Complex Distal Femoral Fractures Research Articles

Three-dimensional computed tomography mapping techniques in the morphometric analysis of AO/OTA 33A and 33C distal femoral fractures: a retrospective single-center study.

Purpose: Complex distal femoral fractures involve a challenging set of considerations that must be known to provide optimal management. This study aimed to determine the location and frequency of fracture lines and comminution zones in AO/OTA types 33A and 33C distal femoral fractures using three-dimensional computed tomography mapping. Methods: Seventy-four consecutive eligible patients were included. Fracture fragments for each patient were reconstructed, virtually reduced, and adjusted to match the distal femoral template. Then, all fracture lines and comminuted areas were extracted in transparent mode, and corresponding heat maps were constructed. Finally, these maps, along with the quantitative analysis findings of the counts and volumes of each fragment, were used to summarize the characteristics of the fractures. Results: Thirty-four females and 40 males [average age, 58years (range, 18-92years)] presented with a distal femoral fracture. There were 53 AO/OTA type 33A fractures, and 21 AO/OTA type 33C fractures. These two patterns differed significantly on fracture fragment count, comminuted zone fracture fragment count, and mean comminuted zone fracture fragment volume (p < 0.05). Most of the fracture line heat zones were in the femoral epiphysis, intercondylar notch of the femur, and patellofemoral joint. The comminuted area heat regions were mostly found on the lateral, anterior, and posterior femoral diaphysis, with less involvement on the medial side. Conclusion: Our findings may serve as a guide for the surgical approach selection of complex distal femur fractures, the placement strategy of the internal fixation, and the optimization of the osteotomy plan for biomechanical studies.

Double fixation for complex distal femoral fractures.

For complex distal femoral fractures, a single lateral locking compression plate or retrograde intramedullary nail may not achieve a stable environment for fracture healing.Various types of double fixation constructs have been featured in the current literature. Double-plate construct and nail-and-plate construct are two common double fixation constructs for distal femoral fractures.Double fixation constructs have been featured in studies on comminuted distal femoral fractures, distal femoral fracture with medial bone defects, periprosthetic fractures, and distal femoral non-union.A number of case series reported a generally high union rate and satisfactory functional outcomes for double fixation of distal femoral fractures.In this review, we present the state of the art of double fixation constructs for distal femoral fractures with a focus on double-plate and plate-and-nail constructs.

Evaluation of the Results of Minimally Invasive Plate Osteosynthesis Using a Locking Plate in the Treatment of Distal Femur Fractures.

IntroductionDistal femur fractures are serious injuries that can be difficult to treat, carry an unpredictable prognosis, and lead to long-term disability and morbidity. The introduction of minimally invasive plate osteosynthesis (MIPO) avoids direct exposure of the fracture site, improves fracture healing and decreases the incidence of complications. The aim of this study was to assess prospectively the early results of the treatment of supracondylar fractures of the femur using minimally invasive percutaneous osteosynthesis using a distal femoral locking plate. The study was a prospective study that included 20 adult patients who sustained distal femur fractures.Materials and methods The study was a prospective study that included 20 patients suffering from supracondylar fractures of the femur. All patients had fixation of the fracture using a distal femur locking plate (less invasive stabilization system (LISS)) in a minimally invasive technique using an anterolateral or direct lateral approach to the distal femur according to the fracture classification. The follow-up was done using the functional evaluation scale for distal femoral fractures as regards range of motion, deformation, pain, walking ability, and return to work.ResultsThe mean age was 52.80 (19-80) years. The mean body mass index of the patients was 28.50, with a range of 23-43 kg/m2. The mechanism of trauma was road traffic accidents (RTAs) in nine patients (45%) and falling from standing height in eleven patients (55%). Fractures were classified according to the Arbeitsgemeinschaft Osteosynthesefragen-Orthopedic Trauma Association (AO-OTA) classification. All patients were followed up for a period of six months and assessed in terms of knee range of motion, deformation, pain, walking ability, and return to work. The mean time of radiological union, in which bony trabeculae crossed the fracture gap, was 3.45 ± 0.79 months. The final results obtained were excellent in four patients (20%), good in nine patients (45%), fair in five patients (25%), and poor in two patients (10%). Complications encountered were knee stiffness (20%), superficial wound infection (10%), and shortening (15%).ConclusionLISS plating using the MIPO approach is useful in treating complex distal femoral fractures. Large studies from independent centers reporting long-term results are needed to further evaluate the role of LISS plating and the MIPO approach in the management of complex distal femoral fractures.

