distal femur fractures

7/21/2019 Distal Femur Fractures

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Orthopaedics & Traumatology: Surgery & Research (2013) 99, 353360

Available online at

www.sciencedirect.com

REVIEW ARTICLE

Distal femur fractures. Surgical techniques and a

review ofthe literature

M. Ehlinger, G. Ducrot, P. Adam, F. Bonnomet

Department ofOrthopaedics andTrauma Surgery, Hautepierre Teaching Hospital Center, StrasbourgAcademyHospital Group, 1,

avenue Molire, 67098 Strasbourg cedex, France

Accepted: 29 October 2012

KEYWORDS

Distal femur;Fracture;Supracondylar andintercondylarfracture;Internal fixation;

Biomechanics

Summary Fractures ofthe distal femur are rare and severe. The estimated frequency is 0.4%

with an epidemiology that varies: there is a classic bimodal distribution, with a frequency peak

formen in their 30s and a peak for elderly women; however, at present it is found predominantly

in women and in the elderly with more than 50% ofpatients who are over 65. The most common

mechanism is an indirect trauma on a bent knee, and more rarely direct trauma by crushing.

The anatomy of the distal femur explains the three major types of fracture. Because of the

anatomy ofthe distal femur, only surgical treatment is indicated to stabilize the fracture. A

non-surgical treatment is a rare option. The aim ofthis report was to provide an update on theexisting surgical solutions for the management of these fractures and describe details of the

surgical technique applicable to these injuries. Recent radiological, clinical and biomechanical

data published in the literature are reported to compare different surgical options.

2013 Elsevier Masson SAS. All rights reserved.

Introduction

Fractures of the distal femur are rare and severe. Theestimated frequency is 0.4% of all fractures and 3% offemoral fractures [1]. A classic bimodal distribution isfound with a peak in frequency in young men (in their30s) and elderly women (in their 70s). The usual con-text is a high energy trauma in a young patient and adomestic accident in an elderly person [1]. The gender

Corresponding author.E-mail address:[email protected]

(M. Ehlinger).

ratio has changed and today there is a majority ofwomen(1man/2women), and the population is also increasinglyolder; mean 61years old at fracture and over 65 in morethan halfthe cases [1]. Sufficient stabilization to withstand

static loading forces on bone and dynamic muscular forcescan only be obtained with surgery. An orthopedic treat-ment is rare: it is proposed in bedridden patients and/or inpatients with reduced autonomy in fractures with little or nodisplacement.

The goal of this study was to provide an update onthe management of these fractures. The basic pointsof treatment are summarized. The technical details andthe indications of the different surgical treatments arethen described. Finally, recent radiological, clinical and

1877-0568/$ see front matter 2013 Elsevier Masson SAS. All rights reserved.http://dx.doi.org/10.1016/j.otsr.2012.10.014


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354 M. Ehlinger et al.

biomechanical results published in the literature arereported to compare the techniques.

Management and therapeutic principles

Initial management

Besides a clinical examination and a standard radiologicalexamination, a CT scan is recommended because 55% ofthese fractures are intra-articular [1]. If there is a doubtabout the presence of vascular injury, appropriate testsshould be performed. It should be remembered that thepresence ofa distal pulse does not exclude vascular injury.Femoral nerve block is indicated and recommended by sameauthors in the emergency room [2]. These fractures are seri-ous with a high mortality rate in elderly populations which iscomparable to that found in the proximal femur. It has beenshown that a delay in surgery by more than 4 days (what-ever the cause) is associated with an increase in mortalityat 6 and 12months of follow-up [3]. The known risk fac-tors are dementia as well as cardiac and kidney disorders[3]. To reduce perioperative morbidity and mortality in thisage group, Kammerlander et al. [4] advise appropriate ini-tial medical management and taking measures to preventcomplications that may compromise functional results. In aseries of43 patients in their 80s, they reported 50%mortalityat the 5-year follow-up, a frequent loss of independence,and only 18% ofpatients who can walk without help.

The major principles oftreatment

Fractures of the distal femur are severe and medicalmanagement and treatment are difficult. The 1988 SOF-

COT symposium reported [5]: infection and septic nonunionin 13% (29% of open fractures), aseptic nonunion in14%, residual stiffness in 35%, secondary post-traumaticosteoarthritis in 50%, with initial chondral injury as well asincomplete reduction.

