|Year : 2020 | Volume
| Issue : 2 | Page : 137-145
Treatment of distal femur fractures with metaphyseal comminution by minimal internal fixation combined with Ilizarov external fixator
Wael Sh Mahmoud, Mohamed A Omar
Department of Orthopedic Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
|Date of Submission||25-Jan-2020|
|Date of Decision||26-Jan-2020|
|Date of Acceptance||06-Feb-2020|
|Date of Web Publication||29-Jun-2020|
MD Wael Sh Mahmoud
Assistant Professor of Orthopedic Surgery, 15, Mohamed Refat St, Abassia, Cairo
Source of Support: None, Conflict of Interest: None
Objectives To evaluate the minimal internal fixation combined with Ilizarov external fixator in treatment of distal fractures of the femur, its effectiveness, complications, and ability to return to work.
Patients and methods Fifteen patients (11 males and four females) with comminuted distal femur fractures (12 patients closed and three open) were treated at our hospital. All patients were admitted to the same treatment procedure, which is open reduction, minimal internal fixation by two cannulated screws, and preplanned Ilizarov frame fixation. Olive wires fixation of the reduced condyles to the distal Ilizarov ring was done, which is just above the knee joint. There is no ring distal to the knee joint.
Results According to ASAMI protocol, we have nine cases of good results, five excellent, and one case of fair result. Operative time for the procedure averaged 70 min (range, 50–140 min). The mean time in fixation was 26.4 weeks (24–32 weeks). The mean follow-up period after removal of Ilizarov frame was 48.6 weeks (36–67 weeks).
Conclusion With short-term follow-up, the Ilizarov external fixator associated with minimal internal fixation is effective in treatment of comminuted distal femur fractures.
Keywords: cannulated screws, fracture distal femur, Ilizarov external fixation, minimal internal fixation
|How to cite this article:|
Mahmoud WS, Omar MA. Treatment of distal femur fractures with metaphyseal comminution by minimal internal fixation combined with Ilizarov external fixator. Sci J Al-Azhar Med Fac Girls 2020;4:137-45
|How to cite this URL:|
Mahmoud WS, Omar MA. Treatment of distal femur fractures with metaphyseal comminution by minimal internal fixation combined with Ilizarov external fixator. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 Oct 23];4:137-45. Available from: http://www.sjamf.eg.net/text.asp?2020/4/2/137/288262
| Introduction|| |
Distal femur fractures account for ∼7% of all femur fractures. If hip fractures are excluded, one-third of femur fractures involve the distal portion. There is a 1 : 2 ratio of men to women .
The treatment of intercondylar distal femur fractures with severe metaphyseal comminution is challenging. It is important to choose a technique that provides secure fixation, minimum tissue handling, and early ambulation .
Risks of infection, nonunion, mal-union, limb-length inequality, and long period of nonweight bearing are major disadvantages that follow internal fixation of distal femoral fractures. Additionally, hardware failure is common because of the high bending stresses on the laterally placed plates. In the presence of marked metaphyseal defects and low incidence of union rate, this may leave the patient with a limb-length discrepancy, which may necessitate another separate lengthening procedure after hardware removal. Ilizarov has been indicated for temporary fixation of open fractures with significant comminution, bone loss, vascular compromise, and extensive soft tissue damage. However, the Ilizarov can be used as a definitive bridging fixation in severely comminuted fractures and in patients who are unsuitable for additional surgery .
The Ilizarov external fixator when used for the treatment of comminuted supracondylar and intercondylar fractures of the distal femur after stabilization of reduced joint space by minimal internal fixation has considerable advantages. These are a shorter operating time, low blood loss, minimal surgical exposure, the lack of periosteal stripping with possible quicker healing of the fracture, and great mechanical stability .
| Patients and methods|| |
From December 2015 to March 2018, a prospective interventional design was adopted to fulfill the purpose of the study. Consent is taken from all patients as regarding all the information about the surgical procedure, including the benefits and risks. All patients underwent Ilizarov external fixation with no frame below knee in the tibia, that is, the knee was free, to avoid stiffness of knee joint and compared it with other modalities of treatment. A total of 15 patients (11 males and four females) with intercondylar distal femur fracture were admitted to Orthopedic Surgery Department at Al-Zahra University Hospital. The study population included patient with comminuted distal femur fracture who were admitted to the Orthopedic Department.
