Evaluation of treatment results of adults distal femur fracture by locking compression plate fixation

Journal of military pharmaco-medicine no5-2018

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
o
o
from 90 - 99 . 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 ()
Date received: 07/03/2018

Date accepted: 20/05/2018

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Journal of military pharmaco-medicine no5-2018
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
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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, SaintPault 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
+ 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).
Age

18 - 40

41 - 60

Male

17

6

Female

2

Total

Gender

Percentage (%)

Total

Percentage (%)

3

26

48.15

4

22

28

51.85

19

10

25

54

100

35.17

18.51

46.32

100

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

> 60

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
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Journal of military pharmaco-medicine no5-2018
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 60year-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).
Type A

Type B

Type C

Types of
fractures

A1

A2

A3

Total

B1

B2

B3

Total

C1

C2

C3

Total

Number of patients

9

12

16

37

-

-

-

-

7

8

2

17

-

-

-

-

3.7

31.48

Percentage (%)

16.67 22.22 29.63 68.52

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
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12.96 14.82

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
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
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Journal of military pharmaco-medicine no5-2018
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
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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.


Journal of military pharmaco-medicine no5-2018
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