ORIGINAL RESEARCH |
https://doi.org/10.5005/jojs-10079-1120 |
Does Dual Plating for Distal Femur Fractures with Metaphyseal Comminution Results in Increased Stability and Early Fracture Healing: A Prospective Randomized Control Study
1-5Institute of Orthopedics and Traumatology, Madras Medical College, Chennai, Tamil Nadu, India
Corresponding Author: Ebin Jose, Institute of Orthopedics and Traumatology, Madras Medical College, Chennai, Tamil Nadu, India, Phone: +91 9562458122, e-mail: ebinthonakkara@gmail.com
Received on: 02 June 2023; Accepted on: 25 June 2023; Published on: 07 July 2023
ABSTRACT
Introduction: The treatment of distal femur fractures with metaphyseal comminution is often complicated by nonunion, varus collapse, and implant failure. The accepted standard of treatment is lateral plating with a distal femur-locking compression plate. The addition of an extra medial plate to the lateral plate provides more mechanical stability. We compared the radiological and functional outcome of these fractures following dual plating and lateral plating.
Materials and methods: A total of 20 were selected and randomized and divided into two groups. The inclusion criteria were all distal femur fractures with metaphyseal comminution. Gustilo-Anderson type IIIB and type IIIC fractures were excluded from the study. Dual plating was done in the first group by two approaches, lateral and subvastus approach, while lateral plating was done in the second group by the lateral approach. Patients were followed up for 2 years. Radiological and functional outcomes were assessed on follow-up.
Result: There was a statistically significant difference in average time for radiological union, which was 13 weeks in the dual plating group and 28 weeks in the lateral plating group (p-value = 0.038). Patients with dual plating had early weight bearing. There was no significant difference in functional outcome between both groups.
Conclusion: Dual plating for distal femur fractures with metaphyseal comminution results in an early radiological union and early weight bearing and allows an early return to work.
How to cite this article: Jose E, V S, Anandan DS, et al. Does Dual Plating for Distal Femur Fractures with Metaphyseal Comminution Results in Increased Stability and Early Fracture Healing: A Prospective Randomized Control Study. J Orth Joint Surg 2023;5(2):59-65.
Source of support: Nil
Conflict of interest: None
Keywords: Distal femur fracture, Dual plating, Lateral plating, Metaphyseal comminution, Varus collapse.
INTRODUCTION
Distal femur fractures account for a total of 7% of all femur fractures. The treatment of distal femur fractures with metaphyseal comminution is often complicated by nonunion, varus collapse and implant failure.1 The accepted standard of treatment is lateral plating with a distal femur-locking compression plate. The addition of an extra medial plate to the lateral plate may provide more mechanical stability without affecting the vascular supply.2 We compared the radiological and functional outcome of these fractures following dual plating and lateral plating.
AIMS AND OBJECTIVES
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To compare the functional and radiological outcome of distal femur fractures with metaphyseal comminution treated by dual plating vs lateral plating.
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To assess the average time of radiological union.
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To assess the average time for clinical union.
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To assess the range of motion of the knee.
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Varus collapse.
MATERIALS AND METHODS
A total of 20 cases of distal femur fractures with metaphyseal comminution who were admitted to the Institute of Orthopedics and Traumatology, Madras Medical College, Chennai, Tamil Nadu, India, from November 2021 to October 2022 were studied and analyzed. These patients were randomized and were divided into two groups. One group was treated by dual plating, and the other group by lateral plating alone. Patients with Muller type A3, C2, and C3 with >1 cm medial cortical defect and age >18 years were included in the study. Patients who had nonunion or implant failure following single lateral plating were added to the dual plating group.
Patients with Gustilo–Anderson grade IIIB and IIIC open injuries were excluded from the study. Other patients who were excluded from the study include those with pathological fractures and periprosthetic fractures.
Patients were evaluated preoperatively (pre-op) by X-ray and computed tomography (CT) scans (Figs 1 to 4). Patients were randomized and were divided into two groups. Patients in the first group were treated by dual plating, and patients in the second group were treated by only lateral distal femur plate.
Fig. 1: Preoperative (pre-op) X-ray of patient 1
Fig. 2: Preoperative (pre-op) CT scan of patient 1
Fig. 3: Preoperative (pre-op) X-ray of patient 2
Fig. 4: Preoperative (pre-op) CT scan of patient 2
All patients in the dual plating group were operated by two approaches,3 that is, lateral and medial subvastus approach (Fig. 5). All patients with lateral plating were operated by the lateral approach (Fig. 6).