The main therapeutic principles are as follows. If thefracture is intra-articular, joint reconstruction is the firststep. The knee must remain free and mobile at the surgicalsite. Exposure of epiphyseal fracture lines is obtained withthe knee bent, especially with frontal lines. Stabilizationon the frontal plane is usually not difficult, while saggitalplane stability with rotation of the condyles is much moredifficult. The metaphyseal portion, in particular ofthe ante-rior cortex can serve as a reference point. The second step

includes reducing the epiphysis on the metaphyso-diaphysis:this is performed with the leg in extension. In case ofa com-minutive fracture, rotation and length should be carefullycontrolled.

Surgical options

For an extra-articular fracture, all therapeutic options arepossible and mini-invasive surgery can be performed. In caseof an intra-articular fracture, open reduction and internalplate fixation should be performed with the patient on astandard operating table.

External fixation

External fixation is not indicated for definitive treatmentof these fractures, in particular in displaced intra-articularfractures. It is difficult to control alignment, the stabilityof this technique is poor (lever arm of the leg), there isno fixation of the articular component and stabilization ofthe fracture requires bridging the knee, which increases the

risk of stiffness. The indications are more often for tempo-rary fixation. Ifthere is a complex fracture, the fracture canbe evaluated and a therapeutic strategy can be determinedusing this solution. A bilateral fracture or a floating kneeare typical examples of these complex fractures (Fig. 1).External fixation provides medical management and a Dam-age Orthopedic Control approach which reduces pain andfacilitates treatment. Local monitoring ofan open fractureis facilitated. Finally, in case of associated vascular injury,the fracture must be stabilized rapidly.

External fixation should bridge the knee when there isintra-articular involvement. The femoral pins should be ata distance from the fracture site and the joint to preventinfection. Anterior femoral pins can be a good choice ifinter-nal fixation with a lateral plate is used later: in that caseexternal fixation is maintained during the procedure to facil-itate control ofalignment during internal fixation. Althoughtemporary external fixation has certain advantages, thereare still certain risks. Control of the fracture is limited,and there is a risk of skin damage from a protruding bonefragment. Oh et al. [6] reported results of a series of 59complex intra-articular fractures with temporary bridgingexternal fixation. There were seven complications includ-ing four that developed in distal femoral fractures. Theauthors explain this rate of infection and the unsuccessfulcontrol oflength that occurred by the abundant femoral legmuscles and the presence of the suprapatellar pouch. On

the other hand, Parekh et al. [7] reported good results inthe two-step management of complex intra-articular frac-tures around the knee (with 16 distal femoral fractures in aseries of47 cases). Finally, Bonnevialle et al. [8] reported aseries of 27 fractures of the femoral diaphysis and 26 frac-tures of the distal femur treated with a lateral externalmonoplane fixator with a high rate of infection and kneestiffening in the distal fracture group. They concludedthat definitive external fixation is only indicated in stabledistal metaphyseal-diaphyseal fractures when the epiphysishas first been stabilized.

Anterograde intramedullary nailing

The indications for anterograde intramedullary nailing areessentially extra-articular fractures. Certain intra-articularfractures without or with very little displacement can betreated with this technique as long as the epiphyseal partof the fracture has been stabilized with isolated screws toavoid opening ofthe fracture site during nailing. Finally, inthe rare cases ofbi- or trifocal fractures ofthe distal femur,nailing is often the only therapeutic alternative (Fig. 2).This solution is contraindicated in complex intra-articularfractures.

The advantages of this technique are that it is closedwith conservation of heamatoma and that the implant is


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Treatment ofdistal femur fractures in adults 355

Figure 1 Bilateral floating knee: a: clinical appearance; b: AP X-ray; c and d: postoperative X-ray, left side; e and f: postoperative

X-ray, right side.

extra-articular which is relatively easy to remove. Thepatient should be installed on a traction table. If condylartraction is being performed (extra-articular fracture), thisshould be as anterior as possible. If there is intra-articularinvolvement, a tractionboot is indicated. Recurvatumdefor-mity of the distal fragment is controlled by providingdistal support attached to the traction table (Fig. 3). Addi-

tional internal fixation of an epiphyseal fragment shouldtake into account the position of the future nail. The nailshould descend as deeply as possible into the condyle formaximum stability. Antekeier et al. [9] defined the min-imum distance between the fracture site and the mostproximal screw for distal fixation of the nail. Anterogradeintramedullary nailing is possible when the fracture islocated more than 3 cm from the proximal screw, which canresist one million cycles of loading. The diameter of thenail is also important. For Huang et al. [10], distal corti-cal contact increases stability ofthe system while reducingstrains which are absorbed by the nail and the lockingscrews.

