Menoufia Medical Journal

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

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


Mahmoud M Hadhoud, Yasser S Hannout, Abd El-Hamid S Abd El-Hamid Rageh 
 Department of Orthopedic Surgery, Faculty of Medicine, Menoufia University, Tala, Egypt

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

Abstract

Objective The aim of this study was 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 72 years of age (mean age: 58.45 years) 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 5.6 months, ranging from 4 to 6 months. Radiographically, all fractures except two healed in good alignment. Solid union took place from 8 to 14 weeks, with a mean of 12 weeks. 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.



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;30:434-441


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 2020 Apr 8 ];30:434-441
Available from: http://www.mmj.eg.net/text.asp?2017/30/2/434/215473


Full Text

 Introduction



Fractures of the distal femur [Figure 1] 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}

Fractures of the distal femur occur in a bimodal distribution; among those between 15 and 50 years of age, predominantly male patients, sustaining high-energy trauma, and those above 50 years 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 et al. [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



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 4–6 months.

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 12 female patients between 45 and 72 years of age (mean age: 58.45 years).

Fracture was classified according to the AO/OTA classification of fracture of the distal femur [Figure 2]. Five cases were of type A1, four cases were of type A2, three cases were of type A3, three cases were of type C1, three cases were of type C2, and two cases were of type C3.{Figure 2}

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 [Figure 3] is recommended in simple articular (AO classification 33-C1) or extra-articular fractures (AO classification 32 or 33-A). A skin incision was performed from Gerdy's tubercle about 80 mm 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 type C2 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}

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. A 2 mm 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 5 mm 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. A K-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, 5 mm 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. A 5 mm locking screw was attached to the 3.5 mm 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 2 mm K-wire, 280 mm length. The wire should be inserted through the 2 mm 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 5 mm 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 3 days 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 [Figure 4]. Exercises were started from the second postoperative day.{Figure 4}

Follow-up

Stitches were removed 10–15 days postoperatively. Patient examination and radiological evaluation were carried out monthly until the sixth month postoperatively [Figure 5]. 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 1 month postoperatively and follow-up of all patients continued for at least 6 months.{Figure 5}

 Results



The duration from trauma to surgery ranged from 2 to 19 days, with a mean range of 8.4 days. 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 [Table 1]. The mean amount of intraoperative bleeding was 102.00 ± 17.04 (range: 80–140) ml [Table 2], and the mean period of hospital stay was 4.65 (range: 3–8) days. The maximum hospital stay was 8 days to completely treat the associated injuries.{Table 1}{Table 2}

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 6 months, 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 P P [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 6 months of follow-up and needed bone graft. The mean time to radiological union was 11.30 ± 1.69 weeks. This is in agreement with the findings of Kolb et al. [34], who reported a mean time of union of about 12 weeks. However, our findings are in disagreement with the findings of Weight et al. [33], Kregor et al. [27], and Apostoloub et al. [36], who reported a mean time of radiological union of about 12.5 weeks, 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 et al. [27] had treated 123 distal femur fractures with the LISS. One hundred and nineteen consecutive patients with 123 distal femur fractures (OTA type 33 and distal type 32 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 et al. [33] conducted a retrospective study on 26 patients 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 ± 7.44 years. The age was statistically nonsignificant and had no effect on the final results. This is in agreement with the findings of Schütza et al. [35], who reported a mean age of 56 years. However, our findings are in disagreement with the findings of Kolb et al. [34], who reported a mean age of 49 years, which was younger than that reported in our study, and that of Michele et al. [28], who reported a mean age of 82 years 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 ± 3.95 days. This was better than that reported in other studies such as that of Weight et al. [33], Kolb et al. [34], and Kregor et al. [27], who reported a mean time lapse before surgery of 11, 9, and 15 days, respectively. This might be attributed to the absence of associated head injuries, which was presented in the study by Weight et al. [33], and the exclusion of multiple second degree open fractures, which were included in the study by Kolb et al. [34]and Weight et al. [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 type C3, and the patient did not complete physiotherapy and four had loss of knee flexion by only about 10°–20°.