Patients with intercondylar distal femur open fracture ‘Gustilo types 1, 2, and 3A,’ patients with type C2 and type C3 unstable comminuted intercondylar distal femur fracture, and both sexes were included. Patients fit for surgery in general. According to OTA classification, 60% of fractures were type C2 and 40% were type C3. Moreover, 80% of fractures were closed and 20% were open.
Under spinal or epidural anesthesia, with the patients placed in supine position on a fluoroscopic table, imaging was done. Initially, incision through parapatellar approach was done. The articular components of the fracture were anatomically reduced. The use of 2.5-mm wires was helpful to manipulate the articular fragments as a joystick. The condyles were reduced using a large pointed reduction forceps, and fixed percutaneously, under fluoroscopy, by two cannulated screws (6.5 mm) ([Figure 1]).
|Figure 1 Condyles reduction using a large reduction clamp that applied percutaneously, then fixation by cannulated screws.|
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A 1.8-mm reference wire was then introduced through the condyles, with special care not to violate the suprapatellar pouch, parallel to the knee joint line as a key for a positioning of the frame. A preassembled Ilizarov frame composed of one distal femur ring for the epiphyseal condylar fragments connected to two or more arches for the proximal diaphyseal main fragment was used ([Figure 2]).
Up to three half pins were inserted in each segment in different planes to increase the construct stability. The safest anatomical zones for pins insertion are the anterolateral and direct lateral regions of the femur. Two or three olive wires were placed in the distal femur from the anterolateral to posteromedial and from anteromedial to posterolateral directions, and each wire was fixed to the distal ring. When the ring was constructed, the wires were tensioned and tightened, and then three half pins were inserted in different planes in the proximal femur arches, and connected to the distal femur ring. The final reduction was checked and finally all connections were retightened. Final fluoroscopic image was taken to ensure good alignment and stability of the frame. In all cases, knee has been free, with no frame extended to the leg to allow early knee mobilization and avoid knee stiffness.
All cases evaluated clinically and radiological have been requested for radiological check for reduction, limb-length discrepancy, and rotational mal-alignment. Postoperative knee mobilization has been encouraged from the second day. The patients have seen in the outpatient clinic after 1 week and then every 2 weeks, and the limbs were examined for alignment, pin site, and knee mobility. Follow-up radiographs have also been obtained for assessment of regenerate bone formation and limb alignment. The frame was then removed after complete union was achieved.
| Results|| |
We have 15 cases in our study (15 limbs) with isolated distal femur fracture. Their mean age was 41.7 years (27–70 years). Overall, 66.7% were male and 33.3% were female. In addition, 60% had right side and 40% left side affection. There was nine (60%) fractures type C2 and six (40%) fractures type C3. All cases were treated by open reduction and minimal internal fixation by two cannulated screws combined with Ilizarov external fixator. Operative time for the procedure averaged 70 min (range, 50–140 min). The age, sex, side, fractures types, and nature of fractures of the patients are listed. After management plan, full union was achieved in all cases. The mean time in fixation was 26.4 weeks (24–32 weeks) for the whole cases. However, the mean time in fixation in male cases was 25.1 weeks, and the mean time in fixation in female cases was 29.3 weeks.