Retrograde nailing

The indications for retrograde nailing are classic: extra-articular fracture, simple intra-articular fractures withlittle or no displacement. This technique may beindicated in cases of floating knee with a singlesurgical approach for stabilization of both fracture

sites.Passing a nail near the fractured trochlea can worsen

the situation by opening the fracture site, thus if thereis an intra-articular fracture line, initial screw fixation isindicated. Retrograde nailing has the advantages ofbeing aclosed technique, but because it is intra-articular, there isa risk ofseptic arthritis in case ofinfection. Removal is alsomore difficult. The patient can be installed on a standardor a fracture table. On a standard table, the knee is in 30

flexion and the distal femur is supported. On a fracturetable, reduction is obtained by skeletal traction at theproximal tibia with the leg hanging slightly. The nail shouldbe inserted deep enough to avoid any impingement with the


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Figure 2 Example ofa bifocal fracture ofthe femur treated with anterograde intramedullary nailing: a, b, c: preoperative X-rays;

d, e, f: immediate postoperative X-rays.

Figure 3 Distal support attached to a traction table to control

tilting ofthe distal fragment.

patella and should not be used as a lever to preventcreating an intercondylar fracture line. Epiphysealfixation can be improved by using a screw and counterscrew.

Simple screw fixation

Simple screw fixation is proposed in the presence ofa frontalor sagittal unicondylar fracture.

A medial or lateral parapatellar approach is oftennecessary, however, in case of a fracture with no or lit-tle displacement, a percutaneous procedure is possible andreduction is controlled by ligamentotaxis. A recent studyshowed that osteosynthesis using two 6.5mm screws weremore effective than osteosynthesis using two or four 3.5mmscrews [11]. A load of 4056% more was required with6.5mm screws to cause system failure. In frontal fractures,the direction ofthe screws changes the mechanical stability.Double screws using cancellous lag screws in a posterior toanterior direction provide better mechanical strength dur-ing loading than those in an anterior to posterior direction

[12].

Blade plate

Classic indications are extra-articular fractures, sagittalunicondylar fractures or supracondylar and intercondylarfractures.

This is a monoblock, preshaped implant that is adapted tothe anatomy of the distal femur. The system is very stableallowing compression of the epiphyseal-metaphyseal frac-ture site. In osteoporotic bone, placement of the bladecan be traumatic and have little resistance to breakage.Mechanically, the plate functions like a dynamic tension


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band and creates medial compression. The 95 blade plate isplaced on a femur whose articular surface is in 13 valgus.In this way, the difference in angle between the plate andthe distal end of the femur results in medial compressionof the metaphyseal fracture site after diaphyseal fixation,thanks to the deformation ofthe blade plate. For an optimaleffect, the medial pillar must be perfectly reconstructed.The diaphyseal position of the plate is determined by the

position of the blade which must be precisely defined. Itshould be located 2cm from the joint line (AP and lateralview), along the axis ofthe femoral diaphysis and in the mid-dle ofthe anterior halfofthe largest diameter ofthe condylein profile. Thus the blade is inserted in front ofthe Blumen-satt line (avoiding the cruciate ligaments) and behind thegroove of the trochlea (avoiding the patellofemoral jointline). The path is perpendicular to the lateral cortex, aimedapproximately a dozen degrees towards the back to preventinternal rotation and medial translation of the distal frag-ment. The blade should not extend beyond themedial cortexto prevent injuries ofthe medial collateral ligament.

Dynamic compression plate

The indications are classic: extra-articular fractures,sagittal unicondylar fractures or supra- and intercondylarfractures.

This solution includes dynamic epiphyseal screw fixation(lag screw) for compression of the fracture site. Epiphy-seal fixation is obtained by a single screw which the platepivots upon for sagittal adjustment. The 95 angle betweenthe plate and the screw facilitates frontal placement andpositions the ephiphyseal screw parallel to the joint. Thissystem has the advantage of being fairly easy to position,because the screw is cannulated, to limit bone trauma andto have good resistance to screw failure. However the screw

hole is large, there may be rotational instability in the dis-tal screw before diaphyseal fixation and the insertion site ofthe screw may be located near a frontal fracture. The inser-tion guide is positioned according to the same criteria as theblade plate, and its direction on the axial plane is parallel tothe anterior trochlear rims, or 10 downwards and inwards.

