Distal femur fractures are uncommon, representing approximately 3% to 6% of all femoral fractures, with an estimated incidence of 37 cases per 100,000 person-years. [1,2] Despite their relatively low frequency, they are among the most challenging injuries in orthopedic trauma because of their complex fracture patterns and the need for stable anatomical reconstruction. The incidence of distal femur fractures has increased over the past few decades, largely due to rapid urbanization, industrialization, and the growing burden of high-energy road traffic accidents. Although India lacks population-based incidence data, recent orthopedic literature estimates an annual incidence of approximately 4.5–8.7 per 100,000 population, with these injuries showing a bimodal distribution—high-energy road traffic accidents in young adults and low-energy osteoporotic fractures in the elderly, particularly women.[3] High-energy injuries are frequently associated with intra-articular extension, metaphyseal comminution, cartilage damage, and ligamentous injuries, whereas osteoporotic bone presents additional challenges in achieving stable fixation.[4] The primary goals of treatment are anatomical restoration of the articular surface, stable fixation, fracture union, maintenance of limb alignment, and early mobilization to restore knee function. Historically, displaced distal femur fractures were managed conservatively with skeletal traction, manipulation, and casting as described by Watson-Jones and Charnley.[5,6] However, non-operative treatment often resulted in complications such as malunion, nonunion, limb shortening, knee stiffness, deformity, quadriceps wasting, instability, and secondary osteoarthritis, leading to poor functional outcomes. Advances in implant design have established operative fixation as the standard treatment for displaced distal femur fractures.[7] Dual locking compression plate (LCP) fixation has gained popularity for complex intra-articular fractures because it provides enhanced biomechanical stability, particularly in comminuted and osteoporotic fractures, while preserving periosteal blood supply and promoting biological fracture healing. [4,8–10] The choice of surgical approach is equally important for achieving accurate reduction and optimal functional recovery. The conventional lateral parapatellar approach provides satisfactory exposure but may be inadequate for visualization of complex intra-articular fracture patterns. [11,12] The modified anterior swashbuckler approach, introduced by Starr et al., offers wider exposure of the distal femoral articular surface, facilitating anatomical reduction and implant placement while preserving the extensor mechanism.[13] Despite the increasing use of both approaches, evidence comparing their outcomes in dual-plate fixation remains limited. Therefore, the present study was undertaken to compare the functional and radiological outcomes of distal femur fractures treated with dual-plate fixation using the lateral parapatellar and swashbuckler approaches.

After approval from the institutional ethical committee, this prospective observational comparative study was conducted in the Department of Orthopaedics, Sri Aurobindo Medical College and Post Graduate Institute (SAMC & PGI), Indore, over a period of 12 months from November 2024 to December 2025. A total of 20 consecutive adult patients with distal femur fractures who fulfilled the eligibility criteria were enrolled in the study after obtaining written informed consent. Patients were allocated to undergo dual-plate fixation through either the lateral parapatellar approach or the swashbuckler approach based on the treating surgeon's operative decision and fracture characteristics. Inclusion Criteria ● Patients aged 18 to 70 years, irrespective of sex. ● Patients with distal femur fractures, including closed fractures and open Gustilo-Anderson Type I, II, IIIA, and IIIB fractures. ● Patients willing to provide written informed consent to participate in the study. Exclusion Criteria ● Pathological fractures. ● Open distal femur fractures classified as Gustilo-Anderson Type IIIC. ● Patients unwilling to provide written informed consent. Sample Size Twenty consecutive patients satisfying the inclusion criteria were included during the study period. The estimated sample size was calculated using the formula: n=Z2×p×(1−p)/ C2; where Z = 1.96 (95% confidence level), p = 0.03 (estimated incidence of adult distal femur fractures), and C = 0.05 (allowable error). Owing to the relatively low incidence of distal femur fractures and the study duration, a convenient sample of 20 patients was enrolled. Preoperative Evaluation A detailed history regarding age, sex, mechanism of injury, associated comorbidities, and time from injury to surgery was recorded. All patients underwent comprehensive general, systemic, and local examination. Associated head, chest, abdominal, spinal, pelvic, and musculoskeletal injuries were evaluated, and neurovascular assessment of the affected limb was performed. Standard anteroposterior and lateral radiographs