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 Table of Contents  
Year : 2021  |  Volume : 36  |  Issue : 2  |  Page : 33-37

Minimally invasive percutaneous plate osteosynthesis in distal femur fractures using locking compression plate (LCP): A prospective study

Department of Orthopaedics, RNT Medical College and MB Government Hospital, Udaipur, Rajasthan, India

Date of Submission23-Jun-2021
Date of Acceptance24-Jun-2021
Date of Web Publication02-Aug-2021

Correspondence Address:
Saumya Agarwal
16 D, Old Fatehpura, Near Seva Mandir, Udaipur, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jbjd.jbjd_4_21

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Background: Distal femoral fractures are frequently seen in high-velocity road traffic accidents. The introduction of locking compression plates with option of locked screws has provided the means to increase the rigidity of fixation in osteoporotic bone or in the presence of periarticular fractures. Materials and Methods: Fifty patients within the span of 3 years underwent internal fixation of distal end femur by LCP using minimal invasive percutaneous plate osteosynthesis (MIPPO) technique. All the patients were assessed using Modified Neer's criteria which assign points for pain, function, working ability, joint movements, gross, and radiological appearance. Results: Out of 50 patients, 48 patients (96%) showed radiological union within 20 weeks. Average time for union was 16.4 weeks. Average knee flexion was 120° with more than 60% of patients having knee range of motion more than 115°. Modified Neer's score was excellent in 32 (64%), good in 12 (24%), fair in 4 (8%), and poor in 2 (4%). There had been one patient each who developed nonunion, deep infection, and valgus malalignment. Conclusion: Locking compression plate used through MIPPO technique is an optimal tool for distal fractures of femur. It provides rigid fixation, where a widening canal, thin cortices, and frequently poor bone stock make fixation difficult.

Keywords: Distal femoral fracture, locked compression plating, minimal invasive percutaneous plate osteosynthesis, range of motion, union

How to cite this article:
Choubisa R, Agarwal S, Meena DK, Sharma A, Prakash S. Minimally invasive percutaneous plate osteosynthesis in distal femur fractures using locking compression plate (LCP): A prospective study. J Bone Joint Dis 2021;36:33-7

How to cite this URL:
Choubisa R, Agarwal S, Meena DK, Sharma A, Prakash S. Minimally invasive percutaneous plate osteosynthesis in distal femur fractures using locking compression plate (LCP): A prospective study. J Bone Joint Dis [serial online] 2021 [cited 2021 Oct 28];36:33-7. Available from: http://www.jbjd.org/text.asp?2021/36/2/33/322951

  Introduction Top

The incidence of distal femoral fractures is approximately 37/100,000 person-years,[1] and high energy trauma mainly sustained in road traffic accidents is responsible for causing the same. Open injuries associated with comminution of femoral condyles and metaphyseal bone are frequently seen, and complex knee ligament injuries occur additionally to extensive cartilage injuries. Extreme osteoporosis represents a particular problem for anchoring the implant in the elderly patients.[2] Before the introduction of less invasive stabilization system (LISS) and indirect mode of reduction such as minimal invasive percutaneous plate osteosynthesis (MIPPO), complications such as varus collapse, malunion, nonunion, and infection were quite frequent.[3] Management of distal femoral fractures requires expertise from an orthopedic surgeon, and it becomes more challenging in elderly patients with osteoporosis.[4] The locked compression plating (LCP) allows the placement of plate without any contact to bone and forms a fixed angle construct, thus maintaining vascularity of the bone underneath and functions as an internal fixator.[4] Restoration of articular congruity, maintenance of soft-tissue attachment, and vascularity to the cortical bone fragment is well achieved using MIPPO as a biological plating.[5] The advantage of MIPPO and the use of LCP includes the preservation of fracture hematoma and very limited soft-tissue dissection, thereby reducing the incidence of malunion and nonunion, which leads to early mobilization, thereby reducing stiffness, leading to an improvement in the union rates, even in the elderly with osteoporosis and decreased need for bone grafting. The soft-tissue envelope is extensively damaged in high-energy distal femoral fractures and conventional plating which requires excessive dissection will further damage blood supply to bone. This explains why conventional treatment of these fractures has been associated with a high rate of wound complications and deep sepsis.[6] The combination of excellent stability provided by locking compression plates and minimally invasive insertion technique lead to improved outcome of the distal femoral fractures over previously used implants. The purpose of the study is to evaluate the functional outcome for internal fixation of fractures of the distal end femur by LCP using MIPPO technique based on rate of union, early mobilization, time till union, varus and valgus malalignment, and fixation failures.