Locking compression plate

The classic indications are extra-articular fractures, sagittalunicondylar fractures or supra- and intercondylar fractures.

The goal of locking plate is to provide better stability infragile bone. Primary stability of the plate is independent

ofthe friction effect as the screw presses the plate, and isobtained by locking the screw into the plate. Plate design isusually anatomicalwhich allows it to be used as a reductionmold, molding the bone to the plate.

The locking plate can be used during an open procedurewhen there is intra-articular involvement, or with mini-invasive surgery using the ancillary less invasive stabilizationsystem (LISS) in case ofan extra-articular fracture or in thepresence ofa simple non- displaced fracture [13]. Combina-tion use is possible, with mini-invasive proximal diaphysealfixation combined with open distal internal fixation. Mini-invasive surgery reduces postoperative pain, and facilitatesfunctional recovery [14]. Its main disadvantage is the lack

of epiphyseal compression with locking screws, requiringprior placement ofstandard additional screws. These screwsshould not interfere with the plate. The rules for fixation ofthis system must be strictly followed, in particular duringmini-invasive surgery to prevent malunion and mechanicalfailure [15]. The patient can be installed according to thesurgeons preference. Ifthe patient is installed on a tractiontable, traction should be moderate and a certain degree of

impaction ofthe fragments should be preserved, especiallyin elderly patients to promote union. The first step of themini-invasive surgery is to mark the skin with references(fracture, joint line, patella, femoral stems of an existingimplant, femoral axis, incision) which will help reduce theamount ofradiation to the patient, choose the length oftheplate and facilitate the procedure. The lateral paracondylarapproach is used. The length ofthe plate is chosen to leaveat least five holes above the fracture. The goal is to obtaincoverage that is as long as possible to absorb and distributestrains and stresses. It is necessary to remain extra-articularby raising the suprapatellar pouch. The beveled tip of theplate allows minimally traumatic submuscular and extrape-riosteal insertion. The plate should be parallel to the lateral

cortex in front, centered on the femoral diaphysis in profile,with the racket of the distal femoral plate located behindthe base ofthe trochlea and in front ofthe Blumensatt line.The anatomical plate can be used as a reduction mold ifandonly if the plate is, firstly, parallel to the lateral cortex ofthe femur (parallel to the cortex does not mean in contactwith bone), secondly, the epiphyseal screws are parallel tothe joint line. The second part of the procedure includesplacing a 2mm pin along the path of the central screw ofthe LISS system which should be parallel to the joint line.The bone can then be pulled towards the plate with a trac-tion screw or by using the LISS system. To obtain a perfectreduction, different technical tricks can be used (lag screw

from the bone to the plate, temporary intrafocal pinning,temporary screws, joystick pin) [1315].Numerous biomechanical studies have been performed

to evaluate and define locking plate fixation systems.The LCP (Synthes, Etupes, France) system is usually thereference and is compared to classic internal fixation sys-tems. Dougherty et al. [16] suggest that bicortical screwsshould be systematically used to provide three points offixation (2 cortical+ the plate) to limit breakage. The posi-tion ofthe screw in relation to the fracture line depends onthe type of fracture. If the fracture is unstable (long frac-ture line, comminutive fracture) locking screws are placednear the fracture line to stabilize the fracture site. If it isa simple fracture, locking screws are placed further away

with an open hole on each side of the fracture to createelasticity in the system, which will promote union [17]. ForAhmad et al. [18], the internal fixation system should beclose to the fracture. A distance ofless than 2mm providesbetter resistance to compression and torsion, while thereis significant plastic deformity with more than 5mm. LCPplates have combination screw holes making it possible touse a locked system, a dynamic compression plate (DCP)system or a combination system. Stoeffel et al. [19] com-pared these three systems. The locking system results inless loss ofreduction under axial compression with less plas-tic deformity and the DCP system provides better strengthunder torsion. The authors propose combination fixation.