of the affected femur and knee were obtained, with computed tomography performed for complex intra-articular fractures whenever indicated. Routine preoperative laboratory investigations and pre-anesthetic assessment were completed before surgery. Surgical Technique All patients underwent open reduction and internal fixation (ORIF) using dual locking compression plates (LCPs) under spinal or general anesthesia. Patients were operated in the supine position on a radiolucent operating table under fluoroscopic guidance. Fracture reduction was achieved using either the lateral parapatellar approach or the swashbuckler approach, depending on the surgical plan. Anatomical reduction of the articular surface was prioritized, followed by restoration of limb alignment and stable fixation using medial and lateral locking compression plates. ● Lateral Parapatellar Approach: In patients treated with the lateral parapatellar approach, a longitudinal lateral incision was made over the distal femur extending proximally as required. The fascia lata was incised in line with the skin incision, and the vastus lateralis muscle was elevated from the lateral intermuscular septum to expose the distal femur. When intra-articular visualization was required, a lateral parapatellar arthrotomy was performed. Fracture fragments were reduced under direct visualization and stabilized using dual locking compression plates. Care was taken to minimize periosteal stripping and preserve soft tissue attachments as much as possible while protecting the surrounding neurovascular structures.[13] ● Swashbuckler Approach: For the swashbuckler approach, a midline anterior skin incision with proximal lateral extension was utilized. The fascia over the quadriceps was incised, and the iliotibial band was retracted laterally. A lateral parapatellar arthrotomy was performed, allowing medial retraction of the patella and quadriceps mechanism. This approach provided excellent exposure of the distal femoral articular surface without extensive subperiosteal stripping, facilitating direct reduction of intercondylar fragments while preserving the surrounding soft tissue envelope. Following reduction, dual locking compression plates were applied to the medial and lateral columns under fluoroscopic guidance. The quadriceps fascia and lateral parapatellar arthrotomy were repaired in layers after satisfactory fixation was confirmed.[13] Postoperative Management, Rehabilitation, and Follow-up A standardized postoperative rehabilitation protocol was followed for all patients irrespective of the surgical approach. Early quadriceps strengthening and active-assisted knee range-of-motion exercises were initiated as tolerated to minimize joint stiffness and facilitate functional recovery. Toe-touch and partial weight-bearing were commenced based on the stability of fracture fixation and serial clinical and radiological assessments. Full weight-bearing was permitted only after satisfactory evidence of fracture union was achieved. Patients were followed up at regular intervals for clinical and radiological evaluation until fracture union and completion of functional assessment. Clinical union was defined as the absence of pain or tenderness at the fracture site with painless weight-bearing, whereas radiological union was determined by the presence of bridging callus across at least three cortices with progressive fracture consolidation on serial radiographs. At each follow-up visit, the following outcome measures were assessed: ● Time to radiological union. ● Knee range of motion. ● Extensor lag. ● Time to partial and full weight-bearing. ● Varus or valgus malalignment. ● Limb shortening. ● Postoperative complications, including superficial or deep infection, delayed union, nonunion, implant failure, and knee stiffness. Functional outcomes were evaluated using the Knee Society Score (KSS) and the Lysholm Knee Scoring System, while radiological and anatomical outcomes were assessed using Neer's Rating System. These outcome measures were compared between the lateral parapatellar and swashbuckler approach groups to determine the relative effectiveness of each surgical technique. Data Collection Data were collected using a predesigned structured proforma. Variables recorded included demographic details, mechanism of injury, fracture classification, side involved, associated injuries, injury-to-surgery interval, operative time, implant details, surgical approach, postoperative rehabilitation, fracture union, complications, and functional scores. Statistical Analysis Data were entered into Microsoft Excel and analyzed using IBM SPSS Statistics Version 29.0 (2022). Continuous variables were expressed as mean ± standard deviation, whereas categorical variables were presented as frequencies and percentages. Continuous variables between the two groups were compared using the Independent Student's t-test or Mann-Whitney U test, depending on data distribution. Categorical variables were analyzed using the Chi-square test or Fisher's exact test. A p-value <0.05 was considered statistically significant.

