Journal of Orthopaedic Surgery 2010;18(1):35-8
Condylar buttress plate versus fixed angle condylar blade plate versus dynamic condylar screw for supracondylar intra-articular distal femoral fractures George Petsatodis, Apostolos Chatzisymeon, Petros Antonarakos, Panagiotis Givissis, Pericles Papadopoulos, Anastasios Christodoulou First Orthopaedics Department, Aristotelian University of Thessaloniki, Greece
ABSTRACT Purpose. To compare outcomes of 3 fixation techniques for intra-articular distal femoral fractures. Methods. Records of 59 men and 49 women aged 16 to 80 (mean, 47) years who underwent internal fixation for 116 type-C (complete intra-articular) distal femoral fractures were retrospectively reviewed. According to the AO classification, 25 fractures were type C1 (23 closed and 2 open), 71 type C2 (69 closed and 2 open), and 20 type C3 (16 closed and 4 open). Based on implant availability at the time, all surgeries were performed by a single surgeon using a condylar buttress plate (n=38), a fixed angle (95º) condylar blade plate (n=24), or a dynamic condylar screw (n=54). The mean follow-up period was 11 (range, 4– 19) years. At the latest follow-up, functional outcome was classified according to Schatzker and Lambert criteria. Results. Functional outcomes were excellent in 64 (55%) of the fractures, good in 37 (32%), moderate in 9 (8%), and poor in 6 (5%). Outcomes in patients treated by the dynamic condylar screw were significantly superior to those treated by the condylar buttress plate
(p=0.016) or condylar blade plate (p=0.001). Good-toexcellent results were achieved in 96% vs 84% vs 71% of these patients, respectively. Complication rates were lower in the dynamic condylar screw group than the other 2 groups (pseudarthrosis, 5% vs 11% vs 25%; varus deformity, 4% vs 26% vs 25%; knee stiffness, 0% vs 5% vs 8%, respectively). No implant failure was encountered. Conclusion. Dynamic condylar screw fixation for distal femoral fractures achieves better functional outcomes and lower complication rates. Key words: bone plates; bone screws; femur; fracture fixation, internal
INTRODUCTION About 30% of all femoral fractures occur in the distal femur,1,2 usually after a fall (in the elderly) or high-energy trauma (in the young). Anatomic and functional restoration of a distal femoral fracture is a challenge.3 Conservative management may result in serious complications such as knee stiffness (reduced range of movement), inadequate alignment, delayed union or non-union, prolonged hospitalisation,
Address correspondence and reprint requests to: Dr George Petsatodis, Aristotle University of Thessaloniki, School of Medicine, First Orthopaedic Department General Hospital, G Papanikolaou, Exochi, Thessaloniki, TK 57010, Greece. E-mail:
[email protected]
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G Petsatodis et al.
(a)
(b)
(c)
Figure Internal fixation of the supracondylar intra-articular distal femoral fractures using (a) a condylar buttress plate, (b) a fixed angle (95º) condylar blade plate, and (c) a dynamic condylar screw.
and related morbidity.4 To achieve better outcomes, surgical treatment should be performed and fulfil the guidelines described by Salter and Harris. These entail: (1) complete anatomic restoration of the joint surface, (2) rigid fixation without external immobilisation, (3) atraumatic reduction of the metaphysis fracture with restoration of femoral length and alignment, (4) adequate support of the metaphysis, and (5) early mobilisation.3,5,6 Various types of internal fixation have been developed for this purpose. We compared outcomes following the use of 3 different fixation techniques for type-C distal femoral fractures.
MATERIALS AND METHODS Between 1988 and 2003, records of 59 men and 49 women aged 16 to 80 (mean, 47) years who underwent internal fixation for 116 type-C (complete intraarticular) distal femoral fractures were retrospectively reviewed. According to the AO classification, 25 fractures were type C1 (23 closed and 2 open), 71 type C2 (69 closed and 2 open), and 20 type C3 (16 closed and 4 open). The commonest mechanisms of injury were road traffic accident and a fall from a height. Surgeries were performed by a single surgeon. Based on implant availability at the time, a condylar buttress plate (n=38), a fixed angle (95º) condylar blade plate (n=24), or a dynamic condylar screw (n=54) were used (Fig.). The dynamic condylar screw became the preferred means of fixation by the end of the study. The rehabilitation protocol was similar in most of the patients. Early passive mobilisation was allowed with a gradual increase in the range of movement. Full weight bearing was allowed when callus was
Table 1 Functional outcomes according to Schatzker and Lambert criteria Outcome Schatzker and Lambert criteria Excellent Full extension Flexion loss of 1.2 cm Varus or valgus deformity of 20º Minimal pain Moderate Any 2 of the criteria in good category Poor Any of the following Flexion to ≤90º Varus or valgus deformity exceeding 15º Joint incongruency Disabling pain
apparent on radiographs, after a mean period of 14 (range, 10–28) weeks. Patients were followed up at 6-week intervals for the first 6 months, and yearly thereafter. Occurrence of complications was recorded. The mean follow-up period was 11 (range, 4–19) years. At the latest followup, functional outcome was classified according to Schatzker and Lambert criteria (Table 1). Differences in outcomes between groups were compared using the Mann-Whitney U test.