  Materials and Methods Top

The prospective study was conducted in the Department of Orthopaedic surgery of R. N. T. Medical College, Udaipur, from April 2016 to September 2019 on fifty patients. These patients presented to the emergency, and the study was done after obtaining approval from the hospital ethics committee.

Inclusion criteria being skeletally mature patient (more than 18 years), patients with Grade I and II fractures (Gustillo-Anderson classification), presenting with distal femoral fractures (AO Type A1, A2, and A3) with or without osteoporotic changes. Exclusion criteria included children <18 years of age, patients having pathological fractures, who are not fit for surgery, not willing for surgery, lost in follow-up, and distal femoral fractures with neurovascular compromise. A well-written informed consent for participation was taken before the surgery for all the patients. Complete history was taken and physical examination was performed. Neurovascular status was assessed in all the patients undergoing procedure. Anteroposterior and true lateral radiographs were obtained in all the cases for both the lower limbs. The AO/OTA (OrthopaedicTrauma Association/Arbeitsgemeinschaft fur Osteosynthesefragen) classification was taken into account to classify the fracture. Thorough irrigation and lavage of associated compound injuries with hydrogen peroxide and normal saline followed by povidone-iodine padded dressings. Injection ATS 1500 IU, Injection AGGS 20,000 IV, broad-spectrum injectable antibiotics, and analgesics were administered for compound injuries of other parts as and when required. Preoperative routine blood investigation and viral markers were performed. Spinal anesthesia was given in all the patients. All the patients were operated in supine position. Affected limb was scrubbed, painted, and draped as standard method. Intravenous antibiotics were administered 30 min before starting the procedure. Tourniquet was applied in all the patients. All patients underwent open reduction and internal fixation with anterolateral plate. All patients were followed up for functional capacity and radiological fracture healing capacity at 6th week, 3 months, 6 months, and 1 year and 2 years postoperatively and thereafter till fracture union was noted [Figure 1].
Figure 1: (a) Preoperative X-ray anteroposterior and lateral view of the patient having distal end femur fracture of the left side; (b) X-ray showing immediate postoperative view of the same patient treated with minimal invasive percutaneous plate osteosynthesis technique using LCP; (c) Follow-up X-ray of the same patient at the end of 3 months showing good signs of radiological union; (d) Follow up X-ray of the same patient at the end of 2 years showing complete union

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Surgical technique

For all the patients with distal femoral fractures, a modified standard lateral approach has been used. Indirect method of reduction using small bolsters/bumps placed underneath the distal thigh to correct sagittal plane deformities has been used. Alignment in the coronal plane was corrected using reduction clamps and traction. Under image intensifier guidance and using the lesser trochanter as a guide, alignment and rotation were restored by judging the hip rotation on the uninjured side. Traction was given to maintain the leg length. Following reduction, appropriate sized plates were made to slide in the submuscular plane holding one end of the plate with a sleeve. After confirming the alignment of the plate, distal segment was fixed provisionally using percutaneous pinning. At least three metaphyseal locking screws were used for distal part fixation. The size of the screw did not violate the intercondylar notch space. An incision was made over the lateral aspect of the thigh at the level of the proximal screw holes using image intensifier. The tensor fascia lata and vastus lateralis were split in the direction of the fibers. This proximal incision was used to check the approximation of the plate to the bone. Kirschner wires were placed through holes in the LCP to maintain the reduction. Comminuted fractures were fixed using the bridging technique, whereas a compression technique was used for fixation of simple fractures. Bone grafting was not performed. All the proximal screws were fixed bicortically and minimum three screws were fixed beyond the proximal extent of the fracture, while the plate used did not extend beyond the joint line. The type of proximal fixation used was based on the fracture pattern and quality of the bone. Regular screws were fixed in neutral or compression mode and locking screws or a combination of both the screws were used. In case of simple transverse metaphyseal fracture where the quality of the bone was good enough, a screw in compression mode was inserted following three to four screws placed in neutral position. These screws were placed in the appropriate dynamic compression holes in the plate, using appropriate drill guides to ensure accurate drill hole. After the plate has been provisionally applied to the proximal segment, fluoroscopy was used to check that the plate was properly seated on the shaft with screw securely locked. In some of the cases, a combination of conventional and locking screws was used, and conventional screws were inserted before locking screws to bring the plate and the bone fragment closer.

