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Intramedullary Fibula with Rigid Osteosynthesis in Revision of Neglected & multiple times Operated Non Union of Long Bones

May 4, 2016/in Uncategorized, Volume 2 | Issue 2 | May-Aug 2016

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 12-16| Author: Address of Correspondence Abstract Background: Plates with Intramedullary Fibula as Strut graft(IFSG) in Non- union of long bone fractures provide most stable construct overall as fibula acts as second implant, screws have better anchorage and Very High Pull Out strength due to […]

Distal Femoral Fractures: Complications and How to Avoid them?

May 4, 2016/in Jan - April 2016 | Volume 2 | Issue 1

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 24-27|Vaibhav Bagaria, Smit Shah, Gaurav Sharma 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 […]

Intramedullary Fibula with Rigid Osteosynthesis in Revision of Neglected & multiple times Operated Non Union of Long Bones

May 4, 2016/in Uncategorized, Volume 2 | Issue 2 | May-Aug 2016

Distal Femoral Fractures: Complications and How to Avoid them?

May 4, 2016/in Jan - April 2016 | Volume 2 | Issue 1

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Intramedullary Fibula with Rigid Osteosynthesis in Revision of Neglected & multiple times Operated Non Union of Long Bones

May 4, 2016/in Uncategorized, Volume 2 | Issue 2 | May-Aug 2016

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 12-16|

Author:

Address of Correspondence

Abstract

Background: Plates with Intramedullary Fibula as Strut graft(IFSG) in Non- union of long bone fractures provide most stable construct overall as fibula acts as second implant, screws have better anchorage and Very High Pull Out strength due to penetration of four cortices and Osteogenic property of the fibula is most helpful.
Aims: re-focus the importance of Non-vascularised intramedullary fibula as a second internal biologic stable splint along with rigid osteosynthesis for the treatment of difficult & neglected non -union of long bones.
Methods and Material:
15 cases (13 :2,M f) of revision surgery for the neglected & multiply operated non-union of the long bones were treated with the debridement, decortication & shingling of the fracture site with addition of the trimmed fibula (as strut) and addition of profuse bone grafting sub periosteally followed by Stable & rigid Internal Osteosynthesis by using LCP. DASH Score was used for upper limb & VAS for lower limb for assessment.
Results: Union was achieved in all patients in 12 months (Av.9-12 Months). Preoperative DASH score averaged 40.86(range 42.6-52.6). DASH score at the last follow-up averaged 20.38 points (range 16.4-24.2).difference was significant. (p=0.0001)
Conclusions: Intra medullary fibula almost works mimicking double plate & adds in the stability as it works as second plate & osteogenic property helps in the healing, not only at the fracture site but proximal & distal to it also thus avoiding SLOW-UNION at the ends of bone which are usually avascular because of the lysis. Screws have a better hold around osteoporotic bones due to four cortices hold in presence of fibula. Strong bony union can be successfully achieved in almost all cases with rigid compression at the fracture site & additional extensive cancelleous bone grafting.
Key-words: Intra- medullary Fibula ,revision Non Union,rigid Osteosynthesis

Introduction

Non -union, of Multiple times operated Long Bone fractures, poses the extreme challenge to the orthopaedic surgeons
Surgical treatment of proxiamal humeral non unions and malunions are technically challenging. Osteosynthesis with bone grafting for the treatment of nonunions is indicated in young, active patients with adequate bone stock in the proximal fragment and preservation of the glenohumeral articular surfaces[2]
Vascularised bone grafting requires surgical experience and equipment not readily available in every hospital. The technique is demanding of time and resources, and vascular thrombosis may compromise the result [5]

Iliac crest cancellous bone graft has no mechanical strength to withstand stresses prior to solid union of the fracture site and also is associated with quite significant graft harvest site morbidity. The fibula transmits one eighth of body weight and can be as useful as vascularised or non-vascularised graft in reconstruction of bony defects.

