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Supracondylar Femur Fracture-What Works?

Hennepin County Medical CenterUniversity of Minnesota

Andrew H. Schmidt, M.D.

Orthopaedics

Disclosure InformationAndrew H. Schmidt, M.D.

Conflicts of Commitment/ EffortEditorial Board: JBJS Essential Surgical Techniques, J Knee Surgery, J Orthopaedic TraumaChief, Dept. of Orthopaedic Surgery: Hennepin County Med Ctr.

Disclosure of Financial RelationshipsRoyalties: Thieme, Inc.; Smith and Nephew.Consultant: Acumed; Conventus Orthopaedics; St. Jude Medical (spouse)Stock: Conventus Orthopaedics; Twin Star Medical; Twin Star ECS; Epien; PreferUS Healthcare, EpixResearch Support: Dept. of Defense, Univ. of Minnesota

Disclosure of Off-Label and/or investigative Uses

I will not discuss off label use and/or investigational use in my presentation.

Distal Femur Fractures

• Relatively non-controversial injury– Well understood fracture patterns– Operative indications defined– Treatment principles straightforward

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Goals

• Reconstruction of the articular surface

• Restoration of the mechanical axis– Length, alignment, rotation

• Stable fixation

• Early return of function

Yet, there remain ?’s

Yet, there remain ?’s

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Yet, there remain ?’s

Plate Nail

• Articular Reduction

• Restoration of Mechanical Axis

• Stable Fixation

• Restoration of Function

Plating• Advantages

– Direct joint visualization– Multiple options for screw fixation– Familiar

• Disadvantages– Blood loss, larger incisions– Quad scarring– Infection

Submuscular Locked Plating has significantly reduced these complications

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Plates

• Multiple screw options within the plate– Locking– Nonlocking– Variable angle locking

• Additional screws outside plate

Nails

• Few screw options within the nail– Mostly nonlocking– Newest nails have locking screws– Limited # of interlocking options

• Blocking screws add significant stability and help maintain reduction

• Additional screws can be placed outside nail.

• Reductions typically percutaneous.

Plates versus Nails

How do they compare?

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Biomechanical Comparison

• LISS vs retrograde IM Nail

• LISS 13% stronger axial loading• LISS 45% weaker torsional loading

• Loss of distal fixation during axial loading occurred in 1/16 LISS and 8/8 retrograde IM Nail

Zlowodzki et al, JOT, 2004

• 12 nails, 3 revision surgery to remove implants– 2 for collapse and nail protrusion, 1 painful screws

• 11 blade plates, no revision surgery.

Femur-LISS and distal femoral nail for fixation of distal femoral fractures: are there differences in

outcome and complications?

Markmiller M; Konrad G; Sudkamp N

• 16 cases of each followedPLATE NAIL

1 yr ROM 110 plate 103 nailLysholm-Gillquist =Malunion 3 2Reoperation 2 1

Clin Orthop Relat Res 2004 Sep;(426):252-7

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Plating

• Fractures with intra-articular involvement

• Multiplanar fractures• Peri-prosthetic fractures• Bone quality of less concern with use

of longer locking plates

2 typical patients

Elderly Female Young Male

Can one repair the geriatric supracondylar fracture with a plate?

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• 54 patients• Mean age 57 (15-99)• 94% united

Clinical results indicate that plate fixation of the distal femur works very well for all fracture patterns

For years, the main issue was coronal plane stability

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Locking plates solved that…

But gave us a new problem

instead…

• 86 fractures• 14% failed to unite• More empty holes

in the plate in those that healed

• Less callus in stainless compared to titanium

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What is the appropriate stiffness and how do you achieve it?

• Working length (do you fill every screw hole?)

• Over-drill the near cortex so the screw is only fixed in the far cortex.

• “Active” or “dynamic” locking.

proximal screw density (PSD) defined as the ratio of the total number of screws applied proximal to the fracture to the total number of screws holes in the shaft section of the plate

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Plating Technique

• Minimally invasive approach• Pre-contoured, Angular-stable locking

plates

“Lines of Weakness”

From Forster et al, Injury, 2005

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Treatment Principles

• Reconstruct condyles first– K-wires, clamps– Lag screws

• Reduce and Fix condyles to shaft• No need to expose and repair the

metaphyseal fracture

Surgical Technique

• Radiolucent table, supine position.

• Triangle• Femoral distractor.

Surgical Approach

• 2 choices for incision– Lateral: Simple Fractures– Lateral peripatellar: Complex Fractures

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Traditional Exposure

Anterolateral Approach

Tibial Tubercle

Midline Femur

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Lateral Peripatellar Approach

From Haidukewych et al, JBJS 2008 90A Suppl 2(1): 120

Lateral Peripatellar Approach

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Step 1: Articular Reconstruction

• Goal is anatomic restoration of the articular surface

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Reduction Aids

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Step 2: Reduction of Condyles to Femoral Shaft

• Bumps / Triangle• Mallet• Joysticks• Clamps

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From Haidukewych et al, JBJS 2008 90A Suppl 2(1): 120

Step 3: Insertion of Final Fixation

Appropriate placement of plate on distal femur

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Check reduction and fix to proximal femur

Correction of alignment

• Clamp

• P-Fix Pin

• Non-locking screw

Place distal screws

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Tips and Tricks

• Understand articular anatomy before surgery.

– Medial Hoffa nearly impossible to treat via lateral approach

• 86 fractures• 40% complications• 20% failed to unite, more empty holes in

fractures that healed.

233 mm3 95 mm3

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Tips and Tricks

• Create a more flexible construct by using a long plate with fewer screws.

Tips and Tricks

• Create a more flexible construct by using a long plate with fewer screws.

Tips and Tricks

• Common deformity is excess valgus, hyperextension of distal femur, and external rotation. Know how to correct these.

– “Notch view” appearanceof distal femur on AP x-ray

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Nailing

• Initial reduction techniques same as plate• Blocking screws aid in reduction and afford

better stability• Entry point variable – depends on nail

curvature– Radius of curvature varies from 150 cm to 400

cm

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Reduction with a nail

• Trajectory control as nail enters distal fragment.

• Must have correct entry portal and insert nail colinear to the axis of the distal fragment.

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Summary

• Plating remains the best option for comminuted, intra-articular distal femur fractures.

• One can adapt the fixation to all fracture patterns - No Surprises!

• With new techniques, plating is no more invasive than nailing.

Plate vs Nail

• Nail OK for simple fractures• May be better in morbidly obese.

• All others = plate

Thank You