Surgical Management Of Distal/Supracondylar Fracture Of Femur With Retrograde Intramedullary Nail


Vol 2 | Issue 2 | May - Aug 2014 | page 50-53 | Ubale T, Ranganath N, U H, Kumar S, Shah K


Author: Tushar Ubale[1], N.Ranganath[2], Harish U[1], Sunil Kumar[3], Kunal Shah[1]

[1]R.N .Cooper Municipal Hospital,Mumbai.
[2]General Hospital Alur Hassan District , Karnataka State.
[3]Mysore Medical College And Hospital Mysore.

Institute at which research was conducted: Mysore Medical College And Institute,Mysore.
University Affiliation of Thesis: Rajiv Gandhi University Of Health Sciences Karnataka.
Year of Acceptance: 2012

Address of Correspondence
Dr. Harish U
No.3 ,2nd Main 7th Crossm Amarjyothinagar,Vijayanagar Bangalore,Karnataka 560040.
E-Mail : 77harish36@Gmail.Com


 Abstract

Background:Supracondylar and intercondylar femoral fractures are serious injuries and difficult to treat and have potential to produce significant long term disability with poor results. It is now recognized that distal femoral fractures are best treated with open/closed reduction and surgical stabilization. Many studies show retrograde intramedullary nailing is the best option.Our aim in this study is to evaluate surgical and functional outcome of retrograde intramedullary nailing in treatment of distal femoral fractures.
Methods: 20 patients,13 male, 7 female, The mean age was 39.7 years. 15 supraacondylar and 5 intercondylar fractures were treated with RIN and evaluated. Closed technique was used in 15 case and open technique in 5 cases.
Results: Results were evaluated by Lysholm knee score rating system. EXCELLENT-40% GOOD-40% FAIR -15% POOR-05%. Complications of 1 case of varus deformity of less than 10°, 1 case of superficial infection and 2 case of delayed union.
Conclusion: In surgical management of distal femoral fractures retrograde intramedullary nailing is one of the better options with good functional outcomes and less complications.
Keywords: Distal femur,Supracondylar,intercondylar, retrograde intramedullary nail.

                                                        THESIS SUMMARY                                                             

Introduction

This is an era of rapid industrialization and fast pace of life which has led to concomitant rise in road traffic accident (RTA), as well as increased life expectancy, old age population, carrying dangers of osteoporosis and fractures. So these major factors contribute to such complex fractures of distal femur. The incidence of distal femoral fractures is approximately 37/I,00,000 person-years.1
The osteosynthesis in the distal femur could be difficult because of thin cortex, communition, osteopenia, complex injuries associated soft tissue injuries, a distal wide medullary canal and involvement of the knee joint. Most surgeons agree that distal femoral fractures need to be treated operatively to achieve optimal outcomes.2
Supracondylar and intercondylar femoral fractures are serious injuries and difficult to treat and have potential to produce significant long term disability with poor results.[3]
In early 1960s, studies of non-operative skeletal traction4 of distal femoral fractures alongwith principle of Watson Jones5 resulted in increased incidence of many complications, like angular deformity, delayed patient mobilization, joint integrity, knee stiffness and post-traumatic osteoarthritis. [6,7]
The options for surgical treatment are open reduction and internal fixation with Dynamic condylar screw, 95 degrees angled blade plate, locking condylar buttress plate, minimally invasive percutaneous plate osteosynthesis (MIPPO), Liss invasive stabilization technique (LISS plate technique), Ante-grade and Retrograde intramedullary interlocking nailing. Most commonly used implant for fixation of distal femoral fractures are 95 degrees angled blade plate, dynamic condylar screw fixation allows correction only in sagittal planes However plating requires extensive stripping of soft tissue structures, which affect soft tissue and osseous healing. The use of plates & screws in the fixation of these fractures has the inherent drawback of producing a load shielding device. The resultant osteopenia creates a substantial risk of refracture proximal to the plate.[ 9,10]
Intramedullary nails offer potential biomechanical advantages over plates and screws because their intramedullary location results in less stress on the implant, they have the potential for load sharing, and can be inserted with minimal stripping of soft tissue. Given the appropriate fracture patterns, ante grade IM nailing in the treatment of distal femoral fractures has been associated with angular deformities because of inability of distal interlock of the antegrade nail to achieve control of the small and often osteoporotic distal fracture fragment. [11]
So Retrograde intramedullary interlocking nailing is best in terms of decreased operative time, blood loss, anatomical reduction of articular surface, restoration of limb alignment, early mobilization and good functional outcome, have been shown to be effective ways of managing notorious distal femoral fractures.
Distal femoral fractures tend to collapse into varus. In surgical fixation of these fractures with AO blade plate or dynamic condylar screw, the shaft of femur is pulled laterally displacing the mechanical axis lateral to anatomical axis of the limb. This creates rotational movements at the fracture site causing pull of blade plate or condylar screws leading to fatigue fracture of the plates, also presence of osteoporotic bones leads to fixation failures with plates and screws traumatic surgeries.
The advantages of intramedullary device is that it aligns the femoral shaft with condyles decreasing the tendency to varus movement of fracture site. Also advantageous in osteoporotic bone stabilization, Retrograde intramedullary nail has got distinct advantage of preservation of fracture haematoma, minimal soft tissue dissection and hence decrease operative blood loss, decreased operative time and reduced incidence of infection, early mobilization and good functional outcome.
The purpose of this study is to evaluate the results of supracondylar and intercondylar fracture of distal femur treated by closed/open reduction and internal fixation using Retrograde intramedullary nail.