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

In the current study, 13 patients 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 et al. [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 et al. [36] in which the results were excellent in eight cases, good in five cases, and fair in three cases.

In the study by Weight et al. [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 et al. [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 et al. [30] reported 23 patients treated with DCS. The mean time of bone union was 20.30 weeks, 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 et al. [32] reported 44 patients treated with the retrograde nail. The mean time to bone union was 17.5 weeks, which was longer than that reported in the current study. Complications included anterior knee pain in 10 patients, 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 et al. [31] conducted a retrospective study on 11 patients 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 6–9 months. The average time lapse before surgery was 9.9 days. 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 ± 1.69 weeks. 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



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.

References

1Schatzker J, Lambert DC. Supracondylar fractures of the femur. Clin Orthop Relat Res 1979; 138:77–83.
2Arneson TJ, Melton LJ 3rd, Lewallen DG, O'Fallon WM. Epidemiology of diaphyseal and distal femoral fractures in Rochester, Minnesota, 1965–1984. Clin Orthop Relat Res 1988; 234:188–194.
3Giles JB, DeLee JC, Heckman JD, Keever JE. Supracondylar–intercondylar fractures of the femur treated with a supracondylar plate and lag screw. J Bone Joint Surg Am 1982; 64:864–870.
4Heiney JP, Battula S, O'connor JA, Ebraheim N, Schoenfeld AJ, Vrabec G. Distal femoral fixation: a biomechanical comparison of retrograde nail, retrograde intramedullary nail, and prototype locking retrograde nail. Clin Biomech 2012; 27:692–696.
5Kolmert L, Wulff K. Epidemiology and treatment of distal femoral fractures in adults. Acta Orthop Scand 1982; 53:957–962.
6Henry SL. Supracondylar femur fractures treated percutaneously. Clin Orthop Relat Res 2000; 375:51–59.
7Kammerlander C, Riedmüller P, Gosch M, Zegg M, Kammerlander-Knauer U, Schmid R, et al. Functional outcome and mortality in geriatric distal femoral fractures. Injury 2012; 43:1096–1101.
8Wähnert D, Hoffmeier K, Fröber R, Hofmann GO, Mückley T. Distal femur fractures of the elderly – Different treatment options in a biomechanical comparison. Injury 2011; 42:655–659.
9Butt MS, Krikler SJ, Ali MS. Displaced fractures of the distal femur in elderly patients: operative versus non-operative treatment. J Bone Joint Surg Br 1996; 78:110–114.
10Marks DS, Isbister ES, Porter KM. Zickel supracondylar nailing for supracondylar femoral fractures in elderly or infirm patients. A review of 33 cases. J Bone Joint Surg Br 1994; 76:596–601.
11O'Connor-Read LM, Davidson JA, Davies BM, Matthews MG, Smirthwaite P. Comparative endurance testing of the Biomet Matthews Nail and the dynamic compression screw, in simulated condylar and supracondylar femoral fractures. Biomed Eng Online 2008; 7:3.
12Siliski J, Mahring M, Hofer HP. Supracondylar–intercondylar fractures of the femur. Treatment by internal fixation. J Bone Joint Surg Am 1989; 71:95–104.
13Sanders R, Swiontkowski M, Rosen H, Helfet D. Double-plating of comminuted, unstable fractures of the distal part of the femur. J Bone Joint Surg Am 1991; 73:341–346.
14Mast J Jakob R, Ganz R. Planning and reduction technique in fracture surgery. Berlin: Springer-Verlag; 1989. 140–187.
15Mallina R, Kanakaris NK, Giannoudis PV. Peri-articular fractures of the knee: an update on current issues. Knee 2010; 17:181–186.