Regarding union assessment, according to the association for the study and application of the method of Ilizarov (ASAMI) protocol. The criteria for determination of bony results were union, infection, residual deformity, and limb-length discrepancy The results in our study were as follows: five (33.3%) cases were considered excellent and nine (60%) cases were good, whereas there was one (6.7%) case fair, and no cases of poor radiological end results ([Table 1]).
|Table 1 Overall bony and functional results of the present study, according to ASAMI system of result evaluation|
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In our study, union was achieved in all cases without bone grafting. The limited range of motion was in flexion and the extension was near normal in all patients. The limitation of knee range of motion was greatest in patients with a type C3 fracture. The knee range of motion of the 15 cases in our study after removal of Ilizarov external fixator and physiotherapy showed full extension was achieved in all patients. Moreover, the range of flexion was 55–115° and the mean was 88.5±5°. In our study, we have 13 cases with superficial pin-tract infection, which was treated by pin site care and antibiotics. Deep pin-tract infection presented in two cases, which were effectively controlled by drainage, debridement, antibiotic therapy, and antiseptic dressings. There was no shortening of more than 2 cm detected in all cases in our series. Four patients had insignificant delayed postoperative pain that resolved completely. Psychological depression was the most common complication that was detected in most of the patients in our study (12 cases), which resolved with time with psychological support and after removal of the frame. There were two cases with limited knee flexion, less than 60°, that respond well to physiotherapy and exercise. The patients were evaluated clinically and radiological after taking a written consent ([Table 2] and [Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10],[Figure 11],[Figure 12],[Figure 13]).
|Figure 3 Preoperative plain radiograph anteroposterior view. Preoperative plain radiograph lateral view.|
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|Figure 5 Immediate postoperative radiograph lateral and anteroposterior views.|
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|Figure 13 Knee range of motion after 2 months after removal of Ilizarov frame.|
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| Discussion|| |
The treatment of comminuted distal femoral intra-articular fractures regarding their exposure and method of fixation is challenging issue. It is important to use a surgical technique that can provide limited open reduction with secure fixation, while allowing early mobilization of the knee and early weight bearing, which can be achieved by using Ilizarov external fixator ,,,,.
However, in previous studies, the external fixator was used as a bridging device that provides alignment by ligamentotaxis to obtain the desired length leaving a comminuted metaphyseal bag of bone for future consolidation and healing. This was complicated by delayed union or nonunion and loss of reduction, requiring later on bone grafting, or other surgical procedures ,,,,,.
Furthermore, other studies used the external fixator in less comminuted type A3 and C1 fractures, which are less challenging in comparison with our study. The metaphyseal area of distal femur usually sustains a high-energy trauma that affect the blood supply of the comminuted fragments. In this study, the epiphyseal (condylar) fragments of the fractures were firstly fixed by limited open reduction and minimal internal fixation by cannulated cancellous screws, and then application of the external fixator. The extra-articular fragments were managed in closed manner by osteogenesis. Several studies have reported a union rate with Ilizarov fixator from 92.3 to 100% and 4–8 months union time ,,,,.
Imam et al.  reported 16 patients with type C3 distal femoral fracture who were treated using double plating (medial and lateral). The follow-up time of the studied cohort ranged from 6 to 24 months, with a mean of 11.5±4.7 months. Bone grafting was required in 10/16 (62.5%). Two (12.5%) cases were treated for infection: one (6.25%) case showed signs of nonunion in postoperative radiograph and one (6.25%) case needed a second procedure. Regrafting was performed to one patient at the eighth month with a complete union at 14-month duration. Mean range of knee motion was 114.6±21.8.
In the present study, all cases (100%) achieved solid union in an average 22–30 weeks after one main operation without any additional bone graft. These results are comparable to those of previous studies that have used Ilizarov external fixator for distal femur fractures. However, the present study included selective group from the challenging type C2 and C3 distal femur fractures with severe metaphyseal comminution. The less invasive nature of the current technique with limited open reduction can explain the high satisfactory union results.
Additionally, early weight bearing may allow controlled amount of axial compressive forces at the fracture site, which probably stimulate bone healing.
Arazi et al.  in their series of 14 comminuted distal femur fractures have treated all fractures by ligamentotaxis and closed reduction, without any internal fixation. They included fractures with lesser degree of severity (type A3 fractures) in 21.42% of their series. Despite their earlier time of union (mean, 16 weeks), they failed to obtain anatomical reduction in all type C2 and type C3 fractures by ligamentotaxis alone and reported fair and poor scores in only these subtypes of fractures.