Methods

In this prospective study of 20 cases of distal femoral fractures who were treated in K.R.Hospital, MMCRI, Mysore between the period of August 2009 and September 2011 are included. The method used for the fracture fixation was RIN. The duration of follow up ranged from 2 to 24 months.The distal femoral fractures studied included the supracondylar and intercondylar fractures. Twenty patients with fifteen SC and five IC of the distal femoral fracture were treated with RIN and evaluated.The mean age of patients in our study was 39.7 years maximum number of patients were between 20-29 years of age. 13 patients were male and 7 were females. The fracture occurred on right side in 8 (40%) patients and in left side 12 (60%) patients. RTA was the main cause of fracture accounting to 80%. Among these fractures, 15 were of closed type and 5 were of open type In our study Mullers type A fractures were more in number i.e. 15 out of which, 6 were of type A1, 6 was of type A2 and 3 were of type A3. There were 5 type C fractures out of which 3 was C1 type and 2 was C2 type.Out of 20 patients closed technique was used in 15 case and open technique in 5 cases. All static locking done. The final results were evaluated by functional evaluation scale developed by Lysholm  knee score rating system.

Results

Results were evaluated by functional evaluation scale developed by Lysholm knee score rating system. According to Lysholm knee scoring system, EXCELLENT-40% GOOD-40% FAIR -15% POOR-05% Comparing our results with standard studies of
1.Emmet Lucas et al.34(1993)
2.Richard. E Gellman et al.45(1996)
3.Patel.K et al. 48 (2004)
4.Present study (2012)
In Lucas study number of cases was 33 with average ROM was 100°, with 1 bent and broken nail and infection with septic knee and average union time of five months.
In Gellman study number of cases was 24 with average ROM was 104°, results were 16 good, 2 fair and 2 poor results and average union time was 4 months.
In Patel K study number of cases was 25, open cases were 28% and closed were 72%. AO classification was used. All cases were operated by percutaneous RIN. Average union time was 3.1 months and average ROM was 117°. 84% showed excellent, 8% showed good and 8% showed fair results correspondingly.
In our study 20 cases were studied with 15 closed and 5 open cases, average age was 39.7 years, 16 cases were due to RTA and 4 due to fall.
In our study we found average union time 3.6 months comparatively less than Lucas and Gellman study and slightly more than Patel case study.
In our study average ROM was 111.25% which is more than Lucas and Gellman study and less than Patel K case study.
We had complications of 1 case of varus deformity of less than 10°, 1 case of superficial infection and 2 case of delayed union.
In our study functional results are better than Lucas and Gellman study and comparatively less better than Patel K case study. We attribute this less better result because we operated five cases by open technique compared to all percutaneous RIN in Patel K case study.