Postoperative regimen

The operated limb was kept in elevation with the knee in 10° to 15° of flexion on a splint. Static quadricep exercises with active hip and knee mobilization were allowed from 1st postoperative day. Crutches/walker was used to mobilize the patients, and toe touch weight bearing was started from day 2. Depending on the radiological evidence of bone union partial weight bearing was initiated. Full weight bearing was not permitted till consolidation of the fracture site was noted. A bridging callus across the fracture site in three of the four cortices on both antero-posterior and lateral radiographs in the absence of migration, loosening or breakage of hardware, and a painless fracture site during weight bearing has been defined as bony union. All the patients were assessed using Modified Neer's criteria[7] which include points for pain, function, working ability, joint movements, gross, and radiological appearance [Figure 2].
Figure 2: Follow-up of the patient operated with minimal invasive percutaneous plate osteosynthesis after 2 years; (a) Full extension at left knee; (b) 120° flexion at left knee joint in supine position; (c) 120° flexion at left knee joint in sitting position; (d) Straight leg raising

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Statistical analysis

Categorical variables are presented in number and percentage (%) and continuous and discrete variables are presented as mean ± standard deviation and median. Quantitative variables are compared using paired t-test. A P < 0.05 is considered statistically significant. Sample size was calculated according to the standard sample size formula taking mean Modified Neer's criteria score value after 2 years as the reference. The data were entered in MS Excel spreadsheet, and analysis was done using Statistical Package for the Social Sciences (SPSS) version 21.0 IBM, United States.

  Results Top

In the present study, a total of fifty patients with fracture of the distal end femur were treated with LCP by MIPPO technique. The age ranged from 18 to 74 years. Maximum patients were between 20 and 30 years (43.33%), and the average age of the patient was 46.1 years. There was male predominance with male-to-female ratio being 21:4. Forty-two patients had road traffic accident and a domestic fall in seven, while one had a history of assault. All of them had acute fresh fractures. Right lower limb of 32 patients was injured and 18 patients had injured their left lower limb. According to Muller's classification of distal femur, 34 were Muller's type A1; 7 had Muller's type A2; and nine patients had Muller's type A3. Forty-five patients had closed fracture and five patients had open type fracture. Thirty-nine patients were operated within 7 days of injury, while in 11 patients, surgery was delayed for more than 7 days. The operative time ranged from 80 min to 110 min with an average of 90 min. The size of plate was selected based on the type of fracture. However, seven and nine holed plates were used commonly. Average blood loss was 150 ml. Out of fifty patients, 48 patients (96%) showed radiological union within 20 weeks. Average time for union was 16.4 weeks. Average knee flexion in this study was 120° with more than 60% of patients having knee range of motion more than 115°. One out of fifty patients (2%) had nonunion and was managed with implant removal, freshening of edges, and bone grafting was done. None of the patients had superficial infection. One patient (2%) developed deep infection, for which extensive wound debridement, thorough irrigation, implant removal, freshening of edges, and bone grafting were done. Out of fifty0 patients, three patients developed shortening, 0.5–1.0 cm in one patient, and 2.0 cm shortening was seen in other two patients. One patient had valgus malalignment. Functional outcome was assessed at the end of 2 years using Modified Neer's scoring system and score was excellent in 32 (64%), good in 12 (24%), fair in 4 (8%), and poor in 2 (4%).

