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Treatment of multifragmentary fractures of the femur by indirect reduction (biological) and plate fixation
Injury, Int. J. Care Injured 33 (2002) 691–699
Treatment of multifragmentary fractures of the femur by indirect reduction (biological) and plate fixation C. Kesemenli, M. Subasi∗ , S. Necmioglu, A. Kapukaya Department of Orthopaedic Surgery, University of Dicle, Diyarbakir, Turkey Accepted 22 May 2002
Abstract We present a retrospective review of the results of 43 multifragmentary femur fractures treated under the principle of indirect reduction (biological) and plate fixation. Fractures were caused by high-energy trauma in all patients. Sixteen were subtrochanteric, 14 diaphyseal and 13 supracondylar. There were 13 open fractures. In six of the patients with diaphyseal fractures, a plate was inserted through isolated proximal and distal incisions only, deep to the vastus lateralis. None of the fractures was treated with bone graft. The mean follow-up time was 28.3 months. Union was achieved in 41 patients within a mean period of 4.25 months. There was delayed union in one patient (subtrochanteric), non-union in two, infection in three, malunion in three, leg shortening in six and mild knee stiffness in seven. In eight patients with diaphyseal fractures in whom a single incision was performed, the average time for fracture healing was 4.14 months in seven and non-union developed in one. In six patients with diaphyseal fractures, in whom proximal and distal incisions were performed, the average time for fracture healing was 4 months. There was no difference (P > 0.05) between single and double incision with reference to infection and time to union, but the indirect reduction methods must be meticulously implemented. The implants we used are cheaper and more easily supplied than many others. The success rate is high when the technique is correctly implemented. We believe that this is a treatment of choice in countries with low socioeconomic status, no efficient health insurance system and no intraoperative image intensification. © 2002 Elsevier Science Ltd. All rights reserved.
1. Introduction Femoral fractures generally occur as a result of highenergy trauma. They have high morbidity and mortality without appropriate treatment [7]. Plate osteosynthesis is an important technique in the treatment of femoral shaft fractures, particularly where an intramedullary nail may not be ideal, as in adult and childhood polytrauma, especially with head injury, pulmonary compromise, complex metaphyseal–diaphyseal or periarticular fractures, open fractures with vascular injury, and an excessively narrow intramedullary canal [6,22]. Open reduction and internal fixation with plates and screws has become a standard method of treatment for many types of fractures. However, the extensive operative exposure required to achieve anatomical reduction often results in devitalisation of the bone and surrounding tissues as well as evacuation of the fracture haematoma, which has osteogenic potential. While most fractures heal without complications, problems with delayed or non-union, ∗ Corresponding author. Tel.: +90-412-2488111; fax: +90-412-2488111. E-mail address: [email protected] (M. Subasi).
infection and stiffness of adjacent joints are not uncommon. Therefore, more biological solutions have been sought [6,13,14,18,19,25,29]. In this study, we reviewed retrospectively the outcome of multifragmentary fractures of the femur treated by indirect reduction and biological osteosynthesis. We also compared the results of single-incision/indirect reduction with double-incision/indirect reduction as two methods for diaphyseal fractures.
2. Patients and methods Forty-three patients with multifragmentary diaphyseal, subtrochanteric and supracondylar fractures of the femur who had been treated with indirect reduction in the Orthopaedics and Traumatology Clinic of Dicle University School of Medicine were included in this study. There were nine females and 34 males with a median age of 41 years (range 17–84 years). All the fractures were sustained in high-energy injuries. Twenty-nine of the patients (67%) had been involved in motor vehicle accidents, eight (19%) had fallen from a height and six (14%) had gunshot trauma. There were 13 (30%) open fractures (four type I, two
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type II, seven type III) [10]; these were treated by initial debridement on the day of injury with subsequent stabilisation, on average, on the ninth day after injury. The fractures were classified according to the AO classification. Sixteen (37%) were subtrochanteric type C3, 14 (33%) diaphyseal (two type B1, five type B2, three type C1 and four type C3) and 13 (30%) supracondylar (one type A2, six type A3, four type C2, two type C3). Twenty-two patients (51%) had multiple injuries (nine head trauma, ten thorax trauma,
six blunt abdominal injury, 16 various other fractures; Table 1). All fractures were placed on skeletal traction at admission and definitive treatment of the femoral fracture was delayed on average 7.4 days (range 2–15 days). Preoperative planning included radiographs of the opposite femur to determine the 95◦ blade-plate entry site and the connect length of the plate. All patients received pre- and postoperative antibiotics for 3–5 days, and fractional heparin. Five
Table 1 Data for each patient Case
Age (years)
Sex
Injury
Region
Type (AO)
Open
Multitrauma
Plate
Preoperative traction (days)
Union (months)
Follow-up (months)
Complications
1 2 3 4 5 6 7 8
84 27 48 20 25 65 42 73
M M M F M M M M
MVA MVA GI MVA FH FH MVA MVA
S.T S.T S.T S.T S.T S.T S.T S.T
C3 C3 C3 C3 C3 C3 C3 C3
– – Type III – – – – Type II
+ − + + − + + +
CBP CBP CBP CBP CBP CBP CBP CBP
4 10 12 11 8 7 10 5
5 4 4 5 3 4 4 8
27 45 36 24 30 21 15 30
9 10 11 12 13 14 15 16 17a 18 19a 20 21a
18 28 80 48 17 22 42 38 50 30 18 18 24
M M F M M M M M F M M M M
FH GI FH MVA FH MVA MVA MVA MVA MVA GI MVA MVA
S.T S.T S.T S.T S.T S.T S.T S.T D D D D D
C3 C3 C3 C3 C3 C1 C3 C3 B1 C1 B2 C3 B1
Type Type Type – – – – – Type – Type – –
I III II
+ + − − + + + − − + − + +
CBP CBP CBP CBP CBP CBP CBP CBP DCP DCP DCP DCP CBP
13 15 5 6 4 10 7 3 4 5 13 3 2
3 6 4 5 4 3 5 4 4 − 4 3 3
37 38 40 20 19 21 24 26 47 9 25 26 22
22a 23 24 25 26 27 28 29a 30a 31 32 33 34 35 36 37 38 39 40 41 42 43
77 19 30 50 33 53 38 32 29 20 40 46 52 63 17 63 67 27 58 46 47 38
M M M F M M M M F M M M F F M M M F M M F M
MVA MVA MVA MVA MVA MVA MVA MVA MVA MVA MVA MVA MVA FH FH FH GI MVA MVA GI MVA GI
D D D D D D D D D S.C S.C S.C S.C S.C S.C S.C S.C S.C S.C S.C S.C S.C
C1 C3 B2 B2 C3 B2 C3 B2 C1 C3 C3 A3 A2 A3 C2 A3 C2 A3 C2 A3 A3 C2
Type – – – – – – – Type – – – – – – – Type Type – Type – Type
I
− + + − + − + − − − − + + − − − − + − − − +
CBP CBP CBP CBP CBP CBP CBP CBP DCP CBP CBP CBP CBP CBP CBP CBP CBP CBP CBP CBP CBP CBP
5 12 3 6 9 7 3 4 5 9 5 12 10 12 5 9 9 8 3 12 2 10
5 3 4 6 4 5 4 4 4 3 4 4 4 4 3 5 4 − 5 5 4 5
25 35 38 28 22 19 22 28 27 48 45 42 31 44 27 13 36 11 22 20 30 22
– – Infecion + 1.5 cm short – – – – Delayed union + 0–100◦ flexion – – 8◦ varus + 1 cm short 10◦ varus + 1 cm short – – – – – Left the control – – 14◦ posterior angulation + 1 cm short – – – Flexion 0–110◦ – – – 1 cm short – Flexion 0–105◦ – – Flexion 0–110◦ Infection + flexion 0–100◦ – – Flexion 0–90◦ Non-union + infection – 1 cm short – Flexion 0–110◦
I III
I
III III III III
Injury: MVA, motor vehicle accident; GI, gunshot; FH, fall from a height. Region: S.T, subtrochanteric; D, diaphyseal; S.C, supracondylar. Plate: CBP, 95◦ condylar blade-plate; DCP, dynamic compression plate. a Double incision.
