Surgical treatment of the intra-articular fractures of the distal femur, type C (AO)

Abstract

Introduction: Distal femoral fractures occur usually in two patient populations: young people, especially young men, after high-energy trauma, and elderly persons, especially elderly women, after low-energy injuries. In the older group, most of the injuries occur after moderate trauma such as a fall on a flexed knee. In the younger group, distal femoral fractures occur after high-energy trauma. These fractures are often open, comminuted, and most probably the result of direct application of load to a flexed knee. Most are caused by vehicle accidents, including motorcycle accidents, but they can also result from industrial accidents or falls from heights. Most of these patients are younger than 35 years, with a definite male preponderance. Surprisingly, the degree of comminution in the supracondylar region is often equivalent in both these groups. However, younger patients experiencing high-energy trauma have a greater incidence of additional intra-articular disruption or segmental or more proximal shaft comminution. Material and methods: During 2010-2011 in NSPCEM were treated surgically 66 patients with distal femoral fractures, 31 patients with intra-articular fractures (AO type Cl-2, C2-19, C3-11); 19 were men and 12 women, aged 17-81 years. Mechanisms of injury were vehicle accidents - 19 cases, accidents at work - 2 cases, catatrauma - 1 case and, habitual trauma - 9 cases. Principles of minimally invasive osteosynthesis of distal femur were used in 1 patient, TARPO procedure - in 7 patients, retronail - in 4 cases, the Ilizarov apparatus - in 1 case, plate osteosynthesis through a lateral approach - in 19 cases. All patients were operated in supine position. Indirect reduction of the fragments (in case of minimally invasive osteosynthesis, TARPO and retronail) was performed by applying a roll under the knee, that permitted a flexion at 60° and on orthopedic table, using skeletal traction system through tibial tuberosity with idling leg.Results: In all cases the reduction of the articular surface (main objective) and fixation of the femoral diaphysis were achieved. In case of classic approach (19) this goal was achieved through a large incision, elevation of the vastus lateralis, ligation of the perforator vessels, soft tissue stripping, and medially placed distractors. Minimally invasive procedures (MIPO, TARPO, retronail) provide a gentler approach to soft tissues, with best results of union. Conclusions: The goal of the treatment of a metaphyseal-diaphyseal fracture does not lie in obtaining of a “beautiful” postoperative radiograph; it consists of the restoration of the function of the respective limb in the shortest time. Minimally invasive techniques contest the indications in complex distal femoral fractures type C/AO, representing, in most authors’ opinion, the best and preferred methods of surgical treatment.