OUTCOMES OF SURGICAL MANAGEMENT OF DISTAL FEMUR FRACTURE WITH DISTAL FEMORAL LOCKING COMPRESSION PLATE AT KOSHI ZONAL HOSPITAL Affiliation

In this cross sec onal study 21 pa ents having closed distal femur fractures with or without intra-ar cular extension to femoral condyle fixed with DF-LCP at Koshi Zonal Hospital, Nepal from March 2016 to March 2017 were included. Pa ents with open fracture, severe comminuted fracture, and neurovascular impairment were excluded. These pa ents were followed-up for up to one year and we recorded the knee range of mo on, full weight bearing me fracture union me, and complica ons. We used Neers' func onal scoring system to evaluate the final outcomes and data was analysed using Microso Excel Programe.


INTRODUCTION
Distal femur fractures are uncommon but challenging injuries to treat.In older age males and females with osteoporo c bone, fractures are usually due to low energy trauma like fall from standing height or during walk.However in young pa ents, these fractures occurs due to high energy trauma 1,2 like motor vehicle accidents, sports injuries and fall from height.
Conserva ve management such as trac on, cas ng or combina on of both demands prolonged bed rest and can result in persistent angular deformity, bed sores and loss of knee range of mo on.Surgical fixa ons has consistently demonstrated be er outcomes than nonsurgical management.At present, early return to func on is possible due to the development of new technology and newer implants for distal femoral fractures.Commonly used implants are external fixators, angled blade plates, dynamic condylar screw plates, condylar bu ress plates, retrograde supracondylar inter-locking nails, Ender's nails, Rush nails etc.These implants are selected based on the fracture pa ern, bone quality, func onal demands and type of trauma, the condi on of the pa ent and exper se of the surgeon.Most of these implants require C-arm fluoroscopy during opera ve period of fixa on.Newly introduced distal femoral locking compression plate (DF-LCP) is precontoured, which provides angular stability and rigid [3][4][5] fixa on.Objec ve of our study is to analyses the func onal outcomes of ORIF with DF-LCP in distal femur fractures.

METHODOLOGY
This cross sec onal study was conducted on 21 pa ents admi ed in orthopedic department of Koshi Zonal Hospital, Biratnagar, Nepal from March 2016 to March 2017 to analyze of the outcomes of surgical management in distal femur fractures with DF-LCP.In this study, we selected adults (skeletally mature) above 18 years and elderly with osteoporo c bone.Simple spiral, oblique, transverse and bu erfly fragment with simple intra-ar cular extension were included but comminuted dia-metaphyseal fractures, open fractures and fractures with neurovascular injuries were excluded.We took convenient sample for this study.Ethical clearance was taken from hospital authority.No pa ent was harmed physically and economically for this study except their regular expenditure for treatment.Data was analyzed using Microso Excel Program.

PRE-OPERATIVE MANAGEMENT
In the emergency department of Koshi Zonal Hospital, we examined thoroughly not only distal femur fracture but also carefully considered the mechanism of injury,mode of injury, associated injuries such as neurovascular injury, head injury and other system involvement.We started emergency treatment and required inves ga ons such as X-Ray, CT scan especially in head injury or intra-ar cular femoral condyle fractures and other rou ne blood inves ga ons.Once the pa ent became stable, we shi ed the pa ent to the ward, elevated the leg on Bohler-Braun splint with non-adhesive trac on.In case of delayed surgery, lower bial skeletal trac on with proper weight was applied.We prepared the pa ent for surgical management a er pre-anesthe c checkup (PAC).Informed consents were taken for all the surgeries.

SURGICAL TECHNIQUE
A er pre-anesthe c checkup, all pa ents received regional spinal anesthesia.The pa ent was placed supine on a radiolucent opera ng table.Sand bag was placed under the ipsilateral hip, another rolled towel was placed under the knee to achieve flexed posi on of the knee, length and rota on was carefully controlled.We applied tourniquet in some pa ent depending on length of femur and extension of fracture.Routine preparation and draping of injured limb was done.Lateral incision (sub-vastus approach) was made directly on the lateral aspect of the thigh and through the midpoint of the lateral condyle distally, staying anterior to the proximal inser on of the lateral collateral ligament.The distal end of the incision was gently curved anteriorly along the lateral border of the patella upto the bial tuberosity.Proximally incision extended as per requirement.The fascia lata was incised in line with skin incision and its fibers were split.Distally for condylar fracture exposure, it was o en necessary to incise the anterior fibers of the ilio bial tract and carry down through the capsule and synovium of lateral aspect of the femoral condyle.Care was taken to iden fy the superior lateral genicular artery, which was ligated and [6][7][8] to avoid damage to the lateral meniscus.Adequate exposure of ar cular surface, par cularly, medial femoral condyle or coronal plane anatomy was managed by extension of incision as per necessity.

