and the affected limb. Patient-related risk factors like tobacco addiction, use of analgesics peripheral vascular disease, diabetes should be looked for and documented. Any clinical symptom that may point towards infection (occult/overt) like fever, malaise, night pain or history of wound healing problem should be elicited.
Physical examination should identify and document any deformity, pain over fracture area, soft tissue cover problems, increased local temperature, drainage, abnormal mobility, crepitation, and limb length discrepancy.
Radiological evaluation should be done with plain x-rays of the affected part in AP, lateral, and both oblique views (45 degrees internal and external views). In majority of patients this will get the accurate diagnosis of nonunion and its subtype. CT scan is a more accurate modality than plain x-rays in diagnosing the non-union.(34)
Infection should be cause in all cases of femoral non-union unless ruled out. Hence proper blood work-up is must which should include complete blood count, ESR and CRP. Deep tissue culture at the time of secondary surgery is the gold standard for diagnosis of infection. (35)

Causes and Risk factors
Main causes of distal femoral nonunion are
Inadequate fracture stabilization leading to motion at fracture site
Avascularity at the fracture ends – due to compound fractures, excessive stripping of soft tissue during surgery
Fracture gap
Infection
Patient related
Surgeon related

Inadequate fracture stabilization leads to micro and macro movements at the fracture site, which may result due to inadequate fixation at the time of primary surgery or due to implant failure.
Avascularity or diminished blood supply to the fracture end results due to compound injury (27), excessive stripping of soft tissue during surgery, comminuted fractures.(36) Decreased blood supply leads to a poor healing response and causes atrophic non-union.
Multiple literature supports that in fractures with significant comminution the soft tissue stripping is more and thus injuring the blood supply.(28)
Presence of gap at the fracture site either due to bone loss or during surgery (fracture fixed in distraction or debridement) also contribute to the occurrence of non-union.(29) Any gap present is usually bridged by the fracture callus, but when the body fails to bridge this gap non union results.
Infection can result as a complication of open injury or surgical treatment. Infection leads to formation of dead necrotic bone in the form of sequestrum, ingrowth of infected granulation tissue, osteolysis and motion at fracture site due to loosening of implant or implant failure.
Patient factors like age, smoking, tobacco use, chronic use of analgesics (NSAIDs), medical comorbidities and obesity to name a few can lead to non-union (22, 37).
Surgeon related factors include technical factors like plate length, screw density of plate, material of implant (titanium vs. stainless steel) and cortical reduction. Studies have shown that use of titanium implants significantly reduces the chances of non-union and thus need for a secondary surgical procedure (22).
In case of implant failure, the most important factor is the length of plate used. Shorter plates are prone to fail earlier than longer plates due to relatively lower fatigue properties because of mechanical disadvantage. Usually, a plate with 9 or more screws are is less liable to give away (37).

Treatment Options
Ultimate aim of the surgeon is to achieve osseous union without complications. Along with this it is important for the surgeon to correct any mal-alignment control infection if present, achieving sufficient muscle strength and rehabilitation.
Currently the accepted method of primary fixation of distal femur fractures is retrograde nail and lateral plating either lateral locked plates or fixed angle plates.

1.    Nail dynamisation
2.    Exchange nailing
3.    Plate osteosynthesis
4.    External fixation
5.    Adjuvant treatment options
a.    Electrical stimulation and ultrasound therapy
b.    Bone grafting
c.    Bone graft substitutes and biologic agents
d.    Bone marrow infiltration

Nail Dynamisation
Nail dynamisation is the term used when the statically locked nail is converted to a dynamically locked plate. This is accomplished by removal of screw/s adjacent to the dynamic hole of the nail.
Mechanism of healing with this technique is that it allows for a controlled axial instability of the bone and implant at the fracture site. This allows transfer of weight bearing forces to non-union site and promotes healing.(38)
Dynamisation is most effective when done at an early stage of non-union or delayed union as judged by serial radiographs. Optimal time for dynamisation is around 3-6 months of injury and primary treatment.(36)
Available literature suggests a success rate of about 50%. Nail dynamisation should be done is axially stable fractures like transverse or oblique fractures.
There are few complications associated with this technique namely shortening, implant failure. Thus a regular follow-up of the patients is a must.

