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(tips of the trade • an original study)

Calcaneal Plate Fixation of Distal Femoral Fractures Donald W. Hohman, MD, Jesse Affonso, MD, Jacob Budny, DO, and Mark J. Anders, MD

Abstract they are often overlooked. These cessfully.4 All condylar plates cur- Open reduction and internal fixa- injuries are often found in associa- rently available are contoured to fit tion constitute the standard of care tion with other injuries of the same the lateral femoral . These for management of displaced dis- limb. The inherent anatomical vari- devices are primarily introduced tal femoral condylar fractures. The ability accounts for unique fracture from the lateral femur; medial-side techniques most commonly used include conventional and locked characteristics (Table), resulting in fracture fragments are addressed plating with the primary goal of artic- difficult radiologic evaluation and with indirect reduction. ular surface congruency. However, no clear consensus on specific oper- With no specific implant design a specific implant for the isolated ative intervention. Open reduction representing the standard fixation medial femoral condyle fracture is and internal screw fixation of uni- method for the isolated medial con- lacking. We report the use of a cal- condylar femur fractures provide dylar fracture, we have applied a caneal plate as a novel technique overall excellent long-term results.5 calcaneal plate to medial, as well as for managing medial and lateral Multiple fixation techniques lateral, condylar fractures of the dis- femoral condylar fractures. have been developed to manage tal femur (AO [Arbeitsgemeinschaft distal femur fractures with articular für Osteosynthesefragen] classifica- nicondylar fractures of involvement. When the articular sur- tion 33-B1/B2). The patients pro- the femur are often char- face is involved, anatomical reduc- vided written informed consent for acterized by avulsion of tion of the articular component is print and electronic publication of Uone femoral condyle with required. Isolated medial condyle these case reports. the other intact condyle remain- fractures of the femur represent ing in continuity with the femoral a unique problem. Percutaneous Case Reports metaphysis.1 Making up less than screw fixation,2 dynamic condylar Case 1 1% of all femoral fractures,2,3 these screws, and conventional and lock- A 53-year-old woman with a pre- injuries have not received exten- ing plates have all been used suc- vious history of trauma requir- sive attention in the orthopedic literature. They have almost always been included in the generic group of distal-third femoral fractures.3,4 Unicondylar femoral fractures rep- resent a diagnostic challenge, as

Dr. Hohman, Dr. Affonso, and Dr. Budny are Resident Physicians, Department of Orthopaedic Surgery, State University of New York, Buffalo, New York. Dr. Anders is Director of Orthopaedic Trauma, Department of Orthopaedic Surgery, Erie County Medical Center, Buffalo, New York.

Address correspondence to: Donald W. Hohman, MD, Department of Orthopaedic Surgery, State University of New York, 562 Grider St, Buffalo, NY 14215 (tel, 716- 898-3810; fax, 716-898-3323; e-mail, [email protected]). A B C Am J Orthop. 2012;41(3):140-143. Figure 1. Radiographic (A) and computed tomography (B,C) evaluations of 53-year-old Copyright Quadrant HealthCom Inc. 2012. woman, with previous history of trauma requiring surgical fixation to left proximal , All rights reserved. who sustained minimally displaced intra-articular left lateral femoral condylar fracture.

140 The American Journal of Orthopedics® www.amjorthopedics.com D. W. Hohman et al

face. Early motion requires Table. Müller AO Classification sufficiently stable fixation of the

