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 Table of Contents  
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 169-175

Radiological and functional outcome of dual plating in distal femur multifragmentary articular fractures: A short term study

Department of Orthopedics, Bangalore Medical College Research Institute, Bengaluru, Karnataka, India

Date of Submission22-Jun-2020
Date of Acceptance02-Sep-2020
Date of Web Publication27-Dec-2021

Correspondence Address:
Dr. Abhishek Patil
Department of Orthopedics, Bangalore Medical College Research Institute, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jotr.jotr_49_20

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Introduction: In this prospective case series, we are reporting a mean 12-month follow up of the utilization of dual plating technique for multi fragmentary articular distal femur fractures. Our technique consists of a lateral distal femoral locked plate and a low profile locked medial plate through a modified anterior (Swashbuckler) approach for the fixation of C2, C3 fractures. Materials and Methods: Fifteen patients (9 males and 6 females) presented with supracondylar femoral fractures type C2/C3, according to Müller long bone classification and its revision, OA/orthopedic trauma association classification. These fractures were treated using dual plating through the swashbuckler approach. They were followed up for clinical and radiological outcomes. Secondary outcomes included postoperative complications. Results: The mean time of radiological union in the studied population was 18 weeks with a range of 14–24 weeks. We did not observe any postoperative varus angulation. 12 out of 14 patients had good to excellent functional outcomes. Fair outcome was reported in only two patients. Conclusion: The technique of Dual plating fixation using modified anterior approach (swashbuckler) for type C2, C3 distal femoral fractures is an efficient method of management. It has several advantages such as precise exposure, easy manipulation, anatomical reduction, and stable fixation. However, surgical indications and principles should be strictly followed. The surgical technique must be perfect, and the biomechanical qualities of the implants must be understood to prevent the development of major complications.

Keywords: Distal femur fractures, dual plating, swasbuckler approach

How to cite this article:
Purushotham V J, Patil A. Radiological and functional outcome of dual plating in distal femur multifragmentary articular fractures: A short term study. J Orthop Traumatol Rehabil 2021;13:169-75

How to cite this URL:
Purushotham V J, Patil A. Radiological and functional outcome of dual plating in distal femur multifragmentary articular fractures: A short term study. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2022 Aug 10];13:169-75. Available from: https://www.jotr.in/text.asp?2021/13/2/169/333565

  Introduction Top

In the modernized world, due to rapid industrialization and road traffic accidents, the incidence of distal femur fractures has increased, which is around 37/100,000-person-years.[1] The distal femur is defined as fractures within 9 cm of the articular surface, the fractures of which account for 6% of all femoral fractures. Distal femur fractures arise from different injury patterns. In the younger age group, injury is often sustained due to road traffic accidents involving high energy trauma leading to compound injuries and comminution of distal femoral condyles and metaphysis. In the elderly, they occur due to low-energy trauma owing to osteoporosis. Restoration of knee joint function in high energy trauma due to comminution of condyles, ligamentous injury, and extensive cartilage injuries is problematic while in elderly patients with osteoporotic bone implant anchorage is difficult.[2]

The conservative management of displaced distal femur fractures was practiced during the early part of the century based on the work of Watson Jones[3] and Charnley.[4] It consists of the application of skeletal traction, fracture reduction through manipulation, application of cast, and cast bracings. Problems such as shortening of the limb, knee stiffness, mal-union, deformity, angulation, nonunion, incongruity of joint, wasting of the quadriceps muscle, instability of knee joint, and secondary osteoarthritis were frequently observed.

Intra-articular fractures of the distal femur are challenging injuries. These require an extensive surgical approach to visualize and reduce the broken articular fragments, particularly in complex fractures. The insult to the periarticular soft tissues caused both by the initial trauma and subsequent surgical approach causes difficulty in early postoperative rehabilitation predisposing to knee stiffness. Frequent complications are malunion, nonunion, stiffness, and secondary osteoarthritis.[5]

In recent years, there is a common consensus among surgeons that supracondylar fracture of the femur has to be surgically treated to achieve good functional outcomes.[6] The various options for operative treatment include blade plate, dynamic compression screw, nonlocking condylar plate, external fixation systems, and submuscular locked internal fixation systems.

