ORIGINAL ARTICLE |
https://doi.org/10.5005/jojs-10079-1168 |
Distal Femur Type III Open Fractures: Functional Outcome Analysis
1–9Unit-1, Department of Orthopedics, Christian Medical College, Vellore, Tamil Nadu, India
Corresponding Author: Jeremy Bliss, Unit-1, Department of Orthopedics, Christian Medical College, Vellore, Tamil Nadu, India, Phone: +91 9488894000, e-mail: drjeremybliss@gmail.com
Received: 30 April 2024; Accepted: 26 May 2024; Published on: 14 June 2024
ABSTRACT
Introduction: The common goal of open distal femoral fracture management is the restoration of bone alignment, soft tissue management, rotation, length, and stable fixation of the fracture and early mobilization. Open distal femur fractures are prone to complications such as knee stiffness and fracture-related infection. The decision of single-stage fixation or staged reconstruction is often multifactorial with a need to assess their impact through functional outcomes.
Methods: Patients who underwent surgical fixation for open distal femoral fractures from January 2015 to December 2020 were included. Functional outcomes were documented using Schatzker and Lambert criteria scoring and the Oxford knee score on follow-up. A total of 30 out of 36 patients had underwent surgical fracture fixation at the time of presentation and 6 patients underwent transfemoral amputation.
Results: AO33C3 was the major fracture type and was also associated with poorer functional outcomes (p-value of 0.037). About 11% of patients had vascular injuries, all of whom underwent amputation. The high velocity of injury correlated with poor knee range of movements (p-value of 0.030). The primary fixation group had 64% patients with excellent functional outcomes, whereas among those who underwent staged procedures, only 30% had excellent functional outcomes. During the course of treatment, 10 patients were diagnosed to have fracture-related infection.
Early presentation and single staged definitive fixation within 24 hours with aggressive follow-up yielded nearly 60% excellent to good outcomes with 83% of the patients returning to some form of vocation, among whom, 55.55% returned to the same profession. There were 17 excellent, 2 good, 1 fair, and 9 poor outcomes in the mean follow-up period of 5.5 years.
Conclusion: Type III open distal femur fractures are a challenging group to manage; however, with early debridement, primary definitive fixation, and aggressive follow-up, it is possible to achieve predictable and optimum outcomes.
How to cite this article: Bhagyaraj AR, Ashok A, Kumar MJ, et al. Distal Femur Type III Open Fractures: Functional Outcome Analysis. J Orth Joint Surg 2024;6(2):142–148.
Source of support: Nil
Conflict of interest: None
Keywords: Early surgical fixation, Open distal femur fracture, Schatzker Lambert criteria, Staged fixation.
INTRODUCTION
Open distal femur fractures are high-energy injuries, often complicated by comminution at metaphysis and extensive involvement of the articular surface.1 Bone loss with multifragmented distal portion and soft tissue injuries are associated with poor quality of life due to ensuing knee stiffness and infections. The complexity of surgical procedures and the possibility of poor bone union also are the major challenges faced by surgeons in managing open distal femur fractures.2 These fractures can lead to lengthy healing and rehabilitation timeframes, particularly when complications arise.3 In comminuted fractures, functional alignment takes precedence over anatomic reduction of the metaphysis. Bone heals by secondary intention with callus formation.4 Locking plates bridge comminuted metaphyseal segments, while distal screws secure multifragmentary articular segments. Locking plates and insertion guides enable minimally invasive reduction of metaphyseal fragments while retaining soft tissue attachments and bone.5 Scarce literature on this topic warrants the study of long-term follow-up and the application of the study results in more comprehensive fracture management.6 Patient factors that may affect outcomes are not well identified. For example, the effect of late presentation, delay in surgery, and the ability to return to work on outcomes is not well documented in the literature.7,10 This study aims to review the effectiveness of a single vs staged reconstruction by evaluating the functional outcomes.
OBJECTIVES
Analyze functional outcomes.
Associate with time to debridement and overall treatment duration.
Correlate with the infection profile.
Document return to work status.
PATIENTS AND METHODS
This is an Institutional Review Board (IRB)-approved (IRB number: 14785) prospective study conducted in a referral care teaching institution in south India. Those older than 18 years, who presented with post-traumatic open distal femur fractures and were treated in the unit between January 2015 and December 2020, were called back for a single follow-up visit to the outpatient clinic. Pathological fractures were excluded. After obtaining written consent for participation, details were obtained for analyzing functional outcomes using the Schatzker and Lambert criteria (clinician reported) and Oxford knee score (patient reported). Fracture-related infection profile and return to work were documented.
