The Foundational And Clinical Study On The Treatment Of The Distal Femoral Fracture

The distal femoral fracture increases along with the rapidallydevelopment of communication and architecture. Commution and unstablefractures often occure as a result of directly voilent injury and are diffcult tocure. These fractures carry high mutilation rate specially to type C distalfemoral fracture which is difficult to treat among the knee joint fracturesalthough the medical treatment constantly increases. Therefore, the treatmentof distal femoral fracture is till a big chanllenge.Distal femur is special in anatomy. Supercondyle of femur refers to thelocation above articular face of distal femur where is the borderline of femoralshaft and metaphysis and with the following characteristics: wider in inter andouter diameters, wider in medullary cavity, decrease in bone mass, thinner inbone cortex and closer to joint.Anatomic axial of femur is 9°estrophy toperpendicular axis with the loading axis 3°estrophy to perpendicular axis andarticular surface parellol to groud thereby these anatomic structures shouldreduce when treated.The distal fractures are divided into abarticular supercodylar fracture andinvolved articular condyle fracture. Because of the complex, malpractis offracture often results in multi-complications. In 1960s, expectant treatmentsuch as traction and gypsum fixation carry better curable effect than openreduction and internal fixation because of no reliable internal fixation. In1966, Stewart et al reviewed 213 patients with supercondyle or condylefractures and the content rate of expectant treatment is 67% compared tocontent rate of opratetive treatment 54%. Disunion and delayed disunion ofexpectant treatment is 9.7% compared to 29% of operative treatment. In 1967,Neer reported 77 distal femoral fracture cases and followed up for more than 1year. Theie study showed that 84% displace fracture ungoing expectant treatment with content outcome, only 5% of operative treatment content with31% malunion, 23% infection and knee rigidity and 14% nonunion.Along with the development of internal fixation and surgery technique,operative treatment become popular and now most surgen hold the view ofopen reduction and internal fixation. Type A1, -2, -3 fractures should be curedapplying retrograde intramedully interlocking nail(RIIN). Type B1, B3fractures fixed only with 2～3 cancellous bone screws and Type B2 fractureswith bolt. Type C1 fracture fixed with dynamic condyle screw, C2, C3 withfemoral condyle supporting plate; C3 or older patients with bone traction.Operation time of distal femoral fracture: Distal femoral fracture is oftensevere. Open injury and assoiated injury is commen. These patients should betreated with early debride and internal fixation which would be easy to thetreatment and nurse of complications. So these patients could take earlyfunctional exercises and prevent complications from long-termimmobilization. Most closed fracture patients also should be treated withinternal fixation after pathogenetic condition stable for 5～7 days. Firm internalfixation can help early functional practice. Anatomic reduction of intraarticularfractures is profit to the stability and functional recovery of article.Problems about bone shaft of distal femoral fracture. Distal femoralfracture is often communicated, severe and with large wounld which oftenaccompany with cancellous cone compression and lose of bone mass so as todirectly effect stability and union of fracture. Internal fixation should be madewith bone shaft to the patients with bone lose. Early internal fixation and boneshaft should be carried to old fracture patients with macro-section bone losefrom which the patients profit stability of fracture, early functional exercisespost operation and union of fracture.Problems about bone shaft of distal femoral fracture. Distal femoralfracture is often communicated, severe and with large wounld which oftenaccompany with cancellous cone compression and lose of bone mass so as todirectly effect stability and union of fracture. Internal fixation should be madewith bone shaft to the patients with bone lose. Early internal fixation and bone shaft should be carried to old fracture patients with macro-section bone losefrom which the patients profit stability of fracture, early functional exercisespost operation and union of fracture.Functional exercise post-operation and distal femoral fracture. Functionalexercise post operation is an important procedure in the treatment of distalfemoral fracture. After operation, the patients with distal femoralcommunication fracture often do not like to exercise because of pain, engorgeand local bandging and so on. If the knee is long-term still, functionaldisturbance of knee joint often occur. Associated animal experiments showedthat arthrodial cartilage in the contacting location occers retrogression afterconstant stillness for 4days. Pathologic test implied that fibrosis take place incartilage and prechondrocytes were replaced by eocollagenoblast. Otherstudies show that movement has the function of friction and squeeze in turn,and maintaining a supply of articular cartilage nutrition which is particularlyimportant, and it will promote the repair of articular cartilage surface damageto the connective tissue conversion making it more joint physiological state;and long-term brake also lead to joint vein and lymph back sluggish, and theslurry tissue fibers exudation and fibrin deposition, then the fibrousadhesions, coupled with the capsule, the muscles and ligaments of thejoints, tendon contracture, a serious impact on the joints function, resultingin dysfunction of the knee joint. Therefore, the systematic and standardizedrehabilitation treatment appears to be particularly important, it wouldfacilitate the restoration of joint function in patients and it is of greatsignificance in improving the walking ability and activities of daily living.Since the brake can cause long-term joint adhesion, stiffness and othersymptoms of pain, so should intervene as soon as possible after rehabilitationtherapy is beneficial to the prevention of dysfunction joint activities topromote functional recovery. The time to begin rehabilitation has greatimpact on patients efficacy. One month after fracture rehabilitation therapy isthe best time to intervene, patients usually had a good prognosis aftertreatment, the basic function of the knee can be fully restored; but four months after the fracture intervention and rehabilitation of patients, mostlypoor efficacy, most patients can resume part of the knee function. CPMtraining after knee surgery can significantly improve fracture dysfunction,CPM movement scope