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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 2  |  Page : 434-441

Treatment of distal femoral fractures in adults using the less invasive stabilization system


Department of Orthopedic Surgery, Faculty of Medicine, Menoufia University, Tala, Egypt

Date of Submission06-Feb-2016
Date of Acceptance07-Apr-2016
Date of Web Publication25-Sep-2017

Correspondence Address:
Abd El-Hamid S Abd El-Hamid Rageh
Department of Orthopedic Surgery, Faculty of Medicine, Menoufia University, El-Horreya Street, Tala, Menoufia, 32611
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.215473

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  Abstract 

Objective
The aim of this studywas to assess clinical outcomes and complications in 20 adult patients with distal femoral fractures treated with the less invasive stabilization system(LISS).
Background
LISS distal femur has been the treatment of choice for distal femoral fractures when operative treatment is needed. However, LISS of comminuted distal femoral fracture is a challenging operation, which requires surgical experience and meticulous attention to soft tissue. The LISS is an emerging procedure for the treatment of distal femoral fractures. It preserves soft tissue and the periosteal circulation, which promotes fracture healing.
Patients and methods
This prospective study included 20 adult patients between 45 and 72years of age(mean age: 58.45years) suffering from fractures of the distal femur who were treated with the LISS at El-Menoufiya University Hospital from September 2014 to September 2015. Among the patients, eight were male and 12 were female.
Results
The patients were followed up for a mean of 5.6months, ranging from 4 to 6months. Radiographically, all fractures except two healed in good alignment. Solid union took place from 8 to 14weeks, with a mean of 12weeks. There were no intraoperative complications, including neurologic or vascular injury, and two patients developed superficial wound infection postoperatively.
Conclusion
It was found that the LISS is an adequate technique for the treatment of distal femoral fractures in adult patients when surgical stabilization is indicated. This simple minimally invasive technique provides stable fixation, with minimal blood loss, minimal soft tissue stripping at the fracture site, and bone union in most of the studied cases.

Keywords: adults, distal femoral fractures, less invasive stabilization system


How to cite this article:
Hadhoud MM, Hannout YS, Abd El-Hamid Rageh AHS. Treatment of distal femoral fractures in adults using the less invasive stabilization system. Menoufia Med J 2017;30:434-41

How to cite this URL:
Hadhoud MM, Hannout YS, Abd El-Hamid Rageh AHS. Treatment of distal femoral fractures in adults using the less invasive stabilization system. Menoufia Med J [serial online] 2017 [cited 2019 Apr 19];30:434-41. Available from: http://www.mmj.eg.net/text.asp?2017/30/2/434/215473


  Introduction Top


Fractures of the distal femur[Figure1] are complex injuries that are difficult to be treated and may result in long-term disability and prolonged morbidity. They constitute 4 – 7% of all femoral fractures and represent 31% of the femoral fractures after exclusion of hip fractures[1],[2],[3],[4],[5],[6],[7].
Figure 1: Fracture of the distal femur.

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Fractures of the distal femur occur in a bimodal distribution; among those between 15 and 50years of age, predominantly male patients, sustaining high-energy trauma, and those above 50years of age, predominantly female patients with osteoporosis, who sustain relatively low-energy trauma[3],[7],[8].

Most classification systems divide distal femoral fractures into three main groups: extra-articular, unicondylar, and bicondylar[9].

Historically, before 1970, most fractures of the distal femur were treated using conservative methods such as skeletal traction and cast bracing until fracture healing producing good results, which was at the expense of prolonged hospitalization and compromised knee motion[9],[10],[11].

In the 1970s, distal femoral fractures were approached with open reduction and internal fixation using established methods and standard implants. After early attempts of surgical treatment, relatively high complication rates were found that adversely affected the clinical results. Common problems include infection, metal failure, nonunion or delayed union, malunion, especially varus collapse, the need for bone graft, and knee stiffness due to delayed mobility. Subsequently, alternative methods for comminuted or unstable fractures of the distal femur were proposed, including double plating, the use of plates for endosteal substitution, and anatomically contoured plates[6],[9],[12],[13].

In the 1980s, many advances in fracture care were applied to these difficult injuries and the clinical results were improved. Indirect reduction and improved maintenance of the fracture biology was popularized by Mast etal.[14].

