Evaluation of treatment results of adults distal femur fracture by locking compression plate fixation – Hoang Ngoc Minh

Journal of military pharmaco-medicine no5-2018 199 EVALUATION OF TREATMENT RESULTS OF ADULTS DISTAL FEMUR FRACTURE BY LOCKING COMPRESSION PLATE FIXATION Hoang Ngoc Minh*; Nguyen Thai Son** Pham Dang Ninh***; Nguyen Quang Trung**** SUMMARY Objectives: To evaluate treatment results of adults’ distal femur fractures by locking compression plate fixation. Subjects: 54 patients (26 males, 28 females), mean age was 51.04 ± 22.29 years old (ranger 18 - 90 years old) who were diagnosed with fractures of the distal femur and were treated by locking compression plate fixation in Duc Giang Hospital, Saint-Paul Hospital and 103 Military Hospital from 7 - 2011 to 07 - 2015. Methods: A prospective, observative and descriptive clinical study. Patients would be treated by locking compression plate fixation method as well as treated after surgery, they also were guided and trained and re-examinated to evaluate results. Results and conclusion: Nearly 100% of patients experienced the early healing. Far results (followed by the score standards of Sander R) were evaluated on 54 patients after operation from 12 to 48 months, which showed that: 59.26% were excellent, 33.33% were good, 7.41%: moderate and 0% bad. Complications: 4 patients (approximately 7.41%) had their knee flex from 90 o - 99 o . Conclusion: Achieving the positive results with the high efficiency, the patients can mobilize early. No muscle atrophy and no stiff knee was observed. * Keywords: Distal femur fracture; Locking plate compression fixation. INTRODUCTION Distal femur fractures which are caused by high-energy forces lead to severe bone, joint and surrounding soft-tissue injuries. These injuries can be encountered in individuals of all ages, mostly occurs in the working-age population. Their main causes are mainly from the traffic and works related accidents. The distal femur fractures are composed of supracondylar fractures, intracondylar fractures, simple medial or lateral condylar fractures of the thigh - bone. These types of fractures are close to the joint or extend into the joint, so the treatment challenge is about healing the femur to its original anatomical conformation and stabilizing the fracture, which can help the patients mobilize early and also prevent muscle atrophy and knee joint stiffness. Many researches on treatments of distal femur fractures have been conducted, but screw plate fixation is the most commonly used technique. The authors have utilised the T and L plate and condylar buttress plate, angle 900 plate, DCS (Dynamic Condylar Screw) plate which combines with inserting cancellous screws to femoral condyle... * ** *** **** Corresponding author: Hoang Ngoc Minh (drhoangngocminh@gmail.com) Date received: 07/03/2018 Date accepted: 20/05/2018 Journal of military pharmaco-medicine no5-2018 200 The studies also suggested that if the position of the fracture was too low and near the joint, normally, the peripheral head would only place 1 to 2 cancellous screws through the plate hole, therefore it was difficult to maintain the fracture stability which were required for the early mobilization after surgery. When using the condylar buttress plate fixation, after a period of mobilization practice that put weight on fracture, the fracture may angulate and change the purchase; consequently, they affect the function of the knee, groin as well as ankle joints. Even though bridging bone at the 95 degree-angle plate have also anatomically manipulated the bone, if the plate anchores to the condyle which was deviated by 1 - 2 mm, it would make the fracture angulate or twist two fracture tips. DCS plate has an advantage for the supracondylar fractures and the intracondylar fractures; however it is not suitable for the complicated, comminuted as well as joint-extended fractures because the size of the plate and screws are too large. In recent years, to overcome the drawbacks of these plates, surgeons have studied the utilization of locking plate in the treatment of long bone fractures that have gained a good result. The benefits of the locking plate are that it does not create friction on the bone surface as well as preserve the maximum blood supply which helps the bone recover faster. The stability of the locking plate does not depend on the bone - plate association; it is maintained by the stability between the screw - plate association. The screws are attached tightly to the plate when the entire locks anchor to the bone, they work in a collaborative way and it is hard for one screw to dissociate from the bone, except for the near screws are dissociated. Thanks to that, the locking plate is well used in the case of low - quality bone such as [5, 6, 7, 8]. Hence, we study this project to: - Assess the treatment outcomes of surgery of the distal femur fractures using locking plate fixation. - Make some remarks on technical indications and treatments. SUBJECTS AND METHODS 1. Subjects. 54 patients (including 26 males and 28 females) who aged from 18 to 90 years old, mean age was 51.04 ± 22.29 years old. They were diagnosed with fractures of the distal femur and were treated by LCP fixation in Duc Giang Hospital, Saint- Pault Hospital and 103 Military Hospital from 7 - 2011 to 07 - 2015. * Exclusive criteria: Patients under 18 years old, patients had open fractures, and patients who were pathologic fractures, extremities fractures affected by sequelae. 