Exploration And Application Of The New Anterolateral Approach Of The Distal Femur Guided By The Modern Concept Of Orthopaedic Rehabilitation

Research backround and objectiveDistal femoral fractures is a common fracture. Due to its special anatomical morphology, close to the knee joint, relatively complex fracture morphology and lack of proper internal fixation instruments, the treatment of distal femoral fracture is difficult and prone to malunion and anchylosis of knee. Distal femoral fractures suggest active surgical treatment. Open reduction and internal fixation is common treatment for distal femoral fracture. But the conventional lateral approach damages the iliotibial band and its surgical exposure is inadequate. The conventional anterolateral approach damages vastus intermedius seriously. So there is no ideal surgical approach for the distal femoral fracture at the moment. Rehabilitation medicine is an emerging discipline with growing attention and rapid development at home and abroad in recent years. It is based on the dysfunction of the treatment object, throughout the whole process of the orthopaedic disease treatment. With the modern orthopaedic rehabilitation theory,the ideal approach for the distal femoral fractures, especially for type C fractures, should meet three conditions.First of all is to expose fully; the second is to minimize tissue damage as soon as possible; again is to facilitate early postoperative functional exercise and rehabilitation.Therefore, this study intends to explore more ideal surgical approach for the distal femoral fractures. Guided by the modern concept of orthopaedic rehabilitation,the study designs the new anterolateral approach of the distal femur on the basis of the anatomic structure of the thigh and the knee combined with clinical experience.The new anterolateral approach of the distal femur is "S" type.The approach incises along the spatium intermusculare between the vastus lateralis and rectus femoris.At deep layer,the approach incises the lateral margin of the distal segment of vastus intermedius along the fiber direction to the pavilion of quadriceps femoris and curved downward to cut open the lateral retinaculum and knee joint capsule to expose the distal femur and the joint surface fully.The study also includes related anatomical study and clinical control study. Content and methods1.Anatomical study of the new anterolateral approach of the distal femur.With formalin preservative adult lower limb specimens of6cases, male in4cases, female in2cases, the study designed the new anterolateral approach of the distal femur and observed the soft tissue structures including common peroneal nerve, popliteal artery and blood vessels around the patellar.2. Prospective studies for the treatment of distal femoral fractures with the new anterolateral approach of the distal femurIn January2010to June2012,60patients with distal femoral fractures in our hospital were randomly divided into new anterolateral approach group and conventional approach group.The study record operation time, blood loss in operation, number of intraoperative fluoroscopy, length of hospital stay, complications and blood creatine kinase and c-reactive protein at preoperative1hour, postoperative6hours, postoperative12hours, postoperative24hours.3. Retrospective study for the treatment of distal femoral fractures with the new anterolateral approach of the distal femurIn July2007to December2009,58patients with distal femoral fractures in our hospital divided into new anterolateral approach group and conventional approach group. The operation time, intraoperative blood loss, number of intraoperative fluoroscopy. length of hospital stay and HSS score of knee were record.Results1.Anatomical study of the new anterolateral approach of the distal femur.(1) With the new anterolateral approach of the distal femur,the damage of the vastus lateralis and rectus femoris is small, and the injury of the vastus intermedius is reduced as far as possible. The pavilion of quadriceps femoris and the lateral retinaculum are An arc incision with small tension.(2) This approach does not damage the popliteal artery and common peroneal nerve, but lateral superior genicular artery across the approach; (3) With the new anterolateral approach of the distal femur, the patella can be turned inward and the distal femur and the joint surface are exposed fully.2.Prospective studies for the treatment of distal femoral fractures with the new anterolateral approach of the distal femur(1) The operation time, blood loss in operation, number of intraoperative fluoroscopy of new anterolateral approach group were significant less than conventional approach group, the differences were significant statistically (P<0.05).The differences of the length of hospital stay and complications in the two groups were not significant statistically (P>0.05);(2) The differences of c-reactive protein levels at each postoperative time point compared with preoperative time point in new anterolateral approach group and conventional approach group were significant statistically (P<0.05).The differences of c-reactive protein levels at each time point after surgery between the two groups are not significant statistically (P>0.05). The differences of creatine kinase levels at each postoperative time point compared with preoperative time point in new anterolateral approach group and conventional approach group were significant statistically (P<0.05). The creatine kinase level at each time point after surgery in the new anterolateral approach group were less than that in conventional approach group, and the differences were significant statistically (P<0.05).3.Retrospective study for the treatment of distal femoral fractures with the new anterolateral approach of the distal femur(1) The operation time and the number of intraoperative fluoroscopy of new anterolateral approach group were significant less than conventional approach group, the differences were significant statistically (P<0.05).But the Intraoperative blood loss and the length of hospital stay compared with no statistical significance between the two groups(P>0.05).(2) The knee HSS score of patients at the last follow-up of the new approach group was94.4±4.2, and the knee HSS score of patients of the conventional approach group was89.2±6.0.The difference between the two groups was significant statistically (P<0.05). ConclusionWith the new anterolateral approach of the distal femur guided by the modern concept of orthopaedic rehabilitation,the damage of the vastus lateralis and rectus femoris is small, and the injury of the vastus intermedius is reduced as far as possible. The exposure of distal femoral fractures is sufficient for the operation. The pavilion of quadriceps femoris and the lateral retinaculum are an arc incision with small tension and facilitate early postoperative functional rehabilitation so as to enhance the recovery of knee joint.