Fractures of the distal end of femur especially comminuted and with intra-articular extension remains one of the most challenging fractures faced by orthopaedic surgeons. These are serious injuries having the potential to produce significant long-term disabilities. Distal femoral fractures reportedly account for less than 1% of all fractures and comprise between 4– 6% of all femoral fractures. If fractures of the hip are excluded, 31% of femoral fractures involve the distal portion. There is bimodal distribution of these fractures [1, 2]. Motor vehicle accidents which cause high energy trauma are responsible for these fractures in 8% of cases. In 1960’s Watson, Jones and John Charnley advocated traditional mangement by cast, manupulation of fracture, external immobilisers and skeletal tractions. Complications of conservative management includes stiffness, deformities, malunion and nonunion. In recent years AO blade fixations, dynamic condylar screw plate fixation, intramedullary nailing, locking compression plate have shown good results.so trend of open reduction /closed reduction and fixation has become popular [3, 4].

The aim and objective of this study was to assess and analyze the final result using Neer score when distal femur fractures are treated with locking compression plate and to assess the union rates clinically, radiologically and complications using locking compression plate.

This prospective study was conducted at the department of Orthopaedics, Government Medical College, Jayasankar Bhupalpally, Telangana, India, for a period from July 2024 to March 2025. Informed written consent is taken. All patients who are subjected to Open Reduction and Internal Fixation (ORIF) with locking compression plate fixation are taken in the study. Follow up is carried out at 3 months, 6 month and final assessment at 9 months after surgery. Follow up will include, Clinical examination, Radiological assessment as per Neers scoring system, Functional assessment as per Neers scoring system will be carried out at 3months,6months and final assessment at the end of 9months.

INCLUSION CRITERIA:

1. The fractures of distal femur metaphyseal, metaphysiodiaphyseal with or without intraarticular extension.
2. Open distal femur fracture type I,II and IIIA.
3. Age>18 year.
4. Patient with or without osteoporosis.
5. Patient who were willing to participate in the Study.

EXCLUSION CRITERIA:

1. Fracture in patients of age <18 years and above 60years.
2. Any pathological fracture. (Except due to osteoporosis)
3. Open fractures with type IIIB and C.
4. Patient lost to follow up.

METHODOLOGY:

The following protocol will be observed for patients with distal end of femur on arrival. General and systemic examinations as well as local examination of the patient. Thorough assessment of patient to rule out head/chest/abdominal/spine or pelvis injury Musculoskeletal system examination of patient to rule out associated fractures. Stabilization of patient with iv fluids, oxygen and blood transfusion as when required. Primary immobilization of involved limb in Bohler and Brown splint with a cotton pad below the distal fragment and transport of patient for radiography. Radiological assessment: AP and lateral view of injured limb including complete knee joint, Ipsilateral pelvis.

Table 1: Age wise distribution of cases in the study (n=15)

Table 2: Sex distribution of cases in the Study (n=15)

Table 3: Distribution of side of injury of cases in the study (n=15)

Table 4: Mode of injury of cases in the study (n=15)

Table 5: Type of fracture according to AO classification in the study (n=15)

Table 6: Post-operative Neer Score (Pain component) (n=15)

Table 7: Post-operative Neer score (Walking capacity component) (n=15)

Table 8: Time of radiological union

Table 9: Complications (During follow up period)

Table 10: Type of fracture and outcome

Type A: Extra articular fracture, Type B: partial articular fracture, Type C: intraarticular fracture.

In present study of 15 cases , Majority Type A fractures has good outcome 5 (33%) followed by excellent outcome 2 (13.3%), Where as Type C Fracture also 5 cases (33%) showed good outcome followed by excellent 2 case (13.3%) and fair 1 case (7%).