2. Methods. clinical studyProspective, observative and descriptive. * Studying content: - Classifying fracture according to AO-ASIF. - Assigning the surgery which uses LCP fixation. - Surgical technique: Journal of military pharmaco-medicine no5-2018 201 + All patients are used the anterior - lateral parapatellar approach. An incision was given at the area between the vastus lateralis and rectus anterior to expose the fractures. The bone fragments were repositioned into its normal anatomical alignment. The locking plates were attached to the outer surface of femur (starts from the outer surface of distal femur). Placing drill plate along with the hole and using the 3.5 mm drilling bit one or two 4.5 mm screws might be firstly inserted to anchor the plate. And then the making drilling and inserting additional screws would be carried out. To make sure that the thread of the screw head fits the hole of plate, we should drill along with the drill guide. + In the case of the supracondylar femur fractures extended into the joint, the joint was first repositioned into their normal alignment, some Kirschner nails were used to anchor temporally, one or two cancellous screws were inserted to hold two condyles together, and finally the locking plate fixation was performed. * Assessing the outcome: - Short-term results: The progress at operating site, the reposition and bone healing outcomes, the early complications. - Long-term results: Based on the standard table of Sander R (1991) including 4 levels: excellent, good, immediate and bad. The minimum time for evaluating the long-term result is about 12 months after the surgery. RESULT AND DISCUSSION 1. Some remarks about the relationship between the cause of distal femur fractures and the age. Table 1: Age and gender (n = 54). 54 patients aged from 18 to 90 years old, mean age was 51.04 ± 22.29 years old. Male: 26 patients (48.15%), Female: 28 patients (51.85%). Most of them are in the working age (from 18 - 60 years old), almost the cases were males (23 cases) while there were only 6 females in the report. There was a signigicant difference about the percentage of two genders. In the age ranged from 18 - 40 years old, male and female ratio was 17/2, the main cause is due to the traffic accident, particularly the accident of motor. From the age of 41 to 60 years old, the main Age Gender 18 - 40 41 - 60 > 60 Total Percentage (%) Male 17 6 3 26 48.15 Female 2 4 22 28 51.85 Total 19 10 25 54 100 Percentage (%) 35.17 18.51 46.32 100 Journal of military pharmaco-medicine no5-2018 202 cause is from the work related to the accident and the ratio of two genders is nearly similar (male/female: 6/4). In the group of people who are 60 years old and above, the study showed that the fractures occured frequently in females (some studies showed that in the elderly, osteoporosis often occured more chiefly in female than male) with the ratio between two genders was 22/3, commonly caused by a fall. This ratio was compatible with a study result by Giang Hoai Nam, Doan Viet Quan, Nguyen Huy Thanh and et al [1, 2, 3]. According to the authors, in group of 60- year-old women, the osteoporosis progressed badly compared to men group, so a low energy deforming force could trigger fractures; and many cases were communicated by distal femur fractures. 2. Distal femur fracture classification according to AO-ASIF. Table 2: Distal femur fracture classification according to AO-ASIF (n = 54). Types of fractures Type A Type B Type C A1 A2 A3 Total B1 B2 B3 Total C1 C2 C3 Total Number of patients 9 12 16 37 - - - - 7 8 2 17 Percentage (%) 16.67 22.22 29.63 68.52 - - - - 12.96 14.82 3.7 31.48 The supracondylar fracture group takes up the high percentage (35 patients = 68.52%), in which 16 cases are complicated fractures (A3). In group of intracondylar fracture, there were 17 patients (31.48%) with 2 cases of complicated fractures (C3). Recently, the numerous distal femur fracture classification systems have been proposed, in which 2 clinically common classification were applied in systems are those of AO-ASIF and Muller. In Vietnam, many surgeons have utilised the AO classification such as Giang Hoai Nam (2002), Luong Dinh Lam (2000), ThanTrong Doan (2005), Do Duy Trung (2009). We also used the AO classification of fractures in our study. For patients in group C, before placing the locking plate, we firstly performed the distal femur bone and the grafted fragments. 3. Combined injuries. Among 19 patients (35.19%), 2 patients suffered from traumatic brain injury, 1 patients had surgical trauma, 2 patients were shocked, 3 patients were patellae fracture on the side and other 11 patients were combined bone fractures. Because the distal femur fractures are mainly triggered by traffic accident and falls with high-energy force, there are some combined injuries. The regimen is supposed to save patient's life first and then treat and recover the bone fractures. 4. Timing of surgery. In our study, these 18 patients (about 33.3%) were performed surgery prior to 24 hours. In our opinion, the patients who Journal of military pharmaco-medicine no5-2018 203 suffred from distal femur fractures after hostpitalization, if the fracture site has not swelled badly, we should perform intervention early. At that time, the swelling condition has not progressed badly, so the reposition was easier to follow-up and the care after the surgery was much simpler. 