16Christodoulou A, Terzidis I, Ploumis A, Metsovitis S, Koukoulidis A, Toptsis C. Supracondylar femoral fractures in elderly patients treated with the dynamic condylar screw and the retrograde intramedullary nail: a comparative study of the two methods. Arch Orthop Trauma Surg 2005; 125:73–79.
17Ali I. Surgical outcome of supracondylar and intercondylar fractures femur in adults treated with dynamic condylar screw. JPMI 2011; 25:49–55.
18Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br 2002; 84:1093–1110.
19Haidukewych GJ, Ricci W. Locked plating in orthopaedic trauma: a clinical update. J Am Acad Orthop Surg 2008; 16:347–355.
20Haidukewych GJ. Innovations in locking plate technology. J Am Acad Orthop Surg 2004; 12:205–212.
21Albert MJ. Supracondylar fractures of the femur. J Am Acad Orthop Surg 1997; 5:163–171.
22Millet M, Moran CG. Fractures and dislocations around the knee. Surgery (Oxford) 2007; 25:434–438.
23Healy WL, Brooker AF Jr. Distal femoral fractures comparison of open and closed methods of treatment. Clin Orthop Relat Res 1983; 174:166–171.
24Nasr A, Mc Leod I, Sabboubeh A, Maffulli N. Conservative or surgical management of distal femoral fractures. A retrospective study with a minimum five year follow-up. Acta Orthop Belg 2000; 66:477–483.
25Hardy AE, White P, Williams J. The treatment of femoral fractures by cast-brace and early walking: a review of seventy-nine patients. J Bone Joint Surg Br 1979; 61-B: 151–154.
26Connolly JF. Closed treatment of pelvic and lower extremity fractures. Clin Orthop Relat Res 1989; 240:115–128.
27Kregor Philip J., Stannard James A., Zlowodzki Michael, Cole PA Treatment of distal femur fractures using the less invasive stabilization system. J Orthop Trauma 2004; 18:509–520.
28Schütz M, Müller M, Krettek C, Höntzsch D, Regazzoni P, Ganz R, et al. Minimally invasive fracture stabilization of distal femoral fractures with the LISS: a prospective multicenter study. Results of a clinical study with special emphasis on difficult cases. Injury 2001;32 Suppl 3:SC48-54..
29Smith 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. Injury 2009; 40:1049–1063.
30Supanich V. Results of the treatment of type-C distal femoral fractures using four different implants: condylar blade plate, dynamic condylar screw, condylar buttress plate, and distal femoral locking plate. J Orthop Surg (Thai) 2012; 36:8–15.
31Yeap EJ, Deepak AS. Distal femoral locking compression plate fixation in distal femoral fractures. J Orthop (Malaysian) 2007; 1:12–17.
32Handolin L, Pajarinen J, Lindahl J, Hirvensalo E. Retrograde intramedullary nailing in distal femoral fractures-results in a series of 46 consecutive operations. Injury 2004; 35:517–522.
33Weight Mark, MD Collinge. Early results of the less invasive stabilization system for mechanically unstable fractures of the distal femur. J Orthop Trauma 2004; 18:503–508.
34Kolb Klaus, MD Koller, Heiko MD. Fixation of distal femoral fractures with the less invasive stabilization system: a minimally invasive treatment with locked fixed-angle screws. J Trauma 2008; 65:1425–1434.
35Schütza M, Müllerb M, Höntzschd D. Minimally invasive fracture stabilization of distal femoral fractures with the LISS. Injury 2004; 35:517–522.
36Apostoloub CD, Papavasilioua AV, Aslamb N. Preliminary results and technical aspects following stabilisation of fractures around the knee with LISS. J Orthop Trauma 2004; 21:43–46.
37Hesham M, El Mwafy, Mohammed M Abd El Gawad, Ahmed F Shams El Din, Wael M Youssef. Surgical treatment of distal femoral fractures using a distal femoral locked plate versus a condylar buttress plate. Menoufia Med J 2015; 28:948–953.