Utility and Outcomes of Locking Compression Plates in Distal Femoral Fractures
Utility and Outcomes of Locking Compression Plates in Distal Femoral Fractures
Utility and Outcomes of Locking Compression Plates in Distal Femoral Fractures
DOI: http://dx.doi.org/10.18203/issn.2455-4510.IntJResOrthop20160343
Research Article
1
Department of Orthopedics, Modern Hospital, Kodungallur, Kerala, India
2
Department of Pathology, Modern Hospital, Kodungallur, Kerala, India
*Correspondence:
Dr. Shriharsha RV,
E-mail: [email protected]
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: Supracondylar and intercondylar fractures of femur present a huge surgical challenge. The purpose of
this study was to evaluate the rate of union, functional outcome and complications of these fractures treated with open
reduction and internal fixation with a locking compression plate- distal femur (LCP-DF).
Methods: A prospective study of 26 fractures in 25 patients was done during a period of June 2012 to July 2014.
Based on clinical diagnosis and x rays, the fractures were managed by surgery and had a minimum follow up of one
year. The decision to fix with Locking compression plates was taken based on extensive comminution, missing bone,
poor quality of bone and a combination of these factors. Primary Bone grafting was done in cases of severe medial
comminution.
Results: Overall 26 fractures were studied. The mean age was 44 yrs. Out of 25 patients, 16/25(64%) were men and
36% were women. There were 10/26 type A and 16/26 type C fractures. There were 57.6% closed fractures and 42.3
% open fractures. Bone grafting was done for 13 fractures. The average time for union in open fractures was 20.60
weeks and 18.53 weeks for closed fractures. The average range of motion for closed fractures was 10- 100.330 and
for open fractures was 50- 84.50The results of entire study group showed 4 excellent, 10 good, 5 fair and 6 poor. We
saw that 2 of 10 (20%) open fractures had excellent or good results whereas 12 of 15(80%) closed fractures had
excellent or good results (p <0.005). The 8 of 10(80%) type A fractures had excellent or good results whereas 6 of
15(40%) type C fractures had excellent or good results (p<0.058). The closed fractures united early as compared to
open fractures (p <0.72). The closed fractures had a mean range of 99 degrees movement against the open fractures
which had 79 degrees (p <0.36). the type A fractures had a better range of movement( 106 degrees) as compared to
type C fractures(81.67 degrees) (p <0.13).
Conclusions: Locking compression plates had better outcome in closed fractures than open fractures. The extra
articular (type A) fractures had better outcome than intra articular (type C) fractures. The closed fractures united
earlier as compared to open fractures. There was no significant difference in time of union in fractures where bone
graft was used and in those where no bonegraft was used. Knee stiffness is a common complication following these
fractures. Therefore the distal femoral LCP provides a stable fixation in comminuted fractures.
Distal femoral fractures account for about 7% of femoral initial management all the open fractures were debrided
fractures. If fractures of hip are excluded, about 31% of on the same day in operation theatre and stabilized
femoral fractures involve the distal portion.2 Advances in temporarily with a spanning external fixator or a long leg
mechanization and acceleration of travel have increased slab with skeletal traction depending on comminution,
the number and severity of these kinds of fractures, and type of open fracture. The condyles were temporarily
their incidence is still increasing.1-4 held reduced and fixed with K-wires in severely
displaced intercondylar fractures. All wounds with type II
Distal femoral locking compression allows both locking (Gustilo-Anderson) fractures were closed either primarily
and compression screw fixation of the femur shaft. These or secondarily over a drain. Patients were given a course
plates are designed to apply in minimally invasive of antibiotics having gram positive, gram negative and
fashion to preserve local biology and avoid problems anaerobic coverage. One type III B fracture needed free
with fracture healing and infection.5,6 vascular flap for coverage. The patients were taken into
definitive fixation once the wounds were healed. In
The purpose of this study was to evaluate the rate of closed fractures, the limb was stabilized temporarily
union, functional outcome and complications of these either with a long leg slab or skeletal traction or both, and
fractures treated with open reduction and internal fixation definitive fixation was considered once patients general
with a locking compression plate- distal femur (LCP-DF). conditions were fit for surgery. The standard lateral
approach was used in most of the closed fractures; two
METHODS patients needed extension of the approach where
osteotomy of tibial tuberosity was done. In case of open
This study was done to evaluate the results of distal fractures the skin incision was modified to incorporate
femoral fractures (Supra-Intercondylar) which were the initial wound where ever possible. Antero lateral
treated using locking compression plate. This is a approach was used in 4 patients and MIPPO in two
prospective study of 26 fractures in 25 patients treated in patients.