  Discussion Top

In this study, fifty patients with distal femoral fractures were treated by locking compression plate using MIPPO technique. In a study by Schütz et al.,[8] internal fixation using the LISS was performed at an average of 5 days (range: 0–29 days) after the injury and within the first 24 h, 48 patients with the facture were operated. Revision was performed for two cases due to implant breakage. Four cases suffered with implant loosening and seven patients underwent debridement to deal with infections. The study showed clearly that, when working with LISS, primary cancellous bone grafting was not necessary. The total follow-up rate was 93%, whereas 4% of the patients had nonunion. Weight and Collinge[9] retrospectively evaluated LISS locked plating construct used in 22 distal femur fractures in 21 patients. All fractures achieved union at a mean of 13 weeks (range: 7–16 weeks) without secondary intervention. There were no implant failures in this cohort study; at a mean of 19 months of follow-up, knee range of motion was found to be 5°–114°. In a similar retrospective evaluation of LISS plate fixation for 103 patients with distal femur fractures, Kregor et al.[10] reported a 93% union rate without secondary bone grafting. The remaining seven cases went on to uneventful union subsequent to bone grafting procedures. At a mean follow-up of 14 months, the average knee range of motion in this cohort study was 1°–109°. In five cases, implant failure in the form of proximal screw loosening was found who then underwent revision surgery. Yeap and Deepak[11] conducted a retrospective study on 11 patients who were treated for Type A and C distal femoral fractures (based on AO classification) between January 2004 and December 2004. All fractures were fixed with titanium alloy distal femur locking compression plate. The mean age was 44 years. Clinical assessment was conducted at least 6 months postoperatively using the Schatzker score system. Four patients had excellent results, four had good, two had fair, and one patient had a failure. Zlowodzki et al.[12] combined these series (n = 327) and evaluated the outcomes as a part of systematic literature review. Average nonunion, fixation failure, deep infection, and secondary surgery rates were 5.5%, 4.9%, 2.1%, and 16.2%, respectively. Some of the technical errors that have been reported for failure of fixation have involved waiting too long, allowing early weight bearing, and placing the plate too anterior on the femoral shaft. Vallier et al.[13] concluded that locking plates should only be used when conventional fixed-angle devices cannot be used. The cost of locking plates has been found to be significant. To decrease the risk of implant failure with locking plates, they recommended accurate fracture reduction and fixation along with judicious bone grafting, protected weight bearing, and modifications of the implant design. Agarwal et al.[14] in a prospective study concluded that retrograde nailing is a better option than locked compression plating in terms of range of motion, early mobilization, and fracture union in all the types of distal femur fracture.

In our study, we treated fifty cases of distal femur fractures with the average union time was 16.4 weeks. There had been one patient each who developed nonunion, deep infection, and valgus malalignment (<10°). At a mean follow-up of 24 months, the mean knee range of motion in this cohort was 0°–120°. Functional outcome at the end of 1 year was assessed using Neer's scoring system. Results were comparable with the other studies. In our study, functional results are close to the functional results achieved in other studies so are the rate of complications [Table 1]. The patients who achieved working capacity as previously or with some alteration have been shown in [Table 2]. Short sample size has been the limitation of the study and all the different types of distal femoral fracture will be considered in the future study.
Table 1: Distal femur comparison studies

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Table 2: Work capacity achieved

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  Conclusion Top

The distal femur locking compression plate represents an evolutionary approach to the surgical management of distal femoral fractures, but it does not completely solve the age-old problems of nonunion and malunion. Locking compression plate is an important armamentarium in the treatment of fractures of distal end femur, especially when fracture is severely comminuted and in situations of osteoporosis. Surgical exposure for plate placement by MIPPO technique requires significantly less periosteal stripping and soft-tissue exposure than that of normal plates. However, a more comprehensive study with longer follow-up periods is essential to throw more light into the advantages, complications, and possible disadvantages of the use of locking compression plate with special attention to the long-term outcomes.[18]

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Conflicts of interest

There are no conflicts of interest.