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Bottlang et al. [20] propose the use ofa standard screw atthe end ofthe plate in case ofa fracture in osteoporotic boneto limit strains and prevent a stress fracture. This type ofsystem increases strength during bending without changingstrength under compression or torsion. The implant must beparallel at a 10 angle to the cortex and the lateral condyle.Indeed Khalafi et al. [21] have shown that these parallel sys-tems are stronger under axial compressionand cyclic loading

than systems in which the plate is not parallel to the lateralcortex. Beingessner et al. [22] compared titanium platesto steel plates as well as unicortical to bicortial screws inthese indications. They showed that strength under torsionis reduced in titanium plates and strength is improvedwith bicortical screws. On the other hand, there is no dif-ference for axial compression strains and plastic deformity.Lujan et al. [23] concluded that titanium plates favorthe formation ofcalluses by increasing elasticity in fixationmaterial. Finally, for Wilkens et al. [24], the placement ofpolyaxial screws increases strength under axial compressionand torsion and reduces deformation observed under cyclicloading.

Total knee arthroplasty

As in complex fractures of the proximal humerus, the dis-tal humerus and fractures of the femoral neck, total kneearthroplasties can be included as a therapeutic option inelderly patients.

This is a difficult procedure in a fragile population requir-ing extensive expertise in arthroplasty. The main technicalpoint is to restore the height of the joint line when thereis no longer any possibility of reduction. An intact lateralor medial pillar facilitates adjustment ofthe replacements.A constrained knee replacement is usually chosen and evenin certain cases a megaprosthesis such as that used after

tumor resection. Postoperative morbidity-mortality is high.In a series of 54 fractures in patients in their 80s, Apple-ton et al. [25] reported a mortality of40% and a morbidityof 15% at 1 year with 11% of surgical revisions and 4% ofimplant revisions. Patient selection is essential to guaranteethe best results. Finally, certain authors propose a hingedprosthesis to treat nonunion of the distal femur in elderlypatients. After a mean follow-up of4 years in a series of10patients mean age 74years old, Vaishya et al. [26] reportedsatisfactory functional results with a very low morbidity ineight patients. Haidukewych et al. [27] proposed a totalknee replacement for nonunion ofthe distal femur as well asfor early failure ofinternal fixation. Survival was 91%, after

5 years in 15 patients with perioperative complications in29%, postoperative complications in 29%, and poorer resultsthan for primary replacements.

Results in the literature

Biomechanical data

Several biomechanical studies have shown that locking sys-tems are better than classic internal fixation (DCP plate,retrograde nailing, blade plate) [2830]. Fulkerson et al.[28] compared locking plates to classic large fragment plateswith cables. Strength under axial compression and torsion

was increased in locking plates, however failures were moresevere with opening of the proximal femoral fragment.Zlowodzki et al. [29] compared LCP, blade plates, and ret-rograde nailing in extra-articular fractures. Strength underaxial compression was better with the LCP system than withthe blade plate or nailing, by 34 and 13% respectively, butstrength under torsion was reduced. The authors observedbetter distal fixation with the LCP system with loss of dis-

tal fixation in only one LCP plate (6%), three blade plates(38%) and eight losses with retrograde intramedullary nail-ing (100%). These same authors compared the blade plate tothe LCP system in cadavers with high bone density and didnot find any significant difference in compression strength[30]. Finally, Hingins et al. [31] concluded that the lockingplate system was better than the blade plate with increasedstrength under axial compression and cyclic loading what-ever the quality of cadaveric bone. To our knowledge, nostudies have been performed to compare anteretrogradeintramedullary nailing to locking plates. Overall, biome-chanical results showed that locking plates are better.

Clinical results

Vallier and Immler [32] compared the 95 blade plateand LCP locking plates in a retrospective series of 71intra-articular and extra-articular fractures. The rates ofcomplications, surgical revisions and nonunion were statisti-cally higher with LCP plates. On the other hand, Nayak et al.[33] support the use ofLCP locking plates for extra-articularfractures, reporting union in all cases, good recovery ofalignment and high quality function. An autologous graft wasnot necessary with the mini-invasive technique, postopera-tive pain was reduced and the rate ofunion was high. Kolbet al. [34] confirmed these results in a retrospective series