Compression plating with autogenous grafting is accepted as the gold standard method so has yielded satisfac¬tory results, with 92 to 100% healing rates
Operative treatment can be very successful when the techniques of plate-and-screw fixation are modified to address osteopenia and relative or absolute loss of bone. Healing of the fracture substantially improves function and the degree of independence[6]

Subjects and Methods: 15 patients of multiply operated non union of long bones (13 humerus, 1 femur and one distal tibia non union) were included in a study. All were treated by open reduction of the fracture, debridement and excision of the fibrosis, SHINGLING of the bone both proximally and distal to fracture site.
& osteosynthesis with strut non vascularised fibular graft and LOCKING COMPRESSION PLATE with few locking screws and rest of all are cortical screws to make it RIGID & STABLE CONSTRUCT with extensive cancelleous bone grafting 3600 surrounding the fracture site.
All patients were assessed at final follow up using D.A.S.H score for upper limb and Visual analogue score for lower limb.
All patients were followed up for 4 to 36 (average mean months is 20 months) except two patient, who are under study with last two-two and half months.
Out of 15 patients,13 were male and 2 were female. Out of 15, 13 patients had humerus non union,two had femoral mid shaft non union and remaining one had lower third distal tibia non union.
Out of the 13 humerus cases 4 had proximal humerus, 7 had mid shaft to lower third humerus(M3-L3RD) non union & two patient has non union of segmental shaft humerus fracture.
All were closed fractures except one open fracture and all had eventual atrophic non-union upon presentation. The patients had mild pain, tenderness and abnormal mobility at the non-union site (except distal tibia and middle femur), and limitation of activities of daily living. All patients had stiff¬ness of shoulder and elbow to varying degrees.
The patients with femoral non unions have constant pain at the fracture site and difficulty while bearing weight.
distal tibia non union patient had not started bearing weight as he was on fixator for three months following the Gun shot injury operated in other country.

Surgical technique:
We discussed, here (figure 1 A,1B) is a case of 52 years old male, who was operated 4 times within last 10 years & presented to us with this latest x rays showing atrophic gap Non union of the Proximal humerus.

Fracture site is exposed using previous scar in all cases as to avoid cosmetic ugly scar. The fibrous non-union and any devitalised bone were thoroughly excised and the medullary canal opened via sharp thinner humerus awl and 3.5-4.5 mm drill bits.
• 3. Preparation of the medullary canal: The humeral medullary canal was prepared to accept the bone graft. Fibrous and pseu¬doarthrosis tissue were removed completely and the medullary cavity reconstituted both proximally and distally by curettage, drill or the use of serial hand reamers (6mm-9mm). Dilate humerus medullary cavity mainly to measure the cavity
• Uniformly expanded medullary cavity by the reamers was prepared to put in the graft.(FIGU 2A,2B)
• 4. preparation of fibular graft: The mid-shaft of the fibula was then harvested under tourniquet control with care taken to identify and protect the superficial peroneal nerve. The fibular shaft of ex¬cess length was harvested so that it could be trimmed as neces¬sary. The fibula graft was trimmed so as to enable it to telescope snugly into the fragments across the fracture site. Size of fibula graft will be one smaller than Last reamer used.
If the thickness did not permit its use, it was conversely bevelled at one of the ends leaving behind proximal wider part in hollow cavity of proximal humerus and remaining part in the distal shaft. Generally in humerus ,it necessary to split fibula in the center, with oscillating saw or reciprocating saw or large bone cutter instruments to reduce the size (FIG 3C & 3D)
5. Insertion of the fibular graft: The fibular autograft was pushed into one of the fracture fragments and the exact length of graft that need¬ed trimming was assessed. Once the final shaping of the graft was done, the fracture was reduced with the intramedullary fibu¬lar graft spanning the fracture site. Confirm it is movable in the humerus medullary cavity on both sides of # easily.
• Plate fixation: Reconfirm graft moving in canal push it up all the way proximally(fig 5 A,B,C& D)
• Reduce # , distract ,hold fibula end and slowly push it distally(fig 4A,4B)
• Compress # maximally. Load cancellous graft after shingling (Fig 4 c & 4 D)

