However, as the complexity of fractures needing treatment has changed from simple extra-articular supracondylar types to intercondylar and metaphyseal comminuted types, these implants may not be ideal.               Double plating and more recently locked plating has been advocated. However, with double plating there is extensive soft tissue stripping in both sides of femur, resulting in reduced blood supply and potential non-union and implant failure.

Distal femur locking compression plate has a smaller application device and allows both locking and compression screw fixation in the femur shaft. In our centre, we have decided to evaluate the short term functional outcome of operative treatment of distal femur fractures using Sander’s et al criteria. We classified distal femur fractures using AO (Muller’s) Classification.¹

AIMS AND OBJECTIVES

To analyse the functional outcome of distal femur fractures treated with locking compression plate.

MATERIALS AND METHODS

The present study has totally 20 cases who took operative treatment for distal femur fractures from April 2013 to October 2015. It is a prospective and retrospective study. For all the cases, we used the Standard Lateral Approach.² Out of 20 cases, 15 cases were closed fractures and 5 cases were grade-I compound fractures. Out of 20 cases, 13 were right-sided and 7 were left-sided distal femur fractures. The age group of patients ranges from 24 to 72 years.

Follow-Up

All patients were followed up regularly and they were assessed using Sander’s et al scoring system.

Patients were followed up at 6 weeks, 3 months, 6 months, 12 months and then yearly.

Inclusion Criteria

• Age 20 to 80 years.
• Closed or open (Gustillo Anderson³ grade I) fractures.
• AO type A, B and C fractures of distal femur.
• Patients with head injury and vascular injury.
• Age <20 years and >80 years.
• Patients not fit for surgical intervention.

Exclusion Criteria

RESULTS

In the period between April 2013 to October 2015, 20 patients with 20 fractures of the distal femur were taken up for this study. In our study, we did not have any bilateral distal femur fractures. All the patients were treated by distal femur Locking Compression Plate.

Age Distribution

In this study, age of the patients ranged from 24 to 72 years. The patients between the age group 31-40 years comprise the majority. The average age of the patients was 39.4 years.

Sex Distribution

Out of 20 patients there were 12 (60%) male and 8 (40%) female in our study.

Side Distribution

Majority of the patients in this study 13 (65%) sustained injury to the right side.

Mode of Injury

In this study, 17 (85%) patients sustained injury due to road traffic accident which comprises the majority.

Type of Injury

In our study, 15 patients had closed injury and 5 patients had compound fracture.

Classification of Fractures

The fractures were classified as per AO (Muller's) classification. Muller's type A1 comprises 7 (35%) cases, with maximum incidence in this study.

Time of Presentation After Injury

Out of 20 patients, 16 patients presented to the hospital within 24 hours, 4 cases presented between 2 to 7 days.

Associated Injuries

Time of Surgery After Admission

In our study, 5 patients were operated within 2 days, 12 patients were operated between 3 to 5 days and 3 patients operated after 5 days.

Mode of Anaesthesia

In our study, majority of patients 11(55%) were operated under combined spinal and epidural anaesthesia.

Rate of Radiological Union

Out of 20 cases, 5 cases showed radiological union within 15 weeks and 14 cases between 16-30 weeks. Average rate of union is 20.5 weeks.

Duration for Full Weight Bearing

In our study, we started full weight bearing once there is evidence of radiological union. For majority of cases, we started full weight bearing at 16-20 weeks after surgery.

Range of Knee Flexion

In our study, less than 70 degrees knee flexion was attained in 2(10%) cases, 71-100 degrees knee flexion in 10(50%) cases and more than 100 degrees of knee flexion attained in 8(40%) cases.

COMPLICATIONS

The complications observed in this study were 1 case with deep infection, 3 cases with superficial infection, 1 case with shortening, 1 case with implant breakage and 4 cases of knee stiffness.

Functional Results

The function results of the study were assessed based on Sander's et al functional evaluation criteria. Out of 20 patients treated surgically, 1 (5%) patient had excellent results, 13 (65%) patients had good results, 5 (25%) cases with fair result and 1 (5%) patient had shown poor result. Hence, overall Locking Compression Plate has given reasonably a better functional outcome.