Fig. 5: Incision for dual plating
Fig. 6: Incision for lateral plating
For dual plating, laterally, we used a distal femur locking compression plate and a medially large fragment T buttress or L buttress plate was used. In the lateral plating group distal femur-locking compression plate was used laterally. We aimed to put five locking screws in the femoral condyle and a minimum of five locking cortical screws in the shaft region. A plate working length of at least 2.5 times the length of the fracture with a screw density ratio of 0.4–0.5 was achieved.
Fracture fragments were reduced and then temporarily repaired using K-wires and lag screws. If the metaphysis had additional bone loss and comminution, the fracture site was bridged. Carefully analyzed and restored the length, coronal and sagittal plane alignment, and rotational alignment.
Care was taken to minimize the soft tissue dissection and to preserve the vascularity of the fragments. Meniscus and collateral ligament were also preserved. After a thorough wash, the wound in the lateral plating group was closed.
A medial plate was put through a separate medial incision in the dual plating group (Fig. 7). This provided adequate medial cortical support and easy reduction.4 Following skin closure, the knee was mobilized to remove any soft tissue that may have become trapped between the bone and the implant or the sutures, which may cause subsequent inexplicable postoperative (post-op) pain. All patients in both groups were given the same antibiotic and analgesics.
Fig. 7: Incision for medial plating
After 48 hours from surgery or when the drain was <50 mL in 24 hours, the drain line was unplugged. On the 12 post-op days, the sutures were removed. The main objective for the first four weeks was full range of motion. Starting with isometric quadriceps exercises, passive and active range of motion exercises was performed. For 4 weeks, nonweight bearing walking was permitted. When post-op X-rays showed a callus in the fractured end, partial weight bearing was allowed.1 Full weight bearing was allowed after the radiological union.
Following surgery, all patients had a post-op thigh with knee X-ray in anteroposterior and lateral view (Figs 8 and 9). They were reviewed on suture removal 6th, 12th, and 24th week, and then once in 3 months (Figs 10 and 11). In order to assess fracture alignment in the sagittal and coronal planes, fixation stability, fracture healing, and fixation failure, the radiographic examination was done on all follow-ups (Figs 12 and 13). Recordings were made of any loss of reduction, collapse, plate liftoff, implant breakage, screw loosening, and any wound complication.
Fig. 8: Postoperative (post-op) X-ray of patient 1 managed by dual plating
Fig. 9: Postoperative (post-op) X-ray of patient 2 managed by lateral plating
Fig. 10: A 1-month follow-up X-ray of patient 1
Fig. 11: A 1-month follow-up X-ray of patient 2
Fig. 12: A 6-month follow-up X-ray of patient 1
Fig. 13: A 6-month follow-up X-ray of patient 2
Patients were assessed for range of motion, fixed deformity, and extension lag at every follow-up.
The functional outcome was evaluated with Neer’s scoring system at the end of 1 year of follow-up. It has a total score of 100 points. By this score, we evaluated a range of flexion and extension, extension lag, pain, walking capacity, working capacity, angular deformity both gross and radiological, limb length shortening, walking and stair climbing ability, and return to previous work status. According to the above findings, the patient’s final outcome and functional status were graded as excellent (>85 points), good (70–85 points), fair (55–69 points), or poor (<55 points) outcomes.
RESULTS
A total of 10 patients were treated by dual plating and 10 by lateral plating alone. All patients were followed up for a maximum of 2 years. Five patients from the dual plating group and four patients from the lateral plating group were initially managed by above knee slab. Three patients from the dual plating and six patients from the lateral plating group were managed by an external fixator initially due to compound injury. Two patients in the dual plating group were initially treated by lateral plate and were cases of implant failure.
One case from the dual plating group went for nonunion after 1-year follow-up. There was an infection at the surgical site, and it was considered an infective nonunion. One case from the lateral plate also went for nonunion and varus collapse due to implant failure. The mean time for fracture union was 13 weeks for dual plating and 28 weeks for lateral plating. Most of the fractures in the dual plating group united between 12 and 16 weeks, and lateral plating between 22 and 28 weeks. There was a statistically significant difference between both groups in time for radiological union with a p-value of 0.038.