30 patients (55.6%) were operated from the second to fourth days, 2 patients were operated from the fifth to seventh days after admission. In this case, the patients did not suffer from combined injuries but were transfered from small hospitals. They had their knee swollen severely, their skin around the fractures had been nutritious disorder; so we had to treat more carefully before the operation. There were 4 patients (approximately 7.4%) undergoing the surgery after 1 week because they had combined trauma which required treatment and observation until no risks threatened their life to receive bone fixation. Doan Le Dan, Do Duy Trung and many other authors [2, 3, 4] recommended that the fractures extending joint should be operated early to reduce the immobilzation time. However, if the early operation is carried out, as the limb is swollen, that will lead to the high risk of infection and splited operative site. During the operation, the swelling condition of limp also made the progress more difficult, after surgery the limb would swells more badly and finally patients could not mobilize early. 5. The problem in selecting the locking plate fixation’s treatment of distal femur fractures. In the distal femur fractures, the bone can heal very fast but it may have much severe complication in case of limiting knee joint movement due to long immobilization or not repositioning the joint. The treatment required: + Absolutely anatomical recovery, especially in aspect of distal femur joint. + Firm stabilization of fractures so patients can mobilize as early as possible. To adapt those two requirements, for the distal femur fractures, we should choose fixation method. Between locking plate and screw plate, we selected the locking plate because the locking plate provides the better stabilization, the connection between the screws and the plate, based on the thread of screw head. This method helps patients practise weightbearing motion and create the opened angle such as common screw plate fixation. Beside, when bone was fixed by the locking plate, the elderly will avoid much complication such as dissociation of plate [6, 7]. Based on these reasons, we have assigned locking plate fixation for the distal femur fractures if the body condition was allowed. According to Doan Le Dan, [2], firm fixation of fracture allowed patients to practice knee joint movement earlier, avoiding the knee ligament sclerosis and the stick of newly formed bone to quads, and consequently it helps to recover the movement angle of joint. In our study, based on firmly stabilizing the fractured site, we have allowed patients practice motion in the second or fourth day after the surgery, the positive excercises which cooperates with passive and active practices. Hence, the knee joint function healing rate is in good level Journal of military pharmaco-medicine no5-2018 204 6. Treatment outcomes. - Short-term results: 53 patients (98.15%) had well healing operative site, 1 patients developed surface infection of the skin. 100% of patients were given X-ray examination: anatomical recovery and firmly straight bone union. The patients were accessed to rehabilitation one week after surgery. We have cooperated with the Rehabilitation Department to help patients practice early on bed. - Long-term result: Based on the observation of 54 patients for 14 - 44 months, mean time was 24.17 ± 8.89 months. 100% of patients had complete bone union. 24 patients (44.44%) could flex their knee at more than 125o, 23 patients (42.60%) could flex from 100o to 124o, 7 patients (12.96%) were limited in folding angle which were 90 - 99o due to high age or laziness in motion. Surgical recovery: 51 patients (94.44%) had straight bone union, 3 patients (5.56%) had less than 10o inward angulation. - General outcome after surgery: According to the criteria of Sander R (n = 54), 32 patients were defined as excellent (59.26%), 18 patients obtained good result (33.33%) and 4 patients (7.41%) had moderate level, no bad result was seen (0%). Hence, the excellent - good results made up 91.84%, this outcome was greater than that by Do Duy Trung on AO condylar buttress plate study [4]. - Side-effect: The common complication is worsening or limitation of knee joint movement after distal femur fractures, which is due to the squad shortening or sticking to newly formed bone around fracture site and joint desmoplasia. There are 4 cases among our patients (7.41%) that suffered from restraining axial rotation of the knee from 90o-99o because of age, restrict to rehabilitation and fear of pain. CONCLUSION Among 54 patients with distal femur fractures that was treated at Duc Giang General Hospital, Saint-Pault Hospital and 103 Hospital from 7 - 2011 to 07 - 2015, we drew some following conclusions: * Treatment outcome: - Short term results (n = 54):100% of patients had well-healing surgical site, firm bone union, no varus, which allowed patients to practice motion early. - Long-term result (n = 54): 100% bone union, 51 patients had no varus (94.44%), 4 patients had less than 10o inward angulation. - General outcome after surgery: 32 patients (59.26%) were defined as excellent, 18 patients gained good outcome (33.33%) and 4 patients (7.41%) were at moderate level, no bad result (0%). Complication: 4 patients (7.41%) had limitation of knee flexion in angle ranged from 90oto 99o. * Comment on indications and techniques: The locking plate fixation was assigned for distal femur fracture type A and type C as AO classification. 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