of 50 fractures. Functional recovery was found to be verygoodwith 80% ofgood and very good results. They concludedthat the locking plate system allows early mobility, rapidfunctional recovery and good radiological results with lowmorbidity, even though these were intra-articular fractures.Kanabar et al. [35] and Kavali et al. [36] proposed fixation ofcomplex fractures ofthe distal femur with locking plates bymini-invasive approach emphasizing the limited blood lossand low rate ofcomplications. Kavali et al. [36] did not findany statistical difference in functional recovery betweenpatients treated for single or multiple fractures. Compar-isons in the literature between retrograde intramedullarynailing and blade plate by a mini-invasive approach havenot shown any difference between intra-articular or extra-

articular fractures. Markmiller et al. [37] did not reportimproved results for any particular implant for identicalindications. Hierholzer et al. [38] confirmed these resultsin a retrospective series of 115 fractures comparing retro-grade nailing (n =59) andmini-invasive locking plate (n = 56).The authors describe the indications for each technique:the plate can be adapted to all fractures, while retrogradenailing is better adapted to extra-articular fractures. Theyemphasize that high quality results are more dependentupon the surgical technique than the choice of implant.On the other hand, results comparing retrograde nailingand classic open internal fixation are clear. For Thomp-son et al. [39], statistical results for the rate of surgical


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revision and the rate ofmalunion are better for retrogradeintramedullary nailing. The rates of infection and nonunionwere higher in the open internal fixation group. After amean follow-up of 6 years nearly 50% of intra-articularfractures showed progression to arthritis on radiologicalimaging. Acharya et Rao [40] reported a prospective seriesin 28 patients treated with retrograde nailing with unionin 93%, malunion in 14% and excellent or good functional

results in 75% of cases. There was no difference betweenresults for retro- and anteretrograde nailing. For Salemet al. [41], results in length, torsion, alignment and functionwere comparable. The only reported difference was in hiprange ofmotionwhichwasmore limited with anteretrogradeintramedullary nailing, and knee range of motion whichwas more limited with retrograde nailing. Hartin et al. [42]did not observe any difference in functional recovery in arandomized comparison ofthe treatment ofextra-articularfractures by retrograde intramedullary nailing and bladeplate. The only element observed was more frequent painin the knee in the retrograde nailing group, so that fixa-tion material had to be removed in 25% of the cases. Theresults in the literature do not provide any consensus on the

technique only closed techniques seem to make a differ-ence. It is important to remember that the best results areobtained with techniques in which the surgeon has the mostexperience.

Conclusion

The quality of the surgical technique is the primary fac-tor, and the only guarantee of obtaining good radiologicaland clinical results in distal femoral fractures. Mini-invasivetreatment (nailing or plates) seems to provide better results.All types of fractures can be treated with locking platesand a classic or mini-invasive surgical approach is possi-ble. Although the overall mid-term results are satisfactory,there are no studies evaluating the long-term functional andradiological results offractures ofthe distal femur. However,there seems to be a tendency towards progression to arthri-tis in intra-articular fractures. Recent biomechanical studieshave shown that results are better with locking plates. Thesurgical technique must be rigorous and the biomechanicalqualities of these implants must be understood to preventthe development ofmajor complications.

Disclosure ofinterest

ME, PA: occasional consultant for Synthes

.

Appendix A. Supplementary data

Supplementary data associated with this article can befound, in the online version, at http://dx.doi.org/10.1016/j.otsr.2012.10.014.

References

[1] Court-Brown M, Caesar B. Epidemiology of adult fracture: areview. Injury 2006;37:6917.

[2] Mutty CE, Jensen EJ, Manka MA, Anders MJ, Bone LB.Femoral nerve block for diaphyseal and distal femora frac-tures in the emergency department. J Bone Joint Surg Am2007;89:2599603.

[3] Streuble PN, Ricci WN, Wong A, Gardner MJ. Mortality afterdistal femur fractures in elderly patients. Clin Orthop RelatRes 2011;469:118896.

[4] Kammerlander C, Riedmaller P, Gosch M, Zegg M,Kammerlander-Knauer U, Schmid R, et al. Functional

outcome and mortality in geriatric distal femoral fractures.Injury 2012;43:1096110.

[5] Asencio G. Les fractures de lextrmit infrieuredu fmur. Table ronde de la Sofcot. Rev Chir Orthop1988;75(Suppl.1):16883.

[6] Oh JK, Hwang JH, Sahu D, Jun SH. Complications rate andpitfalls of temporary bridging external fixator in periarticularcomminuted fractures. Clin Orthop Surg 2011;3:628.

