Distal Femur Fractures

Thomas P. Rüedi, MD, FACSFounder & Honorary memberAOFoundation

AO SEC 1st Principles CourseKathmandu, May 2009

Albin Lambotte 1886- 1955

Pioneer and genius of modernoperative fracture treatment.....

....already 100 years agorecognized that articularfractures must be fixedrigidly with plates andscrews in order to allow forearly, pain free motion

Unfortunatley, Lambottes’ recommendations were forgotten orhis superb operative technique and soft tissue care could not bereproduced, so that X-rays like these can be seen until today:

Such attempts at surgery are totally inadequate !!!!

1965 Allgöwer fixed this IIIB open, 33 C1 fx from hunting incidentas an emergency with 95° blade plate and secondary bonegraft.

• at 6 mo bony union, limited flexion (recurvatum), no pain

• 25 years later: acceptable function, no signs of osteoarthritis

What are the challenges ?• complex anatomy of knee / ligaments

• short distal segment & long leever arm• positioning, approach soft tissue cover• choice and purchase of implant in bone

• functional after care

requires careful planning

• high energy / polytrauma

Planning of surgery

• soft tissue conditions of injured area timing and sequence of surgery

• correct diagnosis for classification

• step-by-step: positioning, approach, reduction, preliminary fixation, choice of implant

• any minimally invasive technique must be decided beforehand and carefully performed

• condition of patient as a whole

Classification (Müller AO) 33 -

B intra-articular unicondylar ( incl.Hoffa)

B

A extraarticular / supracondylar

AC intra-articular bicondylar

C

• Often high energy, open fractures,• neuro-vascular injuries in 3-4%

W.G.m, 19y: collision with ratrac while skiing :• Cranio-facial fractures, GCS 9

• Hemo-pneumothorax, rib fractures

• 23- C2 fracture left distal humerus, bilateral distal radius fx.

• Floating knee with II° open distal femur and tibia fracture, neuro- vascular intact

ISS 38

Emergency fixation: - DCS for distal femur- lag screw for tibia plateau and joint bridging ext. fix.

After 10 days:- lateral bridge plate for tibia, - ex-fix as reduction aid

- Fixation of both radius fractures

W.G.m, 19y: collision with ratrac while skiing : ISS 38

- physiotherapy

- ORIF dist. humerus

W.G.m, 19y: collision with ratrac while skiing : ISS 38• Due to slow healing of tibia:

Cancellous autograft after 5 months

5 mo

• Good functional result after one year, slight varus back to work and sports

12 mo

Distal femur fracture: choice of implantsClassical:• 95° angle blade plate• DCS: dynamic condylar screw• condylar buttress plate

New:• LISS: less invasive stabilisation system• locking condylar buttress plate• LCP: locking compression plate• retrograde im-nail

Sch.W. 61y,m MVA: distal Femur fracture 33- C, circumferential degloving of whole leg

Emergency ORIF with 95° angled blade plate,

Harvesting of defattened,degloved skin for later use

case of P.Tondelli

Sch.W. 61y,m MVA: distal Femur fracture 33- C, circumferential degloving of whole leg

Secondary split skin graftwith defattened skin

Satisfactory functional result

case of P.Tondelli

Patient positioning:

• knee flexed 30- 45° to reduce pull of gastrocnemius muscle

• radiolucent table

Approaches:

Para-patellar

lateral

Hunting accident:III-C open (artery,vein + nerve), 33-C3 fract, 1) Preliminary fixation with DSC and 3cm shortening

2) Repair of politeal artery & vein with venous grafts, nerve bruised, but intact

3) Completion of ORIF and compartment release

Control angiogram

Hunting accident:III-C open(artery, vein+ nerve), 33-C3 fract.at 3 months: good function, uneventful healing, weightbearing w. 40 kg

to correct 3cm shortening: proximal one step lengthening, good one year result

R.O.m, 44y: polytrauma w. 33-C3 open fxAfter 6 we in traction >> 4cm shortening, mal alignment, stiff joints

6 weeksafter injury

Plan: indirect reduction w distractor, minimal exposure, DCS

postop

R.O.m, 44y: polytrauma w. 33-C3 open fxIntensive postop. Physiotherapy > return of function. Good healing