At present, the distal femoral articular fractures are mainly fixed by the lateral anatomical locking plate (LCP). LCP acts as a single beam construct whose fixation strength does not depend on axial stiffness/pull out resistance of single screw, rather it is based on the sum of all the screw-bone interfaces. Its biomechanical function is based on the principle of splinting, which leads to the early formation of callus, flexible stabilization, and stress shielding is avoided. It is associated with lower infection rates, reduced resorption of bones, and faster healing rates when applied through minimally invasive technique.

LCP, with its fixed-angle construct, creates a toggle free fixation. In osteoporotic bone, locked screws increase the rigidity of fixation and are particularly helpful in peri-articular or in the presence of small epiphyseal segment in juxta-articular fractures.[7] However, in multi-fragmented intraarticular fractures, the lateral plate alone may not be able to hold the said multi-fragments leading to inadequate unstable fixation and increased risk of varus collapse. Thus, medial and lateral double plating fixation is suggested to tackle the above-said problems. With double plating, the stability of fixation is increased, patients can be mobilized early, leading to decreased incidence of knee stiffness.[8]

The purpose of this study is to evaluate the outcomes of medial and lateral double plating fixation of distal femur intraarticular multifragmentary fracture.

Aims and objectives of the study

  1. To study the union rates with double plating assessed radiologically
  2. Functional outcome by the Knee Society Score (KSS) system
  3. To study the complications in this treatment modality.

  Materials and Methods Top

It is a prospective study done from May 2018 to March 2020. It includes 15 patients of distal femur multifragmentary intraarticular fractures (AO/Orthopaedic Trauma Association [OTA] 33-C2, C3), who were operated with lateral and medial double plating in the Department of orthopedics, Bangalore medical college and Research Institute, Bengaluru.

Out of 15 patients, 11 were male and 4 were female. AO/OTA classification was used to classify the fracture. Road traffic accident was the most common mode of injury, accounting for 90% of the cases.

Inclusion criteria

  1. Distal femur multifragmentary fractures (C2, C3)
  2. Age group 18–75
  3. Patients willing to give informed consent.

Exclusion criteria

  1. Type III open fractures
  2. Pathological fractures
  3. Fracture in a limb with the prosthesis
  4. Ipsilateral long bone fractures
  5. Associated secondary causes of muscle weakness.


Fifteen Patients, after obtaining written informed consent, admitted as in-patients of the Department of Orthopaedics after fulfilling the inclusion criteria were selected. The radiological evaluation includes anteroposterior and lateral X-rays of the femur with knee, along with a pelvic X-ray to rule out proximal femur fractures. Computed tomography scans with three-dimensional reconstruction was done.

Distal femur multifragmentary intra-articular fractures were fixed with a distal femur locking compression plate on the lateral side and a locked medial plate using the swashbuckler approach.

The patients were clinically examined at the time of discharge from the hospital for any malrotation or limb length discrepancy. A limb malrotation <5° and a limb length discrepancy <5 mm is difficult to detect clinically and were considered as normal. A repeat clinical examination was be done at the final fracture healing to note any further change in limb length and rotation.

AP and lateral radiographs of the femur with knee, taken immediately after surgery and were evaluated for fracture alignment, both in the coronal and sagittal planes. Fracture alignment in the coronal plane is measured by the valgus angle between the anatomic axes of the femoral and tibial shafts. A 5°–10° valgus angle was considered as normal as in the KSS. The alignment in the sagittal plane is measured by noting the angulation between the anterior cortices of the proximal and distal fragments. Sagittal plane angulation within 5° of the opposite side was considered normal.

The patients were followed up at every 6 weeks until the bony union was achieved at both the articular and metaphyseal fracture sites, and the subsequent follow-up were done every 3 months till 6 months.

Outcome measures

Clinical outcome

At 6-month follow-up, the KSS is recorded, including the knee and functional subsets. A KSS between 80 and 100 is regarded as excellent, between 70 and 79 is regarded as good, between 60 and 69 is regarded as fair, and <60 is regarded as poor.

Radiological outcome

Callus formation and progression of fracture union. AP and lateral radiographs of the femur with knee were taken at each visit. Union is defined as bridging callus formed in 3 out of 4 cortices.[8]

Surgical approach

All procedures were carried out under combined spinal and epidural anesthesia. With the patient lying supine, knee flexed. A midline anterior knee incision is made. Proximally, the incision angles slightly laterally.

