Distal femur fractures

Eric Thein

22ndTraumaCourseAIOD-OTCSuisseInterlaken,September11-14,2017

Clinical case

•  36 year old female

•  Fall from a balcony

=> TBI with subdural hematoma & subarachnoidal bleeding (GCS = 7)

Initial X-Rays

Epidemiology •  Rare 0,4-1% of all fractures 3-6% of femoral fractures

Court-Brown M: Epidemiology of adult fracture: a review. Injury 2006

Epidemiology •  Rare 0,4-1% of all fractures 3-6% of femoral fractures

•  Bimodal distribution young male => high energy elderly/old women => low energy Court-Brown M: Epidemiology of adult fracture: a review. Injury 2006

Anatomy •  Supra- & intercondylar region

Anatomy •  Supra- & intercondylar region

•  Coronal plane Anatomic lateral distal femoral angle: 81-84°

Anatomy •  Supra- & intercondylar region

•  Coronal plane Anatomic lateral distal femoral angle: 81-84°

•  Axial plane Trapezoidal shape Paley D: Principles of Deformity Correction. Springer Verlag 2005

Radiology Plain radiographs •  A/P => Varus or Valgus displacement

•  Lateral => Apex posterior angulation

•  Separation & Rotation of femoral condyles

Nork SE: The association between supracondylar-intercondylar distal femoral fractures and coronal plane fractures. JBJS Am 2005

Radiology

Radiology •  Fracture in the coronal plane in > 38%

Radiology •  Fracture in the coronal plane in > 38% •  Missed in 31%

<= Nork SE: The association between supracondylar-intercondylar distal femoral fractures and coronal

plane fractures. JBJS Am 2005

Radiology => CT-Scan •  Intra-articular extension

•  Degree of comminution

•  Fracture lines in the coronal plane

•  Intercondylar fracture lines in osteoporotic

Classification •  AO/OTA

Müller ME: Classification of long-bone fractures. Springer Verlag 1991

Left distal femur fracture AO 43-C2

Left distal femur fracture AO 33-C2 Open Gustilo Grade II !

Management

•  Polytrauma •  Higher Grade Open fractures (5-10%)

Management

•  Polytrauma •  Higher Grade Open fractures => Local Damage control - Debridement +/- closure or coverage - Temporary knee-spanning external fixator

Prepare the patient •  Adequate resuscitation prior to definitive

fixation

Prepare the patient •  Adequate resuscitation prior to definitive

fixation

Prepare the extremity •  (Repeated) debridement(s), closure, skin

grafting or flaps => Soft tissue recovery

Prepare the Surgeon

« Span – Scan – Plan » => Reapproximation of the fracture

fragments by ligamentotaxis => improved quality of CT – Images

(Definitive) Management Nonsurgical - « Stable », minimally displaced => Toe touch weight bearing => (Hinged) brace, (Upper leg) cast => X-ray controls at regular intervals

(Definitive) Management Surgical - Principles •  ORIF of the articular block

(Definitive) Management Surgical - Principles •  ORIF of the articular block •  Reduction & fixation of the articular block

to the diaphysis

•  Day 0: Stabilization by knee-spanning External Fixator

•  Day 6: definitive fixation by retrograde femoral nail

Surgical approach Dictated by

•  Fracture configuration

•  Implant

•  Surgeons experience

Lateral approach •  Type A, C1 (& C2) fractures

Swashbuckler approach => lateral approach extended distally to a

lateral parapatellar arthrotomy => Excellent exposure for ORIF of C2 & C3

fractures

Medial approach •  Isolated medial condylar fractures •  C2 & C3 fractures if medial fixation required

(in combination with lateral approach)

Retrograde nailing 33 A, C1&C2 fractures

•  Knee flexed ~ 60°

•  Longitudinal incision

•  Medial to patellar tendon

Retrograde nailing

Retrograde nailing Pitfalls •  Poor starting point •  Insufficient fracture reduction •  Eccentric reaming => may lead to fracture malreduction

Plating •  MIPO: 33 A, C1 & C2 fractures

• 

Plating •  MIPO: 33 A, C1 & C2 fractures

•  =>

Plating •  MIPO: 33 A, C1 & C2 fractures

•  =>

Plating •  Simple fractures => Anatomic Reduction => Absolute Stability =>

Plating •  Complex fractures => Indirect Reduction => Bridge Plating =>

Plating •  Complex fractures => Indirect Reduction => Bridge Plating =>

Plating •  Complex fractures => Indirect Reduction => Bridge Plating => +/- medial fixation => =>

Postoperative Care •  Started on Day 1 to prevent stiffness &

loss of function

Postoperative Care •  Started on Day 1 to prevent stiffness &

loss of function •  Active-assisted & continuous passive

motion, Quadriceps strengthening

Postoperative Care •  Started on Day 1 to prevent stiffness &

loss of function •  Active-assisted & continuous passive

motion, Quadriceps strengthening •  Toe-touch weight bearing until

radiographic signs of healing

Postoperative Care •  Started on Day 1 to prevent stiffness &

loss of function •  Active-assisted & continuous passive

motion, Quadriceps strengthening •  Toe-touch weight bearing until

radiographic signs of healing => Problem: Elderly & Old Population Criner SH. Immediate weight bearing as tolerated after locked plating of fragility fractures of the distal

femur. Podium Presentation at the Annual Meeting of the Western Orthopaedic Association,2014

In the elderly •  1.6% of fracture in the population older than

80 years •  After minor trauma Ries Curr Osteoporos Rep 2012

– Poor bone quality – Comminution – Osteochondral damage – Pre-existing arthritis

•  9% late amputation rate after non-operative TT or ORIF Karpman et al. CORR 1995

Rosen et al. CORR 2004

Bonnevialle et al. Rev Chir Orthop 2003

What are we looking for? •  Early mobilisation •  Early weight-bearing •  Early return to pre-injury functional level

MalviyaAetal.Injury2011 Nauetal.JArthroplasty2003

Wishfulthinking!