Many different fixation methods have been described for the management of the distal femoral fractures, including the 95° angled blade plate, dynamic condylar screw(DCS), condylar buttress plate, and retrograde supracondylar nail[13],[15],[16],[17].

Recently, the locked plating systems have been developed in Davos Switzerland in the 1990s, in which the screws lock to the plate forming a multiple fixed-angle construct that functions as an 'internal fixator' avoiding compression of the periosteum, thus potentially allowing maintenance of the vascularity to the injured bone and is much less prone to loosening compared with traditional nonlocked plates[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37].

The less invasive stabilization system(LISS) has many advantages, including high union rates without bone graft, a low incidence of infection, maintenance of distal femoral fixation, minimally invasive surgery allowing minimal intraoperative blood loss, minimal soft tissue stripping, small and esthetic scars, and shortened hospital stays[19].


  Patients and Methods Top


Twenty adult patients with distal femoral fractures were included in this study. The patients were admitted in the orthopedic department, Menoufia University Hospital, during the period from September 2014 to September 2015 with a follow-up period of 4–6months.

Criteria for inclusion

Adult patients with fracture of the distal femur, closed physis, closed fracture, first or second degree open fractures, and fractures of nonpathological origin were included in the study.

Criteria for exclusion

Patients with third degree open fracture, nonunited or malunited old fracture, and periprosthetic fractures were excluded from the study.

The study included eight male and 12female patients between 45 and 72years of age(mean age: 58.45years).

Fracture was classified according to the AO/OTA classification of fracture of the distal femur[Figure2]. Five cases were of typeA1, four cases were of typeA2, three cases were of typeA3, three cases were of typeC1, three cases were of typeC2, and two cases were of typeC3.
Figure 2: AO/OTA classification of fracture of the distal femur.

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Technique of less invasive stabilization system

Position of the patient

The patient was positioned in the supine position on a radiolucent table with the ipsilateral hip elevated with a small bump to allow a slight internal rotation of the lower limb.

Incision

The lateral incision[Figure3] is recommended in simple articular(AO classification 33-C1) or extra-articular fractures(AO classification 32 or 33-A). Askin incision was performed from Gerdy's tubercle about 80mm in a proximal direction. The iliotibial tract was split in the direction of the fibers, and the space between the vastus lateralis and the periosteum was opened. After exposing the distal femur, if the condyles were split, they were reduced with Kirschner wires(K-wires) and bone reduction forceps. This was applied in typeC2 distal femoral fractures. Reduction under C-arm guide was performed and assessed in both AP and lateral views. Reduction was confirmed before plate insertion.
Figure 3: The lateral incision for less invasive stabilization system.

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Instrument assembly for plate insertion

Distal femur LISS insertion guide left or right was assembled. The fixation bolt was inserted through hole A of insertion guide by advancing the knurled nut on the fixation bolt fully against the knurled head of the bolt. The fixation bolt was screwed into the LISS plate using the top segment of the bolt. Final tightening was completed with a quarter turn of the pin wrench.

Plate insertion

The plate was inserted between the vastus lateralis muscle and periosteum. The distal end of the plate was placed against the lateral femoral condyle. A2mm K-wire was inserted through the cannula of the fixation bolt to provide preliminary fixation of the plate after its insertion. The proper position of the proximal end of the plate was confirmed with lateral radiograph. The proximal end of the plate should be centered on the femoral shaft in the lateral view. Once the plate had been inserted and positioned properly, with reduction reconfirmed, an incision was necessary at the most proximal plate hole. This location was marked using an insertion sleeve with 5mm trocar in hole 5, 9, or 13. An incision was made at this location. Through this stab incision, the insertion sleeve and trocar were replaced. The sleeve was secured by tightening the nut on side of guide. The trocar was removed and plate insertion frame was closed by threading the stabilization bolt into the proximal plate hole. AK-wire was inserted through the cannula of the stabilization bolt. Proper reduction was confirmed in anteroposterior and lateral views under C-arm and proper plate position was confirmed before any screw insertion.

Use of pull reduction device

The pull reduction device was placed through the guide and the plate holes to pull or push bone fragments in relation to the plate to correct any valgus or varus deformity before locking screw insertion.