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cases were operated under general and 38 under regional anaesthesia. 2.1. Surgical technique All patients were positioned supine on a standard operating table; a special distractor and traction table was not
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used for reduction. The fractures were reduced indirectly by manual traction, checking the length, axial alignment and rotation clinically and under radiographic control (no image intensification was used). Intraoperatively, all the patients were checked radiologically for reduction as well as blade-plate and shaft length. None of the fractures was bone grafted.
Fig. 1. Subtrochanteric fracture with intertrochanteric involvement (type C3). (a) Preoperative anteroposterior roentgenograph; (b and c) 3 months postoperatively; (d and e) 1 year after surgery.
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Fig. 1. (Continued ).
In subtrochanteric fractures, a standard lateral approach to the hip was used. The iliotibial tract was split lengthwise. The fascia of the vastus lateralis was freed laterally and also transversally at the inferior aspect of the greater trochanter. The 95◦ condylar blade-plate was inserted behind the vastus lateralis, which was then carefully retracted to expose the femur just sufficiently to place distal screws. The area of fragmentation was untouched. Homan-type retractors were placed on the proximal and distal main fragments only, not in the area of fragmentation, as this would disturb the blood supply to the separate fragments. All subtrochanteric fractures were secured with a 95◦ condylar blade-plate. The blade was inserted into the proximal fragment at the extraperiosteal location determined in the preoperative plan. No dissection or attempt at reduction of the multifragmented area was made up to this point. The fragments lying medially were reduced indirectly by overdistraction and careful manipulation. The multifragmentary fragments were left undisturbed. Axial alignment, rotation and length was checked clinically and radiologically, and the plate was fixed to the distal fragment with at least four screws (Figs. 1 and 2). In diaphyseal fractures, a standard lateral approach to the femur was used in eight patients. The plate was inserted behind the vastus lateralis as in the subtrochanteric fractures. Out of 14 patients with diaphyseal fracture, a dynamic compression plate was used for five (36%) and a 95◦ condylar blade-plate for nine (64%). In six (43%) of these patients, the plate was secured to the femur by screws placed through the vastus muscle via a proximal incision and a second, more distal incision of similar length (minimally invasive).
The length of the exposure was limited to the proximal and distal extents of the plate. The plate was inserted through isolated proximal and distal incisions only, behind the vastus lateralis. The fracture zone was not exposed (Fig. 3). The reduction was performed as in the subtrochanteric fractures. Intrafragmentary screws and cerclage wiring were not used. For distal femoral fractures with the patient in the supine position, a standard lateral approach to the femoral shaft was used, with the distal portion of the incision extending anteriorly across the lateral femoral condyle ending at the level of the Gerdy’s tubercle. The 95◦ condylar blade-plate was inserted behind the vastus lateralis, which was then carefully retracted to expose the femur just enough to place distal screws. The area of fragmentation was untouched. Meticulous care was taken to avoid excessive contact and initial mobilisation of the metaphyseal fragments to prevent further stripping of periosteum and blood supply. In type C fractures, a lateral arthrotomy was performed, avoiding damage to the attachment of the lateral meniscus. The two condyles were reduced and temporarily stabilised along the intercondylar fracture line with provisional K-wires. The condylar fracture was fixed and then a 95◦ condylar blade-plate was inserted, first in the femoral condyle and then to the proximal fragment, leaving the area of fragmentation undisturbed. Alignment, length and rotation were checked before the insertion of the proximal screws. Arthrotomy was not performed in type A fractures (AO classification). Bone grafts were not used in any of the cases. Isometric quadriceps exercises were begun on the second day. The patients were mobilised from the third postoperative day. Weight bearing was started when there was sufficient callus on radiographs. Radiographic and clinical follow-ups were performed monthly for the first 6 months, and later on those with no problems of union were called for evaluation at 3-month intervals.
3. Results None of the patients developed complications during the intraoperative period. Infection occurred in three (7%) patients in the early postoperative period. Two of these three patients had type II open fractures (one due to a motor vehicle accident, one to gunshot) and the other had a closed fracture caused by a motor vehicle accident (cases 3, 35, 39). Two of the three healed at the expected time and the other developed deep infection (case 39). This patient did not accept our surgical recommendations and left our control. The mean follow-up time was 28.3 months (range 9–48 months). There was non-union in two (4.7%) patients. One of these two (patient 18) had fractures of the humerus, tibia and mandible associated with a femoral fracture caused by a motor vehicle accident. The other had a type III open fracture caused by a motor vehicle accident and had developed infection (patient 39). Both also developed implant failures. Forty-one of the 43 fractures had healed after a mean of 4.3
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Fig. 2. (a) Anteroposterior injury radiograph showing a segmental femoral fracture; (b and c) anteroposterior and lateral radiographs 3 months postoperatively.
months (range 3–8 months). In eight patients with diaphyseal fractures in whom a single incision was performed, the average time for fracture healing was 4.14 months (range 3–6 months) in seven; non-union developed in one patient, and another experienced knee stiffness. In six patients with
diaphyseal fractures in whom proximal and distal incisions were performed, the average time for fracture healing was 4 months (range 3–5 months); shortening of 1 cm developed in two of the six patients and there was 14◦ posterior angulation in one. The average time for fracture healing in both
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groups was evaluated by Mann–Whitney U-test and no statistically significance was found (P > 0.05). Six patients (14%) had leg shortening, of between 1 and 1.5 cm: the shortening was intentional in one patient with
subtrochanteric fracture to obtain stability of the fracture; another two subtrochanteric fractures had 8 and 10◦ varus deformity of the subtrochanteric region. One of the patients with diaphyseal fracture had leg shortening of 1 cm and 14◦
Fig. 3. (a) Femoral fracture with the fracture line extending proximally preoperatively. (b and c) Anteroposterior and lateral radiographs postoperatively. (d and e) Anteroposterior and lateral radiographs 8 months postoperatively. There was 14◦ posterior angulation and 1 cm shortening. (f) Clinical and functional results 8 months postoperatively.