Problems after ORIF •  High 1-year mortality rate (22%) •  Significant decrease in function •  Significant decrease in QoL •  Osteoporosis leads to difficulty in achieving

stable fixation •  High risk of implant loosening •  Lengthy period of non/limited weight-bearing •  Even with LCP-plates

Karpmanetal.CORR1995

Honkonenetal.CORR1994

MalviyaAetal.Injury2011

Haidukewychetal.JBJS-A2008

Why not choose primary TKA in elderly patients?

•  Early immediate full weight-bearing •  Restoration of knee motion •  Good mechanical support due to long

stems and cement •  Fast return to pre-injury level

replacement is used, dislocation is a well-known problemalthough by using an anterolateral instead of a posteriorapproach, a significant reduction in the dislocation rate hasbeen shown.14,15 In addition, the use of larger-sized femoralheads and avoidance of using total hip replacement in patientswith sequelae after neurologic disease such as stroke or anyother disease causing long-standing impaired disturbance ofmuscular activity has also been shown to reduce thedislocation rate. At present, an ongoing and still not solvedquestion is what type of replacement to use: hemiarthroplastyversus total hip arthroplasty and unipolar versus bipolararthroplasty.14,16 The original concept with using cementedstems has also been challenged by favorable results whenusing uncemented fixation.17 In cognitively intact patients, itseems that total hip replacement might be favorable becausea better functional outcome can be expected and thecomplication rate kept low, including a low dislocation rate.As to what type of hemiarthroplasty to use, it seems as thoughthe functional outcome for uni- and bipolar hemiarthroplastiesis equivalent, at least when assessing outcome at 1 to 3 years,whereas the long-term results using modern hemiarthroplastyimplants are still to be shown.16 By using uncementedimplants, one potential advantage that has been postulated isthe avoidance of the systemic complications reported whenusing cement for fixation. On the other hand, a major concernassociated with the use of uncemented stems has been the riskfor inadequate fixation in the usually wide osteoporoticmedullary canal. Recently, uncemented femoral stems withvarious coatings developed specifically for use in patients withfemoral neck fracture have shown promising or even goodresults with a low complication rate and adequate stabilitydespite early weightbearing.18

Trochanteric FracturesIn contrast to the treatment of displaced femoral neck

fractures in which replacement is the dominant type oftreatment, the use of internal fixation dominates when dealing

with trochanteric fractures. A relatively low complication ratecombined with healing disturbances being very uncommon isthe underlying rationale for the strong predominance ofinternal fixation in these fractures. Although internal fixationseems favorable in trochanteric fractures, there has been aninterest in whether subgroups of fractures or patients mightbenefit from replacement. At present, this has been addressedin only a few studies focused on comminuted unstabletrochanteric fractures in patients with severe osteoporosis. Inone study, a cemented replacement was compared witha sliding hip screw. No significant differences in complicationrates between the two methods were seen at 1 year, although inconjunction with the procedure, there was a higher bloodtransfusion need in the arthroplasty group.19 In another studycomparing an uncemented replacement versus a proximalfemoral nail, a similar result with a higher blood transfusionneed in the replacement group was found as well as a greateroperative blood loss and a longer duration of surgery.20 Therewere, however, no significant differences for mechanicalcomplications, reoperations, or mortality at 1 year. Based onthese two studies with the limited number of patients included,there is not sufficient evidence to determine whether replacementhas any advantage over internal fixation in any subgroup ofpatients who sustain a trochanteric hip fracture.

FRACTURES AROUND THE KNEE

Distal Femoral FracturesTreatment of distal femoral fractures in patients with

osteoporosis, especially if intra-articular impaction andcomminution is present, includes several challenges (Fig. 2).Alignment may be difficult to achieve, especially if the fractureis comminuted. Articular reduction can also be problematic,especially if joint impaction is present, as frequently observedin patients with more extensive osteoporosis. In osteoporotic

FIGURE 2. Supra-/intracondylar fem-oral fracture in a woman aged 79years with severe osteoporosis (A).The fracture healed after fixationwith a combination of an intrame-dullary nail and separate screws.Eight years later, the patient sus-tained a proximal tibial fracture afterlow-energy trauma (B); otherwise,the patient is healthy, mobile, andliving independently. There was noantiosteoporotic treatment in be-tween the fracture events. Fracturetreated with a combination of a con-ventional angle-stable plate and in-jectable calcium phosphate aroundthe screws for augmentation (C).

S92 | www.jorthotrauma.com q 2011 Lippincott Williams & Wilkins

Larsson J Orthop Trauma ! Volume 25, Number 6 Supplement, June 2011

! D 82 yo (C1)

Two problems dealt with in one single operation

Conclusions from other authors •  Loss of autonomy but good function

Parrate et al. Orthoph&Traumat 2011

•  Primary arthroplasty is most appropriate for elderly sedentary patients who would not be expected to outlive the anticipated durability of the arthroplasty and for fracture patterns in which ORIF may not provide the best outcome

Ries M. Curr Osteoporos Rep 2012

Take Home Messages •  Anatomy of the distal femur •  High energy lesion / Polytrauma => Two

stage Procedure •  Anatomic Reduction & Rigid Fixation of

Articular Complex •  Length, Axes & Rotation for Metaphyseal

Region •  Nails & Plates equivalent if correctly applied •  TKA an option in elderly patients