Abstract:
Introduction: Treatment
of Supracondylar intercondylar fractures of the femur was always
a challenge to the orthopaedic surgeon because of the poor
results obtained with various treatment modalities. Intra
articular comminution and lack of post-operative physiotherapy
adds to the complexity. Non surgical treatment always results in
stiffness due to lack of early mobilisation. In this study we
analyse the functional out come of open reduction and rigid
internal fixation using various implants and early
post-operative rehabilitation in such fractures.
Materials
And Methods: We
studied the results of various surgical techniques in 25
patients with supracondylar-intercondylar fracture
of femur over a period of 3 years at our institution from
2003 to 2005. The final outcome is compared with the results
available from the latest literature.
Results: In
this study we obtained 68% good or excellent results, which is
significantly better than with conservative treatment. We found
that, open fractures, articular comminution, infection, lack of
rigid internal fixation,and prolonged post operative
immobilisation are the major culprits for a poor functional
outcome.
Conclusion:
Early open reduction and internal fixation using AO
technique give good results in the hands of experienced surgeon,
in patients of any age group, if it is followed by an early
active controlled rehabilation programme.
J.Orthopaedics
2007;4(2)e30
Introduction:
Aim
of the present study is to evaluate the results of early open
reduction and internal fixation of supracondylar intercondylar
fractures of femur done in Calicut Medical college Hospital from
2003 to 2005. Functional results were evaluated with regard to
pain, range of motion of knee, limb length discrepancy any
persisting deformity, presence and absence of early and late
complications etc. Attempts were also made to identify specific
causes directly related to the bad results in this series. It is
hoped that the results of this study will be of help in more
careful selection of patients and implants, and thereby avoiding
a large number of complications which are actually the results
of inadequate preoperative planning and case selection.
Material and Methods :
For
a fracture to be included in this series, part of the fracture
line has to extend distal to a horizontal line drawn on the AP
roentgenogram 9 cm above the distal articular surface of the
femoral condyles. We studied 25 patients presented to our
institution from January 1st, 2003 till December 31st 2005 with the above injury. Patient
of both sexes above 13 years, Closed and Open fractures, and Type C fractures were included in the study. Pathological
fractures and AO type A & B fractures were excluded.
Initial
resuscitation and stabilization of the patients were done.
In terms of the management of open fractures, initial
irrigation, debridement, intravenous antibiotic, upper tibial
pin traction and delayed wound closures were done routinely. 3
Antibiotics (one for gram positive, one for gram negative an one
for anaerobic bacteria) were started and continued till the
wounds healed. From
the initial radiographs, all fractures were classified according
to ASIF classification.
OPERATIVE
TECHNIQUE
Skin
incision was made through a line connecting greater trochanter
to lateral femoral condyle for desired length. Next Interval
between the vastus lateralis and anterior border of the lateral
intermuscular septum was developed to allow full visualization
of the distal part of the femoral shaft.
After analyzing the fragments, temporary reduction was
attained with K wire and knee movements were checked. Definitive
fixation was done with various implants. Internal fixation
devices used were, either dynamic compression screw and side
plate, 950 angled blade plate, screws, intramedullary nail or
condylar buttress plate.
Cancellous
bone graft was used to fill supracondylar defects at the time of
fixation in case of metaphyseal comminution.
Iliac crest was the donor site for cortico-cancellous
grafts. The source of the graft was the iliac crest. Post
operatively the limb was kept in Bohler Braun splint to prevent
contracture of the quadriceps.
After quadriceps and hamstring strengthening exercises,
active and active assisted range of motion exercises of the knee
were initiated.
On
follow up. all patients were assessed using Neer’s Criteria
and Knee Society Score for functional outcome. We considered a
fracture united if there were no pain on palpation or attempted
motion, no increase in warmth at the fracture site, no
discomfort on full weight bearing and serial roentgenograms
demonstrated bone trabaculae crossing the fracture site.
The functional and radiographic results were recorded
according to Neer’s criteria.
Functional grading was made depending on pain, walking
capacity, mobility and work.
Radiological grading was made based on varus or valgus
deformity, shortening, signs of osteoarthritis and union of
fracture.