CLINICAL EVALUATION OF EFFICACY OF MINIMAL INVASIVE PLATE OSTEOSYN THESIS TECHNIQUE FOR SURGICAL MANAGEMENT OF SUPRACONDYLAR FEMUR FRACTURES

AIMS AND OBJECTIVES: To study Union rate (time to union), time of mobilization, functional results, radiological results, complications of supracondylar femur fractures treated by MIPO techniques with distal femur locking compression plate (DF-LCP). MATERIALANDMETHODS: This is a prospective study of 30 Patients, with supracondylar femur fractures (AO classication A) who were treated with distal femur locking compression plate (DF- LCP) by MIPO techniques at Department of Orthopaedics, SSKM &amp; IPGMER KOLKATA from 1stJAN2015 to 31st JULY 2016.The study sample size was 30 patients and all these patients were included with predened inclusion &amp; exclusion criteria in this study. Minimum of 12 months and a maximum of 17 months follow up were done. The functional and radiographic results were recorded according to Knee Society Score criteria. RESULTS: The average time to union was 3.93 months with a range of 2 – 7 months (8 – 28 weeks) and standard deviation being 1.13. The Mean range of exion obtained postoperatively was 108.830 with a range of 900– 1250. Six decreased knee movements, two mal-alignment, two implant failure and two infection were the residual complications in our study. Follow up of our cases included from a minimum of 12 months to a maximum of 17 months. Excellent results were seen in 3 cases, good in 10, fair in 12 and 5 case of poor results was seen. CONCLUSION: We conclude that MIPO technique with DF-LCP in distal femoral fractures is a safe and reliable option. It may substitute a conventional plate and screw system (compression method) in treatment of complex distal femoral fractures especially in osteoporotic bone. Further randomized controlled studies are required in different situations to know the usefulness of this implant.

Early fixation failure of locked plating in complex distal femoral fractures: Root causes analysis

Orthopaedic Trauma Association (OTA) C-type distal femoral fractures can be very challenging to treat effectively. While locked plating is widely used in the complex distal femoral fracture, failure of locked plate fixation is not uncommon. First, we tried to determine the risk factor related to early failure of multiplanar OTA C-type fracture in the distal femur after fixation with lateral locked plate. Second, we tried to provide a strategy for surgeons to prevent pitfalls of early failure in the complex distal femoral fractures treated with lateral locked plating. We retrospectively reviewed 44 adults with OTA C-type fractures of the distal femur treated with locked plate fixation between 2010 and 2016at Tri-Service General Hospital. Average length of follow-up was 27.6 months (range, 12-54 months). Univariate and multivariate logistic regression were used to determine the association of variables on early failure of fixation. A p-value < 0.05 in univariate and multivariate analyses were considered significant. There were six patients experiencing early failure, and the early failure rate was 13.6%. The risk factors associated with early failure of complex distal femoral fracture identified by univariate analysis included sagittal oblique fracture pattern, longer working length and post-operative sagittal malalignment (odds ratio [OR] and 95% confidence intervals [CI]: 90.00 (6.85-1183.33), 0.55 (0.31-0.98) and 8.63 (1.077-69.075) respectively). The multivariate analysis showed only sagittal oblique fracture pattern was associated with early failure [OR: 52.348 (3.06-895.23)]. Sagittal oblique fracture was more likely to result in early postoperative failure. Early recognition of the fracture pattern should be considered to avoid catastrophic results.