Modern hospital, Kodungallur, Kerala, during the period
of June 2012 to July 2014. The fractures were classified Follow up
according to the AO OTA classification and type A and C
fractures were considered in this study. The exclusion Patients were called for follow up every month till
criteria were: 1) Distal femoral fracture as a component fracture union. The follow up period ranged from 4 to
of polytrauma, where in the outcome was severely 18.5 months. Average follow up was 10.72 months.
affected due to associated injuries. This group included a During follow up visits, patients were asked regarding
patient with type III A open, AO- type C3 fracture of any pain, fever, change of daily activities. They were
right distal femur with open comminuted fracture of examined for condition of operative sites, deformity,
ipsilateral patella, Schatzker type VI fracture of ipsilateral tenderness and range of movements. Follow up X-rays
tibial condyle, Type III B open fracture of controlateral were taken to assess any failure of reduction, failure of
tibia and minor fractures involving the upper limbs. 2) fixation and fracture union.
Pathological fractures other than those due to senile
osteoporosis. Bone grafting
When the patients were seen for the first time after injury, Primary Bone grafting was done in cases of severe
a thorough history was taken regarding time of injury, medial comminution. A double vascularised fibular graft
mechanism, first aid received and significant past. was used in one patient with bone loss of about 15 cms,
Patients were assessed as per the ATLS guidelines and and the same patient needed cancellous bone grafts at a
resuscitated whenever required. When patients’ general later stage to facilitate union of fibular strut with the
condition was stable, they were examined giving special femur.
importance to whether the fracture was open or closed,
deformity, associated neuro vascular status, haemathrosis Post-operative protocol
and other bony injuries.
Knee brace was given and were started with range of
The clinical diagnosis was confirmed by routine antero- movement exercises as tolerated. A temporary A/K slab
posterior and lateral radiographs of femur with knee. X- followed by long leg cast for 4 weeks was given for
rays were assessed for comminution, involvement of patients having extensive comminution where stability of
joint, displacement and extension of fracture to the shaft. fixation was under doubt. Active quadriceps and
The fractures were classified according to the AO OTA hamstrings exercises also begun with mobilization. Static
classification system and type A & C fractures were quadriceps exercises were instructed whenever the limb
considered in this study. was in plaster. Graded weight bearing was allowed
depending on X-ray and clinical assessments. The
The decision to fix with LCP was taken based on treatment protocol is described in table 1.
extensive comminution, missing bone, poor quality of
bone and a combination of these factors. As a part of
Descriptive statistics including percentage, standard Of the 26 patients, 15/26 (57.69%) were closed and 11/26
deviation, mean and range were completed. Chi square (42.31%) were open. Of the 11 open fractures 7 were
and t tests were used to compare analysis. type II, 2 type IIIA and type IIIB each. There were no
type I or type IIIA fractures. Of the 25, 11/25(44%)
RESULTS patients had associated bony injuries. The duration
between day of injury and day of fixation in open
The results were assessed using IOWA knee scoring fractures ranged from 8 to 71 days with a mean of 20
system after union of fracture. IOWA scorning, a rating days, and between 1 to 10 days with a mean of 4.2 days
system described by TC Merchant and FR Dietz assigns in closed fractures.
points for function (35), freedom from pain (35), Gait
(10) and absence of deformity (10). 100 points assigned Of the 26, 16/26 (61.53%) were fixed with standard
for normal knee, a score of 90-100 was considered lateral approach, 4/26 (15.38%) by antero- lateral, 2/26
excellent, 80-89 good, 70-79 as fair and less than 70 as (7.69%) by MIPPO and in 4/26 (15.38%) incision was
poor. modified to include previous wound (Figure 1a, 1b, 1c,
1d, 1e). Bone grafting was done for 13 fractures, of
Table 1: Treatment protocol. which iliac crest cancellous grafting alone was done in 9
patients, iliac crest cancellous graft+ bone graft substitute
in 3 patients and vascularized fibular graft in 1 patient.
Out of 16 type C fractures bone grafting was done in
11/16 (68.75%) fractures (Figure 2a, 2b, 2c, 2d, 2e, 2f),
whereas of the 10 type A fractures bonegraft was done in
1/10 (10%) patient. Out of 11 open fractures bone
grafting was done in 8 (72.73%) patients and in 4
(26.67%) out of 15 closed fractures. Time for union in
fractures where bone grafting was done was 18.4 weeks.
Time for union in fractures where bone grafting was not
done was 20.8 weeks. It was observed that the fractures
where bone grafting was done united early compared to
those where no bone grafting was not done. Knee brace
was given for 10/26 (38.46%) patients, long leg plaster in
13/26 (50%) patients and no support in 3/26 (11.54%)
patients. The average time for union in open fractures
was 20.60 weeks and 18.53 weeks for closed fractures.