RESULTS
Twenty-one pa ents were included in this study with average age 45 (range 19-75) years.Among them 14 were female (range 27-75) years and seven were male (range 19-35) years.Five cases had intra-ar cular involvement and 16 cases were with dia-metaphyseal fracture mostly oblique and spiral.The me between injury and surgery was mean 9 (range 5-13) days.Eleven pa ents required blood transfusion before opera ve procedure and three pa ents got blood transfusion a er surgery.All the cases were operated under spinal anesthesia.Dura on of surgery was average 85 (range 60-150) minutes and average blood loss was 208 (range 150-300) ml without intraopera ve complica ons.Opera ve dura on and blood loss was more in intracondylar fractures, bulky pa ents and fractures with difficult reduc on.All pa ents started isometric hamstring, gluteal and quadriceps exercises as taught by the nd physiotherapist on the 2 post-opera ve day and was con nued ll full range of movement of knee was achieved.Pa ents were on intravenous an bio cs a er surgery for (5-7) days depending upon wound condi ons which was switched to oral an bio cs ll suture removal (range 12-14) days.Dura on of hospital stay was average 12 (range 10-19) days.All pa ents were ambulated with non-weight bearing using crutches or walker a er removal of sutures, except those five pa ents with inter-condylar fracture.Full weight bearing was allowed when the fracture union was confirmed both clinically and radiologically on average 16 (range [12][13][14][15][16][17][18][19][20][21][22] weeks.Inter-condylar fractures, osteoporo c bone and pain sensi ve pa ents took longer me for full weight bearing. Radiological union of the fracture was characterized by cortex to cortex healing and bridging callus of the fracture in both antero-posterior and lateral views of follow-up x-rays, average union me was 20 weeks (range 17-29).Neers' scorings recorded at six months post-op with the help of physiotherapists.Score assessment was excellent in 66.66%, sa sfactory in 23.80%, unsa sfactory in 4.76% and poor in 4.76%.Five pa ents complained of knee pain a er radiological healing.Early complica ons were encountered in three pa ents, out of which two pa ents had developed superficial wound infec on and one pa ent had deep infec on.They were managed with intravenous an bio c and proper dressing.None had any implant failure or any deformity.

DISCUSSION
The introduc on of distal femoral locking compression plate (DF-LCP) with fixed-angle screws system offers a number of advantages in fracture fixa on and DF-LCP has been rapidly adopted as an alterna ve to intramedullary nails, blade plates and non-locking condylar screws.Distal femur fracture reconstruc on needs a very skillful hand because it's a very challenging procedures for the orthopedic surgeons.The goal of the reconstruc on is not only the anatomical reduc on of the ar cular surface but also the adequate stabiliza on of the fracture and early mobiliza on along with preven on of the s ffness and early ambula on of the pa ent.The prognos c factors described for distal femur fracture are age, fracture types, ar cular involvement, proper implant selec on, ming of joint mo on and 12-15 surgeon's exper se.The outcomes of DF-LCP in distal femur correlated with the fracture severity, e ology, anatomic reduc on, bone quality, length of me elapsed from injury to surgery, concomitant injuries and proper posi oning and fixa on of the implant.Any slight varia on in implant placement can disturb reduc on.DF-LCP is very much user-friendly technique because it makes anatomical reduc on and fixa on easier.It is ideal implant when rd the fracture of lower 1/3 femur has an intercondylar [16][17][18] extension.

Table 2: Comparison of hospital stay , opera ve me, weight bearing walking, radiological union ORIF with DF-LCP with other published ar cles
Surgical fixa on of distal femur fractures has consistently demonstrated be er outcomes than nonsurgical management based on fixed angle devices star ng with ORIF using condylar blade plate (CBP) or Dynamic Condylar Screw (DCS).However, it requires large incisions that led to increasing complica on rates of infec on, delayed union, non-union, itera ve fractures and need for primary or secondary bone gra ing.For minimizing those disadvantages, close reduc on and minimal exposure to facilitate the inser on of retrograde intramedullary nail with preserva on of periosteum and fracture hematoma.Newly introduced minimal invasive plate osteosynthesis (MIPO) techniques were successfully applied in complex extra-ar cular fractures and a modified technique en tled Transar cular Approach and Retrograde Plate Osteosynthesis (TARPO) was developed for complex [19][20][21] supracondylar and intercondylar femoral fractures.

Table 3: Comparison of Neers' scores of ORIF with DF-LCP
Since the use of pla ng and nailing technique has modernized, there has been a major improvement in the treatment of distal femur fractures.The revision surgery is co-related with the surgical skills of the surgeon, implant and the type of fracture.Selec on of the appropriate implant depends upon the fracture pa ern, the condi on of the so ssues, the need of the pa ent, and the preference of the surgeon.
The mean age of pa ents were higher, which could explain the higher mortality rate.The outcome and the prognosis of fracture depends on micro-mo on and stable fixa on.There are certain variables that can be controlled by surgeons and some are uncontrollable.Among the uncontrollable variables, the poor bone quality of the pa ent and the [22][23] fracture comminu on also plays a vital role.Technically retrograde nailing is said to be a challenging procedure due to its certain complica ons like; iatrogenic fracture of femoral sha , stress fracture above the implant, fa gue failure of the nail, intra-ar cular impingment of the nail due to inadequate entry point, knee pain and injury to the deep femoral artery.In supracondylar fracture femur, supracondylar nailing is useful for fixa on but not in case of comminuted fractures.In comparison with supracondylar nail, DCS is supposed to be a be er op on for management of distal end of femur fracture in terms achieving bony union with less chances of knee s ffness, knee arthrosis and be er Neers' score.In supracondylar nailing group there is benefit of early weight bearing.Drawback of using plate and screws is that plate is a load shielding device and is prone re- [24][25] fractures in osteopenic bone of the proximity of the plate.However, MIPO does not allow direct visualiza on of the fracture and the surgeon is dependent on intraopera ve fluoroscopy for adequate reduc on.The requirement for biological osteosynthesis led to the development of new genera on of plates with angular stability, called Less Invasive Stabiliza on System (LISS).The less invasive stabiliza on system (LISS) is based on MIPO technique.The LCP differs from the LISS in that the LCP has combina on holes and does not have a jig.The LCP acts on the principle of internal fixator and permits percutaneous pla ng, as locking the screws to the plate do not pull the fracture towards the implant so that the fracture does not redisplace a er reduc on.The LCP is compa ble with MIPO.DF-LCP is a useful arsenal for orthopedic surgeons while fixing fractures around the knee especially when the fractures are 26-28 severely comminuted and osteoporo c.