The Olerud Extensile Anterior Approach for Complex Distal Femoral Fractures: A Systematic Review.

The management of AO/OTA (AO Foundation/Orthopaedic Trauma Association) 33-C3 complex distal femoral fractures presents challenges for orthopaedic surgeons. The extensile anterior approach may be an appropriate alternative treatment technique. The purpose of this systematic review is to (1) evaluate the Olerud approach (extensile anterior approach) for the treatment of 33-C3 complex distal femoral fractures and (2) evaluate postoperative patient outcomes. A systematic literature search was performed to retrieve studies that evaluated the treatment of 33-C3 complex distal femoral fractures. The PubMed database query resulted in 429 studies. Two reviewers independently reviewed the studies, of which six were identified. Patient demographics, AO/OTA fracture, surgical intervention, follow-up duration, clinical outcomes, and postoperative complications were collected and analyzed. The systematic review included six studies reporting on 85 patients (43 males and 42 females); the mean patient age was 45 years (range: 16-101 years). The most common cause of injury was road/traffic accident (51 patients). The mean follow-up time was 26 months (range: 3-72 months). In five studies, the mean time for union was 5.8 months (range: 2-9 months). The three most commonly reported complications were infection (seven [8.2%] patients), failure/malunion (three [3.5%] patients), and delayed tibial tuberosity osteotomy healing (three [3.5%] patients). Seventy (82.4%) patients did not suffer any postoperative complications. Out of 72 patients, 7 (9.7%) had resultant varus/valgus deformity. Overall, 57.1% had excellent/good functional outcomes. Based on the systematic literature review, the extensile anterior approach may be a viable alternative surgical option for 33-C3 complex distal femoral fractures. Given the current literature, more comprehensive and extensive studies need to be performed to ensure the best possible outcome.

The outcome following fixation of complex open distal femur fractures

Background: Distal femur fractures account for less than 1% of all fractures and 4%–6% of all femur fractures. Soft tissue damage, comminution and articular extension makes the treatment difficult and they often result in unsatisfactory outcome and poor knee function. Open fractures further complicate the situation. In our study we compared functional outcome, time of union and complications of open complex distal femoral fractures treated with delayed plating or primary Ilizarov ring fixator. Material and Methods: we retrospectively reviewed 23 cases presented at department of Orthopedics, from January 2011 to January 2017. All skeletally mature patients with AO type C distal femur fractures and up to Gustilo Anderson grade IIIA were included. Pathological fractures, types IIIB and IIIC open fractures and patients with other fractures in the ipsilateral limb were excluded from the study. Patients in group A were treated with delayed plating and in group B with primary Ilizarov.Result: Out of the 23 cases, all cases in both groups showed radiological union between 16-22 weeks. 3 cases of group A showed shortening of >2 cm while Ilizarov group had none. In 5 cases of group A, primary bone grafting done during surgery having severe comminution (C3 type) and in one case secondary bone grafting done after 5 months for delayed union. Out of 12 cases of group A, 5 patients (42%) achieved full flexion. In group B limited knee flexion was seen in all cases with mean flexion at final follow-up of 92°. Conclusion: Delayed fixation with autologous fibular grafting and distal femoral locking plate provides adequate restoration of knee motion and early knee mobilization with high risk of infection. Whereas Ilizarov fixator shows better outcome in terms of infection control, LLD management, lesser number of surgeries, lesser hospital stay, earlier post-op rehabilitation and acceptable knee function.

