Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 28  |  Issue : 2  |  Page : 23-25

Locking compression plate in distal intra-articular femoral fractures: The swashbuckler's approach


Department of Orthopaedic Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria

Date of Submission09-Apr-2019
Date of Decision04-May-2019
Date of Acceptance04-Apr-2020
Date of Web Publication1-Aug-2020

Correspondence Address:
Dr. Obinna Henry Obiegbu
Department of Orthopaedic Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njss.njss_4_19

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  Abstract 


Background: Distal femoral intra-articular fractures present a serious surgical challenge to an orthopedic surgeon. These fractures are usually complex and are difficult to treat, and the operative treatment is usually recommended. Problems encountered in the fixation of these fractures include poor exposure of the articular surface, loss of fixation, and joint incongruence. Materials and Methods: This was a prospective review of all patients treated with distal femoral locking plates (including patients presenting with nonunion) between January 2017 and January 2018 using the Swashbuckler's approach. Fractures were categorized using the AO/OTA classification. Patients with AO type A fractures were excluded from this study. Results: Six patients (5 females and 1 male) were recruited into this study. The mean age of the patients was 43.2 years (age range of 31–63 years). Mechanism of injury was road traffic accident in 83.3% of cases. The mean time for radiological union was 12 weeks, and all (100%) patients achieved union without any further intervention. Conclusion: The use of the Swashbuckler's approach for distal intra-articular fractures improves exposure of the articular surface and aids reduction and proper application of the locking distal femoral plate. High union rates can usually be achieved with these implants.

Keywords: Articular surface, exposure, Swashbuckler, union


How to cite this article:
Obiegbu OH, Ndukwu C U. Locking compression plate in distal intra-articular femoral fractures: The swashbuckler's approach. Niger J Surg Sci 2018;28:23-5

How to cite this URL:
Obiegbu OH, Ndukwu C U. Locking compression plate in distal intra-articular femoral fractures: The swashbuckler's approach. Niger J Surg Sci [serial online] 2018 [cited 2020 Sep 21];28:23-5. Available from: http://www.njssjournal.org/text.asp?2018/28/2/23/291235




  Introduction Top


Distal femoral intra-articular fractures present a serious challenge to a trauma orthopedic surgeon. These fractures are usually complex and are difficult to treat, and the operative treatment is usually recommended.[1] Distal femoral fractures arise from either a high-energy trauma, mainly sustained in road traffic accidents, usually in a young patient or a low-energy trauma occurring in a pathological bone (mainly osteoporosis) usually in elderly patients.[2]

Problems encountered in the fixation of these fractures include poor exposure of the articular surface, especially with fractures involving the medial femoral condyle and the intercondylar region, high incidence of loss of fixation, varus collapse, and inability of standard implants, such as condylar blade plate or supracondylar nails, to reduce the articular surface congruently.[3] The distal femoral locking plates are precontoured to fit the average bony anatomy of the distal femur of the adult. The pull-out strength of locking screws is higher than conventional screws and is particularly useful in osteoporotic bone.[3] The Swashbuckler's midline approach offers good exposure not only to the condyles but also to the intercondylar region. The purpose of this study was to evaluate the functional and radiologic outcomes of patients with distal intra-articular femoral fracture managed with locking compression femoral plates using the Swashbuckler's approach.


  Materials and Methods Top


This was a prospective study conducted from January 2017 to January 2018 with a follow-up of 1-year duration. Patients presenting to the Accident and Emergency of Nnamdi Azikiwe University Teaching Hospital with distal femoral fractures were evaluated, stabilized, and X-rayed. Fractures were categorized using the AO/OTA classification. Patients with either extra-articular distal femoral fractures (type A AO/OTA) or open fractures were excluded from the study. Approval was obtained from the hospital ethical committee.

Surgical approach

Patient is positioned supine under regional anesthesia with a rolled sheet under the knee; routine cleansing and isolation sterile draping are applied. A laterally based midline incision is made, and the incision is extended down to the fascia of the quadriceps. The lateral parapatellar retinaculum is incised, and the vastus lateralis is separated. A lateral parapatellar arthrotomy is done, and the femoral condyles are exposed. The fracture is visualized and reduced. A lateral or medial-based distal femoral plate is then applied. In five patients in this study, the plate was inserted laterally. However, in one patient, the plate was placed medially due to an open wound on the lateral part of the distal femur.

Follow-up

All the six patients had a minimum follow-up of 6 months, and the Neer's criteria (which consists of functional and anatomic factors with 70 and 30 units, respectively[4]) was used to determine the functional outcome.


  Results Top


There were three females (50%) and three males (50%) in our study. The age group ranged from 32 to 66 years, with a mean age of 45.2 years. Three patients were within the age range of 30–40 years, while two patients were within the 61–70 years of age group, and the sixth patient was 55 years old.

The predominant mechanism of injury was by a passenger motor-vehicular road traffic accident (high-velocity injury) which occurred in five patients (83.3%), while home fall (low-velocity injury) accounted for injury in only one patient.
Figure 1: Image on the left showing intra-articular distal femoral fracture (AO B3). Image on the right showing postoperative fixation of the fracture using a distal femoral plate via a Swashbuckler's approach

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Three of the patients (50%) had associated limb fractures – a contralateral femoral neck fracture, a tibial plateau fracture, and a humeral shaft fracture. The most common fracture pattern was A0-B2 and AO-B3 [Table 1].
Table 1: Frequency of fracture patterns

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All of the six cases achieved union with an average time to union of 3.8 months, with a range of 3–5 months.