The average range of motion for closed fractures was 10-
100.330 and for open fractures was 50- 84.50
15(40%) type C fractures had excellent or good results degrees (p <0.36). the type A fractures had a better range
(p<0.058). The closed fractures united early as compared of movement( 106 degrees) as compared to type C
to open fractures (p <0.72).The fractures where additional fractures(81.67 degrees) (p <0.13). Descriptive statistics
bone grafting was done united early (18.4 weeks) than including percentage, standard deviation, mean and range
those with no bone grafts (20.8weeks) (p <0.991). The were completed. Chi square and t tests were used to
closed fractures had a mean range of 99 degrees compare the analysis.
movement against the open fractures which had 79
DISCUSSION
Figure 2 (b): AP views of open fractures. Figure 3 (a): Immediate post-operative x-rays.
Figure 2 (c & d): X-rays after limited condylar Figure 3 (b): 20 loss of reduction.
fixation and spanning ex fix application.
or extra articular) on the outcome. The rates of union and as found through t – test. It was seen that type A fractures
complications are also analysed. had a better range of movement (106 degrees) as
compared to type C fractures (81.67 degrees). This
The present study of 26 cases indicates road traffic difference was also statistically not significant as
accidents as predominant cause of fractures (80.77%) and observed through the t- test.
other causes being fall from height and trivial fall on
flexed knee. Majority of patients were males (64%) in Another dreaded complication is infection, Neer et al has
their active age. this reflects that young and active reported 20% infection rate.16 Others like M Silisky et al
individuals are prone to this fracture due to high velocity reported 5.7% infection.17 We had 1/26 (3.85%) infection
injuries. There was no biphasic age distribution as seen in which was superficial and got settled after a course of
other studies (Bell et al, 1992).13 The average age was antibiotics and wound wash out (case No 14).
less (44.69yrs) as compared to other reported series:
Healy et al, 48 yrs.14 There was one case of implant failure, where the implant
got bent following a second fall in early post-operative
Eleven of the patients had associated injuries, which period. The patient was advised resurgery, but, was lost
included 10 major fractures thus proving that these for follow up (case no 26).
fractures are components of poly trauma.
There were three malunions which were due to failure to
Eleven of twenty six (42.31%) fractures were open. The obtain initial reduction of metaphyseal fragment.
incidence was high as compared to that published in However there was no case of secondary loss of
literature i.e. 5-10%. This could be because most of the reduction or non-union. There was one delayed union (33
fractures included in the series were following high weeks) which required a second surgery for bone grafting
velocity road traffic accidents and the study group was (case no 2). Kiran et al reported 2 cases of non-union.
small.
The average follow up was 10.72 months. IOWA scoring
Muller’s comprehensive classification system was used to system was used for functional evaluation. There were 4
classify the fractures. There were 10/26 (38.46%) type A excellent, 10 good, 5 fair and 6 poor results.
and 16/26 (61.53%) type C fractures. It was also
observed that 10 of 16 type C fractures had associated It was observed that 2 of 10 (20%) open fractures had
injuries, again attributing the increased incidence of type excellent or good results whereas 12 of 15 (80%) closed
C injuries to high velocity injuries. fractures had excellent or good results. This difference
was observed to be significant as found through Chi-
The average duration from the date of injury to date of Square test.
surgery was 4.2 days in closed fractures and 20 days in
open fractures. The delay in open fractures was because 8 of 10 (80%) type A fractures had excellent or good
we waited for the initial wounds to heal before definitive results whereas 6 of 15 (40%) type C fractures had
fixation. Cancellous Bone grafts were used in 12 (48%) excellent or good results. However this difference was
of fractures which is in contrast to published literature not significant as found through Chi- Square test and this
which says that bone grafting is rarely required. this could be due to small sample size and as the p value is 0-
difference can be attributed to more number of open and 058, it can become significant with larger number of
type C fractures in a small sample . cases. Comparison of present study with the study by
Yeap et al and the one by Wesley PP et al is shown in
The mean time for union was 19.36 weeks. The closed table 2.3,18,19 Yeap et al, total 11 patients, with 4 excellent,
fractures united early (18.5 weeks) as compared to open 4 good, 2 fair and one failure.3 The weakness of present
fractures (21.4 weeks). However the difference was not study is that there was no randomization of the study
statistically significant as found through t – test. Another population, small sample size.
observation made from the analysis was that the fractures
where additional bone grafting was done united early CONCLUSION
(18.4 weeks) than those with no bone grafts (20.8weeks).
However the difference was not statistically significant as The outcome of closed fractures was found better than
found through the t- test. open fractures. The extra articular (type A) fractures had
better outcome than intra articular (type C) fractures. The
One of the most common complications of distal femoral closed fractures united earlier as compared to open
fractures is knee stiffness. The average post-operative fractures. There was no significant difference in time of
active range of motion as reported by Seinsheimer et al union in fractures where bone graft was used and in those
was 91 degrees.15 The average range of motion in our where no bonegraft was used. Knee stiffness is a common
series is 2 to 94 degrees. It’s observed that closed complication following these fractures. The rate of union
fractures had a mean range of 99 degrees movement is comparable to similar series whereas the average
against the open fractures which had 79 degrees. duration for union is high. There were no cases with
However this difference was statistically not significant secondary loss of reduction, loss of fixation or nonunion.