DISCUSSION

The treatment of complex distal femur fractures requires a thorough understanding of fracture biology. Treatment methods vary from conservative to internal fixation. Conservative treatment is associated with unsatisfactory outcomes. Conservative treatment using tibial traction for distal femoral fractures was reported by Mahorner and Bradburn [1933]⁴, with good final results in only few cases.

Operative treatment of distal femur fractures was revolutionised in the 1970s with the advent of AO implants, instruments and techniques. Dynamic condylar screws and blade plates require removal of large amount of bone for insertion, which limits their use in some fracture types.

Biomechanical studies revealed that gross loosening of the standard condylar buttress plate and DCS occurred because of toggle at the screw-plate interface. To address these issues, locking condylar plate was designed.

Locking compression plate decreases screw-plate toggle and motion at the bone-screw interface and provides more rigid fixation. Its unique biomechanical function is based on splinting rather than compression resulting in flexible stabilisation, avoidance of stress shielding and induction of callus formation.

In our study, 20 patients with distal femoral fractures were treated with distal femur locking compression plate and results were evaluated. Among 20 patients, 12 (60%) patients were male and 8 (40%) were female. The age of the patients in our study ranged from 24 to 72 with mean age of 39.4 years. Mode of injury was road traffic accident in 17 (85%) patients and fall in 3 (15%) patients. Right limb was commonly involved with 13 (65%) fractures in right side and 7 (35%) fractures involving left side. Average number of days from injury to surgery was 5 days with range from 1 day to 8 days. The operative time ranged from 60 min. to 150 min. with average of 102 min. All fractures in our study were classified according to AO classification system. There were 7 (35%) type A1, 6 (30%) type A2, 3 (15%) type A3, 3 (15%) type C1 and 1 (5%) type C2 fractures. Among these, 15 (75%) patients had closed fracture and 5 (25%) had grade I compound fracture.

Yeap EJ et al⁵ in his study on 11 patients with distal femur fractures treated by locking compression plate, seven were male and four female patients. The patient’s age ranged from 15 to 85 with mean age of 44 years. The causes of fractures were motor vehicle accident in 7 patients and fall in 4 patients. Seven fractures involved the right side and four involved the left. The average number of days from injury to surgery was 9.9 days with range of 4 to 18 days. The operative time ranged from 80 min. to 180 min. with an average of 119.2 min. In his study, there were 4 type A1, 2 type A3, 1 type C1, 1 type C2 and 3 type C3 fractures. Four (36.4%) of the fractures were compound and seven (63.6%) were closed fractures.

Hosam M et al⁶ in his study on 23 patients treated for distal femur fractures were in the age group ranging from 28 to 76 years, with an average of 48.25 years.

Fourteen cases (60.7%) were right-sided and nine cases (39.13%) were left-sided fractures. 15 (65.22%) cases suffered from road traffic accident while 8 (34.78%) patients suffered injury due to fall. 2 cases (8.70%) were open fractures and 21 cases (91.3%) were closed fractures. Nine cases (39.13%) were operated upon within the week after injury, eight cases (34.78%) in the second week and six cases (26.09%) two weeks after injury.

In our study, the range of knee flexion is 50 degrees to 120 degrees and average knee flexion is 98 degrees. Average time of union was 20.5 weeks with a range from 10 weeks to 34 weeks. All the patients were evaluated using Sander’s et al scoring system and we had 70% excellent to good result. Various complications encountered in our study are 3 (15%) patients with superficial infection which subsided with oral antibiotics, 1 (5%) had deep infection which subsided with wound exploration and suction-irrigation, 1 (5%) patient with limb shortening, 4 (20%) patients had knee stiffness which needed physiotherapy treatment. Out of this, 1 patient came back with broken implant and re-fracture following native treatment for the knee stiffness and lost follow-up.

Kanabar et al,⁷ in his study noted bone union in a mean period of 17(Range, 10-36) weeks and mean range of knee flexion was 93 degrees (80-130 degrees). Complications encountered in his series included 1 patient with deep infection, 2 patients with superficial infection and 1 patient with implant breakage.

Hosam M et al, in his study had excellent and good results in 18 patients (78.26%), with fair and poor results in 5 patients (21.74%). In his study, various complications encountered were deep infection in one case (4.35%), delayed union in three cases (13.04%), knee joint stiffness in three cases (13.04%) and shortening in two cases (8.70%).