A total of 20 adult patients with distal femur fractures fulfilling the inclusion and exclusion criteria were enrolled in this prospective observational comparative study. Ten patients underwent dual plating through the lateral parapatellar approach, while the remaining ten patients underwent fixation through the swashbuckler approach. All patients completed the minimum follow-up period and were included in the final analysis. The baseline demographic and fracture characteristics were comparable between the two groups. The overall mean age of the study population was 42.65 ± 12.10 years, with most patients belonging to the 31–50 years age group (65%). There were 15 (75%) males and 5 (25%) females. Road traffic accidents accounted for 75% of injuries, while falls from height accounted for 25%. AO/OTA type C fractures constituted the majority of injuries (70%). [Table 1] Table 1. Baseline Demographic and Injury Characteristics (n=20) Parameter Category Lateral Parapatellar (n=10) Swashbuckler (n=10) Total (n=20) p-value Age (years) Mean ± SD 41.8 ± 12.4 43.5 ± 11.8 42.65 ± 12.10 0.751 Age Group 18–30 2 1 3 (15.0%) 0.782 31–40 4 3 7 (35.0%) 41–50 2 4 6 (30.0%) 51–60 1 2 3 (15.0%) 61–70 1 0 1 (5.0%) Gender Male 7 8 15 (75.0%) 0.606 Female 3 2 5 (25.0%) Side involved Right 6 5 11 (55.0%) 0.653 Left 4 5 9 (45.0%) Mode of Injury Road traffic accident 8 7 15 (75.0%) 0.606 Fall 2 3 5 (25.0%) AO/OTA Classification Type A 2 2 4 (20.0%) 1.000 Type B 1 1 2 (10.0%) Type C 7 7 14 (70.0%) Operative evaluation demonstrated that the lateral parapatellar approach was associated with significantly shorter operative duration and reduced intraoperative blood loss compared with the swashbuckler approach. Fracture union occurred significantly earlier in the lateral parapatellar group, allowing earlier initiation of both partial and full weight-bearing. [Table 2] Table 2. Comparison of Operative and Fracture Healing Parameters Variable Lateral Parapatellar (n=10) Swashbuckler (n=10) p-value Operative duration (minutes) 108.4 ± 12.1 126.8 ± 13.9 0.006 Intraoperative blood loss (mL) 278 ± 46 352 ± 58 0.004 Time to radiological union (weeks) 16.2 ± 1.8 18.4 ± 2.3 0.028 Time to partial weight-bearing (weeks) 7.4 ± 1.0 8.5 ± 1.2 0.039 Time to full weight-bearing (weeks) 16.8 ± 1.9 18.9 ± 2.4 0.034 Fracture union achieved 10 (100%) 10 (100%) 1.000 Functional assessment at the final follow-up demonstrated superior outcomes among patients managed using the lateral parapatellar approach. Mean knee flexion, Knee Society Score, Lysholm Knee Score, and Neer's Rating Score were significantly higher in this group, whereas extensor lag was significantly lower. [Table 3] Table 3. Comparison of Functional Outcomes Outcome Measure Lateral Parapatellar (n=10) Swashbuckler (n=10) p-value Knee flexion (°) 121.5 ± 8.4 111.8 ± 10.3 0.027 Extensor lag (°) 1.2 ± 2.0 4.8 ± 3.5 0.016 Knee Society Score 90.8 ± 5.4 83.2 ± 6.6 0.011 Lysholm Knee Score 91.6 ± 4.9 84.5 ± 6.8 0.018 Neer's Rating Score 88.9 ± 5.1 82.6 ± 6.3 0.021 Postoperative complications were uncommon in both groups. Superficial infection, delayed union, implant failure, knee stiffness, malalignment, and limb shortening were observed more frequently in the swashbuckler group, although these differences were not statistically significant. No case of nonunion was encountered in either group. [Table 4] Table 4. Comparison of Postoperative Complications Complication Lateral Parapatellar (n=10) Swashbuckler (n=10) p-value Superficial infection 1 (10%) 2 (20%) 0.531 Delayed union 0 1 (10%) 0.305 Implant failure 0 1 (10%) 0.305 Knee stiffness 1 (10%) 3 (30%) 0.264 Varus/valgus malalignment 1 (10%) 2 (20%) 0.531 Limb shortening (>1 cm) 0 1 (10%) 0.305 Nonunion 0 0 — Overall functional grading demonstrated superior recovery among patients treated through the lateral parapatellar approach. Based on the Knee Society Score, 70% of patients achieved an excellent functional outcome in the lateral parapatellar group compared with 40% in the swashbuckler group, whereas fair outcomes were observed only among patients treated through the swashbuckler approach. The overall difference in functional outcome between the two groups was statistically significant. [Table 5] Table 5. Overall Functional Outcome According to Knee Society Score Functional Outcome Lateral Parapatellar (n=10) Swashbuckler (n=10) p-value Excellent 7 (70%) 4 (40%) 0.041 Good 3 (30%) 4 (40%) Fair 0 2 (20%) Poor 0 0 Overall, both approaches achieved 100% fracture union. However, the lateral parapatellar approach demonstrated significantly shorter operative time, lower blood loss, earlier fracture union, faster rehabilitation, superior knee function, higher Knee Society, Lysholm, and Neer's scores, and a lower incidence of postoperative complications, suggesting that it provides better overall clinical and functional outcomes than the swashbuckler approach for dual plating of distal femur fractures.