Therefore the distal femoral LCP provides a stable 9. Giles JB, Delee JC, Heckman JD. Supracondylar -
fixation in comminuted fractures. In the study, many intercondylar fractures of the femur treated with a
groups taken for comparison were very small (type of supracondylar plate and lag screw. J Bone Joint
open fractures, individual AO types). It needs a wider Surg Am. 1982;64:864-70.
study involving more number of cases in each group and 10. Brown A, D'Arcy JC. Internal fixation for
a larger follow up to fully defined the place of distal supracondylar fractures of the femur in the elderly
femoral LCP alongside the existing technology in patient .J Bone Joint Surg Br. 1971;53-B:420-4.
fractures of distal femur. 11. Ahmad M, Nanda R, Bajwa AS, Candal-Couto J,
Green S, Hui AC. Biomechanical testing of the
ACKNOWLEDGEMENTS locking compression plate: when does the distance
between bone and implant significantly reduce
We thank all the technical staff and nurses who helped us construct stability? Injury. 2007;38(3):358-64.
in performing the surgeries and this study. 12. Parker DA, Lautenschlager EP, Caravelli ML,
Flanigan DC, Merk BR. A Biomechanical
Funding: No funding sources Comparison of Distal Femoral Fracture Fixation:
Conflict of interest: None declared The Dynamic Condylar Screw, Distal Femoral Nail,
Ethical approval: Not required Locking Condylar Plate, and Less Invasive
Stabilization System. OTA, 2005.
REFERENCES 13. Egol KA, Kubiak EN, Fulkerson E, Kummer FJ,
Koval KJ. Biomechanics of locked plates and
1. Kiran kumar GN, Sharma G, Farooque K, Sharma screws. J Orthop Trauma. 2004;18(8):488-93.
V. Locking compression plate in distal femoral intra 14. Bell KM, Johnstone AJ, Court Brown CM, Hughes
articular fractures: our experience. International SP: J Bone Joint surg Br. 1992;74:400-02.
scholarly research, 2014. Article id 372916. 15. Healy WL, Siliski JM, Incavo SJ. Operative
2. Hoffmann MF, Jones CB, Sietsema DL. Clinical treatment of distal femoral fractures proximal to
outcomes of locked plating of distal femoral total knee replacements. J Bone Joint Surg Am.
fractures in a retrospective cohort. Journal of 1993;75:27-34.
orthopedic surgery and research. 2013;8:43. 16. Seinsheimer F. Fractures of the distal femur. Clin
3. Yeap EJ, Deepak AS. Distal Femoral Locking Orthop Relat Res. 1980;153:169-79.
Compression Plate Fixation in Distal. 17. Neer CS, Grantham SA, Shelton ML. Supracondylar
4. Femoral Fractures. Early Results Malaysian fracture of the adult femur. J Bone Joint Surg Am.
Orthopaedic Journal. 2007;1(1). 1967,49:591-613.
5. Parker DA, Lautenschlager EP, Caravelli ML, 18. Siliski JM, Mahring M, Hofer HP. Supracondylar-
Flanigan DC, Merk BR. A Biomechanical Intercondylar fractures of femur. JBJS.
Comparison of Distal Femoral Fracture Fixation: 1989;71A:95-104.
The Dynamic Condylar Screw, Distal Femoral Nail, 19. Phipatanakul WP, Mayo KA, Mast JW, Bolhofner
Locking Condylar Plate, and Less Invasive BR. Reconstruction of the Distal Femur with Use of
Stabilization System. OTA, 2005. a New Device: The Locking Condylar Plate. OTA.
6. Krettek C, Muller M, Miclau T. Evolution of 2001.
Minimally Invasive Plate Osteosynthesis (MIPO) in 20. Phipatanakul WP, Mayo KA, Mast JW. Treatment
the femur. Injury. 2001;3:14-23. of Distal Femur Fractures with New Device; The
7. Krettek C, Schandelmaier P, Miclau T. Minimally Locking Condylar Plate. OTA, 2005.
invasive percutaneous plate osteosynthesis (MIPPO)
using the DCS in proximal and distal femoral
fractures. Injury. 1997;28:20-30. Cite this article as: Shriharsha RV, Sapna M. Utility
8. Kubiak EN, Fulkerson E, Strauss E, Egol KA. and outcomes of locking compression plates in distal
Evolution of Locked Plates. The Journal of Bone femoral fractures. Int J Res Orthop 2015;1:15-21.
and Joint Surgery. 2006;88:189-200.