  References Top

Arneson TJ, Melton LJ 3rd, Lewallen DG, O'Fallon WM. Epidemiology of diaphyseal and distal femoral fractures in Rochester, Minnesota, 19651984. Clin Orthop Relat Res 1988;234:188-94.  Back to cited text no. 1
Schandelmaier P, Partenheimer A, Koenemann B, Grün OA, Krettek C. Distal femoral fractures and LISS stabilization. Injury 2001;32 Suppl 3:C55-63.  Back to cited text no. 2
Martinet O, Cordey J, Harder Y, Maier A, Bühler M, Barraud GE. The epidemiology of fractures of the distal femur. Injury 2000;31 Suppl 3:C62-3.  Back to cited text no. 3
Higgins TF, Pittman G, Hines J, Bachus KN. Biomechanical analysis of distal femur fracture fixation: Fixed-angle screw-plate construct versus condylar blade plate. J Orthop Trauma 2007;21:43-6.  Back to cited text no. 4
Nadkarni B, Srivastav S, Mittal V, Agarwal S. Use of locking compression plates for long bone nonunions without removing existing intramedullary nail: Review of literature and our experience. J Trauma 2008;65:482-6.  Back to cited text no. 5
Lachiewicz PF, Funcik T. Factors influencing the results of open reduction and internal fixation of tibial plateau fractures. Clin Orthop Relat Res 1990;(259):210-5.  Back to cited text no. 6
Neer CS 2nd, Grantham SA, Shelton ML. Supracondylar fracture of the adult femur. A study of one hundred and ten cases. J Bone Joint Surg Am 1967;49:591-613.  Back to cited text no. 7
Schütz M, Müller M, Regazzoni P, Höntzsch D, Krettek C, Van der Werken C, et al. Use of the less invasive stabilization system (LISS) in patients with distal femoral (AO33) fractures: A prospective multicenter study. Arch Orthop Trauma Surg 2005;125:102-8.  Back to cited text no. 8
Weight M, Collinge C. Early results of the less invasive stabilization system for mechanically unstable fractures of the distal femur (AO/OTA types A2, A3, C2, and C3). J Orthop Trauma 2004;18:503-8.  Back to cited text no. 9
Kregor PJ, Stannard JA, Zlowodzki M, Cole PA. Treatment of distal femur fractures using the less invasive stabilization system: Surgical experience and early clinical results in 103 fractures. J Orthop Trauma 2004;18:509-20.  Back to cited text no. 10
Yeap EJ, Deepak AS. Distal femoral locking compression plate fixation in distal femoral fractures: Early results. Malays Orthop J 2007;1:12-7.  Back to cited text no. 11
Zlowodzki M, Bhandari M, Marek DJ, Cole PA, Kregor PJ. Operative treatment of acute distal femur fractures: Systematic review of 2 comparative studies and 45 case series (1989 to 2005). J Orthop Trauma 2006;20:366-71.  Back to cited text no. 12
Vallier HA, Hennessey TA, Sontich JK, Patterson BM. Failure of LCP condylar plate fixation in the distal part of the femur. A report of six cases. J Bone Joint Surg Am 2006;88:846-53.  Back to cited text no. 13
Agarwal S, Udapudi S, Gupta S. To assess functional outcome for intra-articular and extra-articular distal femur fracture in patients using retrograde nailing or locked compression plating. J Clin Diagn Res 2018;12:21-4.  Back to cited text no. 14
Kregor PJ, Stannard J, Zlowodzki M, Cole PA, Alonso J. Distal femoral fracture fixation utilizing the less invasive Stabilization System (L.I.S.S.): The technique and early results. Injury 2001;32 Suppl 3:SC32-47.  Back to cited text no. 15
Marti A, Fankhauser C, Frenk A, Cordey J, Gasser B. Biomechanical evaluation of the less invasive stabilization system for the internal fixation of distal femur fractures. J Orthop Trauma 2001;15:482-7.  Back to cited text no. 16
Markmiller M, Konrad G, Südkamp N. Femur-LISS and distal femoral nail for fixation of distal femoral fractures: Are there differences in outcome and complications? Clin Orthop Relat Res 2004;(426):252-7.  Back to cited text no. 17
Wong MK, Leung F, Chow SP. Treatment of distal femoral fractures in the elderly using a less-invasive plating technique. Int Orthop 2005;29:117-20.  Back to cited text no. 18


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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