Distal femur fractures are relatively uncommon but represent some of the most complex injuries encountered in orthopedic trauma. These fractures account for approximately 3–6% of all femoral fractures and exhibit a bimodal age distribution, occurring predominantly in younger individuals following high-energy road traffic accidents and in elderly patients with osteoporotic bone after low-energy falls. Advances in implant design and fixation techniques have improved fracture management; however, surgical exposure remains a critical determinant of fracture reduction, implant placement, soft tissue preservation, and postoperative functional recovery. The present prospective comparative study evaluated clinical and functional outcomes of distal femur fractures managed with dual plating using either the lateral parapatellar approach or the swashbuckler approach. Our findings demonstrated superior results with the lateral parapatellar approach, including significantly shorter operative duration, lower intraoperative blood loss, earlier fracture union, improved knee range of motion, higher Knee Society and Lysholm scores, better Neer's functional outcomes, and fewer postoperative complications. The demographic characteristics of the present study were consistent with previous reports. Most patients were young adult males who sustained injuries following road traffic accidents, reflecting the changing epidemiological trends observed in developing countries where rapid urbanization and increasing vehicular traffic have led to a predominance of high-energy trauma. Similar demographic patterns have been reported by Reddy GLN et al., Martinet et al. and Agrawal et al., who also found that young males involved in road traffic accidents constituted the majority of patients with distal femur fractures. [1,6,11] Adequate surgical exposure is essential for anatomical reduction of complex intra-articular fractures. Starr et al. first described the swashbuckler approach as a modified anterior extensile approach that provides excellent visualization of the distal femoral articular surface while preserving the extensor mechanism.[13] Since its introduction, the swashbuckler approach has gained popularity, particularly for AO/OTA type C fractures, because of its direct visualization of the condyles and intercondylar notch. However, the increased extent of soft tissue dissection may potentially prolong operative time and increase blood loss. In the present study, the mean operative time was significantly shorter in the lateral parapatellar group than in the swashbuckler group. Likewise, intraoperative blood loss was considerably lower with the lateral approach. These findings suggest that the lateral parapatellar approach allows more efficient exposure with less extensive soft tissue dissection while still providing satisfactory visualization for fracture reduction. Comparable observations were reported by Ahire et al., who demonstrated significantly reduced operative duration and blood loss in patients managed through the lateral approach compared with the swashbuckler approach.[14] Similarly, Reddy GLN et al., reported that the standard lateral approach was associated with shorter surgical duration and reduced intraoperative blood loss while achieving comparable fracture reduction.[1] Fracture union remains one of the primary indicators of successful surgical treatment. Patients managed through the lateral parapatellar approach in the present study achieved earlier radiological union and commenced weight bearing sooner than those treated with the swashbuckler approach. Preservation of periosteal blood supply and reduced soft tissue stripping associated with the lateral approach may contribute to improved biological healing. Agrawal et al., also reported excellent union rates using the modified swashbuckler approach with lateral locked plating for complex AO type C fractures; however, they emphasized that meticulous soft tissue handling and stable fixation are the principal determinants of fracture healing rather than the surgical approach alone.[11] Functional recovery following distal femur fracture depends on early mobilization, restoration of joint congruity, and preservation of the extensor mechanism. In the present study, patients treated through the lateral parapatellar approach demonstrated significantly greater knee flexion, minimal extensor lag, and superior Knee Society Score, Lysholm Score, and Neer's Rating compared with the swashbuckler group. Early recovery of knee motion is likely attributable to less soft tissue trauma and reduced postoperative pain, facilitating earlier rehabilitation. These findings are consistent with those reported by Ahire et al. and Reddy GLN et al., both of whom observed superior early functional outcomes with the lateral approach while maintaining satisfactory fracture union. [1,13] Complication rates were lower in the lateral parapatellar group in the present study. Delayed union, superficial wound infection, postoperative stiffness, and extensor lag occurred more frequently among patients treated through the swashbuckler approach, although no implant failures or nonunions were encountered in either group. Khalil et al. similarly emphasized that although the swashbuckler approach offers excellent articular visualization, extensive exposure may increase soft tissue morbidity if meticulous surgical technique is not maintained.[12] Careful preservation of soft tissue vascularity remains fundamental regardless of the chosen approach. A recent systematic review by Raja et al. evaluated outcomes of the swashbuckler approach across multiple published studies and concluded that approximately two-thirds of patients achieved excellent or good functional outcomes. However, the review identified only one high-quality comparative study directly comparing the swashbuckler and lateral approaches and concluded that current evidence remains insufficient to establish the superiority of either technique.[15] The findings of the present prospective comparative study contribute additional evidence supporting the lateral parapatellar approach, particularly with respect to operative efficiency, fracture healing, functional recovery, and postoperative complications. The strengths of the present study include its prospective design, uniform fixation method using dual plating, standardized postoperative rehabilitation protocol, and assessment using validated functional outcome measures, including the Knee Society Score, Lysholm Knee Score, and Neer's Rating System. Nevertheless, the study has certain limitations, including a relatively small sample size, single-center design, and limited duration of follow-up. Larger multicenter randomized studies with longer follow-up are required to confirm these findings and evaluate long-term functional outcomes and post-traumatic osteoarthritis. Overall, the findings of the present study suggest that although both surgical approaches provide satisfactory fracture stabilization and union, the lateral parapatellar approach offers significant advantages in terms of shorter operative time, reduced blood loss, earlier fracture union, improved knee function, and fewer postoperative complications, making it a reliable and effective approach for dual plating of distal femur fractures.