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Fig. 3. (a) (Continued ).
posterior angulation (Fig. 3). One patient with supracondylar fracture had 1 cm leg shortening. There were malunions in three (7%) patients. Knee stiffness was observed in seven patients (16%). One with subtrochanteric fracture achieved a range of motion of 0–100◦ , one with diaphyseal fracture had 0–105◦ , and five with supracondylar fractures had 0–110◦ . In the rest of the patients, greater than 120◦ knee flexion was obtained. Implant failures were observed in two patients (cases 18 and 39). No refracture or severe rotational malalignment was observed in any case.
4. Discussion The stability and quality of the blood supply to the fracture zone achieved during treatment are the most important factors in the healing of a fracture. Once the importance of bone physiology and blood supply to the bone fragments is understood, reduction to achieve anatomical alignment of extra-articular fractures and optimal, rather than maximal, stability is the goal [21–23]. In extra-articular fractures, the exact reduction of each bony fragment is no longer a goal in itself, but rather, the overall restoration of length, axial alignment and rotation. The previous AO guidelines for a specific number of screws and cortices in each fragment are no longer used. Implants, particularly screws, are used optimally and judiciously to avoid unnecessary surgical trauma to the bone [22]. Biological fixation techniques have been developed in an effort to lessen the incidence of surgical
complications in lower-extremity fractures by minimising the amount of surgical trauma, so sparing the remaining vascular supply and the trophic factors in the haematoma surrounding the fracture [6]. Several clinical and experimental studies report that the results of indirect reduction are better than those accomplished with conventional plate treatment in terms of callus mass, the period required for union and infection rates [1,2,8,9]. Forty-three cases of multifragmentary femoral fractures were here treated by indirect reduction. Sixteen of the cases had subtrochanteric fractures and all of them were type C according to the AO classification. In the treatment of such fractures, especially the multifragmented and those extending towards the trochanteric region as in our cases, there is potential difficulty in the control of rotation and shortness when intramedullary nails are used [14,27]. Patients whose trochanteric fractures are treated with an intramedullary hip screw/nail device, however, are at increased risk for femoral shaft fracture at the nail tip and the insertion sites of the distal locking bolts. The prevalence of diaphyseal fractures reportedly ranges from 0 to 17% [4,11,15]. Failure or non-union was found in 10% of patients who were treated with compression hip screws as a method of internal fixation for subtrochanteric fractures [28]. The 95◦ condylar blade-plate is a fixed-angle device that has wide clinical application [14]. More recently, balanced fixation has been better achieved by the increased use of the 95◦ condylar blade-plate in proximal and distal fractures of the shaft. Because only a short lever arm is possible for the plate on one side of a proximal or distal shaft fracture,
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it is compensated by enhanced fixation at the plate’s end [22]. A 95◦ condylar blade-plate was used for all proximal and distal shaft fractures in our patients. The major breakthrough in the treatment of subtrochanteric fractures was achieved by Kinast et al. [14]: the fracture was reduced indirectly without dissecting the fracture lines and especially the medial cortex. Kinast et al. [14] compared a first group treated by conventional techniques with a second group treated by indirect reduction; the rate of failure was 16.6 and 0% and the mean period for union was 5.4 and 4 months in the first and second groups, respectively. The mean period to union was 3–4 months in subtrochanteric fractures treated with indirect reduction in some previous studies [2,3,24]. Two of our patients had 1 cm and one had 1.5 cm leg shortening and 8–10◦ varus angulation of the subtrochanteric region. One patient with a type II open fracture had delayed union associated with stiffness of flexion at the knee. Fourteen of our cases had diaphyseal fractures. The best treatment for these fractures seems to be biological indirect reduction and splinting with an unreamed locking nail as the first choice, or a bridging plate as a second choice [5,21,23]. Unreamed nails have reduced but not eliminated cardiopulmonary complications [5,23]. Still there is debate absent whether to nail femur fractures in multitrauma patients who have been in shock and have concomitant chest injuries. It has been suggested that long bone fractures in these patients should be plated or stabilised with an external fixator [5]. The number of problems such as fixation failure, rotational instability, shortening, implant failure is higher with intramedullary nailing in fragmented fractures of the femur, reportedly up to 12% [31,32]. Wiss et al. [32] indicate that when the fragmentation is more than 8 cm, fixation failure will develop in the patient treated with an unreamed locked nail and that the complications will increase in proportion to the extension of the fragmented segment. In addition, unreamed locked nails are costly. In many developing areas of the world, as in our country, where there is the lack of a general health insurance, the equipment required for intramedullary nailing may not be easily available and plating can be performed. Patients treated by external fixation are also reported to have pin tract infections and knee stiffness [26]. In order to decrease further the soft tissue trauma in patients with femoral diaphyseal fractures, we used a double-incision technique in six patients (minimally invasive). Theoretically, the limited skin incisions may also lessen the risk of wound complications if tissues have been handled carefully. Union periods were not significantly different between our single- and double-incision groups. However, among the patients with double incisions, one had 1 cm leg shortening and another 1 cm leg shortening and 14◦ posterior angulation. One of the patients with a single incision developed malunion and another had knee stiffness. Wenda et al. [30] used a bridge-plate technique for internal fixation in 17 patients with longitudinal or multifragmentary femoral shaft fractures extending into the
trochanteric or condylar area. Indirect reduction techniques were used and all fractures were secured with a 95◦ angled blade-plate. Primary bone grafting was not performed. All fractures healed without infection. Three patients underwent bone grafting at 3 months when radiographs indicated a delay in healing. In addition, one patient required a corrective osteotomy for rotational malalignment [30]. Krettek et al. [17] report on the use of a percutaneous insertion technique for the treatment of proximal and distal femoral fractures or the stabilisation of osteotomies. The mean time to radiographic evidence of union was 16.3 weeks and there were no non-unions or infections. Supracondylar fractures treated by distally inserted intramedullary devices lack adequate fixation of extensive intra-articular comminution and cannot prevent shortening [12]. Ostrum [20] reports supra-intercondylar fractures treated by indirect reduction, of which 86.8% had excellent or satisfactory results. Johnson [12] describes excellent solidus good results in all of his patients. In another study [16], eight patients with complex supracondylar femoral fractures were treated with transarticular joint reconstruction and indirect plate osteosynthesis performed by using only a lateral parapatellar arthrotomy; no delayed union or non-union occurred, and radiographic union was demonstrated at an average of 11.6 weeks; two patients had 15◦ of rotational malalignment. In our study, there were 13 supracondylar fractures, all of which had healed by 3.5 months except one (case 39); knee stiffness was observed in five of these patients, but only one had flexion of less than 100◦ ; another had 1 cm shortening. If the soft tissues are preserved meticulously and the surgeon resists the temptation to expose the entire fracture, bone grafting may be unnecessary. It is even reported that grafting is contraindicated if soft tissue dissection is necessary to allow placement of the graft [9,22]. There is apparently no difference between cases grafted and not grafted in terms of the period to union [5,21,23]. We have not used grafts in any of our patients. In conclusion, when all of our patients were evaluated, union had been achieved in 41 (95%) out of 43 patients within a mean period of 4.25 months. There was delayed union in one (2%) patient, non-union in two (5%), infection in three (7%), malunion in three (7%) and movement limitation in seven (16%). When injuries and their fracture types are considered, it can be seen in the literature that multifragmented fractures can be treated by indirect reduction without any major complications. There has been no difference between single and double incisions in terms of infection and the period for union if the indirect reduction methods are meticulously implemented. The implants we used are cheaper and more easily supplied than many others. The success rate is high when the technique is correctly implemented. Therefore, we believe that it is a treatment of choice that can be successfully used in countries at a low socioeconomic level, with no efficient health insurance system and no intraoperative image intensification.