Conclusion

The study was conducted to assess fracture pattern, management treatment evaluating the results of RIN in the treatment of supracondylar and intercondylar fractures of distal femur. Analysis of our study showed that this is good method of treating type A and C fractures. In type C fractures good articular congruity was achieved by fixing the fragments with cannulated cancellous screws first and then inserting RIN. Retrograde insertion of nail stabilized the fracture below isthmus and interlocking neutralized the rotational stresses and restricted telescoping of fragments, there by preventing angulation, rotational instability and shortening. This stability allowed us to mobilize the knee early and improve the range of motion and quadriceps power.
So we conclude that in surgical management of distal femoral fractures retrograde intramedullary nailing is one of the best options.

Keywords

Distal femoral fractures,retrograde intramedullary nail,supracondylar,intracondylar.

Bibliography

1. Arneson TJ, Melton LJ, Lewallen DG, et al. Epidemiology of diaphyseal and distal femoral fractures in Rochester, Minnesota, 1965-1984. Clin Orthop Relat Res 1988;234:188-194.
2. Giles JB, Delee JC, Heckman JD, et al. Supracondylar-intercondylar fractures of the femur treated with a supracondylar plate and lag screw. J Bone Joint Surg Am 1982;64:864-870.
3. Weil Kuenher, Henry. Quoted by Stewart MJ, Sisk TD, Wallace SL. Fractures of distal third of femur-A compression method of treatment. JBJS, 48-A, pg. 784-807, June 1966.
4. Modlin. Quoted by Stewart MJ, Sisk TD, Wallace SL. Fractures of distal third of femur - a compression method of treatment. JBJS, 48-A, pg. 784- 807, June 1966.
5. Watson and Jones: fractures and joint injuries, 6th edition 1982, pg. 1003-1070.
6. Charnley John: closed treatment of common fractures 3rd edition 1961: pg 197-204.
7. Enneking W.F, Marshall Horowitz: The intraarticular effects of immobilization on the human knee JBJS: Vol, 54-A, No. 5, July 1972, pg. 973-975.
8. Schatzker J, Lambert DC. Supracondylar fractures of the femur. Clin Orthop Relat Res 1979;136:77-83.
9. Bostman OM. Refracture after removal of a condylar plate from the distal third of the femur. J Bone Joint Surg Am 1990;72:1013-1018.
10. Davidson BL. Refracture following plate removal in supracondylar-intracondylar femur fractures. Orthopedics 2003;26(2):157-159.
11. Helfet DL et. Al RIN of SC fractures of femur.Clin.Orthop Relat Res.350 ; 80-84 ;May 1998.
12. Kumar A, Jasani VM Butt MS. Management of distal femoral fractures in elderly patients using Retrograde titanium supracondylar nails. Injury, 31(3): 169-73, Apr 2000.
13. Henry SL. Supracondylar femur fractures treated percutaneously Clin Orthop, 375:S 1-9, June 2000.
14. Rockwood C.A, D.P. Green: fractures in adults 6th edition, 4th volume, 1991 pg 1915-1965, 1996, IInd vol, pg 1972-1993.
15. Netter's Orthopaedics;1stedition,chapter 18,2006.
16. James E Anderson. Grant's Atlas of Anatomy. 8th Edition, Anastomosis Around Knee, 4-54, 4-55; Knee Joint, 4-56, 4-57, 4-60.
17. Campbell textbook of operative orthopaedics,11th edition ,part 15,chapter 51,Distal femoral fractures.
18. Coupe KJ. Arterial injury during Retrograde femoral nailing: a case report of injury to a branch of the profunda femoris artery. J Orthop Trauma-01-Feb-2001;15(2):140-3.
19. Alms Michael- fracture mechanics: JBJS : VOL.- 43-B NO. 1 FEB 1961: pg 162-166.