Exchange Nailing
Exchange nailing refers to the surgical technique where an already present nail is removed and a larger diameter and stiffer nail is inserted after reaming. It is desirable that the second nail should be atleast 1-2mm larger than the earlier nail and the reaming should be done until the osseous chatter is heard.
This method provides both mechanical and biological stimulus for healing. A larger diameter and stiffer nail provides more mechanical stability along with increased working length of the implant thus decreasing the chances of implant failure. Biologically reaming causes deposition of fresh marrow material in the non-union site and stimulates periosteal reaction.(39) Union rates reported with this technique is variable with some studies showing union rates as high as 97%. (31, 32) Studies show that chances of non-union are more when reaming is not done.(40)

Plate Osteosynthesis
Plate osteosynthesis is the most common and gold standard treatment option in cases of distal femoral non-unions.(37) Plating offers increased mechanical stability to fracture specially in hypertrophic non-unions. Plate osteosynthesis (open reduction and internal fixation) provides an excellent opportunity of the surgeon to correct any associated deformities along with providing an excellent axial and torsional stability. Traditionally fixed angled 95 degree angled blade plate was used for distal femoral fractures, applied on the lateral aspect.(3, 41) The newer locked plates now available are the implant of choice in present scenario.(4, 5, 11-13, 15, 16, 18-20, 42, 43) With the use of compression holes excellent direct compression of the fracture site can be achieved.(44)
Few studies have reported union rates for distal femur non-unions with plate osteosynthesis around 91% to 100%.(45, 46) Even in case of poor bone stock and long standing non-unions the union rates are in range of 95 to 98% (31, 47)
This method of achieving union has its own risks and disadvantages. There is increased risk of infection, blood loss, increased tissue stripping, implant breakage, screw loosening etc. (6, 45, 47-50). Another disadvantage is that patients treated with plate osteosynthesis require strict immobilization for some duration, which may lead to joint stiffness and decreased range of motion of joints along with delay in starting rehabilitation.
Abdel-Aa et al (46) reported in their study that about 13% of patients treated with plate osteosynthesis for distal femoral non union required quadricepsplasty and knee arthrolysis within one year of surgery.
Another technique has been described in literature where both nail and plate are used simultaneously in achieving union. In this technique with an intramedullary implant in situ, a plate is fixed in compression mode at the fracture site. This method provides positive points of both the techniques in the form of early weight bearing, fracture fixed in direct compression thus chances of early union, improved torsional and rotational stability. If required bone grafting can also be done at same time to further increase the osteogenic potential and to fill up any bony defects if present. In studies using this method there has been a union rate of 100% within one year of surgery.(49, 51, 52)

External Fixation
Multiplanar (Ilizarov technique) and uniplanar external fixation for treatment of non-union of femur has been reported in literature with modest success (53, 54). Compression and distraction at non-union site has been demonstrated to show signs of healing(55). However, with the high complication rate (eg osteomyletitis, severe pain requiring opiod anagesics, septic arthritis, pin failure, joint stiffness etc.) use of external fixation for non-union healing is restricted to small number of patients. Along with this, the technical complexity and cost factor also restricts its use to tertiary level centres (54).

Adjuvant Treatment
These treatment options can be used as an isolated treatment option or as a supplementary treatment for achieving union.