Fractures of distal end of femur are complex injuries producing long-term disability. These account for 6% of all femur fractures and 31% if hip fractures are excluded. Nearly 50% of distal femur intra articular fractures are open. The mechanism of injury in most cases is axial loading with valgus or varus or with rotational force. These fractures are common among two populations, young patients involved in high energy trauma (road traffic accidents) and older patients, often osteoporotic sustaining low energy fall fractures. Watson and Jones, along with Charnley, supported conventional treatment approaches that included casting, manual fracture reduction, the use of external immobilization. The goals of surgical treatment are anatomical reconstruction of the articular surfaces, reduction of the metaphyseal component of the fracture to the diaphysis, restoration of normal axial alignment, length and rotation, stable internal fixation, early mobilization and functional rehabilitation of limb [8, 9]. Zlowodzki et al., combined the series of 47 patients with fracture distal end of femur and evaluated the outcomes as a part of a systematic literature review and compare the results of different fixation techniques like traditional compression plating, antegrade nailing, retrograde nailing, submuscular locked internal fixation and external fixation. Average nonunion , fixation failure , deep infection and secondary surgical procedure rate were 5.5%,4.9%,2.1%and 16.8% respectively .Some of the technical errors that have been reported for fixation failure have involved waiting too long to bone graft and allows early weight bearing , and placing the plate too anterior on the femoral shaft. The average secondary surgical procedure rate was 16.8% [10, 11].

Max Markmiller et al., [12] prospectively compared the outcomes of LISS and retrograde Intra medullary inter locking nail and conducted a study on 32 patients with 39 distal femoral fractures which were documented prospectively .At 12months, no statistically significant differences were noted for nonunion ,fixation failure , infection and secondary surgical procedures. The LISS offers some advantages compared with distal femoral nail in periprosthetic fracture. Of their study 12 patients injured in a fall at home, the history revealed six periprosthetic fractures. If there is implant insitu, the LISS offers good stabilization of distal femoral fractures.All the patients in their study were treated with the LISS and achieved bony consolidation after the treatment concluded. Anatomic reconstruction and retention of stability in distal femoral fractures is operatively demanding .There is no significant difference in the rate of nonunion between the LISS and distal femoral nail in our patients. The infection rate is diminished with the newer implants [13]. Ehlinger M et al., [14] describing the technique mentioned that to take full advantage of the anatomical design, the epiphyseal part must be placed exactly in the right position with epiphyseal screws placed parallel to the joint line. The lateral cortex of the diaphysis must be parallel to the plate before the locking screws are inserted. A non-locking screw or a traction system in one of the plate’s holes can be used. This fundamental dual parallelism must be observed otherwise there is a risk of inducing non anatomical bone alignment [15].

The following rules must be followed with this technique; extra-articular fracture, minimally-invasive approach, long plate alternating between locking screw and empty holes ( five holes on either side of fracture),bi-cortical screws, placement of locking screws near a complex fracture but away from a simple fracture. Osteoporotic bone, obesity that interferes with the instrumentation, articular fracture, horizontal fracture line and surgeon experience are all limitations of this minimally- invasive technique [16]. Schatzker et al., published a review of the Toronto experience with supracondylar fracture from 1966 to 1972. Out of 100 patients, 68(with 71 fractures) were suitable for analysis.26 patients were males and 42 females. The average age was 54.2 years, the youngest being 16 and the Oldest 89. They noted two peaks of distribution with approximately 25% of patients falling into the second and third decades and over 50% of the patients between their sixtieth and ninetieth years. This study clearly demonstrated the superiority of AO methods not only as a surgical technique but as a method of choice because the Toronto surgeons were not the members of Swiss AO group but still could obtain comparable results with AO principles [17]. Chun-Jui Weng et al., conducted a study on Comparison of supraintercondylar and supracondylar femur fractures treated with condylar buttress plates on 87 patients with supraintercondylar and supracondylar femur fracture from 2004 to 2008 treated with Condylar buttress plate (CBPs) and assessed by using Modified Mize Criteria. Union rate of supraintercondylar fracture was 90% and supracondylar fractures was 91.7%.In supraintercondylar group 16.7% revealed postoperative varus deformity whereas none in supracondylar group. more over treatment with condylar buttress plate in patient with supracondyar fracture led to better functional outcomes than those with supraintercondylar fractures This study was conducted at KIMS Hospital, Narketpally from May 2022 to May 2024 on 15 patients who were treated with Open reduction and internal fixation using Locking compression plating and follow up was at 3months,6months and final assessment at 9 months which include clinical examination, radiological assessment and functional assessment as per Neer scoring system [18, 19]. Locking compression plates being considered to be external fixators placed under the skin envelope, although they are more stable as a result of the shorter distance between the plate and the bone. The biomechanical and biological advantage of locking plate systems, compared with conventional plates, have led to a widespread use of these new implants in recent years. However the effective and successful use of locking plates and of minimally invasive techniques remains highly challenging and is associated with a substantial learning curves mechanically, one should be able to apply the implant in an angular stable mode, maintaining the reduction till union, and offer high primary stability with sufficient flexibility to allow for dynamic osteosynthesis [20].