How to achieve compression at the fracture with intramedullary graft:
It is safer to do compression by Muller’s device as it is applied at the end of the bone and maximum compression can be achieved by this device. If one chooses to compress by D C P holes. Fix screw on one side of fracture , and for opposite side D C P hole should be used which is not going thru the fibula , as if fibula is fixed it will not allow compression. So under C arm see the end of fibula and go beyond it to put other D C P screw and compress . Generally one hole compression is not enough in this non union set up, so it will have to be reapeted also on 2nd hole . so it is suggested to use muller’s device or a webers device to do compression of the fracture.

A LCP was used with quadricortical screw fixation till fibula is extending. Each screw hole was drilled and tapped through four cortices, two in the fractured bone and two in the intact fib¬ula and 4. 5 mm cortical screws were inserted. End of the bone screws were from parent bone and few locking screws were used for osteoporosis.

Shoulder and elbow exercises were started a day after the opera¬tion. Lifting of weights using the operated limb was deferred for a period of three to four months or until osteo-integration of the fibular ends or fracture healing. After hospital discharge, patients were observed on a monthly basis until healing of the fracture. All pa¬tients were examined both clinically and radiologically. Fracture union was considered radiographically if callus formation was seen in three of four cortices on AP and lateral views. Clinical union was considered when the fracture site was painless.
Data collected retrospectively included grip strength, range of motion, radiographic parameters, and functional outcomes as measured by the DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire.

Results: Patients were followed-up for an average of 1.5-2 years (range 1-2 years). Union was achieved in all patients in 12 months (range9-12 months ) and patients were very satisfied with the treatment. There were no perioperative complications such as wound infection, radial nerve palsy, hematoma formation. Post op two patient had discomfort over the fibular graft harvest site, and one has ASIS graft site morbidity in the form of pain mainly. One patient has persistent fracture line visible on fresh x ray at the shaft of humerus at one year follow up, but still fracture seems to be “ CLINICALLY UNITED “ as patient has painless arm movement.

Preoperative DASH score averaged 40.86(range 42.6-52.6). DASH score at the last follow-up averaged 20.38 points (range 16.4-24.2).(p=0.0001)[Table 1] V.A.S (visual analogue scale) in one patient was improved from 6-7 to 2 at the last follow up.[table 1] There was an average loss of 10-20˚ abduction and 15-20˚ flexion of the shoulder. . Range of motion of adjacent joint (knee in lower limb and elbow in upper limb) was restricted in all patients because of history of multiple surgeries and immobilization periods, but was within the functional limit in all except two patients. There was no change in shoulder rotations following surgery on the contrary three patient had pain free rotation of shoulder who had atrophic proximal humerus non union. One patient with preoperative fixed flexion deformity of elbow to varying degrees had persistence of a similar deformity at the last follow-up.