33 Femur distal articular segment to the intact femur. The main disadvantage of 33-A Extra-articular fracture operative intervention includes the 33-A1 Simple 33-A2 Metaphyseal wedge potential for damage to the local 33-A3 Metaphyseal complex supply. Detrimental effects 33-B Partial articular (unicondylar) of such damage include nonunion, 33-B1 Lateral condyle, sagittal malunion, and infection. As chang- 33-B2 Medial condyle es have been made to implants and 33-B3 Frontal—“Hoffa fracture” strategies in an attempt to mitigate 33-C Complete articular (bicondylar) these complications, the isolated 33-C1 Articular simple, metaphyseal simple 33-C2 Articular simple, metaphyseal complex condylar fracture has not received 33-C3 Articular complex extensive attention. With no specif- ic implant design representing the Abbreviation: AO, Arbeitsgemeinschaft für Osteosynthesefragen. standard fixation method for the isolated medial condylar fracture, ing surgical fixation to the left (ACE, DePuy) were used in an we have applied a calcaneal plate to proximal tibia, fell, and could anterior-to-posterior lag fashion medial, as well as lateral, condylar not weight-bear. She sustained a to capture the posterior fracture fractures of the distal femur (AO minimally displaced intra-articular fragment. The distal femur was classification 33-B1/B2). left lateral femoral condylar frac- then supported by a large titanium We believe that several inherent ture. Radiographic and computed calcaneal plate used as a washer design features make the calcaneal tomography evaluations are shown and fixed in a lag fashion with 3 plate appropriate for fixation of in Figure 1. screws placed through the medial isolated femoral condyle fractures. A standard lateral approach condyle and 1 screw placed above In the senior author’s experience to the femur was used to gain the fracture into the femoral shaft (MJA), this alternative fracture adequate exposure. Provisional (Figure 4). fixation method has been imple- pin fixation was used for fracture mented with a calcaneal plate made fragment reduction. A titanium Discussion of titanium alloy (ACE, DePuy). alloy calcaneal plate (ACE Ti6- Continual improvements in On the basis of individual experi- 4V; DePuy Orthopaedics, Warsaw, implants and surgical techniques ence and implant availability, it Indiana) was used as a washer with have made fixation the treatment of seems plausible that these fixation 4 distal cancellous screws and 2 choice for most distal femoral frac- advantages would be shared across cortical screws placed proximally tures.4 The primary goals of open similar implant designs of similar for fragment fixation. In addition, reduction are attaining and main- materials. a cortical screw and a partially taining length, alignment, rotation, Conventional calcaneal and peri- threaded cancellous anterior-to- and an anatomical articular sur- articular plate designs are usually posterior buried lag screw were placed to capture the lateral condy- lar shear fragments. These screws were countersunk at the articular margin (Figure 2).

Case 2 A 28-year-old man sustained a gun- shot wound to the anteromedial distal femur and fractures of the medial femoral condyle with asso- ciated comminution (Figure 3). The fracture was exposed by anteromedial incision with a sub- vastus-type approach and arthrot- omy. Alignment was achieved and reduction performed and held pro- visionally with Kirschner wires. Titanium small fragment screws Figure 2. Radiographic evaluation 6 months after surgery. www.amjorthopedics.com March 2012 141 Calcaneal Plate Fixation of Distal Femoral Fractures

lateral application. The screw holes allow low-profile interaction with the heads of 3.5-mm cortical screws and 4.0-mm cancellous screws. Contouring the plates for specific fracture patterns may be neces- sary. Although implemented with relative ease, the plate continues to provide adequate fatigue strength and sufficient durability to reduce the risk for secondary displacement of the fracture associated with plate failure or loss of fixation. The intrinsic design features of the calcaneal plate allow for potential A B C reconstruction of the articular sur- face with absolute stability, thereby Figure 3. Radiographic (A) and computed tomography (B, C) evaluations of 28-year- enhancing articulate cartilage via- old man with fractures of medial femoral condyle and associated comminution. bility and primary healing. The calcaneal plates are made in 3 sizes to optimize anatomical use based on individual management requirements. With countersinks on both sides, the plate design can be used on either femora (medi- al or lateral condylar fixation). Numerous holes allow a variety of screw fixation possibilities based on fracture pattern and comminution level, which also is a deciding factor in sizing the plate for application. The “character” of the fracture pat- tern helps dictate plate sizing/tem- plating. In our experience, proximal cortical extension has been success- fully negotiated with application Figure 4. Radiographic evaluation after open reduction and internal fixation. of a larger plate, whereas minimal cortical involvement or a “pure” high-strength and low-profile. One the construct offers regions of condylar fracture can be man- calcaneal plate feature that we intermittent fixation, which likely aged with a smaller plate. The case believe combines the strength and promotes periosteal preservation, reports presented here suggest that durability needed for this expanded and ultimately, fracture healing. In 2 cortical screws placed proximal to indication is the transverse strut, the appropriate setting, the plate the fracture itself provide adequate which extends to the perimeter of may be used essentially as a large fixation in the femoral shaft. Distal the construct, potentially increasing washer, representing a unique fixation must be applied at the overall fixation stability. We believe management option for fracture discretion of the operating surgeon that the strut helps mitigate the rota- comminution, osteopenic or osteo- on the basis of preoperative evalu- tional forces at the implant–bone porotic bone. These plate designs ation, intraoperative findings, and interface. The contained plate design include as many as 12 screw holes, associated fracture lines. lends itself to alternative fixation which may be strategically placed Titanium screw fixation options applications based on the absence to augment fracture reduction or are available in locked and variable- of the cantilever arms common- fixation based on anatomical varia- angle trajectories, offering further ly found in other calcaneal plate tion or injury pattern. The low- versatility. Many of the conven- designs. This plate provides a wide profile design (plate thickness, 1 tional locked implants used in dis- area of bone coverage, increasing mm) reduces the risk for irritation tal femoral fixation have manufac- the surface area of fixation while of the surrounding soft tissues, spe- turer-preset uniaxial screw paths, the spanning structural design of cifically the iliotibial band in the and therefore, are at a potential