Discussion :
Fractures
in the distal femur have posed considerable therapeutic
challenges throughout the history of fracture treatment.27,42,36
. Most of
these surgical failures were due to inadequate fixation of the
fracture fragments. (Mize et al 1982).23
The prognostic factors for supracondylar fracture
included age, intra-articular involvement, methods of treatment,
timing of joint motion, etc (Neer et al 1967; Morre 1987).25,27
The present study does not show a biphasic age
distribution of the patient population as is usually seen in
studies (Bell et al, 1992).1 This is a reflection of the
mechanism of injury which was high energy trauma in 72.13% of
patients most of whom were younger.
This correlates well with the high degree of associated
trauma seen and with the high incidence of open fracture
(39.13%) and intercondylar type fractures (74.2%).
Out of 25 cases, 6 (24%) showed excellent results. All
were operated within 5 days of which 4 were treated in the 1st
day itself. All except one were <55 years. Younger patients
had better result than older age group. These fractures were all
of C1 type. In all these excellent type of cases implants used
were of different types (DCS,CBP,IMN). Selection of implants
were based on the decision of the surgeon during the surgery
depending on fracture configuration. There cannot be a rule laid
down on this matter. Maximum stability with minimum implants was
our aim in choosing the implants.
In all cases of excellent results post operative
mobilisation was started within 10 days of surgery.
There were 6 (24%) open fractures. 5 of them were treated
with external fixator and 1 with Condylar Buttress Plate (CBP).
One of the five cases treated with external fixator and
the one with CBP gave satisfactory results. Of the remaining 4,
two cases had unsatisfactory and two had failure results.
External configuration of knee was always better with surgery;
than treated conservatively. In all satisfactory cases there was
no weakness or knee instability. Poor result in 4 patients could
be attributed to delay in initiating the prescribed post
operative mobilisation protocol, due to various reasons. Our
results are comparable with the results of a study conducted by
John M, Siliski40 et al, where 40% were open fractures, with 40%
good results, and the rest poor. They also had the conclusion
that rigid internal fixation is far superior to external
fixation even in open fractures
All
the cases designated as excellent or good in the overall rating
were similar per-operatively. Our per operative results were
well correlated.
There
were 6 (24%) unsatisfactory and 2(8%) failure cases in this
study. In a study by Roby D, Mize and Robert Bucholz 23there
were 21% poor results which is comparable with the present
study. When these cases are closely analysed, many factors are
found to be responsible for the bad results. Major contributing
factors are:
(1)
Improper fixation due
to a non anatomical reduction or a non-rigid fixation.
(2)
Gross comminution of fragments which prevented a good
reconstruction of distal end of femur.
(3)
Delay in starting active exercises also contributed to
the bad results.
Delay
in surgery is also a factor in contributing bad results (p value
0.0289). Of the 2 failure cases both were open fractures. One
had multiple injuries and the other had initial head injury.
Both fractures were fixed only in the 3rd week. In a study by
Seinshiemer33 there is a positive correlation between time delay
and final outcome. According to them surgery should be conducted
preferably within a week.
According
to schatzker, in an analysis of supracondylar inter condylar
fracture femur, 74% had better results in type-C.
Thus complete articular fractures had poor results
compared to the partial articular and extra-articular
fractures.36
In
our study the percentage of excellent and good result comprises
68%. This closely matches with that reported by schatzker36.
On
analyzing the results according to the type of internal fixation
used dynamic compression screw and side plate and 950 condylar
blade plate had good results.
70% in dynamic compression screw and side plate and 66.6%
in 950 condylar blade plate had excellent results. The one case
treated with IMN gave excellent result. Robbins and Zickel47 in
a study noted excellent results in 30 of 33 cases using IMN and
bone grafting. None of the fractures treated by external
fixation devices had excellent results.
Out of 5 fractures treated by external fixation device,
one had unsatisfactory result and 2 had failure results.
Poor results were mainly because of open fractures. In a
study conducted by Michael W and Chapman MD, 49 found that when
the bone stock is in adequate the better options are either
Dynamic Condylar Srew or
Condylar Buttress Plate.