Efficacy analysis of inverted intramedullary nail combined with medial minimally invasive plate in treatment of type C2 and C3 distal femoral fractures

Objective To investigate the clinical efficacy of inverted intramedullary nail combined with medial minimally invasive plate in treatment of type C2 and C3 distal femoral fractures. Methods A retrospective case control study was conducted on 38 patients with complex distal fractures of the femur treated from January 2015 to January 2017. There were 22 males and 16 females, aged 24-72 years [(45.6±2.5)years]. AO fracture classification was type C2 in 24 patients and type C3 in 14. All of them were fresh closed fractures. The time duration from injury to operation was 4-16 days (average, 7.5 days). Based on the different surgical methods, the patients were divided into lateral single plate fixation group (single plate group, 20 patients) and inverted intramedullary nail combined with medial minimally invasive locked plate fixation group (locked plate group, 18 patients). The two groups were compared in terms of operation condition, early weight bearing time, fracture healing time, postoperative complications, postoperative knee function and activity of living. Hospital for Special Surgery (HSS) score was used for evaluating postoperative knee function and Barthel index for activity of living. Results The patients were followed up for 10-24 months [(12.2±1.8)months]. The operation duration was (110.5±35.4)min for single plate group and (116.7±42.3)min min for locked plate group(P>0.05). Intraoperative blood loss in single plate group was [(450.5±120.7)ml] and [(455.2±130.4)ml]in locked plate group (P>0.05). The early weight bearing time in single plate group was (28.5±8.6)days and 18.7±4.9 (P<0.01)days in the locked plate group. The fracture healing time in single plate group was (8.5±2.2)months, and [(6.5±1.6)months]in locked plate group (P<0.01). After 3 weeks, 6 months and 12 months, HSS scores of knee joint function of the locked plate group was significantly better than that of single plate group (P<0.01). At 6 months and 12 months after operation, Barthel index score of locked plate group was significantly better than that of single plate group (P<0.01). No infection occurred in two groups after operation. There were no complications such as internal fixation failure, knee valgus, external rotation deformity or fat embolism in locked plate group. There were two cases of internal fixation failure, one knee eversion, and two knee varus in single plate group (P<0.01). Conclusion Compared with single plate fixation, the therapeutic method of inverted intramedullary nail combined with medial minimally invasive locked plate has the advantages of early weight bearing time, quick recovery, better function restoration and fewer complications, and hence is a preferable choice for treatment of type C2 and C3 complex distal femoral fractures. Key words: Femoral fractures; Fracture fixation, intramedullary; Interlocking intramedullary nail

Results in treatment of distal femur fractures using polyaxial locking plate

Indications and techniques of locked plate fixation for the treatment of challenging fractures continue to evolve. As design variant of classic locked plates, the polyaxial locked plate has the ability to alter the screw angle and thereby, enhance fracture fixation. The aim of this observational study was to evaluate clinical and radiographic results in 89 patients with 90 fractures of the distal femur treated, between June 2006 and November 2011, with such a polyaxial locked plating system (Polyax™ Locked Plating System, DePuy, Warsaw, IN, USA). Seventy-seven fractures formed the report of this study. These cases were followed up until complete fracture healing or for a mean time of 77 weeks. At the time of last follow-up, 58 of 77 fractures (75.3 %) progressed to union without complication and radiographic healing occurred at a mean time of 16.3 weeks. Complications occurred in ten fractures that did not affect the healing and in nine fractures that showed delayed or non-union. The mean American Knee Society Score at the time of final follow-up was 83 for the Knee Score and 71.1 for the Functional Score. In conclusion, there is a high union rate for complex distal femoral fractures associated with a good clinical outcome in this series.

Distal femoral replacement for selective periprosthetic fractures above a total knee arthroplasty.

