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ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 4  |  Page : 948-953

Surgical treatment of distal femoral fractures using a distal femoral locked plate versus a condylar buttress plate


1 Department of Orthopedics, Shebin Elkom University Hospital, Menoufia University, Menoufia, Egypt
2 Department of Orthopedics, El Hadara University Hospital, Faculty of Medicine, Alexandria University, Alexandria, Egypt
3 Department of Orthopedics, Gamal Abd Elnasr Insurance Hospital, Alexandria, Egypt

Date of Submission12-Nov-2014
Date of Acceptance06-Mar-2015
Date of Web Publication12-Jan-2016

Correspondence Address:
Wael M Youssef
5 Ali Ebn Abi Talb Street, Elnozha Airport, Sidi Gaber, Alexandria, 2111
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.173681

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  Abstract 

Objective
The aim of the study was to evaluate the clinical and functional outcome of internal fixation of distal femoral fractures with a condylar buttress plate versus a distal femoral locked plate.
Background
Distal femoral fractures are serious injuries that are difficult to treat and carry an unpredictable prognosis requiring special preoperative planning and close follow-up. Surgical treatment has become the standard treatment after considerable improvement in surgical techniques and the implants used, which avoid the complications of conservative treatment.
Patients and methods
We conducted a randomized prospective study including 30 patients (17 men and 13 women) with distal femoral fractures who were treated by means of open reduction, internal fixation (ORIF), using a distal femoral locked plate in 15 patients and a condylar buttress plate in 15 patients. Fractures were of types A, B, and C according to the AO/ASIF classification. Patients were followed up for 6 months. The exclusion criteria included open fractures, periprosthetic fractures, and old nonunited fractures. The clinical and functional outcomes were classified according to the functional evaluation scoring system described by Sanders and colleagues .
Results
The functional outcome was excellent in 33.3 versus 20%, good in 46.7 versus 26.7%, fair in 13.3 versus 20%, and poor in 6.7 versus 33.3% of patients treated with the distal femoral locked plate and the condylar buttress plate, respectively. The range of motion was significantly superior in patients treated with the distal femoral locked plate. Complications were significantly fewer with the distal femoral locked plate than with the condylar buttress plate with respect to infection, varus deformity, nonunion, and implant failure.
Conclusion
The distal femoral locked plate fixation provided better functional outcome and achieved better degree of knee flexion compared with the condylar buttress plate in the treatment of distal femoral fractures in the same fracture pattern.

Keywords: buttress plate, distal femur, locked plate


How to cite this article:
El Mwafy HM, Abd El Gawad MM, Shams El Din AF, Youssef WM. Surgical treatment of distal femoral fractures using a distal femoral locked plate versus a condylar buttress plate. Menoufia Med J 2015;28:948-53

How to cite this URL:
El Mwafy HM, Abd El Gawad MM, Shams El Din AF, Youssef WM. Surgical treatment of distal femoral fractures using a distal femoral locked plate versus a condylar buttress plate. Menoufia Med J [serial online] 2015 [cited 2020 Mar 30];28:948-53. Available from: http://www.mmj.eg.net/text.asp?2015/28/4/948/173681


  Introduction Top


The femur is the longest bone in the skeleton and one of the principal load-bearing bones. Fractures of the distal femur are serious injuries that are difficult to treat and may result in long-term disability and prolonged morbidity. They represent the terminal 9-15 cm of the femur. They comprise 4-7% of all femoral fractures. Distal femoral fractures occur in a bimodal distribution: at 15-50 years of age it occurs predominantly in the male population on sustaining high-energy trauma; above 50 years of age it occurs predominantly in the female population ([Figure 1]) [1],[2],[3],[4] .
Figure 1 The osseous anatomy of the femur

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Many classification systems have been designed to describe these common fractures, including classifications by Neer et al. [5] , Seinsheimer [6] , and Egund and Kolmer [7] . However, the most commonly used classification for this fracture was the adjustable objective (AO) classification of fractures of long bones, which classifies the fracture as type A (extra articular), type B (partial articular), or type C (complete articular). It is useful in determining treatment and prognosis ([Figure 2]) [5],[6],[8] .
Figure 2 The AO classification of the distal femoral fracture.

