distal femur fractures are notorious for post operative complications due to malreduction and improper fixation.unless plan and execute a sound and stable fixation,this injury will lead to undesirable results.dr mohamed ashraf HOD orthopaedics govt TD medical college is presenting how to avoid complications in surgical management of these fractures..

1. Distal femoral fractures
What makes it complex
Dr mohamed ashraf
Prof and head of orthopaedics
Govt TD medical college
Alleppey,kerala
drashraf369@gmail.com

2. Complex anatomy
• Thin cortex and wide canal-implant purchase
• Trapezoidal –higher comminution
• Quads/ham-shortening
• Hamstring/gastroc -flexion
• Adductors-varus
• Hunters canal-10cm prox to joint,artery fixed

3. Complex Injury mechanism
bimodal distribution
YOUNG HIGH VELOCITY FRACTURE
ELDERLY POROTIC FRACTURE

4. Complexity by patient factors
• Elderly ,porotic,comminuted
KOLMERT,acta ortho scandin
• Young ,polytrauma,comminuted
• Proximity to major hinge joint
• Presence of TKR implants

5. Complex associated injuries
VASCULAR INJURY RARE BUT MAY BE MISSED
POOR COLLATERAL MAKE BAD OUTCOME
DISTAL PULSE NOT EXCLUDE VASCULAR INJURY
AUFFARTH. J OF TRAUMA

6. Complexity in classification

7. Diagnostic complexity
Coronal # missed in xray-31%
Hence CT must
Norke SE –CT in coronal planr fractures-jbjs Am 2005
Do CT after ex fix

8. Decision making complexities
• Displacement
• Comminution
• Soft tissue injury
• Associated fractures
• Neurovascular conditions
• Patients condition

9. Complex planning
• Incision-medial,lateral,
• midline[future TKR,tibia#,tuberosity
osteotomy,graft]
• Approach-parapatellar,swashbuckler
• Graft
• Associated #femur-implant overlapping

10. implants
• Blade plate-3D accuracy,porosis,articular
• DCS-2D accuracy,need 4cm bone
• LISS-percutaneous,allows elastic deformation
• ILN-C type inferior,large diameter,multi locking
• IMSC-if hip #,breech knee
• EX FIX/RING
• Locking plates

11. nailing
• Antegrade
• Ideal-space for 2 distal locking screws
• More-suboptimal fixation,malalignment
De pedro .Moro,CORR
Henry K S ,JBJS-Am
• Retrograde-all extra articular
articular after reconstruction
periprosthetic with openbox
good knee flexion

12. plating
• For – all types of A and C
B1 and B2
periprosthetic with closed box

13. External fixator
• Temporary-till local /general status improve
• Definitive-porotic/comminuted/open
• Span
• Non-span
• Conversion
• Complications

14. position

15. incisions

16. Swashbuckler approach
• Midline incision
• Lateral parapatellar approach for plating
• Medial parapatellar approach for IMSC
• Both for double plating
Starr A J,JOT 1999

17. Complex reduction
• Articular-direct reduction
• Metaphyseal-indirect [non-touch reduction]
• Diaphysis-get length,rotation,alignment right

18. Articular reconstruction
• Articular fragments fixed with herberts or
countersunk or headless screws
• Intercondylar fixation with partially threaded CCS –
free or through plate
• Check trochlea for step
• Avoid notch
• Avoid arthrostenosis
• Use temporary Kwires,avoid future plate area

19. Plate fixation
• Avoid collateral ligaments
• Distal screw parallel to joint wire[5-7 deg val]
• Confirm length and rotation by C-arm
• First fix distal fragment,then proximal align
• Minimum 5 screws proximally and distally
• More locking screws in distal fragment
• Young patient,avoid locking screw on shaft

20. Bone graft
• In bone loss
• In comminution
• In severe osteoporosis
• In delayed fixation
• Need for graft less in mipo
zlowodski, j ortho trauma

21. Post-op
• CPM
• 2 weeks slab/brace
• DVT-obese,polytrauma,past DVT
• Toe touch down at 6 weeks

22. complications
• Infection 2%-10%
• Malunion valgus in ORIF
• Non-union 5% in ORIF
• Hardware failure 13%
• Proud implant
• Stiff knee
• Sec OA 30%
rademakers m v JOT 2004
krettek, ‘injury’

23. Revision surgery rate
• LISS-16 %
• Retrograde nailing-24%
• Antegrade nailing-23%
• External fixation-30%
Zlowodski,bhandari et al,j ortho trauma

24. pearls
• Articular reduction always direct
• Metaphyseal preferably indirect
• Avoid medial stripping
• Avoid valgus/varus-guide pin in central distal
hole, parallel to joint
• Avoid sagittal deformity-knee flexed,bump
under distal knee
• Peri prosthetic-plate/IMSC/cable,uni plate

25. How I do it

26. Different fractures!
Different options!!
Goal must be same!!!

28. MBBS [GMC CALICUT]
D ORTHO [GMC TRIVANDRUM]
MS ORTHO [MMC MADRAS]
DNB ,MNAMS [NEW DELHI]
drashraf369@gmail.com
DR MOHAMED ASHRAF