Insertion of locking screws

A minimum of four screws were recommended in each main fracture fragment. First, 5mm titanium locking screws were inserted distally, reduction was rechecked, and then the proximal locking screws were placed. The insertion sleeve and trocar were placed in the insertion guide, the location of stab incision was marked with skin impression, and then the sleeve and trocar were removed to create the stab incision. A5mm locking screw was attached to the 3.5mm hexagonal screwdriver shaft until it snapped securely into place. For final tightening, the torque-limiting screwdriver was used to ensure that the torque applied reached the minimum level necessary for locking. Screw lengths might be confirmed using 2mm K-wire, 280mm length. The wire should be inserted through the 2mm K-wire insertion sleeve and measured with a direct measuring device. For insertion of locking screw in the most proximal hole instead of the stabilization bolt, the K-wire was removed, followed by the stabilization bolt, but the sleeve was kept, and then without applying pressure to the insertion guide a 5mm locking screw was applied. Fracture stability was assessed finally through knee flexion and extension. The wound was closed in layers and a sterile dressing was applied.

Postoperative care

Intravenous antibiotics were administered for 3days postoperatively. Nonsteroidal anti-inflammatory drugs were administered. The neurovascular status was monitored. Immediate postoperative radiographs were obtained to check the reduction and adequacy of the fixation[Figure4]. Exercises were started from the second postoperative day.
Figure 4: Immediate postoperative radiograph.

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Follow-up

Stitches were removed 10–15days postoperatively. Patient examination and radiological evaluation were carried out monthly until the sixth month postoperatively[Figure5]. Range of motion exercises and muscle strengthening exercises were increased according to patient tolerance. Weight bearing was started guided by radiological bone healing signs. Physiotherapy was encouraged at 1month postoperatively and follow-up of all patients continued for at least 6months.
Figure 5: Postoperative radiograph at 6 months.

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  Results Top


The duration from trauma to surgery ranged from 2 to 19days, with a mean range of 8.4days. The mean operative time was 92.75(range: 70–120) min. The mean time of intraoperative radiation exposure was 71.75±8.47(range: 60–90) s[Table1]. The mean amount of intraoperative bleeding was 102.00±17.04(range: 80–140) ml[Table2], and the mean period of hospital stay was 4.65(range: 3–8) days. The maximum hospital stay was 8days to completely treat the associated injuries.
Table 1: Intraoperative radiation exposure among studied patients

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Table 2: Intraoperative bleeding among studied patients

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Solid union took place in all studied cases except two cases, which were not fully united and needed bone graft. The mean time to radiological union was 11.30(range: 8–14) weeks. The mean time to return to full activity was 22.75(range: 18–26) weeks. The mean period of follow-up was 5.6(range: 4–6) months.

Active exercises were allowed according to patients' tolerance. At the end of the follow-up period of 6months, all patients were examined both clinically and radiographically and the functional scoring system was completed. According to the scoring system of Sander and colleagues, there were 13(65%) excellent cases, five(25%) good cases, and only two(10%) cases were fair.

In the current study, a significant relation(P<0.05) was found between the time lapse before surgery and the final results[Table3]. Moreover, a significant relation (P<0.05) was found between the type of fracture according to AO/OTA and the final results[Table4]. Finally, a significant relation(P<0.05) was found between the associated injuries and the final results [Table5].
Table 3: Relation between the time lapse before surgery and the final results

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Table 4: Relation between type of fracture (OTA/AO) and final results

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Table 5: Relation between associated injuries and final results

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As regards postoperative complications, three (15%) patients had superficial infection, and good healing was achieved with treatment and continuous dressing. There were no cases of deep infection. One(5%) patient had developed loss of knee flexion by 10°–20°. In two(10%) patients the fractures had not fully united, with loss of knee flexion by 10°–20°. One(5%) patient had less than 90° knee flexion. One(5%) patient had shortening by less than 0.5 inch. Twelve(60%) patients had no postoperative complications.


  Discussion Top


In the past, conservative management of fracture of the distal femur in adults(e.g.,traction and cast) was the most common method of treatment, as the surgical treatment was found to give less satisfactory results with many complications[21],[22],[37].