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Many deforming muscle forces act on the distal femoral fractures rendering them difficult to be treated, including shortening by the pull of the quadriceps and the hamstring muscles, posterior angulation by the action of the gastrocnemius, varus deformity by the pull of the adductor muscles, and rotation of the condyles in intercondylar fractures by the action of the gastrocnemius ([Figure 3]) [3],[4] .
Figure 3 The deforming forces acting on the distal femur

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In the past, fractures of the distal femur were treated conservatively by skeletal traction, cast immobilization, and cast bracing until the fracture healed; however, prolonged immobilization with its complications, stiff knee, deformity, and nonunion were common among these methods of treatment. In 1970, the AO published its first review of distal femoral fractures treated according to their principles of anatomical reduction and stable internal fixation; most of their reviewed patients achieved good or excellent results. However, surgical treatment was complicated by infection and metal failure in the form of breakage of the implant or packing out of the screws [9],[10] .

With the great advancement in surgical techniques and improvement in the implants used, surgical treatment has become the standard treatment for distal femoral fractures. The surgical treatment of the distal femoral fractures aims to restore the normal articular surface, restore alignment of the limb, achieve full or near full range of motion, painless motion, and return to former activities. Several devices were used for internal fixation of distal femoral fractures, such as a condylar blade plate, a retrograde supracondylar nail, a condylar buttress plate, and a dynamic condylar screw ([Figure 4]) [10],[11],[12] .
Figure 4 The condylar buttress plate.

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Locked plating systems were developed in Davos, Switzerland, in the 1990s, wherein 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 being much less prone to loosening compared with traditional nonlocked plates ([Figure 5]) [13] .
Figure 5 The distal femoral locked plate

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  Patients and methods Top


A randomized prospective study was conducted that included 30 patients with distal femoral fractures (17 men and 13 women), who were divided into two groups: group I included 15 patients treated with a distal femoral locked plate and group II included 15 patients treated with a condylar buttress plate. The patients' ages ranged from 20 to 70 years (mean age 45 years). Fractures were of type A in 24 patients, type B in one patient, and type C in five patients according to the AO classification. Of the 30 patients, 15 had right-sided fractures and 15 had left-sided fractures. Trauma was either severe trauma, resulting from road traffic accidents or falling from a height, in 10 patients or mild to moderate trauma, such as those from simple falls, in 20 patients. The mean time lapse before surgery was 7.20 days in patients treated with the distal femoral locked plate and 4.27 days in patients treated with the condylar buttress plate. No associated injuries were present. Of the 30 patients, 22 had concomitant diseases: nine patients were hypertensive, seven were diabetic, six were cardiac, and one patient had poliomyelitis. All patients were followed up for 6 months.

The rehabilitation protocol was the same in all patients. Early passive range of motion was allowed with a gradual increase in the range of movement. Full weight-bearing was allowed when callus was apparent on the radiographs. Complications were recorded. The clinical and functional outcome was classified according to the functional evaluation scoring system described by Sanders et al. [14] ([Table 1]).
Table 1 The functional evaluation scoring system described by Sanders et al. [14]


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Statistical analysis

The data collected were tabulated and analyzed by statistical package for the social science, version 16 (SPSS Inc., Chicago, Illinois, USA) on an IBM compatible computer.

  1. Quantitative data were expressed as mean and SD (X + SD) and analyzed by means of the Student t-test for comparison of two groups.
  2. Qualitative data were expressed as number and percentage [N (%)] and analyzed by means of the c 2 -test.
  3. All of these tests were used as tests of significance at P values less than 0.05.



  Results Top


The functional outcome was excellent in 33.3 versus 20%, good in 46.7 versus 26.7%, fair in 13.3 versus 20%, and poor in 6.7 versus 33.3% of patients treated with the distal femoral locked plate and the condylar buttress plate, respectively. The range of knee motion was 90-140° (mean 112.93 ± 13.91°) in patients treated with the distal femoral locked plate, and 40-140° (mean 89.67 ± 28.12°), in patients treated with the condylar buttress plate. The range of motion was significantly better in patients treated with the distal femoral locked plate than in those treated with the condylar buttress plate. The mean time of radiological union in which bony trabeculae crossed the fracture gap was 5.21 ± 1.19 months (range 3-6 months) for patients treated with the distal femoral locked plate, whereas the mean time of radiological union was 5.42 ± 1.0 months (range 3-6 months) for patients treated with the condylar buttress plate. Complications were significantly fewer in patients treated with the distal femoral locked plate compared with those treated with the condylar buttress plate. In patients treated with the distal femoral locked there was superficial wound infection in three (20%) patients, which improved with dressing and antibiotics, knee stiffness in one (6.7%) patient, and nonunion in one (6.7%) patient due to broken implant after 5 months. In patients treated with the condylar buttress plate there was superficial wound infection in three (20%) patients, which improved with sterile dressing and antibiotics, and deep wound infection in one (6.7%) patient, which was treated initially with sterile dressing and antibiotics. Surgical debridement and suction irrigation were performed after 3 months postoperatively and infection was controlled; after 6 months, nonunion of the fracture occurred and the patient needed a bone graft. Knee stiffness occurred in three (20%) patients, varus angulation (varus angulation is medial angulation of the distal femoral part in relation to the proximal femoral part at the fracture site and it is determined by measuring the angle formed by the intersection between the femoral shaft axes of the proximal and distal femoral part) in two (13.3%) patients, and nonunion in three (20%) patients, one of them due to deep wound infection and two due to implant failure ([Table 2], [Table 3], [Table 4]).
Table 2 The overall results of the two studied groups