In this study we had 8 cases of age >55, of which only
1 had excellent result, 2 had satisfactory results and the rest
are either unsatisfactory or failure Some studies have shown a
less satisfactory outcome in elderly patients with rigid
internal fixation, presumably because of poor quality bone stock
(Seinsheimer, 1980) 33.
When
a femoral fracture involves the knee or quadriceps mechanism or
both, some loss of motion of the knee seems to be inevitable in
most patients, whether they are treated non-operatively or by
internal fixation. Acceptable knee flexion following treatment ranges from 650
in one study (Brown et al, 1971) 5 to 1170 in another study (Shelbourne
et al, 1982).38 The
average post-operative range of motion of 91.30 in our series
compares very favourably with these figures (p value 0.0213).
The average range of motion in type-C were 70.590 .
The average range of motion in closed fractures were
98.40 whereas it was only 77.730 in open fractures. In this
study, average range of motion in type C was 72 degree and in
open fractures it was 58 degrees.
Thus intra-articular fractures lead to intra-articular
stiffness, decreased range of motion and poor result and open
fractures results in extra-articular stiffness.
In
our study male to female ratio is 3:1which is very close to the
study by Muller ME,Algower M26
In
this study ,we obtained 55%fractures in right side and 45%in
left side which closely resembles the results obtained by Neer
CS where they got 60% rightside and 40% left side.27
Average
age under this studyis47.9 yrs(ranging from 24 to 62). Pritchett
JW in their study got an average of 28.5 yrs. This could be
because of the inclusion of fractures with epiphysis still
open.29
77.5%
of the fractures are because of road traffic accidents,15% due
to fall from height and the rest 7.5%is due to domestic fall.
Most of the studies agree with us(shewring DJ,Silisky JM,Wiss
DA)39
In
this study C1 includes48%, C2 includes32% and C3 includes20% of
the fracture.
Average
hospital stay was 15 day which ranges from 10 days to 81 days.
Some studies(Stewart MJ)42 states an average of 30 days. In a
study by Muller26, average was 20 days, whereas by Neer27 it was
21 days. This disparity is because, most of the cases in our
study underwent surgery on the same day or next day itself,
whereas in the other study most of the patients had 2weeks of
preoperative traction..
The
significant morbidity resulting from complications of
supracondylar fractures are well documented (Moore et al,
1987)25. In this
study, 2 cases of chronic osteomyelitis and 2 non unions were
encountered. Giles et al14 (1982) with 5 open fractures of 26 had an
infection rate of 0%, by Pritchett29 from Arizona reported a
5.2% rate, Pritchett (1984)29 and Mize et al (1982)23 a 6.6%
deep infection rate. In
our series, 2 out of 25 fractures (8%) had chronic infection and
all 2 were open fractures. None of the closed fractures treated operatively had chronic
infection. Thus the infection rate
is just above current literature values. We use a
combination of third generation cephalosporin (cephasolin 1g)
and an aminoglycoside (gentamicin 80mg) one hour prior to
surgery and 3 days postoperatively. Metronidazole 500 mg added
to above regime if fracture is open.
In a study by Roby D, Robert W and Bucholz
post op infection rate was 7%54. In our study we got an
infection rate of 8%. Both of these 2 cases presented with open
contaminated fractures.
Deformities
were more common in non-operative methods of management. In our
study angulation >5degrees was reported in none. In a similar
study by James B and Giles MD, they have got a similar result in
26 patients53
Nonunion
in the distal third of femur is and should be relatively rare
for the bone is primarily cancellous and has an excellent
vascular supply with good local osteogenic properties.
The incidence of this complication seems to vary
according to the method with which the fracture was treated.
In two large series (Neer et al, 1967; Butler et al
1991)27,7 involving both open and closed methods of treatment,
there was nonunion in 19 of 315 (6.5%) and 16 of 110 (15%) cases
respectively (Conolly et al, 1973)11.
Therefore all forms of treatment have had nonunion as a
significant complication.
In
our series, there were only 2 cases of delayed union (8%). They
were treated by bone grafting.
Non union in non-operative group may be due to
distraction of the fracture fragments in skeletal traction.
Traction must be applied carefully and good quadriceps
muscle tone must be maintained to prevent distraction.
The length of follow up evaluation is insufficient to
allow calculation of the incidence of late degenerative joint
disease.