Electrical Stimulation
Multiple studies show that mechanical forces, electrical forces, magnetic forces and ultrasound waves have variable level of effect on bone healing and growth (56-59). Electrical stimulation is thought to be effective non-invasive modality for promoting fracture healing and in treatment of non-unions.
Generation of electrical potentials around bone occurs when mechanical stress is applied(60, 61). Electronegative and electropositive potentials are generated with compression and tension respectively (62). It has been proven that in electronegative potential bone growth occurs and with electropositive potential bone is resorbed (63).
There are three techniques of electrical stimulation, namely, direct electric current, capacitive coupling and inductive coupling.
Direct electrical current is an invasive technique involving one or more cathode electrodes being implanted in the bone and an anode usually placed on the skin over the fracture site(64). In a case series by Brighton et al. (65) out of 168 fractures, 76% showed good bony union by 12 weeks of electrical stimulation therapy.
Capacitive coupling is a noninvasive technique where two electrodes are placed over the skin such that fracture site lies in between the electrodes. Here alternating current (AC) is used and an electric field is generated in and around the fracture site. It is a dose dependent technique whereby the greater electrical field leads to more osteoblastic cell response along with increased time of exposure leading to increased osteoblastic cell proliferation (66, 67).
Inductive coupling uses the principle of Pulsed Electromagnetic Field (PEMF) generation using specific device. The device is placed over the skin (non-invasive) over the fracture site. Passing current in the device generates the magnetic field. This magnetic field induces an electrical field, which leads to a bone healing response. This time-varying electrical field simulates normal response of osteoblastic cells to mechanical stimuli (68).

Bone Grafting, bone marrow aspirate and biologic agents

These procedures and materials can be used as an isolated or adjuvant treatment depending of the non-union type.
Autogenous bone grafts are considered gold standard for grafting procedures(69). Autologous bone grafting in past has got a bad review mainly due to donor site complications(70). With advances in harvesting techniques there is a renewed interest in this procedure(71-73).
Biologic agents like Bone Morphogenic Proteins (BMP) have been studied in detail both in animals and in humans and gives promising results.
Bone Morphogenic Proteins are part of the Transforming Growth Factor-Beta (TGF-B) superfamily and with a cascade sequence of events leads to bone healing via chondrogenesis, osteogenesis, angiogenesis and extracellular matrix remodeling (74). There are more than 20 BMP identified in humans. Studies in animals and in-vitro have shown BMP -2,4,6,7,9 have high osteogenic potential (75-78). Recombinant BMP-2 and 4 are in use clinically (74) but with questionable safety and efficacy profile(79-82).

Summary
Every surgically managed fracture is a race between bony union and implant/biological failure leading to non-union. Management of acute distal femur fracture with a nail or plate has good union rate or more than 90%. But when non-union occurs, it becomes a challenging task for the surgeon and patient both. It presents a significant mental, emotional and financial implication on the patient and his/her family.
Careful history taking and meticulous examination during routine follow-ups can help a surgeon to diagnose a delayed union or non-union in early stage and can modify the management as per the need to achieve bony union. Established non-union requires a well planned out management protocol to be decided before hand. Surgeon should decide the management plan (either non-invasive or invasive) on case-to-case basis to achieve union, correction of deformities. Surgeon should also take care of the patient modifiable risk factors like use of NSAIDs, smoking, medical co-morbidities and nutritional status of patient.

 


References

1. Zlowodzki M, Bhandari M, Marek DJ, Cole PA, Kregor PJ. Operative treatment of acute distal femur fractures: systematic review of 2 comparative studies and 45 case series (1989 to 2005). J Orthop Trauma. 2006;20(5):366-71.
2. Davison BL. Varus collapse of comminuted distal femur fractures after open reduction and internal fixation with a lateral condylar buttress plate. American journal of orthopedics. 2003;32(1):27-30.
3. Merchan ECR, Maestu PR, Blanco RP. Blade-Plating of Closed Displaced Supracondylar Fractures of the Distal Femur with the AO System. The Journal of Trauma: Injury, Infection, and Critical Care. 1992;32(2):174-8.
4. Haidukewych G. Results of Polyaxial Locked-Plate Fixation of Periarticular Fractures of the Knee. The Journal of Bone and Joint Surgery (American). 2007;89(3):614.
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How to Cite this article: Maheshwari P, Maheshwari P. Non Union Distal Femur Fracture: Causes and Management Options. Trauma International Jan-Apr 2016;1(2):28-33.

Dr. Pramod Maheshwari

Dr. Pramod Maheshwari

Dr. Puneet Maheshwari

Dr. Puneet Maheshwari

 


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