142 The American Journal of Orthopedics® www.amjorthopedics.com D. W. Hohman et al disadvantage in unique injury pat- recommendations as to a manage- tion and internal fixation of a terns. The screw path options that ment approach. Our experience distal femoral condylar fracture accompany the calcaneal plate con- in operatively managing isolated with a calcaneal plate may be struct represent potential solutions condylar fractures has been suc- appropriate. Other orthopedic to various fracture patterns and cessful. Our indications essentially surgeons, particularly those man- provide anatomical variation about are fracture fragments amenable to aging cases of complex orthope- the distal femur. Conventional fixation and displacement of 2 mm dic trauma, may be able to apply plates with only predetermined or more. These indications serve as this technique. screw trajectories and precontoured general guidelines, as all injuries designs cannot address the varia- are unique. We use the surgical Authors’ Disclosure tion in femoral , fracture approach that the fracture requires, Statement patterns, or alterations in plate and achieve rigid fixation with lag The authors report no actual or positioning. screw and calcaneal plate fixation potential conflict of interest in rela- Innovative polyaxial screw plate with the goal of perfect anatomical tion to this article. designs allow more variation in reduction. The stability conferred fixation constructs and the ability allows for unrestricted immedi- References 1. Manfredini M, Gildone A, Ferrante R, to perform targeted percutaneous ate range of motion of the , Bernasconi S, Massari L. Unicondylar fixation. These devices rep- lessening the risk for postoperative fractures: therapeutic strategy and long-term resent a significant advance in fixa- joint ankylosis. We emphasize that results. A review of 23 patients. Acta Orthop Belg. 2001;67(2):132-138. tion of complicated supracondylar this technique is appropriate only 2. McCarthy JJ, Parker RD. Arthroscopic reduc- injuries to the distal femur, but for partial articular injuries, those tion and internal fixation of a displaced intraar- ticular lateral femoral condyle fracture of the their increased surgical morbidity with intact contralateral condyle knee. . 1996;12(2):224-227. and higher cost make it seem dif- and cortex. This type of fixation 3. Smith EJ, Crichlow TP, Roberts PH. Monocondylar fractures of the femur: a review ficult to justify their use in isolated is clearly inadequate when there is of 13 patients. Injury. 1989;20(6):371-374. condylar fractures, both high- and bicondylar involvement or a lack 4. Forster MC, Komarsamy B, Davison JN. Distal femoral fractures: a review of fixation meth- low-energy in nature. of metaphyseal stability. Such pat- ods. Injury. 2006;37(2):97-108. Schatzker and Tile6 noted that terns require implants that impart 5. Ostermann PA, Neumann K, Ekkernkamp A, Muhr G. Long term results of unicondylar nonoperative management of iso- adequate angular stability. fractures of the femur. J Orthop Trauma. lated condylar fractures leads to We have described our surgical 1994;8(2):142-146. 6. Schatzker J, Tile M. The Rationale of Operative less than satisfactory outcomes, but technique and reviewed the con- Fracture Care. 2nd ed. Berlin, Germany: they did not describe any specific ditions under which open reduc- Springer-Verlag; 1996.

This paper will be judged for the Resident Writer’s Award

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