There was no significant difference between ranges of movement in both groups (p-value of 0.512). The average range of movement in dual plating cases was 72° (Figs 14 and 15), while in lateral plating cases was 74° (Figs 16 and 17). At the end of the study, minimum knee flexion was 20° for dual plating and 25° for lateral plating and a maximum of 110° for dual plating and 120° for lateral plating (Table 1 and Fig. 18).
| Flexion | Dual plate | Lateral plate |
|---|---|---|
| Upto 30° | 2 | 4 |
| Upto 60° | 1 | 1 |
| Upto 90° | 5 | 3 |
| >90° | 2 | 2 |
Fig. 14: Clinical picture showing maximum extension of patient 1 at 6-month follow-up
Fig. 15: Clinical picture showing maximum flexion of patient 1 at 6-month follow-up
Fig. 16: Clinical picture showing maximum extension of patient 2 at 6-month follow-up
Fig. 17: Clinical picture showing maximum flexion of patient 2 at 6-month follow-up
Fig. 18: Graphical representation of a range of movement of the operated limb knee joint at 6-month follow-up
In the dual plating group, 70% of cases started partial weight bearing by 6 weeks, while in the lateral plating group, it was 10%. Full weight bearing was started by 12 weeks in 70% of cases of the dual plating group, while 60% of cases started full weight bearing only by 24 weeks in the lateral plating group. Dual plating allowed early weight bearing. There was a significant difference in early weight bearing between the two groups, with a p-value of 0.014.
The results, according to Neer’s scoring system, were almost the same in both groups. There was no statistically significant difference between the two groups (p-value = 0.753).
DISCUSSION
High-velocity injuries typically result in distal femur fractures. Despite being frequent in young adults between the ages of 15 and 40, it is more common in women over the age of 50 due to osteoporosis. In the metadiaphyseal junction, high energy trauma causes significant bone comminution and voids, which complicate reduction when the fracture line reaches the articular surface. Management of these distal femur fractures is challenging due to medial cortical loss, comminution, intraarticular extension, and muscular stress acting on fracture fragments.2 Open wounds account for 5–10%.1
When a patient is injured and has a fracture fixed, the surgeons have no control over risk factors such as old age, obesity, diabetes mellitus, and osteoporosis. These elements may slow the process of healing. Chronic smokers and open wounds make the healing environment even worse. During fracture reduction, these thorns are to be expected. We can still change the other elements, such as the surgical methods and implant selection, to promote healing. When compared to dual plate fixation in an unstable distal femur fracture, single lateral plating still increases the risk of fixation failure in addition to the likelihood of malreduction and varus collapse.1
All the patients were followed up for a maximum of 2 years with an average of 1.5 years. In our study, there were three compound cases in the dual plating group and 6 compound cases in the lateral plate group. Between the two groups, there was no statistical difference (p = 0.457). Initial external fixators were used to manage compound cases. Repeated debridements and wound washes were done for infected cases. Due to the prolonged period of wound care, the time required for definitive management, such as lateral or dual plating, was increased. Knee stiffness and difficulty in post-op mobilization were caused by prolonged immobilization.
In our study, 30% of the dual plating cases experienced infection. Of them, two included open fractures that were first treated with external fixators, and the next was a closed case. In one case, the infection was eliminated after multiple wound washes. Repeated antibiotic spacer placement and wound washing were done for the second case. After a year, this case was found to have nonunion and was treated by bone grafting. Even after numerous wound washes and the insertion of antibiotic beads, the third case still had a persistent infection. This case was a grade IIIA open fracture at the time of admission and was treated by the plastic team for two months with multiple wound debridement and flap cover. Later this case was treated by implant removal and limb reconstruction system.
Two patients (20%) in the lateral plating group experienced surgical site infection. Both cases were first managed with an external fixator because they were initially open cases at the time of admission. After numerous wound washes, the wound healed. By 6 months and 1 year, respectively, the fracture was united. These findings are comparable to those of a study conducted in 2014, where he studied 335 distal femur fracture cases. In that study, the infection rate was 33% after open fractures and 4% after closed fractures.
At least three of the four cortexes must exhibit signs of fracture union in order to define as a radiological union.4 In our study, the time for the radiological union for dual plating and lateral plating (Table 2 and Fig. 19) was 13 and 28 weeks, respectively. It was statistically significant (p = 0.038). This demonstrates that dissection of the medial soft tissue has no impact on the distal femur’s blood supply or rate of fracture union. However, due to early weight bearing and greater biomechanical strength of the fixation, dual plating resulted in a higher rate of callus formation and fracture union.
| No of weeks | Dual plating | Lateral plating | ||
|---|---|---|---|---|
| Number | % | Number | % | |
| 12 weeks | 7 | 70 | 1 | 10 |
| 24 weeks | 1 | 10 | 6 | 60 |
| 1 year | 0 | 0 | 2 | 20 |
| Nonunion | 2 | 20 | 1 | 10 |
Fig. 19: Graphical representation showing the time of union
Early union made it possible for the patient to bear weight and move around more quickly (Fig. 20), which further encouraged fracture remodeling and a quicker return to regular work for the patients. As soon as callus development was visible, partial weight bearing was permitted, and full weight bearing was permitted upon the radiographic union. Early mobilization would increase the knee’s range of motion.