20. Neer CS, Grantham SA, Shelton ML. Supracondylar fracture of the adult femur. J Bone Joint Surg Am 1967;49:591-613.
21. Stewart MJ, Sisk TD, Wallace SL. Fractures of the distal third of the femur. J Bone Joint Surg Am 1966;48:784-807.
22. Schatzker J. Fractures of the distal femur revisited. Clin Orthop Relat Res 1998;347:43-56.
23. Muller M.E, Nazarian S, Koch P, Schatzker J: The comprehensive classification of fractures of long bones Springer Verlag 1990.
24. Riggins RS, Garrick JG, Lipscomb PR Supracondylar fractures of femur - Survey of treatment. Clin Orthop, B2, pg. 32-36, 1972
25. Tees. Quoted by Stewart MJ, Sisk TD, Wallace SL Fractures of distal third of femur - A compression method of treatment. JBJS, 48-A, pg. 784-807, June 1966
26. Connoley JF, Paul King. cast brace ambulation in the treatment of Closed reduction and distal femoral fractures. JBJS, Vol. 55-A, Pg. 1559-99, Dec 1973.
27. Vert Mooney. Quoted by Wardlaw D, James Mclauchalan et al. A biomechanical study of cast brace treatment of femoral shaft fractures. JBJS, Vol. 63-B, No. 1, pg. 7-11, 1981.
28. Healy WL, Brooker AF. Distal femoral fractures: comparison of open and closed methods of treatment. Clin Orthop Relat Res 1983;174:166-171.
29. Iannacone WM, Bennett FS, Delong WG Jr, et al. Initial experience with the treatment of supracondylar femoral fractures using the supracondylar intramedullary nail: a preliminary report. J Orthop Trauma 1994;8:322-327
30. Leung KS, Shen WY, Mui LT, et al. Interlocking intramedullary nailing for supracondylar and intercondylar fractures of the distal part of the femur. J Bone Joint Surg Am 1991;73:332-340.
31. Fritz Steinman. Quoted by Rockwood CA, Green DP. Fractures in adult, 4th ed, Vol.III pg. 1972-93, 1996
32. MIZE R D AND R.W BUCHOZ et all: Surgical treatment of displaced communicated fractures of distal end of femur. JBJS: 64-A , No. 5 July 1982, pg 871-879.
33. Siliski JM, Mahring M, Hopir P. Supracondylar and intercondylar fractures of femur treated by internal fixation. JBJS, Vol. 70-A, No. 1, pg. 95-104, Jan 1989.
34. Lucas SE, Seligson D, Henry SL. Intramedullary supracondylar nailing of femoral fractures: a preliminary report of the GSH supracondylar nail. Clin Orthop Relat Res 1993;296:200-206.
35. Austin Brown, J.C. D`ACRY;Internal fixation for supracondylar of femur in elderly patient JBJS;53B,1970,Pg 420-424.
36. Christodoulou A, Terzidis I, Ploymis A, Metsovitis S, Koukoulidis A, Toptsis C. Supracondylar femoral fractures in elderly patients treated with the dynamic condylar screw and the Retrograde intramedullary nail: A comparative study of the two methods. Arch Orthop Trauma Surg, 125(2): 73-9, March 2005. Epub 2004 Dec. 21.
37. Radford J, Howell CJ. The AO dynamic condylar screw for fractures of the femur. Injury 1992;23:89-93.
38. Saunders R, Regazzoni P, Ruedi TP. Treatment of supracondylar-intracondylar fractures of the femur using the dynamic condylar screw. J Orthop Trauma 1989;3:214-222.
39. Saunders R, Swintkowski M, Rosen H, et al. Double-plating of comminuted, unstable fractures of the distal part of the femur. J Bone Joint Surg Am 1991;73:341-346.
40. Shewring DJ, Meggitt BF. Fractures of distal femur treated with AO dynamic condylar screw. JBJS, Vol. 74-B, No. 1, pg. 122-25, Jan 1992.
41. Yang-Rong-Sen, Hwa-Chang Liv et al. Supracondylar fractures of the femur. J Trauma, Vol. 30, pg. 315-19, Mar 1990.