However, conservative methods has many complications as well, including complications due to prolonged recumbency in the form of chest complications such as pneumonia and pulmonary embolism, renal complications such as renal failure, thromboembolic complications, bed sore, toxemia, psychological troubles, knee stiffness, muscle atrophy, constipation, and gastrointestinal tract troubles[23],[24],[25],[26],[37].

With the improvement in surgical techniques, implant design, and understanding of the principles of the fracture management, operative treatment is now considered the standard for the treatment of distal femoral fractures. In recent times, the technique of LISS distal femur has gained popularity[29].

In the current study, all fractures united except two, which were not fully united after 6months of follow-up and needed bone graft. The mean time to radiological union was 11.30±1.69weeks. This is in agreement with the findings of Kolb etal.[34], who reported a mean time of union of about 12weeks. However, our findings are in disagreement with the findings of Weight etal.[33], Kregor etal.[27], and Apostoloub etal.[36], who reported a mean time of radiological union of about 12.5weeks, which was longer than ours.

In all cases, intraoperative fluoroscopic control was used to assess reduction and have a satisfactory alignment in both anteroposterior and lateral views.

Kregor etal. [27] had treated 123 distal femur fractures with the LISS. One hundred and nineteen consecutive patients with 123 distal femur fractures(OTA type33 and distal type32 fractures) were treated by three surgeons. This is in disagreement with the current study with respect to the more number of studied cases in a longer period, and this is an advantage to obtain more accurate results in a large number of cases.

Weight etal. [33] conducted a retrospective study on 26patients with 27 high-energy AO/OTA types A2, A3, C2, and C3 fractures of the distal femur treated by means of indirect fracture reduction and internal distal femoral fixation using the LISS. Twenty patients had associated injuries. Six fractures were open. All fractures were comminuted; according to the AO/OTA fracture classification there were four A2, three A3, 12 C2, and three C3 fractures. This is in agreement with the current study as regards the number of studied cases, but in disagreement with the current study in terms of the more number of associated injuries and the more number of open fractures.

In the current study, the mean age was 58.45±7.44years. The age was statistically nonsignificant and had noeffect on the final results. This is in agreement with the findings of Schütza etal.[35], who reported a mean age of 56years. However, our findings are in disagreement with the findings of Kolb etal.[34], who reported a mean age of 49years, which was younger than that reported in our study, and that of Michele etal.[28], who reported a mean age of 82years for patients managed with LISS distal femoral plate, which was older. In such studies, the age was statistically significant; thus, the younger the age, the better the outcome and vice versa.

In the current study, the mean time lapse before surgery was 8.40±3.95days. This was better than that reported in other studies such as that of Weight etal.[33], Kolb etal.[34], and Kregor etal.[27], who reported a mean time lapse before surgery of 11, 9, and 15days, respectively. This might be attributed to the absence of associated head injuries, which was presented in the study by Weight etal.[33], and the exclusion of multiple second degree open fractures, which were included in the study by Kolb etal.[34]and Weight etal.[33], which required more time for preparation before surgery.

In the current study, only one case had knee flexion less than 90° as the type of fracture was typeC3, and the patient did not complete physiotherapy and four had loss of knee flexion by only about 10°–20°.

Weight etal. [33] mentioned that the average knee range of motion was 5°–114°. Kregor etal. [27] mentioned that the mean range of knee motion was 1°–109°.

In the current study, 13patients had excellent results, five had good results and two had fair results according to the scoring system of Sander and colleagues This is in disagreement with the findings of Kolb etal. [34] in which the function according to the scoring system of Sander and colleagues was excellent in 15(48%), good in 10(32%) patients, and fair in six(20%) patients. The mean score was 80(60–100). This is in agreement with the study by Apostoloub etal. [36] in which the results were excellent in eight cases, good in five cases, and fair in three cases.

In the study by Weight etal.[33], complications included one malunion, in which the fracture was fixed in 8° of valgus, and two cases of external rotation between 10° and 15°. Painful hardware occurred in four patients, of whom three underwent implant removal.

In the study by Kregor etal.[27], there were five losses of proximal fixation, two nonunions due to infection and high comminution, and three acute infections due to bad soft tissue handling and concomitant debilitating disorders such as diabetes mellitus. Malreductions of the femoral fracture were seen in six(6%) fractures.