Bone
grafting was done in 13 fractures, out of which 6 were of type-C
fractures. Out of
6, primary bone grafting was done in 4 fractures
The remaining 2 bone grafting was done for delayed union
. Thus,
displaced and comminuted type-C fractures required open
reduction and rigid internal fixation with bone grafting.
According to Michael M and Chapman MD, comminuted articular and
metaphyseal fractures give better results with bone grafting49
According
to Benum 2, bone cement is not required in osteoporotic or
highly comminuted fractures for early posy-operative
mobilisation.2 In none of our cases we have done cementing
technique.
Thus,
analysis of the results of the supracondylar fracture shows that
it is a good option to treat displaced fractures (Type-A and C)
by operative methods and undisplaced fractures (Type-B) by
non-operative methods.
3
of 25 patients in our study had post op pain even after an
average follow up of 18 months
other than due to knee stiffness and infection.
Two of them were due to projecting nail tip medially and
1 due to implant failure. In a study by schatzker36 in 78
patients for a follow-up of 10 years implant failure rate
was14.6%. In our study it is 4%, difference could be due to
shorter follow-up.
By
analysig the gait 4
of the 25 patients had short limbed gait.,maximum shortening
being 3.5 cm,which was treated with shoe modification.
Shortening less than 2 cm were not given any form of treatment.
In
our study ,in the early followup period, quadriceps wasting and
resultant weakness was present in 20 of 25 patients. This was
mainly due to lack of doing quadriceps exercises by the patients
because of pain. But in the later follow-up 15 of them regained
good power. Those who had not regain power were
with open fractures
Since
supracondylar inter condylar fractures of femur is
associated with high velocity trauma it also has got associated
injuries.In our study we had 6 knee instabilities, 3fracture
patella, 2 ipsilateral fracture tibia(floating knee), 1 neck of
femur fracture and
1 case of fracture spine(L2). In a similar study by Schartzker
and Lambert36 there
were 2cases of fracture talus and calcaneum,8 cases of floating
knee, 5 cases of central fracture dislocation of ipsilateral
hip, 8cases of PCL and medial collateral ligament tear and
3cases of both spine and patella. (out of total 64 cases) . Such
a significant number of associated injury could be due to very
high velocity trauma occurring in western countries.
Complications
of surgery in early stages are never problematic. There was
insignificant number of cases with non-union or articular
stenosis. Articular stenosis was measured using condylar width
index (CWI) which is assessed with a condylar notch view x-ray.
In this series follow-up period was of comparatively short
duration.
Necessity
of early fixation, anatomic and stable reduction with early
motion as advocated earlier by Cassebaum56 is once again
reiterated through the present study.
Conclusion:
Results
are generally good in patients of younger age group.Results are
good even in elderly with early internal fixation.Preoperative
reduction and stability is an important factor in determining
the end result.Earlier the surgery, better the results.
No
arbitrary rule can be laid down regarding the implants to be
used, which depends entirely on the fracture geometry studied at
the time of surgery. Hence different types of implants must be
available during the surgery.
Comminution
of the fracture adversely affects the results.Intra articular
communition is not unsuitable for internal fixation. Unstable
and incongruent reduction
resulted in poor outcome.Early open reduction with internal
fixation can be done in open uncontaminated fractures.AO
technique of fixation
offers good compression and adequate stability.
Surgeon must be well versed in the AO technique and should
adhere to the principles throughout fixation. Earlier the
mobilisation, earlier the restoration of movement and better is
the final outcome.Active mobilisation is the key stone in
determining long term functional outcome.
Undisplaced
fractures had good results comparing displaced
fractures.Displaced fractures with intra-articular extension had
bad prognosis, irrespective of the method of treatment
adopted.However, incidence of complication was less, when
displaced fractures were treated operatively.Open fractures
always carry a poor functional outcome
Primary
or secondary bone grafting is often necessary with severely
comminuted fractures.Rigid internal fixation and early post op
rehabilitation are the key factors for a better functional
outcome. Complications
like neurovascular injury, non union, traumatic arthritis,
significant mal union etc. are rare after ORIF.
Incidence
of infection is
more and is a reason for
concern.
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