[7] Parekh AA, Smith WR, Silva S, Aqudelo JF, Williams AE, HakD, et al. Treatment of distal femur and proximal tibia frac-tures with external fixation followed by planned conversion tointernal fixation. J Trauma 2008;64:7369.

[8] Bonnevialle P, Mansat P, Cariven P, Bonnevialle N, Ayel J,Mansat M. Fixation externe monoplan latral des fracturesfraches du fmur : analyse critique de 53 cas. Rev Chir Orthop

2005;91:44656.[9] Huang SC, Lin CC, Lin J. Increasing nail-cortical contact

to increase fixation stability and decreased implantstarin inantegrade locked nailing of distal femoral fractures: a biome-chanical study. J Trauma 2009;66:43642.

[10] AntekeierSB,Burden RL,Voor MJ,RobertsCS. Mechanical studyof the safe distance between distal femoral fractures site anddistal locking screws in anterograde intramedullary nailing. JOrthop Trauma 2005;19:6937.

[11] Khalafi A, Hazelwood S, Curtiss S, Wolinski P. Fixation of thefemoral condyles: a mechanical comparison of small and largefragment screw fixation. J Trauma 2008;64:7404.

[12] Jarit GJ, Kummer FJ, GibberMJ, Egol KA. A mechanical evalua-tion of twofixationmethods using cancellous screwsfor coronalfractures of the lateral condyle of the distal femur (OTA type

33B). J Orthop Trauma 2006;20:2736.[13] Ehlinger M, Adam P, Abane L, Arlettaz Y, Bonnomet F.

Minimally-invasive internal fixation of extra-articular distalfemur fractures using a locking plate: tricks of the trade.Orthop Traumatol Surg Res 2011;97:2015.

[14] Ehlinger M, Adam P, Cognet JM, Simon P, Bonnomet F.Aide la rduction des fractures du membre infrieure parplaque vis bloques LCP (SynthesTM) par voie dabord mini-invasive. Astuces techniques.Maitrise Orthopedique 2008;178:1821.

[15] Ehlinger M, AdamP, Arlettaz Y, Moor BK, DiMarco A, Brinkert D,et al. Minimally-invasive fixation of distal extra-articular femurfractures with locking plates: limitations and failures. OrthopTraumatol Surg Res 2011;97:66874.

[16] Dougherty PJ, Kim DG, Meisterling S, Wybo C, Yeni Y. Biome-

chanical comparison of bicortical versus unicortical screwplacement of proximal tibia locking plates: a cadavericmodel.J Orthop Trauma 2008;22:399403.

[17] Stoffel K, Dieter U, Stachowiak G, Gachter A, Kuster MS. Howcan stability in locked internal fixators be controlled? Injury2003;34:119.

[18] Ahmad M, Nanda R, Bajwa AS, Candal-Coutou J, Green S, HuiAC. Biomechanical testing of the locking compression plate:when does the distance between bon and implant significantlyreduce construct stability? Injury 2007;38:35864.

[19] Stoffel K, Lorenz KU, Kuster MS. Biomechanical considerationsin plate osteosynthesis: the effect of plate-to-bone compres-


8/8


sion with andwithout angular screw stability. J Orthop Trauma2007;21:3628.

[20] Bottlang M, Doornink J, Byrd GD, Fitzpatrick DC, Madey SM.A nonlocking end screw can decrease fracture risk caused bylocked plating in the osteoporotic diaphysis. J Bone Joint SurgAm 2009;91:6207.

[21] Khalafi A, Curtiss S, Hazelwood S, Wolinsky P. The effect ofplate rotation on the stiffness of femoral LISS: a biomechanicalstudy. J Orthop Trauma 2006;20:5426.

[22] BeingessnerD,Moon E, Barei D,Morshed S. Biomechanical anal-ysis of the less invasive stabilization system for mechanicallyunstable fractures of the distal femur: comparison of titaniumversus stainless steel and bicortical versus unicortical fixation.J Trauma 2011;71:6204.

[23] Lujan TJ, Henderson CE, Madley SM, Fitzpatrick DC, Marsh JL,Bottlang M. Locked plating of distal femur fractures leads toinconsistent and asymmetric callus formation. J Orthop Trauma2010;24:15662.