Statistical Methods
Descriptive statistics were used such as mean ± standard deviation (SD) or median [interquartile range (IQR)] for continuous variables and all the categorical variables, frequencies, and percentages were used. The functional outcomes through Schatzker and Lambert criteria the score was categorized into categorical variables: excellent, good, moderate, and poor. To find the association between two qualitative variables Chi-squared test/Fisher’s exact test was used. Statistical comparisons between the means for groups were done by using an analysis of variance (ANOVA) with normally distributed data and nonnormal data Kruskal–Wallis one-way ANOVA was used. p-value < 0.05 was considered a statistical significance. All the statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) 21.0 version.
RESULTS
A total of 36 patients were included, who had a mean follow-up of 5.5 years (range—3–8 years). There was a male preponderance with a ratio of 6:1, respectively. The mean age was 41.6 years (Table 1).
| Variable | Value |
|---|---|
| Age | 41.6 years |
| Sex | |
| Male | 31 (86.1%) |
| Female | 5 (13.8%) |
| Comorbidities | |
| Diabetes | 3 (8.3%) |
| Hypertension | 1 (2.7%) |
| Diabetes with hypertension | 1 (2.7%) |
| Mode of injury | |
| Two-wheeler hit by motor vehicle | 30 (83.3%) |
| Fall from height | 1 (2.7%) |
| Workplace injury | 4 (11.1) |
| Four-wheeler vs motor vehicle | 1 (2.7%) |
| AO type | |
| AO33A1 | 2 (5.5%) |
| AO33B1 | 4 (11.1%) |
| AO33B2 | 5 (13.8%) |
| AO33C1 | 5 (13.8%) |
| AO33C2 | 6 (16.6%) |
| AO33C3 | 14 (38.8%) |
| Mode of fixation | |
| Open reduction and internal fixation (ORIF) with plate | 12 (32.4%) |
| ORIF with screws | 5 (13.8%) |
| External fixation | 5 (13.8%) |
| External fixation + screws | 8 (22.2%) |
| Amputation | 6 (16.6%) |
The average time from injury to index surgery was 24.46 hours with a minimum being 6 hours and a maximum being 192 hours (irrespective of the time from injury to presentation to our hospital). The average time to surgery in patients with excellent scores was 21 hours (minimal time of presentation being 6 hours, and maximum time of presentation being 25 hours). In nine patients with poor scores, 31 hours was the average time to surgery (minimum time of presentation was 20 hours, and maximum delay in presentation was 192 hours). This indicates that the earlier the presentation to the hospital after injury, the better the results.
The average presenting time of the vascular injury was 20 hours (range: 16–24 hours) and was the predominant cause in five out of six patients who underwent amputation as index surgery.
The initial velocity of injury had a significant correlation with the final knee range of movements (p-value of 0.036).
AO33C3 was the major fracture type (38.8%) followed by AO33B2 (16.6%) and C2 types of fracture (16.2%). AO33C3 type fractures were significantly associated with poorer functional outcomes (p-value of 0.037) (Fig. 1). Only one patient with an AO33C2 type fracture had a full knee range of movement from 0 to 140°. Seven patients had knee range of movement from 0 to 120° out of which, two patients had 33C3 type fractures and two patients had 33C2 fractures. Statistically, there was a significant correlation (p-value of 0.037) in the type of fracture and Schatzker and Lambert score on linear by linear association. This signifies the association of complicated fractures with poor functional outcomes.
Fig. 1: Comparison of working group for osteosynthesis issues (AO) types with Schatzker and Lambert functional outcome scores
Early primary fixation included open reduction internal fixation as index surgery (n = 17) of whom, 11 (64%) had excellent, 1 (6%) had good outcomes, and 5 (30%) had poor outcomes (one patient underwent transfemoral amputation due to the persistence of infection).
