Functional outcome of ORIF of distal femur fracture (AO TYPE B) with intra-articular extension

Background: Distal femur fractures with intra-articular extension (AO TYPE B) are   complex injuries   which   have   been   treated   by   different   methods.   The   authors studied the    functional outcome of management of distal femur fractures with the published literature. Aim and objectives: The purpose of this study is to evaluate the outcome of operated cases of distal femur fracture with intra-articular (AO TYPE B) with open reduction and internal fixation and also to study union rates, full weight bearing of it by fixation. Study design: Retrospective study Materials and methods : Distal femur fractures with intra-articular extension (AO TYPE B) treated   with open reduction and internal fixation during the period Jan 2011-Dec 2012 at Govt. Medical College, Surat   formed   the   study   population.   They   were   evaluated to assess their clinical and functional results using Neer’s Scoring system and compared with the available literature. The results were analysed using different parameters; male vs. female, age distribution, functional outcomes and complications etc. Results: The results were excellent in 70%, good in 19%, fair in 11% and poor in 0%. Results were assessed and found to be excellent in majority of cases with mean knee flexion being 102.8 degrees, mean fracture union time of  15.5 weeks, with mean full weight bearing duration of 12.7 weeks .complications being knee stiffness (0),delayed union (01),infection (01),shortening(01)knee pain (04) C onclusion: Surgery in the form of ORIF is recommended for Distal femur fractures with intra-articular extension (AO TYPE B) for good outcome and early mobilization with minimum preventable complications.


Introduction
"Few injuries present more difficult problems than those associated with supracondylar and intercondylar fractures of femur "-Sir Reginald Watson Jones 1 .
The above statement by one of the great orthopaedician aptly describes the complexity in treating these fractures. Severe soft tissue damage, comminution, intraarticular extension, injury to the Quadriceps and extra articular adhesions are some of the challenges faced by the surgeon.
In the early part of 20 th century closed reduction as described by Watson Jones and John Charnley 1 led to stiffness, angular deformities or shortening and needed prolonged confinement to the bed. This prompted the present generation of Orthopaedicians to indulge in a more aggressive treatment i.e. open reduction and internal fixation which led to complications like infection, non-union and inadequate fixation by an inexperienced surgeon.

Aims and objectives
The aim of the study was to evaluate the functional outcomes of distal femur fractures with intra-articular extension (AO TYPE B) in Government Medical College, Surat from Jan 2011-Dec 2012

Materials and methods
The present study was conducted to study the outcomes of management of distal femur fracture with inter-articular extension (AO TYPE B) in department of orthopaedics, Government Medical College, Surat on patients operated during the period of two year from January 2011 to December 2012.

Study design: Retrospective study 2.2 Source of data
Patients operated for Distal femur fractures with intra-articular extension (AO TYPE B) in the Department of Orthopaedics, New civil hospital Surat during the period of two year from January 2011 to December 2012.

Sample size
All patients with for Distal femur fractures with intra-articular extension (AO TYPE B) who underwent operative procedure from January 2011 to December 2012 were selected for the study.

Procedure
The study was approved by Ethical and Research committee of Government medical college, Surat. After finding suitability of inclusion and exclusion criteria patients were selected for study and briefed about the nature of the study, the interventions used and written informed consent was obtained. The consented patients were enrolled into present study. Further descriptive data of the participant's like name, age, sex, detailed history were obtained by interviewing the participants and clinical examination and necessary investigations were recorded.
Upon arrival of the patient, primary emergency management was carried out. A thorough examination was done to rule out life threatening injuries. Once the patient was hemodynamically stable; the fractured extremity was immobilised in a Thomas's Splint and later in the emergency operation theatre upper tibial traction was applied and traction was given over a Bohler's frame in the ward.
In the present series there were 13 open fractures. All were treated by parenteral Cephalosporins from day one to a week thereafter or till the sutures was removed. Gentamycin was given for 5 days.
All procedures were done under spinal anesthesia. Implants used were Dynamic Condylar Screw (DCS), Locking Compression Plate (LCP) or Condylar Buttress Plate (CBP).
Gentamycin was injected into the surgical site after fixation. Post operative assessment of knee joint stability was done. Sutures were removed; Physiotherapy was started immediately and all patients were personally followed up. The functional and radiographic results were recorded according to Neer's Criteria and Knee Society Score 2 .