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References [1] Baumgaertal F, Buhl M, Rahn BA. Fracture healing in biological plate osteosynthesis. Injury 1998;29(Suppl 3):C3. [2] Baumgaertel F, Gotzen L. The ‘biological’ plate osteosynthesis in multi-fragment fractures of the para-articular femur. A prospective study. Unfallchirurg 1994;97:78. [3] Blatter G, Janssen M. Treatment of subtrochanteric fractures of the femur: reduction on the traction table and fixation with dynamic condylar screw. Arch Orthop Trauma Surg 1994;113:138. [4] Butt MS, Krikler SJ, Nafia S, Ali MS. Comparison of dynamic hip screw and gamma nail: a prospective, randomized, controlled trial. Injury 1995;26:615. [5] Chrısovitsinos JP, Xenakis T, Papakostides KG, Skaltsoyannis N, Grestas A, Soucacos NP. Bridge plating osteosynthesis of 20 multifragmentary fractures of the femur. Acta Orthop Scan 1997; 68:72. [6] Collinge CA, Sanders RW. Percutaneous plating in the lower extremity. J Am Acad Orthop Surg 2000;8:211. [7] DeLee JC. Fractures and dislocation of the hip. In: Rockwood CA, Green DP, editors. Fractures in adults. Philadelphia: Lippincott Company, 1996. p. 1653. [8] Farouk O, Krettek C, Miclau T, Schandelmaier P, Guy P, Tscherne H. Minimally invasive plate osteosynthesis and vascularity: preliminary results of a cadaverinjection study. Injury 1997;28(Suppl 1):A7. [9] Gerber C, Mast JW, Ganz R. Biological internal fixation of fractures. Arch Orthop Trauma Surg 1990;109:295. [10] Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 1976;58:453. [11] Hardy DCR, Descamps PY, Krallis P, Fabeck L, Smets P, Bertens CL, et al. Use of an intramedullary hip-screw compared with a compression hip-screw with a plate for intertrochanteric femoral fractures. A prospective, randomized study of one hundred patients. J Bone Joint Surg 1998;80-A:618. [12] Johnson EE. Combined direct and indirect reduction of multifragmentary four-part intraarticular t-type fractures of the distal femur. Clin Orthop 1988;231:154. [13] Johnson KD. Internal fixation of distal femoral fractures. AAOS ICL 1987;36:437. [14] Kinast C, Bolhofner BR, Mast JW, Ganz R. Subtrochanteric fractures of the femur. Clin Orthop 1989;238:122. [15] Koval KJ, Swiontowski MF. Intertrochanteric fractures. Orthopedic knowledge update. In: Beaty JH, editor. American academy of orthopaedic surgeons, 1999. p. 448.
699
[16] Krettek C, Schandelmaier P, Miclau T, Bertram R, Holmes W, Tscherne H. Transarticular joint reconstruction and indirect plate osteosynthesis for complex distal supracondylar femoral fractures. Injury 1997;28(Suppl 1):A31. [17] Krettek C, Schandelmaier P, Miclau T, Tscherne H. Minimally invasive percutaneous plate osteosynthesis (MIPPO) using the DCS in proximal and distal femoral fractures. Injury 1997;28(Suppl 1):A20. [18] Moore TJ, Watson T, Green SA, Garland DE, Chandler RW. Complication of surgically treated supracondylar fractures of the femur. J Trauma 1987;27:402. [19] Necmioglu S, Kapukaya A, Kesemenli C. Treatment of femur segmentary multifragmentary fractures by indirect reduction. Acta Orthop Traumatol Turc 1997;31:296 (in Turkish). [20] Ostrum RF, Geel C. Indirect reduction and internal fixation of supracondylar femur fractures without bone graft. J Orthop Trauma 1995;9:278. [21] Perren SM. The concept of biological plating using limited contactdynamic compression plate (LC-DCP). Scientific background, design and application. Injury 1991;22(Suppl 1):1. [22] Rozbruch RS, Müller U, Gautier E, Ganz R. The evolution of femoral shaft plating technique. Clin Orthop 1998;354:195. [23] Schatzker J, Tile M. The rationale of operative fracture care. Berlin: Springer, 1996. [24] Siebenrock KA, Muller U, Ganz R. Indirect reduction with a condylar blade plate for osteosynthesis of subtrochanteric femoral fractures. Injury 1998;29(Suppl 3):7. [25] Subasi M, Kesemenli C, Kapukaya A, Tuzuner T, Necmioglu S, Kirkgoz T. Treatment of femur segmentary fractures by intramedüller nailing. Turkish J Arthrop Arthrosc Surg 2000;11:32 (in Turkish). [26] Subasi M, Kesemenli C, Kapukaya A, Necmioglu S. Treatment of intertrochanteric fractures by external fixation. Acta Orthop Belg 2001;67:468. [27] Thomas WG, Villar RN. Subtrochanteric fractures: Zickel nail or nail-plate? J Bone Joint Surg 1986;68B:255. [28] Waddell JP. Subtrochanteric fractures of the femur: a review of 130 patients. J Trauma 1979;19:582. [29] Wagner HE, Jakob RP. Zur problematik der plattenosteosynthese bei den bikondylaren tibiakkopffarkturen. Unfallchirurgie 1986;89:304. [30] Wenda K, Runkel M, Degreif J, Rudig L. Minimally invasive plate fixation in femoral shaft fractures. Injury 1997;28(Suppl 1):S13. [31] Winquist RA, Hansen ST, Clawson DK. Closed intramedullary nailing of femoral fractures. A report of five hundred twenty cases. J Bone Joint Surg 1984;66A:529. [32] Wiss DA, Brien WW, Becker Jr V. Interlocked nailing for the treatment of femoral fractures due to gunshots wounds. J Bone Joint Surg 1991;73A:598.