Staged surgical fixation included external fixation followed by definitive fixation (n = 13), these patients had undergone external fixation with or without minimal internal fixation (screws) as index surgery. All of them subsequently underwent secondary procedure(s), eight patients (60%) had excellent outcomes with full knee range of movements and minimal pain score. One (10%) patient had a moderate outcome probably due to the presence of an ipsilateral leg and both bone fractures. Four (30%) patients had poor outcomes. Poor outcome in one patient could be attributed to delayed presentation of 8 days following the injury (Table 2).
| Number | Age | Gender | Gustilo Anderson type | AO type | Time to surgery (hours) | Stages of surgeries | Treatment duration (days) | Fracture-related infection | Soft tissue cover | Oxford knee score | Schatzker and Lambert score | Return to work# | Time to return (months) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 39 | F | IIIB | 33B1 | 8 | 2 | 15 | Yes | Yes | 32 | Moderate | Yes | 8 |
| 2 | 23 | M | IIIA | 33B2 | 8 | 1 | 10 | No | No | 30 | Good | Yes | 6 |
| 3 | 43 | M | IIIB | 33C3 | 16 | 1 | 10 | Yes | Yes | NA* | Poor | No | NA |
| 4 | 21 | M | IIIB | 33C3 | 8 | 2 | 10 | No | No | 42 | Poor | No | NA |
| 5 | 23 | M | IIIA | 33B1 | 48 | 1 | 14 | No | No | 46 | Excellent | Yes | 12 |
| 6 | 20 | M | IIIB | 33C2 | 24 | 1 | 10 | Yes | No | 48 | Excellent | Yes | 5 |
| 7 | 57 | M | IIIC | 33C2 | 16 | 1 | Not applicable (NA) | No | No | NA* | Amputated | No | 24 |
| 8 | 36 | M | IIIC | 33C2 | 22 | 1 | NA | No | No | NA* | Amputated | No | NA |
| 9 | 43 | M | IIIA | 33B2 | 18 | 1 | 10 | Yes | No | 30 | Excellent | Yes | 12 |
| 10 | 38 | M | IIIA | 33B2 | 120 | 4 | 180 | Yes | No | 42 | Excellent | Yes | 12 |
| 11 | 48 | M | IIIA | 33A1 | 16 | 2 | 60 | No | No | 44 | Excellent | Yes | 24 |
| 12 | 46 | M | IIIB | 33B2 | 48 | 6 | 30 | Yes | Yes | NA* | Poor | No | NA |
| 13 | 39 | M | IIIC | 33C1 | 12 | 2 | 10 | No | Yes | 33 | Poor | No | NA |
| 14 | 61 | M | IIIB | 33C3 | 7 | 2 | 90 | No | No | 44 | Good | No | NA |
| 15 | 47 | M | IIIB | 33C3 | 11 | 2 | 60 | No | No | 42 | Poor | Yes | 24 |
| 16 | 28 | M | IIIA | 33C1 | 16 | 3 | 60 | No | No | 42 | Excellent | Yes | 6 |
| 17 | 50 | F | IIIC | 33C3 | 18 | 1 | NA | No | No | NA* | Amputated | No | NA |
| 18 | 52 | M | IIIA | 33C2 | 10 | 1 | 10 | No | No | 44 | Excellent | No | NA |
| 19 | 52 | M | IIIA | 33C3 | 16 | 3 | 210 | No | No | 48 | Excellent | Yes | 18 |
| 20 | 44 | M | IIIC | 33C3 | 10 | 2 | 60 | No | No | NA* | Amputated | Yes | 12 |
| 21 | 56 | M | IIIB | 33B1 | 16 | 2 | 300 | No | No | 46 | Excellent | Yes | 24 |
| 22 | 25 | M | IIIB | 33C3 | 6 | 5 | 90 | Yes | Yes | NA* | Amputated | Yes | 8 |
| 23 | 40 | M | IIIB | 33B2 | 11 | 1 | 10 | Yes | Yes | 46 | Excellent | Yes | 8 |
| 24 | 23 | M | IIIB | 33C3 | 10 | 1 | 16 | No | No | 32 | Poor | Yes | 6 |
| 25 | 40 | M | IIIA | 33C3 | 24 | 1 | 10 | No | No | 28 | Poor | No | NA |
| 26 | 37 | M | IIIB | 33C2 | 26 | 1 | 60 | Yes | No | 32 | Excellent | No | NA |
| 27 | 28 | M | IIIB | 33C3 | 12 | 1 | 90 | No | Yes | 48 | Excellent | Yes | 12 |
| 28 | 41 | M | IIIA | 33C2 | 24 | 1 | 14 | No | No | 42 | Excellent | No | NA |
| 29 | 49 | M | IIIC | 33C3 | 24 | 2 | 10 | Yes | No | NA* | Amputated | No | NA |
| 30 | 65 | F | IIIC | 33C1 | 11 | 1 | NA | No | No | NA* | Amputated | Yes | 12 |
| 31 | 38 | M | IIIA | 33A1 | 8 | 1 | 10 | No | No | 48 | Excellent | Yes | 24 |
