Session I - Femur Fractures
Treatment of Complex Intraarticular Distal Femur Fractures with Limited Internal and External Fixation
James J. Hutson, Jr, MD, Nicholas J. Connors, MD, Gregory A. Zych, DO
University of Miami School of Medicine, Miami, FL
Purpose: Severe comminution of distal femur intraarticular fractures with shaft extension have been difficult to manage. Retrograde intramedullary nailing with limited internal fixation and lateral and medial plating have been used for these difficult fractures. Severe comminution of the joint surface may compromise retrograde nailing and extensive surgical approach is required to plate these complex injuries. In a prospective study, 18 patients with severe distal femur intraarticular fractures have been treated with limited internal fixation and hybrid circular wire external fixation for these complex fractures as an alternative to lateral and medial plating.
Methods: Ten male and 8 female patients with distal femur intraarticular fractures (AO Classification of Fractures: 2 C2.3; 1 C3.l; 1 C3.2; 14 C3.3), five closed, one GI, six GII, two GIIIA, two GIIIB, and one GIIIC open injuries were treated. Average age 38 years. Ipsilateral extremity injuries were common. There were three tibial plateau, one tibial shaft, one pylon, four patella, one calcaneus, three quadriceps tendon disruptions and one severe crush injury of the foot.
Initial management for open fractures was early debridement and stabilization with a half-pin bridging frame or tibial traction. Patients with closed injuries were stabilized with tibial traction. Pre-operative CT scans of fractures with extensive comminution aided in reconstruction. Two patients with C2.3 fractures had percutaneous fixation, 16 fractures had limited internal fixation with "free pins" and screws, long 3.5-mm pelvic screws were frequently used. Two fractures with low coronal splits required mini plates to secure the fragment. Extensive comminution of the condylar surface required osteotomy of the patellar tendon tibial tubercle in four patients. Severe crushing of the condylar joint surface required acute autologous bone grafting in three patients. Following stabilization of the condylar mass, 3 to 4 tensioned wires were placed into the condylar and secured to a stable base ring with 3 to 4 femoral shaft half-pins proximally.
Results: 17/18 fractures healed, average frame time was 24 weeks (12 - 60 weeks). Average ROM was 0° to 35° (55° - 135°). Average follow-up was 24 months (12 - 51). 14/18 patients have returned to work.
Complications: Seven patients had flexion less than 90°. Bone loss of the condylar joint surface, patella fracture with quadriceps tendon injury or ipsilateral tibial fracture were observed in patients with less than 90° range of motion. Two patients had late bone grafting for delayed union. One deep infection of the shaft fracture site required debridement and antibiotic beads. One septic arthritis required arthrotomy and IV antibiotics. One patient had IM nailing for nonunion at 14 months. Persistent recurvatum of 15° in these fractures, osteotomy and correction done 4 months post injury. Three patients had quadriceps plasty to improve motion.
Discussion: Limited internal fixation with circular wire external fixation is a technically complex procedure. Severe comminution in "unsalvageable" fractures can be successfully reconstructed with this method. There is a high rate of complication which must be managed assiduously. In this series of 18 fractures, all patients have returned to independent gait, but with compromise of knee function. This technique is recommended only for severe injuries which are not amenable to retrograde nailing or plating.