Treatment of multifragmentary fractures of the femur by indirect reduction (biological) and plate fixation C. Kesemenli, M. Subasi∗ , S. Necmioglu, A. Kapukaya Department of Orthopaedic Surgery, University of Dicle, Diyarbakir, Turkey Accepted 22 May 2002
Abstract We present a retrospective review of the results of 43 multifragmentary femur fractures treated under the principle of indirect reduction (biological) and plate fixation. Fractures were caused by high-energy trauma in all patients. Sixteen were subtrochanteric, 14 diaphyseal and 13 supracondylar. There were 13 open fractures. In six of the patients with diaphyseal fractures, a plate was inserted through isolated proximal and distal incisions only, deep to the vastus lateralis. None of the fractures was treated with bone graft. The mean follow-up time was 28.3 months. Union was achieved in 41 patients within a mean period of 4.25 months. There was delayed union in one patient (subtrochanteric), non-union in two, infection in three, malunion in three, leg shortening in six and mild knee stiffness in seven. In eight patients with diaphyseal fractures in whom a single incision was performed, the average time for fracture healing was 4.14 months in seven and non-union developed in one. In six patients with diaphyseal fractures, in whom proximal and distal incisions were performed, the average time for fracture healing was 4 months. There was no difference (P > 0.05) between single and double incision with reference to infection and time to union, but the indirect reduction methods must be meticulously implemented. The implants we used are cheaper and more easily supplied than many others. The success rate is high when the technique is correctly implemented. We believe that this is a treatment of choice in countries with low socioeconomic status, no efficient health insurance system and no intraoperative image intensification. © 2002 Elsevier Science Ltd. All rights reserved.
1. Introduction Femoral fractures generally occur as a result of highenergy trauma. They have high morbidity and mortality without appropriate treatment [7]. Plate osteosynthesis is an important technique in the treatment of femoral shaft fractures, particularly where an intramedullary nail may not be ideal, as in adult and childhood polytrauma, especially with head injury, pulmonary compromise, complex metaphyseal–diaphyseal or periarticular fractures, open fractures with vascular injury, and an excessively narrow intramedullary canal [6,22]. Open reduction and internal fixation with plates and screws has become a standard method of treatment for many types of fractures. However, the extensive operative exposure required to achieve anatomical reduction often results in devitalisation of the bone and surrounding tissues as well as evacuation of the fracture haematoma, which has osteogenic potential. While most fractures heal without complications, problems with delayed or non-union, ∗ Corresponding author. Tel.: +90-412-2488111; fax: +90-412-2488111. E-mail address: [email protected] (M. Subasi).
infection and stiffness of adjacent joints are not uncommon. Therefore, more biological solutions have been sought [6,13,14,18,19,25,29]. In this study, we reviewed retrospectively the outcome of multifragmentary fractures of the femur treated by indirect reduction and biological osteosynthesis. We also compared the results of single-incision/indirect reduction with double-incision/indirect reduction as two methods for diaphyseal fractures.
2. Patients and methods Forty-three patients with multifragmentary diaphyseal, subtrochanteric and supracondylar fractures of the femur who had been treated with indirect reduction in the Orthopaedics and Traumatology Clinic of Dicle University School of Medicine were included in this study. There were nine females and 34 males with a median age of 41 years (range 17–84 years). All the fractures were sustained in high-energy injuries. Twenty-nine of the patients (67%) had been involved in motor vehicle accidents, eight (19%) had fallen from a height and six (14%) had gunshot trauma. There were 13 (30%) open fractures (four type I, two
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type II, seven type III) [10]; these were treated by initial debridement on the day of injury with subsequent stabilisation, on average, on the ninth day after injury. The fractures were classified according to the AO classification. Sixteen (37%) were subtrochanteric type C3, 14 (33%) diaphyseal (two type B1, five type B2, three type C1 and four type C3) and 13 (30%) supracondylar (one type A2, six type A3, four type C2, two type C3). Twenty-two patients (51%) had multiple injuries (nine head trauma, ten thorax trauma,
six blunt abdominal injury, 16 various other fractures; Table 1). All fractures were placed on skeletal traction at admission and definitive treatment of the femoral fracture was delayed on average 7.4 days (range 2–15 days). Preoperative planning included radiographs of the opposite femur to determine the 95◦ blade-plate entry site and the connect length of the plate. All patients received pre- and postoperative antibiotics for 3–5 days, and fractional heparin. Five
Table 1 Data for each patient Case
Age (years)
Sex
Injury
Region
Type (AO)
Open
Multitrauma
Plate
Preoperative traction (days)
Union (months)
Follow-up (months)
Complications
1 2 3 4 5 6 7 8
84 27 48 20 25 65 42 73
M M M F M M M M
MVA MVA GI MVA FH FH MVA MVA
S.T S.T S.T S.T S.T S.T S.T S.T
C3 C3 C3 C3 C3 C3 C3 C3
– – Type III – – – – Type II
+ − + + − + + +
CBP CBP CBP CBP CBP CBP CBP CBP
4 10 12 11 8 7 10 5
5 4 4 5 3 4 4 8
27 45 36 24 30 21 15 30
9 10 11 12 13 14 15 16 17a 18 19a 20 21a
18 28 80 48 17 22 42 38 50 30 18 18 24
M M F M M M M M F M M M M
FH GI FH MVA FH MVA MVA MVA MVA MVA GI MVA MVA
S.T S.T S.T S.T S.T S.T S.T S.T D D D D D
C3 C3 C3 C3 C3 C1 C3 C3 B1 C1 B2 C3 B1
Type Type Type – – – – – Type – Type – –
I III II
+ + − − + + + − − + − + +
CBP CBP CBP CBP CBP CBP CBP CBP DCP DCP DCP DCP CBP
13 15 5 6 4 10 7 3 4 5 13 3 2
3 6 4 5 4 3 5 4 4 − 4 3 3
37 38 40 20 19 21 24 26 47 9 25 26 22
22a 23 24 25 26 27 28 29a 30a 31 32 33 34 35 36 37 38 39 40 41 42 43
77 19 30 50 33 53 38 32 29 20 40 46 52 63 17 63 67 27 58 46 47 38
M M M F M M M M F M M M F F M M M F M M F M
MVA MVA MVA MVA MVA MVA MVA MVA MVA MVA MVA MVA MVA FH FH FH GI MVA MVA GI MVA GI
D D D D D D D D D S.C S.C S.C S.C S.C S.C S.C S.C S.C S.C S.C S.C S.C
C1 C3 B2 B2 C3 B2 C3 B2 C1 C3 C3 A3 A2 A3 C2 A3 C2 A3 C2 A3 A3 C2
Type – – – – – – – Type – – – – – – – Type Type – Type – Type
I
− + + − + − + − − − − + + − − − − + − − − +
CBP CBP CBP CBP CBP CBP CBP CBP DCP CBP CBP CBP CBP CBP CBP CBP CBP CBP CBP CBP CBP CBP
5 12 3 6 9 7 3 4 5 9 5 12 10 12 5 9 9 8 3 12 2 10
5 3 4 6 4 5 4 4 4 3 4 4 4 4 3 5 4 − 5 5 4 5
25 35 38 28 22 19 22 28 27 48 45 42 31 44 27 13 36 11 22 20 30 22
– – Infecion + 1.5 cm short – – – – Delayed union + 0–100◦ flexion – – 8◦ varus + 1 cm short 10◦ varus + 1 cm short – – – – – Left the control – – 14◦ posterior angulation + 1 cm short – – – Flexion 0–110◦ – – – 1 cm short – Flexion 0–105◦ – – Flexion 0–110◦ Infection + flexion 0–100◦ – – Flexion 0–90◦ Non-union + infection – 1 cm short – Flexion 0–110◦
I III
I
III III III III
Injury: MVA, motor vehicle accident; GI, gunshot; FH, fall from a height. Region: S.T, subtrochanteric; D, diaphyseal; S.C, supracondylar. Plate: CBP, 95◦ condylar blade-plate; DCP, dynamic compression plate. a Double incision.