The incision is carried down to the fascia, overlying the quadriceps muscles. This fascia is split in line with the skin incision and lifted off the underlying vastus lateralis muscle belly. Separation of the iliotibial band from the vastus lateralis is carried down to the lateral intermuscular septum, which is confluent with the iliotibial band. The septum is followed to the shaft of the femur. Once the vastus lateralis has been reflected off the lateral intermuscular septum, a retractor placed under the quadriceps muscle is used to expose the femur and to evert the patella medially. The synovium was then incised in line with the capsular incision, and hematoma was washed out. The joint was thoroughly inspected to evaluate the severity of the injury and degree of intra-articular comminution of the femoral condyles. This approach allows direct exposure of both condyles and adequate reduction can be done. Both lateral and medial distal femoral plating can be done through the same incision.

Reduction in small condylar fragments was made with pointed bone reduction clamps. The lateral column reconstructed with bony fragments.

Thereafter preliminary wires fixation and cannulated inter-fragmentary screws of 4 mm were recruited to restore anatomical congruity. Definitive fixation was initiated by countersunk cannulated cancellous 6.5 mm/4 mm screws, followed by applying for a distal femoral locked plate on the lateral side and secured with locked screws through the plate.

A second lateral mini-open incision was used when needed to insert screws in the long plate to fix the proximal locking screws.

The medial column of the distal femur was reconstructed as much as possible and preliminarily secured with K-wires and 4 mm screws, after which locked medial plate was applied to stabilize the medial column.

The closure was done using absorbable sutures after ensuring hemostasis. The skin was closed using staples.

Postoperatively, all patients were immobilized in hinged knee brace for 3 weeks and were advised non-weightbearing ambulation. After 3 weeks, patients were mobilized with gradual progression of knee flexion as tolerated.

Partial weightbearing ambulation was allowed once there was radiographic evidence of callus formation.

Full weightbearing was postponed till radiological union was established.

Statistical analysis

Descriptive and inferential statistical analysis has been carried out in the present study. Results on continuous measurements are presented on mean and standard deviation (Min–Max), and results on categorical measurements are presented in Number (%). Significance is assessed at 5% level of significance. The following assumptions on data are made, Assumptions: (1) Dependent variables should be normally distributed (2) Samples drawn from the population should be random. Cases of the samples should be independent.

Analysis of variance has been used to find the significance of study parameters between three or more groups of patients.

Chi-square/Fisher's Exact test has been used to find the significance of study parameters on categorical scale between two or more groups, Nonparametric setting for qualitative data analysis. Fisher's Exact test used when cell samples are very small.

  Results Top

In this study, 15 patients who met the inclusion criteria were included in the study and were followed up for a minimum period of 6 months (6–19 months, mean 12.43).

One patient was lost for follow-up as the patient died due to cerebrovascular accident 2 months post follow-up.

The age group of maximum number of study participants was between years 40 and 50 years (40%) [Table 1], and the majority were male (60%) [Table 2]. The most common mechanism of injury was motor vehicle accidents (80%) [Table 3]. The majority of participants had open fracture (9 patients, 60%) [Figure 1]. About 67% of them were AO type C3 fractures and 33% were type C2.
Table 1: Age distribution of patients studied

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Table 2: Gender distribution of patients studied

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Table 3: Mode of injury distribution of patients studied

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Figure 1: Open/closed distribution of patients

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All fractures united at a mean of 18 weeks (18 ± 4) [Table 4]. Two patients had residual pain and 2 (14.3%) patients had an extensor lag of 10°. Eleven cases (78%) had knee range of motion (ROM) exercises more than 90° [Table 5] and [Figure 2]. No patients had laxity.
Table 4: Time to union distribution of patients studied

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Table 5: Range of motion - distribution of patients studied

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Figure 2: Range of motion among patients

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KSS calculated by combined KSS1 and KSS2 was excellent for 7 patients (50%), good for 5 patients (36%) and fair in 2 patients (14%) [Table 6] and [Figure 3]. Complications were noted in 3 patients which were Knee stiffness, peri-implant fracture, superficial infection, and delayed union [Table 7]. Preoperative and post operative radiograph with clinical images of one of the cases in our study given in [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9].
Table 6: Knee society score distribution of patients studied