Functional outcome was done using Neer's rating system, which allots points for pain, function, working ability, joint movements, and gross and radiological appearance [Table 2]. Four patients (66.7%) had excellent outcome, while 1 had a good, and the other a fair outcome using the Neer's criteria [Figure 2]. The patient who had a fair outcome had a complex A0 C3 distal femoral fracture.
Table 2: Neer's functional rating system

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Figure 2: Neer's functional knee score

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  Discussion Top


Management of the distal intra-articular fractures of the femur still poses a considerable challenge, with variations in surgical approach, implant choice, and outcome. Anatomical reduction of articular surface, maintenance of limb alignment, and early ambulation remain the goals of management. High-velocity trauma accounting for these fractures also leads to damage in the peri-articular tissue, and additional insult to these tissues by surgery often leads to difficulty in early mobilization and subsequent knee stiffness.

Multiple surgical approaches have been previously described for the management of distal intra-articular femoral fractures, including anterolateral approach,[5] lateral approach,[6] tibial tubercle osteotomy,[7] and combined medial and lateral approaches.[8] Frequent complications such as delayed wound healing, flap necrosis, and delayed healing of the osteotomy have been reported using the latter two approaches.[8] The Swashbuckler's approach to the distal femur gives excellent exposure of the femoral condyles and the intercondylar region and also fasters rehabilitation.[6]

Poor patient outcomes have been reported after management of these fractures, especially when locking precontoured plates are not used. Zlowodzki et al.[9] in the review of the different fixation techniques used in distal intra-articular femoral fractures found that the use of locked precontoured plates is associated with a decreased relative risk of nonunions and infections compared to the use of compressive plates. The locking compression plate is a single beam construct, where the strength of its fixation is equal to all the screw bone interfaces, and therefore has more pull-out resistance. Union was achieved in all patients (100%) in this study without the need for primary bone grafting. This is similar to the results obtained by Virk et al.,[10] where the fracture union was achieved in all patients, though primary bone grafting was done in some of their patients. In a study done by Rademakers et al.,[11] similar findings were also obtained and they concluded that surgical treatment of mono- and bi-condylar femoral fractures shows good long-term results after open reduction and internal fixation with locked distal femoral plate. In this study, four patients (66.7%) had excellent, while one had a good, and the other had a fair outcome using the Neer's criteria. The patient who had a fair outcome had a complex AO C3 distal femoral fracture.


  Conclusion Top


Distal femoral intra-articular fractures remain an operative challenge considering the difficulties in reduction, fracture healing, associated comorbidities, and variable outcomes. However, the use of distal femoral locking plates via a Swashbuckler's ensures good exposure of both the distal femoral condyles and the articular surface and also ensures stable fixation, resulting in favorable outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Giles 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;64:864-70.  Back to cited text no. 1
    
2.
Schandelmaier P, Partenheimer A, Koenemann B, Grün OA, Krettek C. Distal femoral fractures and LISS stabilization. Injury 2001;32 Suppl 3:SC55-63.  Back to cited text no. 2
    
3.
Gwathmey FW Jr., Jones-Quaidoo SM, Kahler D, Hurwitz S, Cui Q. Distal femoral fractures: Current concepts. J Am Acad Orthop Surg 2010;18:597-607.  Back to cited text no. 3
    
4.
Neer CS 2nd, Grantham SA, Shelton ML. Supracondylar fracture of the adult femur. A study of one hundred and ten cases. J Bone Joint Surg Am 1967;49:591-613.  Back to cited text no. 4
    
5.
Kretteck C, Schandelmaier P, Miclau T, Bertram R, Holmes W, Tscherne H. Transarticular joint reconstruction and indirect plate osteosynthesis for complex distal supracondylar femoral fractures. Injury 1997;28:31-41.  Back to cited text no. 5
    
6.
Rajendra A, Saurabh J, Phujhele S, Narayan D, Gautam K. A comparative study between swashbuckler approach (modified anterior approach) and lateral approach for the distal femur fractures. IJOS 2018;4:184-8.  Back to cited text no. 6
    
7.
Khalil Ael-S, Ayoub MA. Highly unstable complex C3-type distal femur fracture: Can double plating via a modified Olerud extensile approach be a standby solution? J Orthop Traumatol 2012;13:179-88.  Back to cited text no. 7
    
8.
Lin D, Chen C, Lian K, Zhai W. Treatment of type C3.3 distal femoral fractures with double-plating fixation via U-shaped incision. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2010;24:683-6.  Back to cited text no. 8
    
9.
Zlowodzki M, Bhandari M, Marek DJ, Cole PA, Kregor PJ. Operative treatment of acute distal femoral fractures: Systematic review of 2 comparative studies and 45 case series (1989 to 2005). J Orthop Trauma 2006;20: 366-71.  Back to cited text no. 9
    
10.
Virk JS, Garg SK, Gupta P, Jangira V, Singh J, Rana S. Distal Femur Locking Plate: The Answer to All Distal Femoral Fractures. J Clin Diagn Res 2016;10:RC01-5.  Back to cited text no. 10
    
11.
Rademakers MV, Kerkhoffs GM, Sierevelt IN, Raaymakers EL, Marti RK. Intra-articular fractures of the distal femur: A long-term follow-up study of surgically treated patients. J Orthop Trauma 2004;18:213-9.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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