Hassankhani et al.  have treated 34 patients with open comminuted type C2 and C3 fractures using Ilizarov bridging fixator and have performed proximal osteotomy and gradual transport in some of their cases to compensate for major defects. They reported that 14.7% of their series had autogenous bone graft. In their series, a longer duration of union (mean, 24.4 weeks) was reported, as they focused on treating open fractures and included some cases with C3 subtypes. The results of the present series were also comparable to those of previous studies that have used plate fixation for such fractures ,,,. However, the need to make permanent femoral shortening to get good contact, the necessity of extensive bone grafting, and the invasive nature of the commonly used extensile or modified approaches are concerns in plate fixation of comminuted articular fractures ,,. Mal-union and implant-related problems were reported to be common after plating of such fractures .
In a series of 103 distal femur fractures (57% of them were intra-articular), the use of less invasive stabilization system was associated with 93% union results, 2.9% infection rates, 4.8% implant failures, and 18% overall reoperation rate .
Potential reasons for failures after less invasive stabilization system included technical errors in plate placement and early weight bearing in the presence of delayed fracture union . All these issues were overcome in the present study by using the aforementioned less invasive procedure. In our study, bone healing, limb-length equality, and normal alignment were achieved, resulting in satisfactory ambulatory capacity in all cases. The overall bony and functional results were excellent in 33.3% of the cases, good in 60%, and fair in only 6.7% of the cases. Interestingly, despite the better overall bony and functional results in favor of cases with type C2 fractures, the difference does not reach the level of significance. This can be attributed to the anatomical reduction of the articular fracture components, which convert type C3 to a similar geometry of type C2 with minimum handling of soft tissues. Pin-track infections was the commonest complications associated with Ilizarov external fixator ,,,.
Good care of pin entry sites and good treatment of superficial infections in our patients helped in decreasing this problem and preventing deep infections (except in one case). Muscle contracture and stiffness of the knee are common sequelae after Ilizarov in different studies ,,,,.
In the present series, cases with intercondylar distal femur open fracture ‘Gustilo type 3B and 3C‘ were excluded; however, open groups I, II, and IIIA were included, and the articular congruity was restored in all cases. Furthermore, the juxta-articular wire insertion was carried out, while the knee was left free with no frame extended to tibia below knee joint preventing tightness of ilio-tibial tract and quadriceps, which is a causative factor in knee stiffness.Percutaneous ilio-tibial tract and capsular release, around the wires, were done in some cases to ensure good knee movement. Additionally, all wires and pins were inserted away from the suprapatellar pouch, decreasing the incidence of adhesions. Moreover, the controlled modification technique was helpful in correction of any deviation in the mechanical axis and restoration of alignment at the comminuted metaphyseal area.
Lastly, none of the patients in our study had stiffness in knee joint or any extensor lag. Refracture in the regenerate is a troublesome complication, seen in up to 8% of cases in other series .
Premature removal of the frame usually leads to refracture, which did not happen in any of our patients. Additionally, we braced the knee for 2 weeks after removal of the frame to avoid this complication. Our findings extend previous studies showing the importance of external fixator in bone defects reconstruction ,,.
Moreover, our results suggest that limited open reduction is a valid alternative in the treatment of specific types of comminuted distal femur fracture. Fixation with cannulated screws of femoral condyles provides stability of reduction and facilitates Ilizarov stabilization. Our study has some limitations: the lack of control group owing to small number of cases that met our selection criteria and accepting the use of external fixator. Additionally, our study had a short-term follow-up period, which gave an idea about bone consolidation and healing and early functional results. Secondary osteoarthritis with its bad clinical outcomes is a late complication that follow comminuted intra-articular fractures. However, the nearly anatomical fracture reduction with stable fixation, the soft tissues preservation, and the early rehabilitation may reduce the incidence of osteoarthritis later on.
| Conclusion|| |
The Ilizarov external fixator when used for the treatment of comminuted supracondylar and intercondylar fractures of the distal femur after stabilization of reduced joint space by minimal internal fixation has considerable advantages. These are a shorter operating time, low blood loss, minimal surgical exposure, the lack of periosteal stripping with possible quicker healing of the fracture and great mechanical stability.