In the present study the mean age of the patients who sustained fracture lower end of femur was 39.5 years ranging from 18 – 60years. In the study conducted by Ravi M Naik et al., the mean age was 42 years. In a similar study done by Mahesh et al., mean age was 49.6 years. Amit kumar et al., in their study of 35 patients has mean age of 48.5 years. The majority of fractures in the elder age group (5th decade) were caused by trivial trauma, whereas all younger patients (2nd to 4th decade) suffered high velocity trauma as in a car accident. Because of the high frequency of traffic accidents in our study, a greater proportion of cases in this study involved individuals under the age of 50 [21, 22].

In the present study 12 patients had sustained injury due to road traffic accidents and 3 patients had sustained injury due to fall. In a study done by J.-C Bel et al., (n=102) number of patients that sustained injury due to road traffic accidents were 52 and number of patients that sustained injury due to fall were 50. In a similar study conducted by Mahesh D V et al., (n=10) the number of patients that sustained injury due to road traffic accidents were 7 and number of patients that sustained injury due to fall were 3. In the another study done by Sreedhar et al24] (n=30) the number of patients that sustained injury due to road traffic accidents were 21 and the number of patients that sustained injury due to fall were 9. Amit kumar et al., in their study of 35 patients; of which 26 patients had RTA and 9 patients had fall [23, 24].

The results in all the five studies are consistent. Mode of injuries in majority of the fractures is attributed to road traffic accidents which are due high velocity injuries followed by fall from standing height which most commonly occurs in women due to osteoporotic quality of bones in the later part of life i.e, 5th decade and later. In the present study 11 patients were males and 4 patients were females. In study done by Girisha B A et al.,] (n=21) 10 patients were males and 11 patients were females. In a similar study conducted by Sreedhar et al., (n=30) 19 patients were males and 11 patients were females. SKV Gupta et al., in their study of 100 patients; 5 patients had superficial infection and 2 patients developed implant failure. In similar study done by Amit kumar et al., 2 patients has superficial infection, 3 patients has > degrees varus/valgus and 6 patients developed knee stiffness. In the study conducted by Mahesh D V et al., 2 patients shows delayed union [27, 28].  The present study is limited by a small number of cases, which prevents making an accurate overall judgment about the functional outcomes. Additionally, a longer follow-up period is required, and the study lacks a comparison with other treatment modalities.

This study recommends Locking Compression Plate (LCP) as the preferred treatment for managing comminuted distal femur fractures, particularly Type A fractures, where a higher Neer score has been observed. The LCP also helps prevent compression of periosteal vessels. While it may not entirely resolve longstanding issues such as non-union and union, it provides a versatile technique for managing these fractures. With this study we conclude that distal femur fractures treated with locking compression plate is effective has consistent results, good union rates and least complications.