The management of distal femur periprosthetic fractures in the elderly remains a challenge. The aim of this study was to evaluate the results of distal segmental femur replacement as an alternative to fixation in complex distal femoral periprosthetic fractures in elderly patients. Twelve patients were included in this prospective study, with a mean age of 78years (range 68-90years); incidentally, all were female. Fractures of the distal femur were classified as per Kim et al.'s classification (Clin Orthop Relat Res 446:167-175, 2006); our series included eight patients with type III and four patients with type II periprosthetic fractures. All 12 patients were treated with segmental distal femur replacement (Zimmer Inc., Warsaw, IN, USA). Nine patients required 90cm and three patients required 130cm of distal femur segment with a rotating hinge knee prosthesis. The mean follow up period was 20months (range 15-28months), with no major surgical complications reported. The mean duration of hospital stay following surgery was 12days (range 7-36days). All patients were mobilising full weight-bearing by day 3. All patients returned to their prior living arrangements. Ten patients returned to their original domicile, with one patient being discharged to a care home requiring minimal ambulatory assistance. The remaining two patients returned to their care homes. WOMAC scores improved from the pre-injury state with a mean of 49.62 to 72.54 post-surgery (p-value of 0.0001). The Knee Society scores, possible only following surgery, had a mean value of 72. The mean VAS pain score was 1.75 (0 = no pain to 10 = worst pain ever felt). The average range of knee flexion was from 4° to 89° (range -5° to 110°). The mean SF-36 physical functioning score was 45.64 [range 40.70-48.90; standard deviation (SD) -2.62] and the mean SF-36 mental functioning score was 52.94 (range 45.8-57.70; SD -3.38).

Highly unstable complex C3-type distal femur fracture: can double plating via a modified Olerud extensile approach be a standby solution?

BackgroundMultiplanar complex C3-type unstable distal femoral fractures present many challenges in terms of approach and fixation. This prospective study investigates a possible solution to these problems through double plating with autogenous bone grafting via a modified Olerud extensile approach.Materials and methodsTwelve patients with closed C3-type injuries were included; eight of them were male, and their mean age was 33.5 years (range 22–44 years). Mechanism of injury was road traffic accident (RTA) in nine patients and fall from height in the other three cases. Eight cases were operated during the first week and four cases during the second week after injury. Mean follow-up was 13.7 months (range 11–18 months).ResultsMean radiological healing time was 18.3 weeks (range 12-28 weeks), and all cases had good radiological healing without recorded nonunion or malunion. Clinically, two cases (16.7 %) had excellent results, five cases (41.7 %) had good results, three cases (25 %) had fair results, and two cases (16.7 %) had poor results. No cases developed skin necrosis, deep infection, bone collapse, or implant failure. However, two cases (16.7 %) had limited knee flexion to 90° and required subsequent quadricepsplasty.ConclusionsUse of this modified highly invasive approach facilitated anatomical reconstruction of C3-type complex distal femoral fractures with lower expected complication rate and acceptable clinical outcome, especially offering good reconstruction of the suprapatellar pouch area. It can be considered as a standby solution for managing these difficult injuries.

Internal Fixation of Type-C Distal Femoral Fractures in Osteoporotic Bone

Fixation of distal femoral fractures remains a challenge, especially in osteoporotic bone. This study was performed to investigate the biomechanical stability of four different fixation devices for the treatment of comminuted distal femoral fractures in osteoporotic bone. Four fixation devices were investigated biomechanically under torsional and axial loading. Three intramedullary nails, differing in the mechanism of distal locking (with two lateral-to-medial screws in one construct, one screw and one spiral blade in another construct, and four screws [two oblique and two lateral-to-medial with medial nuts] in the third), and one angular stable plate were used. All constructs were tested in an osteoporotic synthetic bone model of an AO/ASIF type 33-C2 fracture. Two nail constructs (the one-screw and spiral blade construct and the four-screw construct) were also compared under axial loading in eight pairs of fresh-frozen human cadaveric femora. The angular stable plate constructs had significantly higher torsional stiffness than the other constructs; the intramedullary nail with four-screw distal locking achieved nearly comparable results. Furthermore, the four-screw distal locking construct had the greatest torsional strength. Axial stiffness was also the highest for the four-screw distal locking device; the lowest values were achieved with the angular stable plate. The ranking of the constructs for axial cycles to failure was the four-screw locking construct, with the highest number of cycles, followed by the angular stable plate, the spiral blade construct, and two-screw fixation. The findings in the human cadaveric bone were comparable with those in the synthetic bone model. Failure modes under cyclic axial load were comparable for the synthetic and human bone models. The findings of this study support the concept that, for intramedullary nails, the kind of distal interlocking pattern affects the stabilization of distal femoral fractures. Four-screw distal locking provides the highest axial stability and nearly comparable torsional stability to that of the angular stable plate; the four-screw distal interlocking construct was found to have the best combined (torsional and axial) biomechanical stability.

