1. Distal Femur Fractures

2. Overview
Evaluation
Planning
Surgery
Options
Techniques

3. Distal Femur Fractures
Assess fracture/patient
“Personality of the fracture”
Other patient issues (e.g. polytrauma)
Plan your surgery
Implants, positioning, technique
Reduce fracture
Stabilize fracture
Rehabilitation

4. Articular Fractures Overriding principles:
Anatomic reduction of joint surfaces
Reduce articular surface to shaft with appropriate length, alignment, rotation
Stable fixation with safe implant placement and minimal biological insult
Allows for early motion of the joint and early rehabilitation
Principles similar for all articular fractures

5. Evaluation of Distal Femur Fractures
Plain radiographs
AP/lateral knee
AP/lateral femur
AP/lateral contralateral distal femur for planning
Consider traction views or obliques
CT Scan?

6. Evaluation of Distal Femur Fractures
CT scan – gives details about articular surface involvement
Wait for traction if ex-fix planned

7. Evaluation of Distal Femur Fractures
Don’t forget the Hoffa fragment!
38% of supracondylar/intercondylar distal femur fractures have a coronal plane fracture
(Nork et al, J Orthop Trauma, 87:564, 2005)
Most precisely diagnosed via CT scanning

8. Classification Schemes - Caution
Classification schemes are mediocre at best
A good classification:
Describes the fracture pattern well
Describes the prognosis/outcome for the patient
Is reproducible for multiple fractures for the same practitioner
Is reproducible across multiple practitioners
Guides treatment
Few classification schemes do all of this well

9. External Fixation?
Valuable for tibial plateau fractures and pilon fractures for temporary stabilization to allow for soft tissue recovery
Distal femur fractures can often be fixed definitively without delay, unless…
Patient condition precludes long procedure or definitive fixation
Non-patient-specific factors (OR availability, etc.)

10. External Fixation? Spanning knee external fixation
Allows for temporary stabilization of fracture if delayed reconstruction is necessary
External fixator as a reduction aid at time of definitive reconstruction
Keep pins out of planned surgical field!

11. Planning Definitive Reconstruction
Avoid notch and concomitant injury to cruciate ligaments
Avoid penetration of medial cortex with anterior screws X X

12. Planning Definitive Reconstruction – Posterior Condylar Alignment with Shaft
Posterior condyles project POSTERIORLY with regard to femoral shaft!
Don’t do
this!

13. Planning Definitive Reconstruction – Distal Femoral Valgus
9° valgus anatomic axis for distal femur

14. Planning Definitive Reconstruction – Deforming Forces
Short and extended is no way to go through life, son
Hamstrings Shorten
Gastrocnemius
Extends

15. “Method of Attack” Reduce articular surfaces first
Direct reduction techniques
Secure fixation of articular surfaces
Interfragmentary screws
Restore continuity of articular block with shaft
Indirect reduction techniques

16. Internal Fixation Options
Condylar buttress plates
Fixed-angle devices
Blade plate
Dynamic Condylar Screw (“DCS”)
Retrograde intramedullary nail
Locked plates
All implants can work if utilized properly

17. Prior to Applying Implants…
Reduce the fracture!

18. Surgical Technique
Internal fixation implants do NOT reduce the fracture (although they may aid reduction)
The surgeon reduces the fracture
Distal femur extended

19. Indirect Reduction Not for articular surfaces
Direct visualization and reduction
Preserves soft-tissue envelope around metadiaphyseal fracture lines
Achieve restoration of length, alignment, and rotation via traction and manipulation utilizing reduction aids that do not strip soft tissues around the fracture site

20. Respect the Biology! Indirect reduction techniques: External fixator
Femoral distractor
“Joysticks”
Percutaneous clamps
Bumps

21. Indirect Reduction Aids
BEFORE
AFTER
BUMP

22. Respect the Biology – Indirect Reduction
Limit soft tissue dissection
Indirect reduction techniques
Submuscular plate application without extensive stripping
Preserve periosteal blood supply when able

23. Which Implant? Condylar buttress plate Fixed-angle device
Blade plate
Dynamic Condylar Screw (“DCS”)
Retrograde intramedullary nail
Locked plate
All implants can work if utilized properly

24. Retrograde Intramedullary Nail
Advantages
Smaller incision
“Percutaneous” joint fixation
Limited exposure
Decreased blood loss (?)
Load-sharing device, longer lever arm (if long nail utilized)
Soft tissues intact
Disadvantages
Arthrotomy required
“Percutaneous” joint fixation
Lack of alignment control (“windshield wipering” of implant”
Insertion thru cartilage
Difficulty of insertion with total knee arthroplasty component in place

25. Retrograde Intramedullary Nail
Don’t forget to reduce the fracture first!
Nail will not assist with this as you are not achieving an isthmic fit as can be achieved with diaphyseal femoral shaft fractures
Nail will happily “lock” a fracture in a malreduced position as easily as it will “lock” a fracture reduced

26. Plate-and-Screw Constructs
Advantages
Direct visualization of joint with fixation
Restoration of mechanical axis
Improved fixation over nail (?)
Disadvantages
Blood loss (?)
Soft tissue stripping (?)
Screw purchase in osteopenic bone
Load-bearing device

27. Which Implant? Condylar buttress plate Fixed-angle device
Blade plate
Dynamic Condylar Screw (“DCS”)
Retrograde medullary nail
Locked plate
All implants can work if utilized properly

28. Plan Ahead Principles of surgical treatment:
1. Careful handling of soft tissues
2. Indirect reduction techniques
3. Anatomic reduction of the articular surface and restoration of limb axial alignment, rotation, and length
4. Stable internal fixation
5. Early rehabilitation

29. Plating Technique
Limited incisions with exposure of joint and articular segment
Submuscular (not subperiosteal) plate application
Fixation of implant to articular block
Restore alignment
Fixation of implant to shaft
NO SOFT TISSUE STRIPPING !!!!

30. Locked Plates Advantages Disadvantages COST
Submuscular “percutaneous” insertion
Anatomically contoured
Resists varus deformation – “fixed-angle” devices
Good fixation for osteopenic bone
Disadvantages
May be difficult to avoid screw “traffic” utilized for reduction and fixation of articular surfaces (polyaxial implants may avoid this)
COST

31. Locked Plating
Locked plates can avoid difficulty encountered with stabilization of coronal splits in distal femoral fractures that were problematic with blade plate fixation

32. Locked Plating
CT scan reveals multiple articular splits in both the sagittal and coronal planes

33. Special Tip for Locking Plates
The C-Arm rarely tells the truth!
Can’t judge coronal/sagittal plane alignment in small field of view
Get long cassette AP/Lat views after provisional fixation and shaft reduction

34. Summary Have a full understanding of fracture anatomy
Understand the benefits and limitations of each implant
Utilize reduction techniques that are soft-tissue friendly
Beware of common pitfalls (sagittal plane malreductions, etc)
Results Largely Based on Surgical Technique
Not on the Implant Choice