Assessment of Patient with Neer's scoring system
Functional (70 points) and Anatomical (30 points) Excellent-more than 85 points Good-70 to 85 points Fair-55 to 69 points Poor-less than 55 points

Observation and results
Out of 16 patients, 13 (81%) were males and 03 (19%) were females. Age: The youngest patient was 18 years old and the oldest 72 years old. The average age was 39.3years. Mode of injury: About 75% patients had sustained road traffic accidents, remaining 25% were due to fall from height or domestic falls. The delay in discharge was due to associated injuries or infection.
The average duration for full weight bearing was 12.7 weeks. Average range of motion of knee was 102.8° with the average time of union was 15.5 weeks. Among 16 patients there were 11(70%) excellent results, 03 had (19%) good results, 2(11%) had fair results and 0 (0%) were classified as poor.      IJBR (2014) 05 (11) www.ssjournals.com   Poor <50 points 0 0 Long term final results were rated using Neer's rating system, which allots points for pain, function, working ability, joint movements, gross and radiological appearance. Neer's score was assigned for each patient.

Complications
The complications we encountered include anterior knee pain in 04 patients, shortening in 01 patient. There were 01 cases infection which subsided after debridement and antibiotics. There was 01 delayed union. There were no cases of implant failures.

Discussion
The prognostic factors for condylar fracture include age, intra articular involvement, method of treatment, timing of joint mobilisation etc. Comparison of studies is often difficult because of difference in the classification schemes and the use of different methods of treatment 2,3 . Several articles have been published documenting superior functional results using internal fixation 4,5,6 . Rigid fixation has also enabled earlier knee motion and weight bearing, which help prevent some of the serious complication attributed to prolonged bed rest and traction 2,7 .
There were 2(11%) fair and 0(0%) poor reults in this study which was lower when compared to the study by Siliski et al and Yeap et al which had 20% poor results. 6,8 Major contributing factors were: (1) Improper fixation due to complexity of comminution or surgical technique.
(2) Elderly age group constituted majority, who were less motivated than young people to initiate exercises. Their bones were osteoporotic with very low osteogenic potential.
(3) Delay in surgery was a factor which resulted in bad results.
Schatzker obtained 74% better results 3 . In our study it was 70%. Acceptable knee flexion following treatment ranges from 65° to 117°. 5,9 In our study it was 102.8°, which compared favourably with the literature. Hence our study matches with most studies. A study by Siliski 6 et al had post operative infection rate of 6%, while our study it was 6%. 6

Conclusion
Though the series is relatively small and it is retrospective study and period of follow up is small, however it appears that the results presented here indicate the value of stable internal fixation, when anatomical reconstruction of the distal end of femur can be accomplished, thereby reducing the risk of post traumatic arthritis due to incongruence of articular surfaces and early mobilization of the knee joint. It provides predictably reproducible good functional results with low morbidity and good healing rates as well as satisfactory mobility in AO type B distal femoral fractures.
Detail clinical examination and good radiological evaluation including CT scan in selected cases are important. A possibility of associated injury should always be kept in mind to minimize complication. Open fracture should be treated in emergency with adequate debridement, anatomical fixation and proper antibiotics. A good surgical technique and judicial use of antibiotic will prevent infection. Adherence to technique and AO principle will reduce the occurrence of complication and helps in achieving good results. Anatomical distal femur locking plate appears to be good surgical options for treatment of Distal femur fracture with intra-articular extension. A good soft tissue handling and accurate reduction along with stable fixation are key point to good outcome. Stable fixation and early post-operative physiotherapy is very important for good outcome. Communition of fracture adversely affects the results. Unstable and incongruent reduction resulted in poor outcome. Early open reduction and internal fixation can be done in open uncontaminated fracture. Open fractures always carry poor outcomes in terms of infection.