Discussion: Non -union of the long bone, after repeated surgery with multiple failed attempts poses challenging reoperation.
Healing is challenge & unpredicted with any kind of surgery and may have sub-optimal result .
We have done 15 cases of previously operated multiple times with failed union
As we have used massive mixed cortico-cancelleous auto graft in almost all cases circumferentially at the non-union site –the reason why it unites in each cases is not definite what worked out of these procedure is not predictable, like shingling & solid compression at the fracture site+cancelleous autograft Vs IMSF autograft.
Before we conclude, that fracture is united, we need evidence of circumferential callus formation , and osteo-integration, which takes long time , to be observed . Though patient is using arm almost normally, probably due to good long bony rigid fixation, and hence clinical signs of union are not convincing. This is observed most often in such multiple times operated cases only after 12 months and so we feel, 12 months minimum time should be considered for union.
The main weakness of our study is
1. Very few number of cases(only 15 cases)-so difficult to judge trend of results
2. What exactly helped union , out of everything we did.
The main strength of our study:
Our procedure can not only salvage the “function less –atrophic non united bone “—-it can even have profound effect on the overall compliance of the patient, reduce repeated morbidity from the lengthy & costly treatment like illizarov, which has frustrated outcome and at the same time gives pain free extremity function up to its fully maximum ability.
We did not seen any complication like post op infection, radial nerve palsy, implant cut through, not even
fracture of the fibula graft in any case. Two patient had fibula graft site pain, which subsided within 6 months and another female patient had ASIS graft site pain mainly which also settled within a year.
The reason for low complications in all cases may be we were lucky .
Osteoporosis, either as a result of disuse or due to
generalised metabolic causes, compounds the choice of surgical treatment in these patients. It significantly reduces the pull out strength of the screws thus increasing the chance of implant failure. Humeral nonunion in osteoporotic bone presents a reconstructive challenge for the treating orthopaedic
surgeon [3,4].
In case of non-union, mechanical stability at the fracture site and biologic re¬vitalization are keys for the management.
A non-union of a diaphyseal fracture of the humerus can present a major functional problem even in the elderly population. Advances in operative exposures combined with newer techniques of achieving stable internal fixation even in the presence of pathologic bone have enabled the surgeon to successfully treat even the most complex non unions [7]
Approximately 10% of all long-bone fractures occur in the humerus. Although primary treatment usually is successful, humeral nonunion can lead to marked morbidity and functional limitation. Complications include joint contractures of the shoulder and elbow, especially with periarticular pseudarthrosis. Marked osteopenia or bone loss, or both, often occur after fracture and after failure to achieve union. Retained implants often break, impeding fixation and requiring removal. Soft-tissue deficits and incisions from the original injury or prior surgeries also may complicate reconstruction, as can intra-articular fractures and associated nerve palsies. Successful surgical management of humeral nonunion requires stable internal fixation that allows early joint motion and uses autogenous bone graft to promote healing [8,9]
DCP with cancellous bone graft is a reliable and an effective treatment for revision of aseptic nonunion of humeral shaft fracture after surgical treatment [10,11]
We have used LCP in all 15 cases.
.There are four main indications reported in the literature for use of LCP in fractures:1)osteoporoticbone,
2) comminution, 3) intra-articular fracture, and4) short segment periarticular fracture [12,13]
Locked plates and conventional plates rely on completely different mechanical principles to provide fracture fixation and in so doing they provide different biological environments for healing. Locked plates may increasingly be indicated for indirect fracture reduction, diaphyseal/metaphyseal fractures in osteoporotic bone, bridging severely comminuted fractures, and the plating of fractures where anatomical constraints prevent plating on the tension side of the bone. Conventional plates may continue to be the fixation method of choice for periarticular fractures which demand perfect anatomical reduction and to certain types of nonunions which require increased stability for union.[14]

Conclusion:
Non-vascularised intramedullary fibula(along with debridement, decortication & shingling ) as a second internal biologic stable splint along with rigid osteosynthesis can achieve excellent Union for treatment of revision of difficult & neglected non -union of long bones.

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

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Distal Femoral Fractures: Complications and How to Avoid them?

May 4, 2016/in Jan - April 2016 | Volume 2 | Issue 1

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 24-27|Vaibhav Bagaria, Smit Shah, Gaurav Sharma

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

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.

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.

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.

$Figure 8: Malreduction of distal femur fracture.$

Figure 8: Malreduction of distal femur fracture.

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 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

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;2(1):24-27.

Dr. Vaibhav Bagaria

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Intramedullary Fibula with Rigid Osteosynthesis in Revision of Neglected & multiple times Operated Non Union of Long Bones

Distal Femoral Fractures: Complications and How to Avoid them?

Intramedullary Fibula with Rigid Osteosynthesis in Revision of Neglected & multiple times Operated Non Union of Long Bones

Distal Femoral Fractures: Complications and How to Avoid them?

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Intramedullary Fibula with Rigid Osteosynthesis in Revision of Neglected & multiple times Operated Non Union of Long Bones

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Abstract

Introduction

References

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Distal Femoral Fractures: Complications and How to Avoid them?

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

Abstract

Introduction

References

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