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Table 7: Complications- distribution of patients studied

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Figure 3: outcome among patients

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Figure 4: Pre-operative X-ray and computed tomography images

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Figure 5: Exposure of distal femur before and after reduction

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Figure 6: Immediate post op

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Figure 7: Post operative 1-month follow-up

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Figure 8: Six-month follow-up

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Figure 9: Range of motion at 6 months

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  Discussion Top

In our study, 15 patients were treated with dual plating of the distal femur through modified anterior approach (Swashbuckler). The approach provides adequate exposure of both the condyles and helps in achieving adequate fixation of these complex fractures.

ORIF of complex C2, C3 fractures is technically challenging. The ability to supplement a lateral plate with a medial plate increases the stability and resists deformation analogous to distal humerus fixation The standard fixation used for other types of distal femur fractures is not optimum for anatomic articular surface reduction and in the setting of medial communition, there is high prevalence of fixation loss and varus collapse.[9]

Broadly speaking, the surgical options here are internal fixation or primary replacement. If the knee had been symptomatic, it may be appropriate to perform primary arthroplasty. Because of the position of the fracture, this would likely involve a distal femoral replacement with constrained articulation, such as rotating hinge. However, this will be a major surgery with very little bailout options.[10]

Muller et al. proposed the treatment of low condylar fractures having medial comminution and loss of medial cortex with a lateral plate and medial buttress plate.[9] To enhance fixation in these fractures with poor screw purchase, cement may be used; However, extravasation into the intra-articular surface may occur and which has been reported.[11]

In our study, we report no varus deformities after the operation and 78% showed a good ROM (90°–120°) during follow up. 7 patients (50%) showed excellent outcome and only 2 showing fair outcome.

Although favorable results have been reported using intramedullary nailing of distal femoral fractures,[12] others have shown that the intramedullary nail to be inferior to plate concerning mechanical properties such as stiffness.[13] Surgeons promoting the use of nail claim that rigid internal fixation can yield a high incidence of complications such as delayed union, implant failure, and infection.[14] Furthermore, intramedullary nailing cannot be used for the more severe intraarticular fractures. Distal femoral nailing cannot secure these complex fractures due to the articular comminution and requirement of screws to fix these fragments. Consequently, poor outcome, failure of nailing, and other surgical complications, including instability and mal-reduction in the fragments, are reported in intramedullary nailing.[9]

External fixators with minimal internal fixation have several problems in treating type C femur fractures. These include septic arthritis, pin site infection, and osteomyelitis. Furthermore, inadequate reduction, delayed union or nonunion with the requirement of bone grafting, stiffness, and subsequent need for manipulation under anesthesia have been reported.[15],[16]

Ziran et al. assessed 19 patients with displaced AO type C3 distal femoral fractures. The patients were treated with an anterior approach and double plating. They concluded that dual plating of the distal femur can be fixed using a single anterior approach.[17]

Zhang et al. investigated the clinical efficacy and feasibility of double plating fixation through anterior/middle approach in treating type C3 distal femoral fractures. Among them, there were eight males and 4 females with an average age of 40 years (range 25–55 years). Nine cases injured in motor vehicle accidents and 3 cases by fall. After skin traction for 5–8 days, the surgery was performed by double plating through anterior/middle approach and bone grafting used as well.Four cases got excellent results, 6 good, 1 fair, and 1 poor.[18]

Sanders et al. evaluated 9 patients with compound fracture of the distal femur and a deficient medial cortical buttress. Stable fixation was inadequate with the utilization of the lateral plate alone. Intraoperatively, the authors noted the collapse of distal fragments into varus angulation. A medial plate with bone graft was needed for extra stabilization and it was applied in all cases. The functional results revealed 5 cases with good outcomes and 4 with fair outcomes.[19]

Imam et al. investigated double plating of intraarticular multifragmentary C3type distal femoral fractures through the anterior approach reported mean union time of 6 ± 3.5 months with a range of 3–14 months with a mean follow-up of 11.5 months.[8]

In our study, we have shown better outcomes than other studies, probably due to the inclusion of C2 fractures and exclusion of type 3 open fractures. Dual plating enables more rigid fixation, and hence, the patient can be mobilized early. It also prevents collapse. The addition of another plate adds to the operative time and increase in intraoperative blood loss.