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cases were operated under general and 38 under regional anaesthesia. 2.1. Surgical technique All patients were positioned supine on a standard operating table; a special distractor and traction table was not
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used for reduction. The fractures were reduced indirectly by manual traction, checking the length, axial alignment and rotation clinically and under radiographic control (no image intensification was used). Intraoperatively, all the patients were checked radiologically for reduction as well as blade-plate and shaft length. None of the fractures was bone grafted.
Fig. 1. Subtrochanteric fracture with intertrochanteric involvement (type C3). (a) Preoperative anteroposterior roentgenograph; (b and c) 3 months postoperatively; (d and e) 1 year after surgery.
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Fig. 1. (Continued ).
In subtrochanteric fractures, a standard lateral approach to the hip was used. The iliotibial tract was split lengthwise. The fascia of the vastus lateralis was freed laterally and also transversally at the inferior aspect of the greater trochanter. The 95◦ condylar blade-plate was inserted behind the vastus lateralis, which was then carefully retracted to expose the femur just sufficiently to place distal screws. The area of fragmentation was untouched. Homan-type retractors were placed on the proximal and distal main fragments only, not in the area of fragmentation, as this would disturb the blood supply to the separate fragments. All subtrochanteric fractures were secured with a 95◦ condylar blade-plate. The blade was inserted into the proximal fragment at the extraperiosteal location determined in the preoperative plan. No dissection or attempt at reduction of the multifragmented area was made up to this point. The fragments lying medially were reduced indirectly by overdistraction and careful manipulation. The multifragmentary fragments were left undisturbed. Axial alignment, rotation and length was checked clinically and radiologically, and the plate was fixed to the distal fragment with at least four screws (Figs. 1 and 2). In diaphyseal fractures, a standard lateral approach to the femur was used in eight patients. The plate was inserted behind the vastus lateralis as in the subtrochanteric fractures. Out of 14 patients with diaphyseal fracture, a dynamic compression plate was used for five (36%) and a 95◦ condylar blade-plate for nine (64%). In six (43%) of these patients, the plate was secured to the femur by screws placed through the vastus muscle via a proximal incision and a second, more distal incision of similar length (minimally invasive).
The length of the exposure was limited to the proximal and distal extents of the plate. The plate was inserted through isolated proximal and distal incisions only, behind the vastus lateralis. The fracture zone was not exposed (Fig. 3). The reduction was performed as in the subtrochanteric fractures. Intrafragmentary screws and cerclage wiring were not used. For distal femoral fractures with the patient in the supine position, a standard lateral approach to the femoral shaft was used, with the distal portion of the incision extending anteriorly across the lateral femoral condyle ending at the level of the Gerdy’s tubercle. The 95◦ condylar blade-plate was inserted behind the vastus lateralis, which was then carefully retracted to expose the femur just enough to place distal screws. The area of fragmentation was untouched. Meticulous care was taken to avoid excessive contact and initial mobilisation of the metaphyseal fragments to prevent further stripping of periosteum and blood supply. In type C fractures, a lateral arthrotomy was performed, avoiding damage to the attachment of the lateral meniscus. The two condyles were reduced and temporarily stabilised along the intercondylar fracture line with provisional K-wires. The condylar fracture was fixed and then a 95◦ condylar blade-plate was inserted, first in the femoral condyle and then to the proximal fragment, leaving the area of fragmentation undisturbed. Alignment, length and rotation were checked before the insertion of the proximal screws. Arthrotomy was not performed in type A fractures (AO classification). Bone grafts were not used in any of the cases. Isometric quadriceps exercises were begun on the second day. The patients were mobilised from the third postoperative day. Weight bearing was started when there was sufficient callus on radiographs. Radiographic and clinical follow-ups were performed monthly for the first 6 months, and later on those with no problems of union were called for evaluation at 3-month intervals.
3. Results None of the patients developed complications during the intraoperative period. Infection occurred in three (7%) patients in the early postoperative period. Two of these three patients had type II open fractures (one due to a motor vehicle accident, one to gunshot) and the other had a closed fracture caused by a motor vehicle accident (cases 3, 35, 39). Two of the three healed at the expected time and the other developed deep infection (case 39). This patient did not accept our surgical recommendations and left our control. The mean follow-up time was 28.3 months (range 9–48 months). There was non-union in two (4.7%) patients. One of these two (patient 18) had fractures of the humerus, tibia and mandible associated with a femoral fracture caused by a motor vehicle accident. The other had a type III open fracture caused by a motor vehicle accident and had developed infection (patient 39). Both also developed implant failures. Forty-one of the 43 fractures had healed after a mean of 4.3
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Fig. 2. (a) Anteroposterior injury radiograph showing a segmental femoral fracture; (b and c) anteroposterior and lateral radiographs 3 months postoperatively.
months (range 3–8 months). In eight patients with diaphyseal fractures in whom a single incision was performed, the average time for fracture healing was 4.14 months (range 3–6 months) in seven; non-union developed in one patient, and another experienced knee stiffness. In six patients with
diaphyseal fractures in whom proximal and distal incisions were performed, the average time for fracture healing was 4 months (range 3–5 months); shortening of 1 cm developed in two of the six patients and there was 14◦ posterior angulation in one. The average time for fracture healing in both
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groups was evaluated by Mann–Whitney U-test and no statistically significance was found (P > 0.05). Six patients (14%) had leg shortening, of between 1 and 1.5 cm: the shortening was intentional in one patient with
subtrochanteric fracture to obtain stability of the fracture; another two subtrochanteric fractures had 8 and 10◦ varus deformity of the subtrochanteric region. One of the patients with diaphyseal fracture had leg shortening of 1 cm and 14◦
Fig. 3. (a) Femoral fracture with the fracture line extending proximally preoperatively. (b and c) Anteroposterior and lateral radiographs postoperatively. (d and e) Anteroposterior and lateral radiographs 8 months postoperatively. There was 14◦ posterior angulation and 1 cm shortening. (f) Clinical and functional results 8 months postoperatively.