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Table 3 The final range of motion


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Table 4 Complications


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  Discussion Top


Distal femoral fractures are complex fractures that primarily occur as a result of high-energy injuries in young men or from low-energy osteoporotic fractures in elderly women. Careful examination of the patient's history and circumstances is compulsory before selecting the treatment plan [15] .

The current treatment of distal femoral fractures is almost exclusively operative and aims at restoring articular congruity, anatomical length, rotation, and axial alignment and establishing adequate fixation to initiate early unrestricted range of motion and a subjective sense of well-being for the patient. Many different fixation methods have been described. Fixation options can be grouped into three broad categories: open anatomical reduction with plate and screw fixation, bridge plating or submuscular plating, and intramedullary nailing. The choice of implant in the management of the distal femoral fractures is likely to depend on several factors, including bone quality, fracture type, fracture pattern, degree of comminution, articular involvement, and surgeon preference, as the angled blade plate is surgically demanding and needs 2 cm of the distal fragment to be intact to allow blade entry. Surgical experience is required as improper orientation in the sagittal plane will result in anterior or posterior angulation, and incorrect positioning in the coronal or axial plane will lead to axial malalignment or intra-articular insertion. Moreover, the positioning of the guidewire must be precise; impaction of the seating chisel or blade may result in further comminution. The dynamic condylar screw has a large lag screw, and therefore a minimum of 4 cm of intact bone is required in the distal fragment. Thus, the compression screw system in not suitable for low transcondylar fracture or fractures with extensive intra-articular comminution. The condylar buttress plate lacks rigid interface at the screw-plate junction and hence varus collapse may occur in highly comminuted fractures with loss of the medial column. Thus, the buttress plate may not provide sufficient fixation for highly comminuted fractures with fragmentation of the medial cortex, segmental loss of bone, or a very short distal condylar segment. Without adequate medial buttress, collapse of the fracture can occur. The retrograde nail is a good device for type A and B distal femoral fractures in obese patients and in patients with osteoporosis, but it is not preferred in type C fractures as the intra-articular entry portal may produce more fracture comminution. The distal femoral locked plate is a fixed-angle device with locking technology, thus providing angular stability and preservation of the periosteal blood supply. The distal femoral locked plate can be applied by less invasive techniques and can be used in patients with osteoporosis. Locked plates cannot be used to aid the reduction of the nonarticular component of the fracture as conventional fixed-angle devices can. The fracture must be reduced and provisionally fixed before plate placement. Delayed union, nonunion, or even plate fracture can occur if any distraction exists at the fracture site due to the rigidity of the screw-plate construct. Therefore, treatment of distal femoral fractures needs surgical experience to avoid these complications [15],[16],[17] .

The condylar buttress plate is a single-piece implant with a cloverleaf distal portion that fits the distal portion of the femur. The condylar buttress plate has the advantage of multiple multidirectional screw insertion in the distal part of the plate, allowing good fixation of the articular fragments. However, because of loss of rigid interface between the screws and the plate, varus collapse and packing out of the screws may occur in highly comminuted fractures with loss of the medial column, as well as in osteoporotic bone [17] .

The distal femoral locked plate is an anatomically precontoured fixed-angle device with the advantage of insertion of locking screws and conventional screws. This feature allows easy application of the implant, with the locking screws providing rigid fixation and angular stability, thus guarding against varus collapse, whereas conventional screws allow intrafragmentary compression [18],[19] .

