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Distal Femur Fractures
Mark Lee, M.D.
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Overview
The basics New fixation concepts New implants
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Know the shape
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Anatomy Condyles project posteriorly
Anterior half of the condyles
Too posterior
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Too Posterior
Medialization of condyles:
“Golf club” Hockey stick deformity Posterior condyles flare
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Distal Femur is a trapezoid
1. Over-penetration medially
2. Anterolateral slope
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Femoral Axis LDFA
–Anatomic Axis and articular surface
Mechanical axis
Femoral head ankle
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Don’t miss the Hoffa
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Understanding the Fracture Imaging is essential
• Femur • Knee • CT scan
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Classification A-type: Extra-articular
B-type: involves one
condyle
C-type: involves both condyles
Coronal fracture = 38% (Nork, et al. JBJSA 2005)
Don’t Miss
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Pick the right exposure and implant
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A type fractures
• Plate with angular stability
• IM nail
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B-Type Fractures • ORIF
• Absolute stability
• Screws
• Locking not required
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C-Type Fractures Anatomical reduction of articular segment
• Absolute stability
Articular surface to diaphysis • Relative stability
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Surgical Approaches Parapatellar joint
exposure – 33-C2 or C3
Krettek et al. Injury 1997
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Role of Locking Plates Short articular segment
Loss of medial support
– Comminution – Bone loss
Osteoporotic bone
Periprosthetic
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70y/o s/p MVC
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Classification?
33C2
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Approach
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Direct Articular Reduction and Fixation
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Articular Surface to Shaft
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Plate Application
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New problem?
28
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Overheard at many “expert” discussions
“Our current plates are too stiff!”
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Their conclusion and purpose?
Up to 32% healing problems in distal femur fractures treated with locking plates
Callus asymmetry is a clue
We have a problem here!
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Titanium versus stainless for distal femur
109 fractures Nonunion rate titanium 7% Nonunion rate stainless 23%
Gaines, OTA 2008
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Theory of flexible locking fixation
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Ideal stiffness
Basic science suggests ideal stiffness range Locked constructs far exceed ideal range Stiffness reduction + maintenance of
stability
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Near cortical slotting
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Far cortical locking
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Bicortical Technology
Dynamic Locking Screw
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New toys
42
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Retrograde nail may have limited fixation in small segment.
Some total knees may not be able to accommodate a retrograde nail.
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Pre-determined Screw trajectory may not capture
enough bone
Flange and posts also
block passage of
screws
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14 Weeks Post Op
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18 wks Post op
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Failure through osteotomy
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Postop Plating
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6 month f/u healed
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Postop
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2 mo F/U
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6 month weight bearing
pain free
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Postop
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3 mo f/u
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Interlocks with angular stability
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Locking interlocks
Extending nail indications Proximal and distal Threaded interface
– Not true locking Threading cortex and nail interference
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Metaphyseal clamshell
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