| 32 | 68 | M | IIIB | 33C3 | 10 | 1 | 10 | No | No | 18 | Poor | No | NA |
| 33 | 61 | F | IIIB | 33C1 | 8 | 1 | 10 | No | No | 24 | Poor | No | NA |
| 34 | 50 | F | IIIA | 33C3 | 48 | 2 | 13 | No | No | 48 | Excellent | Yes | 6 |
| 35 | 27 | M | IIIB | 33B1 | 24 | 2 | 14 | No | Yes | 48 | Excellent | Yes | 4 |
| 36 | 23 | M | IIIB | 33C3 | 10 | 1 | 16 | No | No | 32 | Poor | Yes | 3 |
*Oxford knee score not calculated since knee was stiff or limb amputated above the knee; #return to same work as before surgery
Out of 29 patients for whom the tibiofemoral angle can be calculated, the average angle was found to be a valgus of 4.9°. There was a significant difference when age was compared with tibiofemoral angle (p-value of 0.509) due to the presence of preexisting arthritis in this population. The mean of the tibiofemoral angle in the excellent functional outcomes group was 5.02° [confidence interval (CI): 2.86–7.183°]. The mean of the joint congruence angle in the excellent functional outcomes group was 1.828° (CI: 1.248–2.408°).
During treatment, nine patients (25%) had fracture-related infection. Enterococcus was the most common pathogen (Fig. 2). In this group, three patients had multidrug resistance to first-line drugs, among them, two had poor functional scores. One patient, despite multiple procedures, had persistent septicemia and eventually underwent amputation.
Fig. 2: Fracture-related infection—organism profile
CASE ILLUSTRATION I
A 21-year-old gentleman, cook by profession, met with a road traffic accident while driving a two-wheeler collided with another two-wheeler. He had sustained AO33C3 type of open distal femur fracture. He presented 8 days after the injury. Initially, he underwent wound debridement, minimal internal fixation, and knee-spanning external fixation, followed by second-look debridement and washout 5 days later with antibiotic cement beads placement. He was advised another surgery for removal of the cement beads and definitive fixation; however, the patient was lost to follow-up. At a 3-year follow-up when he was called for this study, his knee range of movement was 10–60° (Figs 3A and B) with a valgus deformity and he had not returned to any work. He underwent distal femur opening wedge osteotomy and condylar blade plate fixation along with quadricepsplasty. Post surgery with better-aligned limb and adequate physiotherapy, he had achieved knee range of movement of 5–90° (Figs 3C and D) and he was able to return to his preinjury profession.
Figs. 3: A to D: Comparison of 3-year follow-up and final follow-up photographs: (A) 3-year follow-up: stiff knee; (B) 3-year follow-up: restricted knee ROM; (C) Final follow-up: Post 2nd stage deformity correction; (D) Final follow-up: improved knee ROM
CASE ILLUSTRATION II
A 28-year-old gentleman, driver by profession met with a road traffic accident while he was driving a two-wheeler and collided with another two-wheeler. He had sustained an AO33C3 type of left open distal femur fracture. Initially, he underwent wound debridement with transarticular external fixation (Fig. 4), followed by open reduction internal fixation and soft tissue cover with medial gastrocnemius flap and split-thickness skin grafting 5 days later. At 3 years’ follow-up, his knee range of movement was 0–130° (Figs 5 and 6) and he was able to return to his preinjury work of driving (Fig. 7).