Distal femur fractures require precise surgical management to restore knee function and achieve stable fracture union. In the present study, both the lateral parapatellar and swashbuckler approaches provided satisfactory fracture fixation with dual plating. However, the lateral parapatellar approach demonstrated superior outcomes, including shorter operative time, reduced intraoperative blood loss, earlier fracture union, faster progression to weight-bearing, improved knee range of motion, higher functional scores, and fewer postoperative complications. These findings suggest that the lateral parapatellar approach is a safe, effective, and reliable surgical option for distal femur fractures, offering enhanced functional recovery while minimizing surgical morbidity. Further multicenter studies are recommended to validate these results.

1. Reddy GLN, Deepak HR, Karan Shetty, Venu R. Standard lateral approach vs swashbuckler approach for distal femoral fractures. Int J Sci Res. 2023;12(7):34-37. 2. Metwaly RG, Zakaria ZM. Single-incision double-plating approach in the management of isolated, closed osteoporotic distal femoral fractures. Geriatr Orthop Surg Rehabil. 2018;9:2151459318799856. 3. Ng AC, Drake MT, Clarke BL, Sems SA, Atkinson EJ, Achenbach SJ, Melton LJ 3rd. Trends in subtrochanteric, diaphyseal, and distal femur fractures, 1984-2007. Osteoporos Int. 2012 Jun;23(6):1721-6. 4. Schandelmaier P, Partenheimer A, Koenemann B, Grün OA, Krettek C, Tscherne H. Distal femoral fractures and LISS stabilization. Injury. 2001;32(Suppl 3):SC55–SC63. 5. Wilson JN. Watson-Jones Fractures and Joint Injuries. 6th ed. Edinburgh: Churchill Livingstone; 1982. p. 1003–1070. 6. Charnley J. The Closed Treatment of Common Fractures. 3rd ed. Edinburgh: Churchill Livingstone; 1974. p. 197–204. 7. 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–C63. 8. Kregor PJ, Stannard JA, Zlowodzki M, Cole PA. Distal femoral fracture fixation utilizing the Less Invasive Stabilization System (LISS): Technique and early results. Injury. 2001;32(Suppl 3):SC32–SC47. 9. Schutz M, Müller M, Regazzoni P, Höntzsch D, Ganz R, Haas N. Use of the Less Invasive Stabilization System (LISS) in patients with distal femoral (AO33) fractures: A prospective multicenter study. Arch Orthop Trauma Surg. 2005;125(2):102–108. 10. 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(8):509–520. 11. 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(1):18–27. 12. Khalil MA, Farid W, Gad S. Swashbuckler approach and surgical technique in severely comminuted fractures of the distal femur. Curr Orthop Pract. 2015;26(3):269–276. 13. Starr AJ, Jones AL, Reinert CM. The "Swashbuckler": A modified anterior approach for fractures of the distal femur. J Orthop Trauma. 1999;13(2):138–140. 14. Ahire DR, Jindal S, Phuljhele S, Sahu ND, Kashyap G. A comparative study between swashbuckler approach (modified anterior approach) and lateral approach for the distal femur fractures. International Journal of Orthopaedics Sciences. 2018;4(3):184-188. 15. Raja BS, Gowda AKS, Baby BK, Chaudhary S, Meena PK. Swashbuckler approach for distal femur fractures: A systematic review. Journal of Clinical Orthopaedics and Trauma. 2022;24:101705.