Concerning other methods of fixation of distal femoral fractures, the DCS and angled blade plate are available. However, the DCS allows more interfragmentary compression in C1 and C2 fracture, is easier to be inserted, and allows more accurate reduction in the sagittal plane compared with the angled blade plate[37].

However, such methods of fixation have many disadvantages. All except closed retrograde nail are open technique for fixation, with more intraoperative blood loss, more soft tissue dissection, more periosteal stripping, and disturbance of fracture hematoma with increased incidence of complications such as infection and nonunion. However, retrograde nail acts as an internal splint and does not allow rigid fixation such as plating and it increases the incidence of septic arthritis and stiffness of the knee joint. Such disadvantages are avoided with LISS technique.

Supanish etal. [30] reported 23patients treated with DCS. The mean time of bone union was 20.30weeks, which was much longer than that reported in the current study. The mean range of knee flexion was 113.26. Good-to-excellent results were found in 78% of patients. Complications included varus deformity in five(22%) patients, knee stiffness in one(4%) patient, and shortening in one(4%) patient.

Handolin etal. [32] reported 44patients treated with the retrograde nail. The mean time to bone union was 17.5weeks, which was longer than that reported in the current study. Complications included anterior knee pain in 10patients, superficial wound infection in three patients, loss of reduction in three patients, malalignment in two patients, breakage of the distal locking screws in two patients, and nonunion in one patient.

Yeap etal. [31] conducted a retrospective study on 11patients with 12 distal femoral fractures fixed with the distal femoral locked plate. The average age was 15–85(mean: 44) years. Fractures were of types A and C. The average follow-up of the patients was 6–9months. The average time lapse before surgery was 9.9days. The mean time of union was 18(range: 6–36) weeks, which was longer than that reported in our study in which the mean time of radiological union was 11.30±1.69weeks. The mean range of knee flexion was 107.7°. This study reported good-to-excellent results in 73% of patients treated with distal femoral locked plate; this was much lower than that reported in our study, which recorded 90% satisfactory results in patients treated with the LISS plate. Only one(9%) patient treated with distal femoral locked plate in that study had varus deformity, and this is similar to that reported in our study, which also had one case with 10° varus deformity.

Hence, LISS distal femur has many advantages over other methods of surgical management–mainly, minimal blood loss, minimal soft tissue dissection, minimal rate of infection, and high union rate[35],[36],[37].

LISS has many advantages, including high union rates without bone graft, a low incidence of infection, maintenance of distal femoral fixation, minimally invasive surgery allowing minimal intraoperative blood loss, minimal soft tissue stripping, small and esthetic scars, and shortened hospital stays[27],[28].

Other advantages of LISS include the following: little disruption of the periosteal blood supply due to maintenance of the perforating and nutrient vessels using the minimally invasive plate osteosynthesis techniques; closed reduction without additional traumatization of the diaphyseal area, leading to improved fracture healing and improved local resistance to infection; no or only small compression forces between the plate and the periosteum; and largely intact periosteal blood supply[27],[28].


  Conclusion Top


LISS distal femur is an optimum method for fixation of distal femoral fractures in adults for the following reasons: high union rates without bone graft, a low incidence of infection, maintenance of distal femoral fixation with stable fixation as it is a locked plate with fixed-angle construct, minimally invasive surgery allowing minimal intraoperative blood loss, and minimal soft tissue stripping.

Other advantages of LISS include the following: short hospital stay; little disruption of the periosteal blood supply due to maintenance of the perforating and nutrient vessels using the minimally invasive plate osteosynthesis techniques; closed reduction without additional traumatization of the diaphyseal area leading to improved fracture healing and improved local resistance to infection; no or only small compression forces between the plate and the periosteum; and largely intact periosteal blood supply.

Age, sex, side affected, mechanism of injury, occupation, and concomitant diseases did not have a significant effect on the results, whereas type of fracture, associated injuries, and time lapse before surgery had a significant effect on the final results.

Complication rates were lower in patients treated with the LISS distal femur than in other methods of treatment, especially postoperative wound infection and union rate.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table1], [Table2], [Table3], [Table4], [Table5]



 

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  In this article
Abstract
Introduction
Patients and Methods
Results
Discussion
Conclusion
References
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