[24] Wilkens KJ, Curtiss S, LeeMA.Polyaxial locking plate fixation indistal femur fractures: a biomechanical comparison. J Orthoptrauma 2008;22:6248.

[25] Appleton P, Moran M, Houshian S, Robinson CM. Distal femoralfractures treated by hinged total knee replacement in elderlypatients. J Bone Joint Surg Br 2006;88:106570.

[26] Vaishya R, Singh AP, Hasija R, Singh AP. Treatment of resis-tant non-union of supracondylar fractures femur by megaprosthesis. Knee Surg Sports Traumatol Arthrosc 2011;19:113740.

[27] HaidukewychGJ,Springer BD, JacofskyDJ,BerryDJ. Total kneearthroplasty for salvage of failed internal fixation or non-unionof the distal femur. J Artrhoplasty 2005;20:3449.

[28] Fulkerson E, Koval K, PrestonCF, IesakaK, Kummer FJ, Egol KA.Fixation of periprosthetic femoral shaft fractures associatedwith cemented femoral stems. A biomechanical comparison oflockedplating and conventional cable plates. J Orthop Trauma2006;20:8993.

[29] Zlowodzki M, Williamson S, Cole PA, Zardiackas LD, KregorPJ. Biomechanical evaluation of the less invasive system,angled blade plate, and retrograde intramedullary nail for the

internal fixation of distal femur fracture. J Orthop Trauma2004;18:494502.

[30] Zlowodzki M, Williamson S, Zardiackas LD, Kregor PJ. Biome-chanical evaluation of the less invasive stabilisation systemand the 95-angled blade plate for the internal fixation of dis-tal femur fracture in human cadaveric bones with high bonemineral density. J Trauma 2006;60:83640.

[31] Higgins TF, Pittman G, Hines J, Bachus KN. Biomechanicalanalysis of distal femur fracture fixation: fixed-angle screw-plate construct versus condylar blade plate. J Orthop Trauma2007:21436.

[32] Vallier HA, Immler W. Comparison of the 95-degree angledblade plate and the locking condylar plate for the treatmentof distal femoral fractures. J Orthop Traum 2012;26:32732.

[33] Nayak RM, Koichade MR, Umre AN, Ingle MV. Minimally inva-sive plate osteosynthesis using a locking compression plate

for distal femoral fractures. J Orthop Surg (Hong Kong)2011;19:18590.

[34] Kolb W, Guhlmann H, Windisch C, Marx F, Kolb K, Koller H.Fixation of distal femoral fractures with the Less Invasive Sta-bilization System: a minimally invasive treatment with lockedfixed-angle screws. J Trauma 2008;65:142534.

[35] Kanabar P, Kumar V, Owen PJ, Ruhston N. Less invasive sta-bilisation system plating for distal femoral fractures. J OrthopSurg (Hong Kong) 2007;15:299302.

[36] Kavali C, Agus H, Turgut A. LISS: comparative study of mul-tiply injured and isolated femoral fractures. J Orthop Sci2007;12:45865.

[37] Markmiller M, Konrad G, Sadkamp N. Femur-LIS and distalfemoral nail for fixation of distal femoral fractures: are theredifferences in outcome and complications? Clin Orthop Relat

Res 2004;426:2527.[38] Hierholzer C, von Raden C, Patzel T, Woltmann A, Bahren V.

Outcome analysis of retrograde nailing and less invasive sta-bilization system in distal femoral fractures: a retrospectiveanalysis. Indian J Orthop 2011;45:24350.

[39] Thompson AB, Driver R, Kregor PJ, Obremskey WT. Long-term functional outcomes after intra-articular distal femurfractures: ORIF versus retrograde intramedullary nailing.Orthopedics 2008;31:74850.

[40] Acharya KN,RaoMR. Retrograde nailing fordistal third femoralshaft fractures: a prospective study. J Orthop Surg (Hong Kong)2006;14:2538.

[41] Salem KH, Maier D, Keppler P, Kinzl L, Gebhard F. Limbmalalignment and functional outcome after antegrade versusretrograde intrameduulary nailing in distal femoral fractures.

J Trauma 2006;61:37581.[42] Hartin NL, Harris I, Hazratwala K. Retrograde nailing ver-

sus fixed-angled blade plating for supra-condylar femoralfractures: a randomized controlled trial. ANZ J Surg2006;76:2904.

distal femur fractures

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