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Functional outcome of orif of distal femur fracture with intra-articular extension.

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 20th century closed reduction as described by Watson Jones and John Charnley 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, nonunion 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 in Government Medical College, Surat from Jan 2011Dec 2012.

MATERIALS AND METHODS: The present study was conducted to study the outcomes of management of distal femur fracture with inter-articular extension 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.

Source of Data: Patients operated for distal femur fractures with intra-articular extension 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 who underwent operative procedure from January 2011 to December 2012 were selected for the study.

Selection Criteria:

Inclusion Criteria:

* All patients with age above 18 years having supracondylar and intercondylar fractures of femur with an indication for surgical management.

Exclusion Criteria:

* Pathological fractures.

* Polytrauma patients.

* Patients treated conservatively.

* Patients who were bed ridden or non-ambulatory.

* Patients with severe life threatening medical problems.

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 immobilized 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 after 10-12 days.

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.

OBSERVATION AND RESULTS: Out of 50 patients, 39 (78%) were males and 11 (22%) were females.

Age: The youngest patient was 18 years old and the oldest 75 years old. The average age was 38.9years.

Mode of Injury: About 78% patients had sustained road traffic accidents, remaining 22% 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 13.92 weeks. Average range of motion of knee was 94.10. The average time of union was 16.7 weeks.

Among 50 patients there were 28(58%) excellent results, 12 had (24%) good results,6 (12%) had fair results and 4 (8%) were classified as poor (Table 1).

COMPLICATIONS: The complications we encountered include anterior knee pain in 15 patients, shortening in 5 patients. There were 7 cases infection which subsided after debridement and antibiotics. There were 6 delayed unions. There were no cases of implant failures.

DISCUSSION: The prognostic factors for supracondylar fracture include age, intra articular involvement, method of treatment, timing of joint mobilization etc.

Comparison of studies is often difficult because of difference in the classification schemes and the use of different methods of treatment [Neer et al (1967), (2) Stewart et al (1996), Shatzker & Lambert]. (3)

Multiple articles have been published documenting super or functional results using internal fixation (Chiron et al 1974, Muller et al, 1974 (4); Shelbourne et al, 1982, (5) Siliski et al, 1989.(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 (Mooney et al, 1970, (7) Neer et al 1967, (2) Stewart et al, 1966).

There were 6 (12%) fair and 4 (8%) poor results in this study which was higher when compared to the study by EJ Yeap (8) and Siliski (6) which had 20% poor results.

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. In our study it was 78%.

Acceptable knee flexion following treatment ranges from 650 (Brown et al, 1971)(9) to 1170 (Shelbourne et al, 1982). (5) In our study it was 94.10, which compared favorably with the literature. Hence our study matches with most studies.

A study by SILISKI (6) had post op. infection rate of 6%, while our study it was 14%.

CONCLUSION:

* Results are better in young patients. With early fixation, results are good even in the elderly.

* Earlier the surgery, better the results. Comminution of the fracture adversely affects the results.

* Early ORIF can be done in open uncontaminated fractures. Earlier the mobilisation, earlier the restoration of movement and better the outcome.

ACKNOWLEDGEMENT: The author did not receive any grants or outside funding for support of the research or preparation of the manuscripts. No funding was received for this work from any of the organizations.

DOI: 10.14260/jemds/2014/3812

REFERENCES:

(1.) Brown D, D' Arcy W, Internal fixation for supracondylar fractures of the femur in the elderly patient. J Bone Joint Surg 1971; 53B: 420-424.

(2.) Mize R D, Bucholz R W, Grogan DP, surgical treatment of displaced communited fractures of distal end of femur. JBJS 1982;64A;871-879

(3.) Mooney V, Nickel VL, Harvey JP, Snelson R, Cast braced traement of fracture of distal part of femur. JBJS ;1970;52A;1563-1578

(4.) Moore TJ, Watson T, Green SA, Garland DE, Chandler RW. Complications of surgically treated supracondylar fractures of the femur.

(5.) Muller ME, Allgower M, Schneider R, Willenegger H. Manual of Internal fixation. New York, Springer-Verlag 1979.

(6.) Neer CS II, Grantham SA, Shelton ML, Supracondylar fracture of the adult femur. J Bone Joint Surg 1967; 49A: 591-613

(7.) Scott W, Kenneth. Fracture and dislocation a manual of Orthopeadic trauma.

(8.) Shatzker J, Lambert DC. Superacondylar fractures of the femur. Clin Orthop 1979; 138:77-83.

(9.) Shelbourne DK, Brueckmann FR, Rushpin fixation of Supracondylar, and intercondylar fractures of the femur. J Bone Joint Surg 1982; 64A; 161-169.

(10.) Siliski JM, Mahring M, Hofer HP. Supacondylar-Intercondylar fractures of the femur. J Bone joint surg 1989; 71A: 95-104.

(11.) Watson-Jones R. Fractures and joint injuries. 6th ed, BI Churchil Livingston Pvt. Ltd, New Delhi, 1990.

(12.) EJ Yeap , AS Deepak, Malysian Orthopaedics journal 2007;1(1).

(13.) Manohar G, Shibu Andrews; functional outcome following ORIF of supracondylar intercondylar fracture femur; Kerala journal of orthopaedics2012; 25; 1-5.