Yeap and Deepak [20] reported good to excellent results in 73% of patients treated with a distal femoral locked plate. Bolhofner et al. [21] reported good to excellent results in 68% of patients treated with the condylar buttress plate. The functional outcome in the current study was excellent in 33.3 versus 20%, good in 46.7 versus 26.7%, fair in 13.3 versus 20%, and poor in 6.7 versus 33.3% of patients treated with the distal femoral locked plate and the condylar buttress plate, respectively, demonstrating better results with the use of a distal femoral locked plate. This might be attributed to the fact that the distal femoral locked plate is a fixed-angle device with the locking technology providing angular stability and rigid fixation, which guards against varus collapse, which can occur with the use of the condylar buttress plate, which lacks a rigid interface at the screw-plate junction. Indeed, the distal femoral locked plate preserves the periosteal blood supply and thus promotes fracture healing [20],[21] .

Yeap and Deepak [20] reported in their study that the mean time of union was 18 weeks (range 6-36 weeks). Bolhofner et al. [21] reported that the mean time of union was 10.7 weeks (range 8-16 weeks). In the current study the mean time of radiological union, in which bony trabeculae crossed the fracture gap, was 5.21±1.19 months (range 3-6 months) for patients treated with the distal femoral locked plate, whereas the mean time of radiological union was 5.42 ± 1.0 months (range 3-6 months) for patients treated with the condylar buttress plate [20],[21] .

Yeap and Deepak [20] reported in their study that the mean range of knee flexion was 107.7 for patients treated with the distal femoral locked plate, and this study concluded better knee motion with the use of the distal femoral locked plate. Bolhofner et al. [21] reported that the mean range of knee flexion was 98.8 for patients treated with the condylar buttress plate. In the present study the mean range of knee flexion was 112.93 ± 13.91 and 89.67 ± 28.12 for patients treated with the distal femoral locked plate and the condylar buttress plate, respectively; in this study the range of knee flexion was significantly better in patients treated with the distal femoral locked plate than in those treated with the condylar buttress plate [20],[21] .

Vallier et al. [22] and Petsatodis reported that complications were more in cases treated with the distal femoral locked plate (35%, 13/37 cases) than in those treated with the angled blade plate (10%, 3/29 patients), including malalignment (four with the distal femoral locked plate and one with the angled blade plate), nonunion (six with the distal femoral locked plate and one with the angled blade plate), implant failure (seven with the distal femoral locked plate and no cases with the angled blade plate), and infection (three with the distal femoral locked plate and one with the angled blade plate). Petsatodis et al. [23] reported varus deformity in 10 (26%) cases treated with the condylar buttress plate, in six (25%) cases with the condylar blade plate, and in two (4%) cases with a dynamic condylar screw; knee stiffness was seen in two (5%) cases treated with the condylar buttress plate, in two (8%) cases with the condylar blade plate, and in no cases with the dynamic condylar screw; and pseudarthrosis was seen in four (11%) cases treated with the condylar buttress plate, in six (25%) cases with the condylar blade plate, and in three (5%) cases with the dynamic condylar screw. In the current study the complications in patients treated with the distal femoral locked plate included knee stiffness in one (6.7%) patient, nonunion in one (6.7%) patient, and superficial wound infection in three (20%) patients, whereas complications in patients treated with the condylar buttress plate included knee stiffness in three (20%) patients, varus angulation in two (13.3%) patients, superficial wound infection in three (20%) patients, deep infection in one (6.7%) patient, and nonunion in three (20%) patients. It was noted that complications were significantly fewer in patients treated with the distal femoral locked plate compared with those treated with the condylar buttress plate [22],[23] .


  Conclusion Top


The distal femoral locked plate achieved better outcomes than the condylar buttress plate in the management of distal femoral fractures; this might be attributed to the more rigid fixation provided by the distal femoral locked plate as the distal femoral locked plate is a fixed-angle device with the locking technology providing angular stability and rigid fixation, which guards against varus collapse as seen with the use of the condylar buttress plate, which lacks a rigid interface at the screw-plate junction. The distal femoral locked plate preserves the periosteal blood supply and hence promotes fracture healing.


  Acknowledgement Top


The author extends his heartfelt gratitude and appreciation to Professor Hesham Mohammed Zaki El Mwafy, Professor of Orthopaedic Surgery, Faculty of Medicine, Menoufia University, Egypt; to Professor Mohammed Moustafa Abd El Gawad, Professor of Orthopaedic Surgery, Faculty of Medicine, Alexandria University, Egypt; and to Dr Ahmed Fouad Shams El Din, Lecturer of Orthopaedic Surgery, Faculty of Medicine, Menoufia University, Egypt.

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

  [Table 1], [Table 2], [Table 3], [Table 4]


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