Removal of sequestrum, playing tennis after 2y, follow-up at 4y

27 weeks 4 years

A.B.m 26y, motorbike injury, III B open, 33- C3 fracture neuro-vascular intactEmergency ORIF, attempt at anatomical reconstruction of condyles, fixation w.

condylar buttress plate, all stripping of the bone is traumatic

such surgery can hardly be done through a keyhole incision

A.B.m 26y, motorbike injury, III B open, 33- C3 fracture

In spite of considerable exposure, bone graft & cerclage wire, unproblematic healing, return of satisfactory function, here at one year follow-up

Similar 33- C3 fracture in 70 y old man, Initial ORIF w condylar buttress plate, osteoporosis, poor purchase, no support

Collapse of fixation after 5 we redo w 95° angle blade plate:

5 weeks

redo w 95° angle blade plate, bony union after 1 y, satisfactory functional result

1 year

With the new concept of the, internal fixatorbased on angular stability of the screws, suchscrew loosening & collapse will not occur anymore!

LISSlLess invasive stabilisation system

LISS (less invasive stabilisation system)

• locking head screws provide angular stability - uni-cortical or bi-cortical - plate not pressed against bone

• reduction: - direct (vision) of articular components - indirect of meta- / diaphysis• minimally invasive, submuscular insertion of long bridging plates

• no bone graft required

• excellent purchase also in osteopenic bone, - eg. periprosthetic fractures

Distal femur fracture 33- C2 (metaphyseal comminution)• initial, temporary joint bridging external fixator,

• reconstruction and alignment of articular surface/ block > plate insertion

postop

• secondary ORIF with LISS

2 mo

• Planning position / length of LISS

• Submuscular insertion of plate sliding along femur

• Preliminary distal fixation for indirect reduction with distractor

• Lateral view and ap after reduction

Step-by-step procedure for the LISS

Peri-prosthetic fractures or in osteopenic bone:

• poor purchase of standard screws / implants

• locking head screws provide - angular stability - less risk for pull- out

LISS or LCP Internal fixator principle

LISSDCU Combi-hole= LCP

Advantages of LISS in periprosthetic fractures:• Locking head screws - providing firm purchase in osteoporotic bone - unicortical application (around stem of prosthesis)• no cement required

I.K., 40y, distal femur C2-type, 2° open

LCP: clinical handling tests (2000) Dr.Ch.Sommer, Chur

I.K., 40y, distal femur C2-type, 2° open

LCP: clinical handling tests (2000) Dr.Ch.Sommer, Chur

I.K., 40y, distal femur C2-type, 2° open

3 months

LCP: clinical handling tests (2000) Dr.Ch.Sommer, Chur

I.K., 40y, distal femur C2-type, 2° open

6 months

LCP: clinical handling tests (2000) Dr.Ch.Sommer, Chur

M.36 y. Motorbike accident, polytrauma (case of Dr.Turchetto)

- abdominal injuries (spleen & ileum) - bilateral identical, segmental distal 3rd femur fractures

• preliminary external fixation until recovery >> bilat. retrograde im-nail

leftright

M.36 y. Motorbike accident, polytrauma- bilateral identical segmental femur fract. • secondary bilateral retrograde nailing : Right side: - ORIF intraarticular fx w cancellous screw - retrograde nail insertion

rigth

M.36 y. Motorbike accident, polytrauma- bilateral identical segmental femur fract. Left side:• percutaneous reduction / cannulated screw

• minimal approach for retrograde nail

left

M.36 y. Motorbike accident, polytrauma-bilateral identical segmental femur fract. 7 days postoperatively

(case of Dr.Turchetto)

• 40 days follow up >> callus formation

right left

M.36 y. Motorbike accident, polytraumabilateral identical segmental femur fract.

(case of Dr.Turchetto)

Conclusions:• distal femur fractures 33- A- C are: - absolute indications for ORIF - often high energy injuries, open, & polytrauma

• require careful planning as to: - timing, positioning, approaches (soft tissues !)

- reduction techniques - choice of implant

• variety of implants today available: - 95°angle blade pl. / DCS condylar buttress pl. - LISS / LCP (locking head screws > angular stability)

- retrograde intra-medullary nails

• minimally invasive techniques w indirect reduction and bridging implants to be preferred

Thank you !!

Motorcycle injury: 33- C3 (not suited for blade plate or DCS)

ORIF w. condylar buttress plate, uneventful healing and functional recovery

B.L.40y