1. Distal Femur Fractures Thomas P. Rüedi, MD, FACS Founder & Honorary member AOFoundation AO SEC 1st Principles Course Kathmandu, May 2009

2. Albin Lambotte 1886- 1955 Pioneer and genius of modern operative fracture treatment.........already 100 years ago recognized that articular fractures must be fixed rigidly with plates and screws in order to allow for early, pain free motion

3. Unfortunatley, Lambottes’ recommendations were forgotten or his superb operative technique and soft tissue care could not be reproduced, so that X-rays like these can be seen until today: Such attempts at surgery are totally inadequate !!!!

4. 1965 Allgöwer fixed this IIIB open, 33 C1 fx from hunting incident as 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

5. 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

6. 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

7. Classification (Müller AO) 33 - B intra-articular unicondylar ( incl.Hoffa) B A extraarticular / supracondylar A C intra-articular bicondylar C Often high energy, open fractures, neuro-vascular injuries in 3-4%

8. 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

9. 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

10. 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

11. Distal femur fracture: choice of implants Classical: 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

12. 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

13. Sch.W. 61y,m MVA: distal Femur fracture 33- C, circumferential degloving of whole leg Secondary split skin graft with defattened skin Satisfactory functional result case of P.Tondelli

14. Patient positioning: knee flexed 30- 45° to reduce pull of gastrocnemius muscle radiolucent table Approaches: Para-patellar lateral

15. 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

16. 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

17. R.O.m, 44y: polytrauma w. 33-C3 open fx After 6 we in traction >> 4cm shortening, mal alignment, stiff joints 6 weeks after injury Plan: indirect reduction w distractor, minimal exposure, DCS postop

18. R.O.m, 44y: polytrauma w. 33-C3 open fx Intensive postop. Physiotherapy > return of function. Good healing Removal of sequestrum, playing tennis after 2y, follow-up at 4y 27 weeks 4 years

19. A.B.m 26y, motorbike injury, III B open, 33- C3 fracture neuro-vascular intact Emergency 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

20. 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

21. 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

22. With the new concept of the, internal fixator based on angular stability of the screws, such screw loosening & collapse will not occur anymore! LISS l Less invasive stabilisation system

23. LISS ( l ess i nvasive s tabilisation s ystem ) 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

24. 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

25. 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

26. 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 LISS DCU Combi-hole= LCP

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

28. I.K., 40y, distal femur C2-type, 2° open LCP: clinical handling tests (2000) Dr.Ch.Sommer, Chur

29. I.K., 40y, distal femur C2-type, 2° open LCP: clinical handling tests (2000) Dr.Ch.Sommer, Chur

30. I.K., 40y, distal femur C2-type, 2° open LCP: clinical handling tests (2000) Dr.Ch.Sommer, Chur

31. I.K., 40y, distal femur C2-type, 2° open 3 months LCP: clinical handling tests (2000) Dr.Ch.Sommer, Chur

32. I.K., 40y, distal femur C2-type, 2° open 6 months LCP: clinical handling tests (2000) Dr.Ch.Sommer, Chur

33. 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 left right

34. 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

35. M.36 y. Motorbike accident, polytrauma - bilateral identical segmental femur fract. Left side: percutaneous reduction / cannulated screw minimal approach for retrograde nail left

36. M.36 y. Motorbike accident, polytrauma -bilateral identical segmental femur fract. 7 days postoperatively (case of Dr.Turchetto)

37. 40 days follow up >> callus formation right left M.36 y. Motorbike accident, polytrauma bilateral identical segmental femur fract. (case of Dr.Turchetto )

38. 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

39. Thank you !!

45. Motorcycle injury: 33- C3 ( not suited for blade plate or DCS) ORIF w. condylar buttress plate, uneventful healing and functional recovery

46. B.L.40y