RESULTS Functional outcomes were excellent in 64 (55%) of the
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Table 2 Comparison of fixation techniques Parameter
Fracture type C1 (n=25; 23 closed, 2 open) C2 (n=71; 69 closed, 2 open) C3 (n=20; 16 closed, 4 open) Functional outcome Excellent (n=64, 55%) Good (n=37, 32%) Moderate (n=9, 8%) Poor (n=6, 5%) Complication Pseudarthrosis (n=13, 11%) Varus deformity (n=18, 16%) Knee stiffness (n=4, 3%) Total
No. (%) of fractures Condylar buttress plate (n=38)
Fixed angle condylar blade plate (n=24)
Dynamic condylar screw (n=54)
8 (21) 23 (61) 7 (18)
5 (21) 15 (63) 4 (17)
12 (22) 33 (61) 9 (17)
18 (47) 14 (37) 4 (11) 2 (5)
8 (33) 9 (38) 4 (17) 3 (13)
38 (70) 14 (26) 1 (2) 1 (2)
4 (11) 10 (26) 2 (5) 16 (42)
6 (25) 6 (25) 2 (8) 14 (58)
3 (5) 2 (4) 0 (0) 5 (9)
fractures, good in 37 (32%), moderate in 9 (8%), and poor in 6 (5%) [Table 2]. Outcomes in patients treated by the dynamic condylar screw were significantly superior to those treated by the condylar buttress plate (p=0.016) or fixed angle condylar blade plate (p=0.001). Good-to-excellent results were achieved in 96% vs 84% vs 71% of these patients, respectively. Complication rates were lower in the dynamic condylar screw group than the other 2 groups (pseudarthrosis, 5% vs 11% vs 25%; varus deformity, 4% vs 26% vs 25%; knee stiffness, 0% vs 5% vs 8%, respectively) [Table 2]. The 13 patients with pseudarthrosis underwent revision with a more stable fixation and autologous bone grafts. Most of the 18 cases of mild (>5º) to severe (>15º) varus or valgus deformity occurred in the elderly, or in patients with a severely comminuted fracture. The 4 patients with knee stiffness had flexion of 10º. The 5 patients developing superficial infections were treated with antibiotics but without wide debridement. Four of the 10 patients had leg length discrepancy of >2 cm together with knee joint dysfunction. No implant failure was noted.
DISCUSSION The introduction of the AO/ASIF guidelines and the development of modern fixation devices changed the treatment for distal femoral fractures,8 as superior results could be attained using the Ender nail and screw,7 Zickel nail,8 blade pate,9 condylar buttress plate,10,11
dynamic condylar screw,12–14 retrograde intramedullary nail,15,16 and less invasive stabilisation system plate.17 The fixed angle condylar blade plate is more technically demanding, as it requires precise placement of the chisel to achieve satisfactory axial and rotational alignment.18 The need to hammer the implant into the position may lead to displacement of the femoral condyles during insertion.19 The condylar buttress plate requires a larger surgical exposure to achieve proper placement and avoid varus or valgus malalignment, which leads to extensive soft-tissue trauma and higher rates of infection and pseudarthrosis. Augmented fixation with cement may be needed owing to the poor hold of the screws on osteoporotic bones, but should be used cautiously to avoid intra-articular cement leakage.12 The dynamic condylar screw is technically easier to apply, and allows more freedom in the coronal and sagittal planes because the plate and screw are separate pieces. Nonetheless, a large bone fragment in the intercondylar region is required for proper placement of the lag screw. The bulky side of the plate may irritate the iliotibial band.13 In a study of 21 elderly patients treated with dynamic condylar screws,18 no knee stiffness was reported and all patients attained a good range of movement. Excellent-to-good results have been reported in 50 to 84% of patients, with no implant failure.9,12,20,21 Dynamic condylar screw fixation for distal femoral fractures achieves better functional outcomes and lower complication rates than several other techniques.
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