Fig. 20: Graphical representation of the time of full weight bearing
In the dual plating group, one case (10%) went for infective nonunion, and one (10%) case from lateral plating went for nonunion, screw breakage, implant failure, and varus collapse. This result was similar to the reports obtained by Ricci et al.,6 where there was a nonunion rate of 19%, Imam et al.,5 where the nonunion rate was 12.5% and Peschiera et al.,7 where it was 23%.
When compared to the earlier study by Imam et al.,5 where 68% of patients had an average range of motion of 90–120° flexion, the post-op knee movement at 1-year follow-up in our study was less in both groups. The average degree of knee flexion in our study was 74° for the lateral plate group and 72° for the dual plating group. The dual plating group had a maximum range of motion of 0–110°, whereas the lateral plating group had a maximum range of motion of 0–120°. This may be because there are more compound cases, which often involve fractures of other bones in the same leg and necessitate prolonged pre-op immobilization on an external fixator.
The least movement in the study group was experienced by one patient in the dual plating group who also had an ipsilateral proximal tibia fracture. Although 40% of the patients did not have a full range of motion, stabilization of the knee allowed for the majority of daily activities to be performed.
Finding the difference between the angle measured between the anatomical axis of the femur and the line perpendicular to the distal femur joint orientation line in the immediate post-op period and at the 1-year follow-up allowed us to quantify post-op varus collapse. This discrepancy suggests that there may have been a collapse after weight bearing. The average collapse following dual plating was 1.5° varus collapse ranging from 7° valgus to 11° varus angulation. In the lateral plate, the group mean varus collapse was 2.6° ranging from 2° valgus to 7° varus. There was no statistically significant difference between both groups (p-value of 0.422).
This outcome is close to that attained by Davison8 in 2003, who studied 26 patients who had distal femur fractures treated simply with lateral plating and found that 42% of the time, there was a varus collapse of greater than 5°. In our study, 40% of the cases that were treated with lateral plating had varus collapse of greater than 5°.
Neer score was used to analyze the functional result. One patient with lateral plating and two patients with dual plating had excellent results. Five patients with lateral plating and two with dual plating had good outcomes. While three patients from each group had poor results, one patient from lateral plating and three patients from the dual plate group had fair results. There was no statistically significant difference in Neer’s functional score between the two groups (p = 0.753).
In the study conducted by Ricci et al.,6 complications related to loss of reduction, malunion, rotational malalignment, and implant breakage were documented with single lateral locking plates at a rate of 7%. However, despite the fact that two cases from the dual plating group experienced nonunion, there was no implant failure or varus collapse during weight bearing in our study. However, there was a case (10%) of nonunion in the lateral plate group that resulted in screw breakage and varus collapse after weight bearing. In the dual plating group, two patients had previously undergone lateral plating treatment, which resulted in nonunion and implant failure.9 This demonstrates the biomechanical advantage of dual plating over single lateral plating.
Limitations of this study include a small number of patients and a short-term duration of follow-up. Larger long-term comparative studies are required for better evaluation and establishment of the treatment protocol.
CONCLUSION
Good fracture union mainly depends on giving a stable fixation and soft tissue handling. The use of a second incision by subvastus approach does not decrease the vascularity, instead helps in earlier union by giving better stability.
Based on our study, the double plating method for unstable distal femur fractures increases the stability of fixation when compared to a single lateral plate. Dual plating improves the healing rate and allows early weight bearing. It accelerates the rehabilitation and allows an early return to work for the patients.
We conclude that on comparing dual plating with the lateral plating method, the lateral plating group showed a better functional outcome which was not significant, whereas double plating is found to be a more reliable and effective method to achieve early radiological union.
Clinical Significance
Dual plating for distal femur fracture with metaphyseal comminution achieves early union and allows early weight bearing and early return to work when compared with a single lateral plate.
ORCID
Cheralathan Senguttuvan https://orcid.org/0000-0003-2974-6845
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