Dynamization of locked plating on distal femur fracture

Most of the clinical studies on the results of MIPO (minimally invasive plate osteosynthesis) with the use of anatomically preshaped locking plates for the complex distal femoral fractures have shown favorable results. In the application of bridge plating, placement of lag screws to the butterfly fragments is usually not recommended because it may make the whole construct too stiff. Recently, problems of nonunion related to excessive stiffness after MIPO using a locked plate were reported but the only solution suggested was reoperation with a bone graft. We herein report a case of nonunion after MIPO of the distal femoral fracture where we applied a concept of "dynamization of the plate-bone construct" to make it less stiff and in turn to get fracture healing with bridging callus formation. A 58-year-old woman sustained a simple oblique fracture of the distal femur (AO-OTA 33A1). We performed MIPO procedure using a locking compression plate-distal femur. To get the alignment, we have placed a conventional screw across the fracture line through the dynamic compression unit (DCU) of the combination hole. Postoperative radiographs revealed 7-8 mm gap across the entire fracture surface which was not obvious on the intra-operative C-arm images. Radiographs taken 6 months after operation showed almost no callus formation with shuttle marginal resorption. We interpreted the situation that the construct was too stiff to allow motion across the fracture site due to the lag screw. We thought we have used it as a reduction screw but it acted as a lag screw, preventing motion at the fracture site. Given this analysis, we have only taken the lag screw out to make the construct less stable. It caused the situation of absolute stability with a significant gap to turn into the one of relative stability with acceptable gap. Fracture has solidly healed with bridging callus formation 6 months after lag screw removal under local anesthesia. We would like to call this strategy as "dynamization" of the locked plating.

Utility of Intraoperative Three-Dimensional Imaging at the Hip and Knee Joints with and without Navigation

Intraoperative three-dimensional imaging in orthopaedic trauma care has achieved greater importance over the last few years in some specialized hospital centers. For various types of peripheral-extremity trauma, clinical studies have confirmed, on the basis of three-dimensional information, an intraoperative revision rate ranging from 7% to 19%. Three-dimensional C-arm imaging may be used to achieve adequate intraoperative information about the quality of fracture reduction, residual steps, and correct implant placement, and this technique has been described for use in both the hip joint (for acetabular fractures, isolated femoral head [Pipkin-type] fractures, three-dimensional navigated sacroiliac screw or acetabular column screw placements, and, less frequently, for navigated drilling of tumors or osteochondral lesions) and the knee joint (for tibial plateau fractures, complex distal femoral condylar fractures, and navigated targeting of osteochondral lesions in combination with the use of preoperative magnetic resonance imaging scans). Major limitations of this technology include increased intraoperative time requirements, limited image quality compared with that of computed tomographic scans, cost, specific positioning techniques, and the need for radiolucent operating-room tables. Although prospective studies have yet to be conducted, the ways in which the surgeon will benefit from the use of intraoperative three-dimensional imaging are apparent, but indications for combined three-dimensional C-arm navigated procedures at the hip and knee joint are still limited. Future directions may include the use of digital flat-panel detectors and even robotic-controlled C-arm motion.

Less Invasive Stabilisation System Plating for Distal Femoral Fractures

To review the outcome of less invasive stabilisation system (LISS) plating for complex distal femoral fractures. Records of 6 men and 11 women who underwent LISS plating for complex distal femoral fractures from September 2001 to August 2005 were reviewed. One patient who died 12 months after surgery due to a cardiac problem was excluded. The mean age of the remaining patients was 61 years and the mean follow-up period was 12 months. Four patients, 3 of whom had open fractures, had sustained high-energy trauma. According to the AO classification, 8 fractures were type 33A and 9 type 33C. The mean time to union was 17 weeks. Two patients with non-union underwent a second LISS plating and bone grafting, resulting in a satisfactory final outcome. Delayed radiographic union was observed in one patient, but clinically he was asymptomatic and mobile. The fracture finally united at 9 months. LISS plating is useful in treating complex distal femoral fractures, resulting in reduced blood loss and low infection rates, while achieving early mobility due to primary stability of the construct.