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Fig. 3. (a) (Continued ).
posterior angulation (Fig. 3). One patient with supracondylar fracture had 1 cm leg shortening. There were malunions in three (7%) patients. Knee stiffness was observed in seven patients (16%). One with subtrochanteric fracture achieved a range of motion of 0–100◦ , one with diaphyseal fracture had 0–105◦ , and five with supracondylar fractures had 0–110◦ . In the rest of the patients, greater than 120◦ knee flexion was obtained. Implant failures were observed in two patients (cases 18 and 39). No refracture or severe rotational malalignment was observed in any case.
4. Discussion The stability and quality of the blood supply to the fracture zone achieved during treatment are the most important factors in the healing of a fracture. Once the importance of bone physiology and blood supply to the bone fragments is understood, reduction to achieve anatomical alignment of extra-articular fractures and optimal, rather than maximal, stability is the goal [21–23]. In extra-articular fractures, the exact reduction of each bony fragment is no longer a goal in itself, but rather, the overall restoration of length, axial alignment and rotation. The previous AO guidelines for a specific number of screws and cortices in each fragment are no longer used. Implants, particularly screws, are used optimally and judiciously to avoid unnecessary surgical trauma to the bone [22]. Biological fixation techniques have been developed in an effort to lessen the incidence of surgical
complications in lower-extremity fractures by minimising the amount of surgical trauma, so sparing the remaining vascular supply and the trophic factors in the haematoma surrounding the fracture [6]. Several clinical and experimental studies report that the results of indirect reduction are better than those accomplished with conventional plate treatment in terms of callus mass, the period required for union and infection rates [1,2,8,9]. Forty-three cases of multifragmentary femoral fractures were here treated by indirect reduction. Sixteen of the cases had subtrochanteric fractures and all of them were type C according to the AO classification. In the treatment of such fractures, especially the multifragmented and those extending towards the trochanteric region as in our cases, there is potential difficulty in the control of rotation and shortness when intramedullary nails are used [14,27]. Patients whose trochanteric fractures are treated with an intramedullary hip screw/nail device, however, are at increased risk for femoral shaft fracture at the nail tip and the insertion sites of the distal locking bolts. The prevalence of diaphyseal fractures reportedly ranges from 0 to 17% [4,11,15]. Failure or non-union was found in 10% of patients who were treated with compression hip screws as a method of internal fixation for subtrochanteric fractures [28]. The 95◦ condylar blade-plate is a fixed-angle device that has wide clinical application [14]. More recently, balanced fixation has been better achieved by the increased use of the 95◦ condylar blade-plate in proximal and distal fractures of the shaft. Because only a short lever arm is possible for the plate on one side of a proximal or distal shaft fracture,
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it is compensated by enhanced fixation at the plate’s end [22]. A 95◦ condylar blade-plate was used for all proximal and distal shaft fractures in our patients. The major breakthrough in the treatment of subtrochanteric fractures was achieved by Kinast et al. [14]: the fracture was reduced indirectly without dissecting the fracture lines and especially the medial cortex. Kinast et al. [14] compared a first group treated by conventional techniques with a second group treated by indirect reduction; the rate of failure was 16.6 and 0% and the mean period for union was 5.4 and 4 months in the first and second groups, respectively. The mean period to union was 3–4 months in subtrochanteric fractures treated with indirect reduction in some previous studies [2,3,24]. Two of our patients had 1 cm and one had 1.5 cm leg shortening and 8–10◦ varus angulation of the subtrochanteric region. One patient with a type II open fracture had delayed union associated with stiffness of flexion at the knee. Fourteen of our cases had diaphyseal fractures. The best treatment for these fractures seems to be biological indirect reduction and splinting with an unreamed locking nail as the first choice, or a bridging plate as a second choice [5,21,23]. Unreamed nails have reduced but not eliminated cardiopulmonary complications [5,23]. Still there is debate absent whether to nail femur fractures in multitrauma patients who have been in shock and have concomitant chest injuries. It has been suggested that long bone fractures in these patients should be plated or stabilised with an external fixator [5]. The number of problems such as fixation failure, rotational instability, shortening, implant failure is higher with intramedullary nailing in fragmented fractures of the femur, reportedly up to 12% [31,32]. Wiss et al. [32] indicate that when the fragmentation is more than 8 cm, fixation failure will develop in the patient treated with an unreamed locked nail and that the complications will increase in proportion to the extension of the fragmented segment. In addition, unreamed locked nails are costly. In many developing areas of the world, as in our country, where there is the lack of a general health insurance, the equipment required for intramedullary nailing may not be easily available and plating can be performed. Patients treated by external fixation are also reported to have pin tract infections and knee stiffness [26]. In order to decrease further the soft tissue trauma in patients with femoral diaphyseal fractures, we used a double-incision technique in six patients (minimally invasive). Theoretically, the limited skin incisions may also lessen the risk of wound complications if tissues have been handled carefully. Union periods were not significantly different between our single- and double-incision groups. However, among the patients with double incisions, one had 1 cm leg shortening and another 1 cm leg shortening and 14◦ posterior angulation. One of the patients with a single incision developed malunion and another had knee stiffness. Wenda et al. [30] used a bridge-plate technique for internal fixation in 17 patients with longitudinal or multifragmentary femoral shaft fractures extending into the
trochanteric or condylar area. Indirect reduction techniques were used and all fractures were secured with a 95◦ angled blade-plate. Primary bone grafting was not performed. All fractures healed without infection. Three patients underwent bone grafting at 3 months when radiographs indicated a delay in healing. In addition, one patient required a corrective osteotomy for rotational malalignment [30]. Krettek et al. [17] report on the use of a percutaneous insertion technique for the treatment of proximal and distal femoral fractures or the stabilisation of osteotomies. The mean time to radiographic evidence of union was 16.3 weeks and there were no non-unions or infections. Supracondylar fractures treated by distally inserted intramedullary devices lack adequate fixation of extensive intra-articular comminution and cannot prevent shortening [12]. Ostrum [20] reports supra-intercondylar fractures treated by indirect reduction, of which 86.8% had excellent or satisfactory results. Johnson [12] describes excellent solidus good results in all of his patients. In another study [16], eight patients with complex supracondylar femoral fractures were treated with transarticular joint reconstruction and indirect plate osteosynthesis performed by using only a lateral parapatellar arthrotomy; no delayed union or non-union occurred, and radiographic union was demonstrated at an average of 11.6 weeks; two patients had 15◦ of rotational malalignment. In our study, there were 13 supracondylar fractures, all of which had healed by 3.5 months except one (case 39); knee stiffness was observed in five of these patients, but only one had flexion of less than 100◦ ; another had 1 cm shortening. If the soft tissues are preserved meticulously and the surgeon resists the temptation to expose the entire fracture, bone grafting may be unnecessary. It is even reported that grafting is contraindicated if soft tissue dissection is necessary to allow placement of the graft [9,22]. There is apparently no difference between cases grafted and not grafted in terms of the period to union [5,21,23]. We have not used grafts in any of our patients. In conclusion, when all of our patients were evaluated, union had been achieved in 41 (95%) out of 43 patients within a mean period of 4.25 months. There was delayed union in one (2%) patient, non-union in two (5%), infection in three (7%), malunion in three (7%) and movement limitation in seven (16%). When injuries and their fracture types are considered, it can be seen in the literature that multifragmented fractures can be treated by indirect reduction without any major complications. There has been no difference between single and double incisions in terms of infection and the period for union if the indirect reduction methods are meticulously implemented. The implants we used are cheaper and more easily supplied than many others. The success rate is high when the technique is correctly implemented. Therefore, we believe that it is a treatment of choice that can be successfully used in countries at a low socioeconomic level, with no efficient health insurance system and no intraoperative image intensification.