1. Venkatesh Gupta SK, Dande R. Surgical management of fracture of distal end of femur in adults by minimally invasive percutaneous plate osteosynthesis (MIPPO) with locking condylar plate. Int J Orthop Sci. 2015;1(2):7–11.
2. Singh S, Arif M, Gupta A. Functional and radiological outcome of surgical fixation of distal femoral plate in tertiary care hospital in North India. Int J Res Med Sci. 2021;9(11):3411–5.
3. Kumar A, Das SP, Mohanty SN, Saha D, Subramanian A. Functional outcome of OTA type-C distal femur fracture fixed with locking compression plate. Int J Health Clin Res. 2021;4(10):149–52.
4. Zade SS, Sonawane R, Pangavane S, Harkar V, Devasthali K, Chudasama VD. Functional outcomes of intra-articular distal end femur treated with locking compression plate. MVP J Med Sci. 2021;8(2):199–208.
5. Kohli S, Chauhan S, Vishwakarma N, Salgotra K. Functional and radiological outcomes of distal femoral intraarticular fractures treated with locking compression plate. Int J Orthop Sci. 2016;2(4):17–21.
6. Charnley J. The closed treatment of common fractures. 3rd ed. London: Churchill Livingstone; 1972. p. 197–204.
7. Banks HH. The healing of intraarticular fractures. Clin Orthop Relat Res. 1965;40:17–29.
8. Reddy AVK, Srikanth S, Omkarnath G. A clinical study of surgical management of distal femur fracture using locking compression plate. Int J Res Orthop. 2019;5(5):787–91.
9. Schatzker J, Home G, Waddell J. The Toronto experience with supracondylar fracture of the femur. Clin Orthop Relat Res. 1974;6(2):113–28.
10. Markmiller M, Konrad G, Südkamp N. Femur-LISS and distal femoral nail for fixation of distal femoral fractures: Are there differences in outcome and complication? Clin Orthop Relat Res. 2004;426:252–7.
11. Egol KA, Kubiak EN, Fulkerson E, Kummer FJ, Koval KJ. Biomechanics of locked plates and screws. J Orthop Trauma. 2004;18(8):488–93.
12. Zlowodzki M, Bhandari M, Marek DJ, Cole PA, Kregor PJ. Operative treatment of acute distal femur fractures: systematic review of two comparative studies and 45 case series. J Orthop Trauma. 2006;20(5):366–71.
13. Kolmert L, Wulff K. Epidemiology and treatment of distal femoral fractures in adults. Acta Orthop Scand. 1982;53:957–62.
14. Raghu KJ, Anaberu P, Oswal VM. Minimally invasive plate osteosynthesis of lower end femur fractures using locking compression plating: a prospective study. Int J Res Orthop. 2017;3(5):1045–50.
15. Kumar GN, Sharma G, Farooque K, Sharma V, Ratan R, Yadav S, et al. Locking compression plate in distal femoral intra-articular fractures. ISRN Orthop. 2014;2014:1–5.
16. Rathi P, Paknikar KP, Malve SP, Kulakarni GS, Kulakarni MG, Kulakarni SG, et al. Role of locking compression plate in management of metaphyseal fractures in osteoporotic bones: an experimental study from rural Maharashtra. Int J Res Orthop. 2019;5(3):388–92.
17. Ali FA, Karunakaran G, Hameed H. Assessment of efficacy of locking compression plate in distal femur. Int Surg J. 2021;8(9):2590–4.
18. Lal AK, Kaushik SK, Gupta ZU, Agarwal V, Anant S. Evaluation of results of locking compression plate in distal femur fractures. Int J Sci Study. 2018;6(1):42–3.
19. Vikranth PS, Chaitanya V, Vamshi VN. Management of distal femur fractures treated with locking compression plate: a prospective study. Int J Res Orthop. 2019;5(3):478–82.
20. Bhimani R, Bhimani F, Singh P. Functional outcome of distal femur fractures treated with locking compression plate. J Orthop Res Ther. 2016;10(3):1–6.
21. Bachu S, Ramulu L. A study of surgical management of distal femoral fractures in adults using locking compression plate. Int Res Orthop. 2017;3(2):253–6.
22. Weng CJ, Wu CC, Kou FH, Tseng IC, Lee PC, Huang YC. Comparison of supracondylar and supraintercondylar femur fractures treated with condylar buttress plates. BMC Musculoskelet Disord. 2016;17:413.
23. Mahesh DV, Gunnaiah, Vishwanath. Management of distal femur fracture by locking compression plate. Int J Health Sci Res. 2014;4(5):235–40.
24. Sreedhar M, Luther ME, Anudeep B, Prashanth, Swaroopa, Madhav V. Functional and radiological outcome of distal femoral fractures treated with locking compression plate. J Evid Based Med Healthc. 2015;4(38):6664–71.
25. Gawali SR, Kathar MG, Bhosage M, Niravane PV. Management of fractures of distal femur. J Med Thesis. 2015;3(2):31–5.
26. Steward JDM, Hallet JPH, editors. Traction and orthopaedic appliances. New Delhi: B.I. Churchill Livingstone Pvt. Ltd.; 1993. p. 13, 27, 195–7.
27. Link BC, Babst R. Current concepts in fractures of the distal femur. Acta Chir Orthop Traumatol Cech. 2012;79(1):11–20.
28. Borgen D, Sprague BL. Treatment of distal femoral fractures with early weight bearing: a preliminary report. Clin Orthop Relat Res. 1975;111:156–62.