42. Ostrum RF, Agarwal A, Lakatos R, Poka A. Prospective comparison of Retrograde and antegrade femoral intramedullary nailing. J Orthop Trauma, 2000;14:496.
43. Ostermann PA, Hahn MP et al. Retrograde interlocking nailing of distal femoral fractures with the intramedullary supracondylar nail. Chirurg, 67(11): 1135-40, Nov 1996.
44. Danziger MB, Louci D, Zecher SB. Treatment of intercondylar and supracondylar distal femur fractures using the GSH supracondylar nail. Am J Orthop, 24 (9): 684-90, 1995.
45. Gellman RE, Guy D Paiement, Hellary D Green Treatment of supracondylar femoral fractures with a Retrograde intramedullary nail. CORR, No. 332: 90-97, 1996.
46. Helfet DL, Lorich DG. Retrograde intramedullary nailing of supracondylar femoral fractures. Clin Orthop Relat Res. 350; 80-84: May 1998.
47. Marks DS, Isbister ES, Porter KM. Zickel supracondylar nailing for supracondylar femoral fractures in elderly or infirm patients: a review of 33 cases. J Bone Joint Surg Br 1994;76:596-601.
48. Patel.K.Kapoor,Daveshwar,Golwala.P; Percutaneous RIN for distal femoral fractures.Med.J.Malasia.2004,May:59 Suppl B; 206-7.
49. Schatzker J, Home G, Waddell J. The Toronto experience with supracondylar fractures of femur. Injury, 6, pg. 113-28, 1975.
50. Watanabe Y, Takai S, Yamashita F, Kusakabe T. Second generation intramedullary supracondylar nail for distal femur fractures. International ortho (SICOT), 26:85-88, 2002.
51. Zickel R.E, V.G. Fietti: A new fixation device for distal femoral fractures.
52. Wolfgang A et al. Retrograde nailing of surpacondylar femoral fractures in patients with Total Hip Arthroplasty. A preliminary report. Journal of Trauma, December 1996;41:1059-62.
53. Pao JL, Jaing CC. Retrograde intramedullary nailing for non-unions of supracondylar femur. J. Formos Med Assoc. 104(1): 54-9: Jan 2005.
54. Zhang X. Treatment of distal femoral non-union and delayed union by using a Retrograde intramedullary interlocking nail. Clin J Traumatol-01-Aug-2001;4(3):180-4.
55. Koval KJ et al. Distal femoral non-union: treatment with a Retrograde inserted locked intramedullary nail. J Orthop Trauma, 1995;9(4):285-291.
56. Siefert et al. RIN of distal femoral fractures results using new name.
57. Wang J, Weng et al. Results of distal femoral fractures non union treated with internal fixation. JBJS 2003;85A(3):436-440.
58. Firoozbaksh K, Behzodi K, Decoster TA. Mechanics of Retrograde nail versus plate fixation for supracondylar femur fractures. J Orthop Trauma, 9(2) : 152- 7, Apr 1995.
59. Marsh J L et al. Supracondylar fractures treated with external fixation.
60. Dabezies EJ, D'Ambrosia RD, Shoji H et al. Fractures of the femoral shaft treated by external fixation with the Wagner device. J Bone Joint Surg. 1984;66a 360.
61. Leggon RE, Feldmann DD. Retrograde femoral nailing: A focus on the knee. Am. J. Surg, 14(2); 109: 2001.
62. Lysholm J.Gillquist J. Evaluation of knee surgery results with special emphysis on use of scoring scale. Am J Sports Med 1982;10:150-153.
63. Hugh Owen Thomas. Quoted by Rockwood CA, Green DP. Fractures in adult, 4th ed, Vol. II, pg. 1972-1993, 1996.
Walling AK, Seradge H, Speigel PG. Injuries to the knee ligaments with fractures of the femur. J Bone Joint Surg Am 1982;64:1324-1327.


How to Cite this Article: Ubale T, Ranganath N, U H, Kumar S, Shah K. Surgical Management Of Distal/Supracondylar Fracture Of Femur With Retrograde Intramedullary Nail. Journal Medical Thesis 2014 May-Aug ; 2(2):50-53

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