Fig. 4: Comparison of 3-year follow-up and final follow-up radiographs
Figs. 5: A to F: Preop imaging [radiograph and computed tomography (CT)]: (A) Preop X-ray: anteroposterior view; (B) Preop X-ray: lateral view; (C) Preop CT: axial section; (D) Preop CT: coronal section; (E) Preop CT: coronal section 2; (F) Preop CT: sagittal section
Figs. 6: A to F: Final follow-up imaging (radiograph and CT): (A) Postop X-ray: anteroposterior view; (B) Postop X-ray: lateral view; (C) postop CT: axial section; (D) postop CT: coronal section 1; (E) postop CT: coronal section 2; (F) postop CT: sagittal section
Figs. 7: A to C: Final follow-up clinical photographs: (A) Terminal extension; (B) Terminal flexion; (C) Anterior view: no limb length discrepancy nor coronal plane deformity
DISCUSSION
In this study, we find that the average time from injury to index surgery was 24.46 hours (range: 6–192 hours). Excellent functional outcomes were observed in patients who presented early to the hospital (p-value of 0.059). The duration of the overall treatment period including secondary procedures did not affect the outcomes. AO33C3 was the major fracture type (37.8%). AO33C3 type fractures were significantly associated with poorer functional outcomes (p-value of 0.037). The high velocity of injury correlated with poor knee range of movements (p-value of 0.030). However, it is worth mentioning that even within the high-velocity group, 14 patients (48%) had a good knee range of movements.
Among those who underwent early single-stage definitive surgical fixation, 64% had excellent functional outcomes, whereas among those who underwent staged surgical procedures, only 30% had excellent functional outcomes.
The average presenting time of the vascular injury was 20 hours (range: 16–24 hours) and was the predominant cause in five out of six patients who underwent amputation as index surgery. In a study by Kluckner et al.,10 28.2% of patients who sustained a vascular injury in road traffic accidents had to undergo amputations. Since vascular trauma in lower extremity injuries is associated with higher amputation rates, early presentation and identifying predictors are of utmost significance. The initial velocity of injury had a significant correlation with the final knee range of movements (p-value of 0.036).
Nine patients had fracture-related infections; Enterococcus was the most common pathogen. Hoffmann et al.4 also reported a similar rate of infection in his study, of which, one was superficial, and eight were deep infections requiring secondary surgery.
Quadriceps scarring with or without arthrofibrosis of the knee or patella-femoral joint is thought to restrict knee movement.5 These effects are greatly magnified by immobilization after the fracture or internal fixation. Malalignment of 10° is likely to affect knee mechanics and gait. Increased varus or valgus may lead to overloading of the joint and subsequent arthrosis of the medial or lateral compartment, respectively.5 In the excellent functional outcomes group, the mean of the tibiofemoral angle was 5.02° and the mean of joint congruence angle was 1.828°. Prolonged immobilization and malalignment affect knee mechanics and gait and hence affects return to work.
Return to the preinjury profession happened in 20 patients (55%), 10 patients (28%) had to change the profession. Of the six amputees, four did not return to any work, one had returned to an alternate profession and one had returned to the same profession.
Functional outcomes assessed by Schatzker and Lambert Criteria and Oxford knee score correlated with high significance (p-value of 0.005). Based on this, there were 17 excellent, 2 good, 1 fair, and 9 poor outcomes.
CONCLUSION
Open distal femur fractures were common in men of 4th decade riding two-wheelers. Most fractures were of AO33C3 type (37.8%). Polymicrobial and multidrug resistant wound infections and high-velocity injuries adversely affect the outcome. Prolonged immobilization and malalignment affect knee mechanics and gait and hence affect return to work.
Among those who underwent staged fixation, 30% had excellent functional outcomes, whereas those with single-stage definitive fixation had 60% excellent to good outcomes with 83% of the patients returning to work.
Type III open distal femur fractures are a challenging group to manage; however, with early debridement, primary definitive fixation, and aggressive follow-up, it is possible to achieve predictable and optimum outcomes.
ORCID
Arul R Bhagyaraj https://orcid.org/0009-0004-7012-8592
Anand Ashok https://orcid.org/0000-0001-9904-8028
Manisha J Kumar https://orcid.org/0000-0002-2241-1076
Krupakaran Ganesan https://orcid.org/0000-0002-3280-8747
Anand Kurian https://orcid.org/0000-0002-9950-6276
Dan B Inja https://orcid.org/0000-0002-2466-0391
Manasseh Nithyananth https://orcid.org/0000-0002-3845-4900
Vinoo M Cherian https://orcid.org/0000-0003-0481-1145
Jeremy Bliss https://orcid.org/0000-0003-3973-5058
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