A limitation of this study is the relatively short follow-up period in some of the cases. However, we plan to continue to follow-up this cohort of patients. Another limitation is the relatively small number included in this study, which is mainly because we have excluded multiple trauma patients that required multiple procedures.

  Conclusion Top

Dual plating of complex distal femur articular fracture is a viable option which is safe and efficient and should be in the armament of any surgeon. It has several advantages such as anatomical reduction, rigid fixation, early mobilization, and reduced varus collapse. Nevertheless, proper patient selection, adequate surgical technique, and diligent follow-up of cases will yield a better result. Bigger sample size and longer follow-up period will throw more light on the outcome of this method of treating complex distal femoral fractures.

Financial support and sponsorship


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, 1965-1984. 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):SC55-63.  Back to cited text no. 2
Wilson JN. Fractures and Joint Injuries. 6th ed. Churchill livingstone, edinburgh: Watson Jone's; 1982. p. 1003-70.  Back to cited text no. 3
John C. The Closed Treatment of Common Fractures. 3rd ed. E and S Livingstone, edinburgh,1961. p. 197-204.  Back to cited text no. 4
Agrawal A, Kiyawat V. Complex AO type C3 distal femur fractures: Results after fixation with a lateral locked plate using modified swashbuckler approach. Indian J Orthop 2017;51:18-27.  Back to cited text no. 5
[PUBMED]  [Full text]  
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. 6
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. 7
Imam MA, Torieh A, Matthana A. Double plating of intra-articular multifragmentary C3-type distal femoral fractures through the anterior approach. Eur J Orthop Surg Traumatol 2018;28:121-30.  Back to cited text no. 8
Gwathmey FW Jr., Jones-Quaidoo SM, Kahler D, Hurwitz S, Cui Q. Distal femoral fractures: Current concepts. J Am Acad Orthop Surg 2010;18:597-607.  Back to cited text no. 9
Crist BD, Della Rocca GJ, Murtha YM. Treatment of acute distal femur fractures. Orthopedics 2008;31:681-90.  Back to cited text no. 10
Benum P. The use of bone cement as an adjunct to internal fixation of supracondylar fractures of osteoporotic femurs. Acta Orthop Scand 1977;48:52-6.  Back to cited text no. 11
Tornetta P 3rd, Tiburzi D. Anterograde interlocked nailing of distal femoral fractures after gunshot wounds. J Orthop Trauma 1994;8:220-7.  Back to cited text no. 12
Meyer RW, Plaxton NA, Postak PD, Gilmore A, Froimson MI, Greenwald AS. Mechanical comparison of a distal femoral side plate and a retrograde intramedullary nail. J Orthop Trauma 2000;14:398-404.  Back to cited text no. 13
Della Torre P, Aglietti P, Altissimi M. Results of rigid fixation in 54 supracondylar fractures of the femur. Arch Orthop Trauma Surg 1980;97:177-83.  Back to cited text no. 14
Arazi M, Memik R, Ogün TC, Yel M. Ilizarov external fixation for severely comminuted supracondylar and intercondylar fractures of the distal femur. J Bone Joint Surg Br 2001;83:663-7.  Back to cited text no. 15
Schandelmaier P. Ilizarov external fixation for severely comminuted supracondylar and intercondylar fractures of the distal femur. J Bone Joint Surg Br 2002;84:148-9.  Back to cited text no. 16
Ziran BH, Rohde RH, Wharton AR. Lateral and anterior plating of intra-articular distal femoral fractures treated via an anterior approach. Int Orthop 2002;26:370-3.  Back to cited text no. 17
Zhang ZM, Liu J, Huang CX, Zhao ZF, Wang G, Qin CC. Treatment of type C3 distal femoral fractures with double-plating fixation via anteriormiddle approach. Zhongguo Gu Shang 2012;25:1049-52.  Back to cited text no. 18
Sanders R, Swiontkowski M, Rosen H, Helfet D. Double-plating of comminuted, unstable fractures of the distal part of the femur. J Bone Joint Surg Am 1991;73:341-6.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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