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References [1] Baumgaertal F, Buhl M, Rahn BA. Fracture healing in biological plate osteosynthesis. Injury 1998;29(Suppl 3):C3. [2] Baumgaertel F, Gotzen L. The ‘biological’ plate osteosynthesis in multi-fragment fractures of the para-articular femur. A prospective study. Unfallchirurg 1994;97:78. [3] Blatter G, Janssen M. Treatment of subtrochanteric fractures of the femur: reduction on the traction table and fixation with dynamic condylar screw. Arch Orthop Trauma Surg 1994;113:138. [4] Butt MS, Krikler SJ, Nafia S, Ali MS. Comparison of dynamic hip screw and gamma nail: a prospective, randomized, controlled trial. Injury 1995;26:615. [5] Chrısovitsinos JP, Xenakis T, Papakostides KG, Skaltsoyannis N, Grestas A, Soucacos NP. Bridge plating osteosynthesis of 20 multifragmentary fractures of the femur. Acta Orthop Scan 1997; 68:72. [6] Collinge CA, Sanders RW. Percutaneous plating in the lower extremity. J Am Acad Orthop Surg 2000;8:211. [7] DeLee JC. Fractures and dislocation of the hip. In: Rockwood CA, Green DP, editors. Fractures in adults. Philadelphia: Lippincott Company, 1996. p. 1653. [8] Farouk O, Krettek C, Miclau T, Schandelmaier P, Guy P, Tscherne H. Minimally invasive plate osteosynthesis and vascularity: preliminary results of a cadaverinjection study. Injury 1997;28(Suppl 1):A7. [9] Gerber C, Mast JW, Ganz R. Biological internal fixation of fractures. Arch Orthop Trauma Surg 1990;109:295. [10] Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 1976;58:453. [11] Hardy DCR, Descamps PY, Krallis P, Fabeck L, Smets P, Bertens CL, et al. Use of an intramedullary hip-screw compared with a compression hip-screw with a plate for intertrochanteric femoral fractures. A prospective, randomized study of one hundred patients. J Bone Joint Surg 1998;80-A:618. [12] Johnson EE. Combined direct and indirect reduction of multifragmentary four-part intraarticular t-type fractures of the distal femur. Clin Orthop 1988;231:154. [13] Johnson KD. Internal fixation of distal femoral fractures. AAOS ICL 1987;36:437. [14] Kinast C, Bolhofner BR, Mast JW, Ganz R. Subtrochanteric fractures of the femur. Clin Orthop 1989;238:122. [15] Koval KJ, Swiontowski MF. Intertrochanteric fractures. Orthopedic knowledge update. In: Beaty JH, editor. American academy of orthopaedic surgeons, 1999. p. 448.
699
[16] Krettek C, Schandelmaier P, Miclau T, Bertram R, Holmes W, Tscherne H. Transarticular joint reconstruction and indirect plate osteosynthesis for complex distal supracondylar femoral fractures. Injury 1997;28(Suppl 1):A31. [17] Krettek C, Schandelmaier P, Miclau T, Tscherne H. Minimally invasive percutaneous plate osteosynthesis (MIPPO) using the DCS in proximal and distal femoral fractures. Injury 1997;28(Suppl 1):A20. [18] Moore TJ, Watson T, Green SA, Garland DE, Chandler RW. Complication of surgically treated supracondylar fractures of the femur. J Trauma 1987;27:402. [19] Necmioglu S, Kapukaya A, Kesemenli C. Treatment of femur segmentary multifragmentary fractures by indirect reduction. Acta Orthop Traumatol Turc 1997;31:296 (in Turkish). [20] Ostrum RF, Geel C. Indirect reduction and internal fixation of supracondylar femur fractures without bone graft. J Orthop Trauma 1995;9:278. [21] Perren SM. The concept of biological plating using limited contactdynamic compression plate (LC-DCP). Scientific background, design and application. Injury 1991;22(Suppl 1):1. [22] Rozbruch RS, Müller U, Gautier E, Ganz R. The evolution of femoral shaft plating technique. Clin Orthop 1998;354:195. [23] Schatzker J, Tile M. The rationale of operative fracture care. Berlin: Springer, 1996. [24] Siebenrock KA, Muller U, Ganz R. Indirect reduction with a condylar blade plate for osteosynthesis of subtrochanteric femoral fractures. Injury 1998;29(Suppl 3):7. [25] Subasi M, Kesemenli C, Kapukaya A, Tuzuner T, Necmioglu S, Kirkgoz T. Treatment of femur segmentary fractures by intramedüller nailing. Turkish J Arthrop Arthrosc Surg 2000;11:32 (in Turkish). [26] Subasi M, Kesemenli C, Kapukaya A, Necmioglu S. Treatment of intertrochanteric fractures by external fixation. Acta Orthop Belg 2001;67:468. [27] Thomas WG, Villar RN. Subtrochanteric fractures: Zickel nail or nail-plate? J Bone Joint Surg 1986;68B:255. [28] Waddell JP. Subtrochanteric fractures of the femur: a review of 130 patients. J Trauma 1979;19:582. [29] Wagner HE, Jakob RP. Zur problematik der plattenosteosynthese bei den bikondylaren tibiakkopffarkturen. Unfallchirurgie 1986;89:304. [30] Wenda K, Runkel M, Degreif J, Rudig L. Minimally invasive plate fixation in femoral shaft fractures. Injury 1997;28(Suppl 1):S13. [31] Winquist RA, Hansen ST, Clawson DK. Closed intramedullary nailing of femoral fractures. A report of five hundred twenty cases. J Bone Joint Surg 1984;66A:529. [32] Wiss DA, Brien WW, Becker Jr V. Interlocked nailing for the treatment of femoral fractures due to gunshots wounds. J Bone Joint Surg 1991;73A:598.