[TABLE 9 OMITTED]

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. Using this scale there were 28(56%) excellent results, 12 (24%) good results, 6 (12%) fair results and 4 (8%) poor result.

ASSESSMENT OF PATIENT WITH NEER's SCORING SYSTEM:

Functional (70 points) and Anatomical (30 points):

Excellent- more than 85 points Fair- 55 to 69 points

Good- 70 to 85 points Poor- less than 55 points

Shiblee S. Siddiqui [1], Shiv Acharya [2], Johny Joshi [3], Ravish Patel [4], Vishal Dindod [5]

AUTHORS:

[1.] Shiblee S. Siddiqui

[2.] Shiv Acharya

[3.] Johny Joshi

[4.] Ravish Patel

[5.] Vishal Dindod

PARTICULARS OF CONTRIBUTORS:

[1.] Senior Resident, Department of Orthopaedics, GMC, Surat.

[2.] Associate Professor, Department of Orthopaedics, GMC, Surat.

[3.] Resident, Department of Orthopaedics, GMC, Surat.

[4.] Resident, Department of Orthopaedics, GMC, Surat.

[5.] Resident, Department of Orthopaedics, GMC, Surat.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Shiblee S. Siddiqui, RM No. 85/16, N-Block, V. P. Nagar, Lotus, Worli, Mumbai-400018. Email: siddiquishiblee@gmail.com

Date of Submission: 23/09/2014.

Date of Peer Review: 24/09/2014.

Date of Acceptance: 10/11/2014.

Date of Publishing: 12/11/2014.
TABLE 1: Age distribution

Age (years)            Total
              No.   PERCENTAGE(%)

18-30         19         38
31-40          9         18
41-50         14         28
51-60          5         10
61-70          1          2
71-80          2          4
Total         50         100

TABLE 2: SEX DISTRIBUTION

Sex      No of patients   Percentage
Male           39            78
Female         11            22

TABLE 3: MECHANISM OF INJURY

Mechanism of injury     No. of case   Percentage

Road traffic accident       39            78
Fall from height            11            22
Total                       50           100

TABLE 4: RELATIONSHIP BETWEEN SEX AND CAUSE OF FRACTURE

Sex      Vehicular accident   Fall
         No.  Percent   No.   Percent
Male     33   66        6     12
Female   6    12        5     10
Total    39   78        11    22

TABLE 5: Type of fracture

Type of fracture   No of fracture   Percentage

Open                     13            26
Closed                   37            74

TABLE 6: TIME TO UNION

Union (weeks)   No. of cases   Percentage
<16                 21            42
16-18               12            24
18-20                8            16
20-22                4             8
22-24                5            10

TABLE 7: TIME AT WHICH FULL WEIGHT BEARING ACHIEVED

Achieved time (weeks)   No. of cases   Percentage

8-10                        7             14
>10-12                      11            22
>12-14                      14            28
>14-16                      10            20
>16-18                      3             6
>18-22                      3             6
>22                         2             4

TABLE 8: KNEE FLEXION

Knee Flexion   No. of cases   Percentage
(Degrees)

<90                27            54
91-109             19            38
>110               04            08

TABLE 10: FUNCTIONAL RATING AS PER NEER'S RATING SCORE

Rating                 No. of cases   Percentage
Excellent >85 points       28            56
Good 70-84 points          12            24
Fair 50-69 points          06            12
Poor <50 points            04            08

TABLE 11: COMPARISON OF DEMOGRAPHIC PROFILE WITH OTHER STUDIES

STUDY           Age group   Average age    Male       Female
(years)          (years)     (years)      (In no.)   (In no.)

EJ Yeap          15 - 85        44           07         04
Siliski          15 - 82       47.2          34         17
Manohar          21 - 75        45           15         10
Present study    18 - 75       38.9          39         11

TABLE 12: COMPARISON OF MECHANISM OF INJURY
AND FRACTURE TYPES

STUDY           TOTAL   RTA %   COMPOUND
EJ Yeap          11      07      04(36%)
Siliski          52      75      19(38%)
Manohar          25      60      03(12%)
Present study    50      78      13(26%)

TABLE 13: COMPARISON OF UNION RATE, FULL WEIGHT BEARING
AND AVERAGE KNEE FLEXION BETWEEN DIFFERENT STUDIES

Study           Average union   Full weight    Average knee
                 rate (wk)      bearing (wk)   flexion (in degree)

EJ Yeap              18                               107.7
Siliski             13.6            13.6               107
Manohar                              21               75.6
Present study       16.7           13.92              94.1

TABLE 14: COMPARISION OF FUNCTIONAL OUTCOMES

Study                                          Complications
              Excellent   Good   Fair   Poor

EJ Yeap          04        04     02     01    0 knee pain;
(SCHATZKER)                                    0 infection;
                                               2 implant failure

Siliski          26        16     06     04    8 knee pain;
(NEER's)                                       3 infection;

Manohar          06        10     05     04    5 early OA;
(NEER's)                                       infection
                                               1 non-union

Pres. Study      28        12     06     04    15 knee pain
(NEER's)                                       7 infection
                                               6 delayed union
                                               5 shortening
                                               5 stiffness
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Title Annotation:ORIGINAL ARTICLE
Author:Siddiqui, Shiblee S.; Acharya, Shiv; Joshi, Johny; Patel, Ravish; Dindod, Vishal
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Nov 13, 2014
Words:2002
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