High-energy fractures of the distal femur are difficult cases that require an exacting reduction and fixation of the joint with restoration of the mechanical axis, length, and rotation. Before the advent of locking plates and minimally invasive techniques, these surgeries were performed with large open exposures and stripping of soft tissues. Early attempts at less invasive, biologically friendly, surgery were performed without locking plates and would often proceed to heal as a varus malunion with abundant callus.1,2 Early endeavors with locking distal femoral plates, with an “outrigger” to place shaft screws percutaneously, had good clinical results, but there were some complications because of a learning curve with these new techniques and implants.3,4 Adding a degree of complexity are coronal plane fractures, mostly of the lateral condyle, which requires identification and fixation before plate placement.5 The advancement of locked plating has yielded good outcomes, but risk factors for reoperation include comorbidities such as diabetes, smoking, body mass index > 30, and open fractures all out of the surgeon's control.6,7 Recent studies have demonstrated that the type of plate (stainless vs. titanium), number and location of locking screws, and plate length all can determine the healing parameters of these fractures.6–9 This video (see Video, Supplemental Digital Content 1, http://links.lww.com/JOT/A379) demonstrates the use of an anterloateral approach to the distal femur for fixation of a supracondylar femur fracture with intercondylar and coronal extensions with preservation of biology, open reduction of the articular surface, and submuscular plating. Emphasis is placed on the articular reduction and intraoperative techniques to achieve limb alignment with limited exposure.
This case is that of a 33-year-old woman who was involved in a car versus tree accident and presented as a polytraumatized patient to our trauma bay. She sustained a liver laceration, pneumothorax, and a right knee traumatic arthrotomy. She had multiple fractures that included the right clavicle, L5 (compression), right calcaneus, and a left intercondylar/supracondylar distal femur fracture. This surgical video will focus on the left distal femur fracture. X-rays performed in the trauma bay demonstrated a fracture of the left distal femur with metaphyseal comminution. After hemodynamic stabilization of the patient, a computerized tomography scan of the knee was obtained and revealed intra-articular comminution, as well as a coronal fracture through the lateral femoral condyle (Hoffa). The patient was placed in a knee immobilizer with 5 lbs of Buck's traction for the left leg. After clearance by the trauma service, she was taken to the operating the next day. A bolster was placed under the left buttocks to bring the leg into a neutral position. A tourniquet was placed on the proximal left thigh and the leg was prepped and draped in a sterile fashion. The knee was placed over a triangle at approximately 40 degrees of flexion. The tourniquet on the proximal thigh was elevated to 250 mm Hg after elevation of the limb. The incision was lateral and slightly anterior to the midline and proceeded from the tibial tubercle to the proximal extent of the lateral femoral condyle. The iliotibial band, capsule, and synovium were incised to expose the distal femoral articular surfaces. The Hoffa fracture of the lateral femoral condyle was then reduced and fixed provisionally with a K-wire. Overdrilling of the proximal cortex and countersinking for the head of the screw on the far lateral portion of the condyle allowed for insertion of a fully threaded cancellous screw in a lag fashion. Large K-wires were placed in the medial and lateral femoral condyles to act as joysticks to aid reduction. The patella was subluxed laterally but the metaphyseal area of the fracture was not exposed or stripped of soft tissues. Once a reduction was performed, a large pointed bone clamp and K-wires were placed from lateral to medial to reduce the articular segment. There was comminution in the femoral groove, and a small piece of cartilage could not be fixed but was used as a template during surgery to assess the quality of the articular reduction. Again, by overdrilling the lateral cortex, a fully threaded cancellous screw was inserted from lateral to medial to reduce and compress the femoral condylar articular segments together. An 8-hole distal femoral locking plate was inserted through the incision and submuscularly up the lateral femoral shaft. Plate placement should be anterior to the distal condylar segment to avoid medialization of the femoral condyles seen with posterior plate placement. A nonlocking screw was placed through the distal segment to compress the plate to the lateral femoral condyle. A large tenaculum clamp was placed, without stripping, to correct the apex posterior angulation. Length and rotation were obtained, and using the outrigger device, a nonlocking screw was placed proximally in the femoral shaft. This screw may often need to be a little longer than measured if the shaft has to be pulled to the plate. Using the locking holes in the distal portion of the plate, locking screws were then inserted. Proximally, using the outrigger attachment, 3 more nonlocking screws were placed in the diaphysis. With good quality bone, there was no indication for locking screws in the shaft. The choice of a longer plate with fewer screws allows for a better mechanical advantage, and by not placing too many screws in the metaphyseal flare just proximal to the fracture, we attempted to create a less rigid construct. The tourniquet was deflated before closure, which started with the capsule and iliotibial band with absorbable suture and finished with nylon sutures for the skin.
The incisions were covered with sterile gauze pads and a long elastic bandage from the toes to the groin; no bracing was used. We started the patient on early range of motion of the knee because she was awake and alert. Because she had a calcaneus fracture on the contralateral right side, she was on bed to chair transfers in the hospital. The patient was on low-molecular-weight heparin while in the hospital, and this was continued until the 2-week postoperative visit in the clinic. At 6 weeks, the patient was allowed to do standing transfers using the left lower extremity. Because of her multiple injuries and pain, despite physical therapy, the patient developed a 10-degree flexion contracture when seen at 8 weeks. X-rays at that time demonstrated maintenance of alignment and early callus, and she was progressed to weight-bearing as tolerated on her left lower extremity.
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