The present study has some limitations. The number of cases is small. Additionally, in this short-term follow-up series, secondary complications as osteoarthritis with its worse clinical outcomes are not evaluated.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Zuckerman JD, Egol KA, Koval KJ. Handbook of fractures
. 4th ed. Philadelphia: Lippincott Williams and Wilkins; 2010.
Dennis DA, Mahfouz MR, Komistek RD, Hoff W. In vivo determination of normal and anterior cruciate ligament-deficient knee kinematics. J Biomech
Ford KR, Myer GD, Hewett TE. Valgus knee motion during landing in high school female and male basketball players. Med Sci Sport Exerc
Azam M. Management options and decision making algorithm for distal femur fractures. Trauma Int
Arazi M, Memik R, Ögün TC, Yel M. Ilizarov external fixation for severely comminuted supracondylar and intercondylar fractures of the distal femur. J Bone Joint Surg Br
Imam MA, Torieh A, Matthana A. Double plating of intra-articular multifragmentary C3-type distal femoral fractures through the anterior approach. Eur J Orthop Surg Traumatol
Ali F, Saleh M. Treatment of isolated complex distal femoral fractures by external fixation. Injury
Zlowodzki M, Bhandari M, Marek DJ, Cole PA, Kregor PJ. Operative treatment of acute distal femur fractures: systematic review of 2 comparative studies and 45 case series (1989 to 2005). J Orthop Trauma
Pavolini B, Maritato M, Turelli L, D’Arienzo M. The Ilizarov fixator in trauma: a 10-year experience. J Orthop Sci
Hassankhani E, Birjandinejad A, Kashani F, Hassankhani G. Hybrid external fixation for open severe comminuted fractures of the distal femur. Surg Sci
Hutson Jr JJ, Zych GA. Treatment of comminuted intraarticular distal femur fractures with limited internal and external tensioned wire fixation. J Orthop Trauma
Siliski JM, Mahring M, Hofer HP. Supracondylar-intercondylar fractures of the femur. Treatment by internal fixation. J Bone Joint Surg Am
Lujan TJ, Henderson CE, Madey SM, Fitzpatrick DC, Marsh JL, Bottlang M. Locked plating of distal femur fractures leads to inconsistent and asymmetric callus formation. J Orthop Trauma
Handolin L, Pajarinen J, Lindahl J, Hirvensalo E. Retrograde intramedullary nailing in distal femoral fractures—results in a series of 46 consecutive operations. Injury
Collinge CA, Gardner MJ, Crist BD. Pitfalls in the application of distal femur plates for fractures. J Orthop Trauma
Button G, Wolinsky P, Hak D. Failure of less invasive stabilization system plates in the distal femur: a report of four cases. J Orthop Trauma
Duda GN, Kassi JP, Hoffmann JE, Riedt R, Khodadadyan C, Raschke M. Mechanical behavior of Ilizarov ring fixators. Effect of frame parameters on stiffness and consequences for clinical use. Unfallchirurg
Cavusoglu AT, Ozsoy MH, Dincel VE, Sakaogullari A, Basarir K, Ugurlu M. The use of a low-profile Ilizarov external fixator in the treatment of complex fractures and non-unions of the distal femur. Acta Orthop Belg
Song H-R, Kale A, Park H-B, Koo K-H, Chae D-J, Oh C-W et al.
Comparison of internal bone transport and vascularized fibular grafting for femoral bone defects. J Orthop Trauma
Catagni MA, Guerreschi F, Holman JA, Cattaneo R. Distraction osteogenesis in the treatment of stiff hypertrophic nonunions using the Ilizarov apparatus. Clin Orthop Relat Res
Kocaoglu M, Eralp L, Sen C, Cakmak M, Dincyürek H, Göksan SB. Management of stiff hypertrophic nonunions by distraction osteogenesis: a report of 16 cases. J Orthop Trauma
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]
[Table 1], [Table 2]