Role of long stem revision knee prosthesis in periprosthetic and complex distal femoral fractures: A review of eight patients

Eight patients, six with periprosthetic and two with complex distal femoral fractures (one pathological, and one with failed internal fixation) were treated with a cemented long stem revision arthroplasty prosthesis to address the issues of articular comminution, stability, alignment and early mobilisation. The average age of the patients was 78 years (range 39-81). There were no intra-operative complications. The mean hospital stay was 12 days (range 8-21). Post-operative complications included one case of posterior dislocation and one superficial infection. All patients had remarkable symptomatic relief at 3 months as indicated by the visual analogue scores. All periprosthetic fractures achieved bony union at a mean time of 3.8 months. The mean follow up was 24 months (range 14-42). The American Knee Society score revealed one 'excellent', five 'good', one 'satisfactory' and one 'poor' result. The mean loss of extension was 7.7 degrees (range 5 degrees -15 degrees ) and the mean flexion achieved was 66 degrees (range: 15 degrees to 85 degrees ). The mean alignment was 6 degrees (range 0 degrees -10 degrees ) valgus. This study highlights the role of long stem prosthesis in periprosthetic and some complex distal femoral fractures in offering stability and early mobilisation.

Indirect reduction and bridge plating of supracondylar fractures of the femur

Between October 1995 and December 1998, 16 patients with A–O type A3, C2 or C3 supracondylar femoral fractures were treated by open reduction and internal fixation using indirect reduction and bridge plating. Seven (44%) patients had open fractures. The patients were followed for a mean of 46 months (range 24–71). All fractures healed. The average time for fracture healing was 18.5 weeks (range 12–28). Four primary bone grafts and three secondary bone grafts were performed. By using the modified Schatzker rating scale, the result of 13 patients (81%) were rated as excellent or good. Complications included two implant failures that were due to full weight bearing before bone healing, and one superficial delayed wound healing. No deep infections were found in this series. The open fracture group needed longer time to heal and had a higher rate of receiving bone grafts. We conclude that indirect reduction and bridge plating with a 95° dynamic condylar screw (DCS) or condylar blade plate can produce favourable results for complex distal femoral fractures. We suggest primary bone grafts or early secondary bone grafts for comminuted open fractures using an indirect reduction technique.

Supracondylar nailing of distal periprosthetic femoral fractures.

Seven patients who sustained complex distal femoral fractures above total knee arthroplasties all treated by supracondylar (retrograde) femoral nailing were retrospectively evaluated. All the patients demonstrated uncomplicated postoperative follow-ups and returned to weight bearing between 2 and 3 months after surgery. No delayed healing occurred and alignment of the femur was satisfactory.

Treatment of isolated complex distal femoral fractures by external fixation

Thirteen patients with isolated distal femoral fractures were treated by external fixation. There were seven males and six females with an average age of 45 years. Four were Type A3 fractures, one Type C1, five Type C2 and three Type C3 fractures. Seven of these were open. In seven cases the articular surface was first reduced and fixed. The fixation was extended across the knee to supplement the distal fixation in six severe cases. The average follow up was 30 months. There was one non-union in the study with the average time to union in the other patients being six months. Using the Mize criteria for assessing clinical results we found that nine patients obtained a good to excellent score and four were classed as failures. The average range of movement of the knee in the study was 100°. Apart from the single non-union all the fractures healed and there were no other serious complications. Considering the severity of the fractures we did not find any evidence to suggest that temporary fixation of the lateral soft tissues by fixator pins was detrimental. The results suggest that external fixation may be used to treat these difficult fractures without the risk of serious complications.