should be gradual, increasing the number of activitiesby small and gradual, flexible joints of patients until a near-normal angle.accelerate the restoration process; CPM training while also promot localblood circulation and relieve muscle and joint capsule, ligament contracture,and eliminate swelling of the joints and surrounding tissues, and promotecartilage repair to prevent adhesion, to maintain and improve the range ofmotion with a certain role. O'Driscoll et al. through radioactive marked RBCconfirmed that CPM training can accelerate intra-articular joints andsurrounding tissue positive blood, the fluid absorption process, and inhibitfurther swelling of the soft tissue around joints. Therefore, the use of CPMtraining must be in the early postoperative period. Furthermore, CPMtraining can reduce postoperative pain, postoperative decrease in the amountof pain drugs. Coutt's study showed that CPM training accelerate the lowerlimb venous blood flow velocity, and lower the incidence of venousthrombosislimb following knee in the lower part of the. Distal femoralfractures lead easily to obstacles adhesion with the impediment of themovement of the knee, due to a serious knee injury, coupled with surgicaltrauma, large hemorrhage.Dealing immediately with ice treatment after rehabilitation therapy willeffectively reduce the amount of bleeding and prevent the adhesion ofmyositis ossificans and knee channels, So the knee joint dysfunction degreewill lead to reduced adhesion. Firmly fixed on the distal femur fractures afterearly intervention and rehabilitation (including CPM training, strengthtraining, local ice treatment), it will not only effectively reducepost-operative pain and swelling, but also promote healing of wounds andfractures, and reduce knee stiffness and adhesion to maximize the recoveryof knee function, after rehabilitation therapy for early intervention is veryimportant, further enhancing efficacy and improving motor function in patients is of great significance.In recent years, many authors have done some researches on thebiomechanical properties of these fixation. Biomechanical report variousdifferent results. Li Qiang-Yi reported that the use of adult male body femur,produced C1 kind sample by the AO classification of supracondylar fracture,specimens were fixed to produce three types of test samples randomly: GSHGroup, L-shaped plate fixation, compression plate fixation group, showedthe smallest contingency load GSH Group, condylar displacement axialcompression load and displacement of the smallest separation. UltimateStrength tests show: GSH group was damaged on averaged 6100N, femerwas splitted when L-shaped on average 5230N, showing GSH biomechanicalproperties is of great superiority. Zhi-Jun Lai selected 12-femoral specimen onfresh frozen, caused human femur fractures artificially, then were randomlydivided into two groups: retrograde femoral intramedullary nailing group,dynamic condylar screw fixation, internal fixation of samples for testing. Theresults show that: the anti compression, bending, anti-reverse ability ofdynamic condylar screw is stronger than that of reverse nail. Femur retrogradeintramedullary nail in the biomechanical properties is far less than dynamiccondylar screw. However, the device in closed reduction surgery can performfracture fixation of fracture, healing faster, less bleeding, and thebiological fracture fixation requirements can be achieved.The bio-mechanical tests by Leung showed that steel is stronger thanintramedullary nailing. Juha use synthetic femur to produce by the AOclassification A3 supracondylar fracture specimens. Test specimens wererandomly divided into two groups: condylar buttress plate fixation (95°angled blade plate. ABP). dynamic condylar plate (95°condylar side plateand screw. DCS) for seven biomechanics: axial compression and flexion,flexor, compressed medial, lateral compression, internal rotation,external rotation experiment. The results showed: DCS Group is smaller thanABP group in the average maximum load displacement axial compressionload than; and fatigue experiments indicate: the two implants were no lasting deformation and relaxation. Michael Zlowodzki et al. chose femur ofold fresh frozen men corpses to produce by AO classification A3supracondylar fractures, which were randomly grouped to six groups,each with 8 specimen. LISS fixed versus buttress plate fixation group (95°angled blade plate. ABP); LISS fixed versus retrograde intramedullary nailfixation of the femoral fixation, which were subjected to axial compression,spin, cycle axial experiments. The results showed: axial compression. LISSis 34% stronger than 95°angle plate (95°angled blade plate ABP); 32%weak in rotation. LISS is 13% stronger than retrograde intramedullary nail inaxial compression, 45% less in axial compression. And they concluded that:Three fixed rotation can provide adequate stability under axial compressionand can provide sufficient fixation of the past. LISS distal fixation can beimproved, especially the bones of osteoporosis. Robert W use 11 pairs offresh frozen bodies of old men femur, according to AO classificationproducing A3 supracondylar fracture specimens, using the side of the femurfracture with retrograde intramedullary nail fixation, contralateral femoralcondyle using force plate (95°condylar side plate and screw DCS). Theresults showed: retrograde intramedullary nail in the vertical stability is 14%worse than that of DCS%, 17% poor rotation. It came to a conclusion thatDCS fixation is fixed if the stability of fixation is emphasized. Two fixed werefixed in the axial failure.David et al. use fresh frozen corpses of 12 femoral specimens, whichwere randomly divided into four groups: femur retrograde intramedullary nailfixation, dynamic condylar plate (95°condylar side plate and screw. DCS).Screw focus groups were further divided into groups and dispersed groups.The results showed: DCS screws scattered is strongest in rotation;Retrograde intramedullary nail fixation compared with DCS group, axialload can absorb more energy. And dynamic condylar fracture with retrogradeintramedullary nail fixation of supracondylar fracture of the femurbiomechanical testing axial compressive strength and torsional strengthshowed no difference differences. And they concluded: the choice of internal fixation to fracture of the distal femur, we should not depend on the severityof fracture. If the choice is DCS, screws should be decentralized so that itcan provide relatively strong compared with retrograde intramedullary nail ina fixed rotation, which have the same stability in axial compression. If thechoice is retrograde intramedullary nail, screw should be concentrated socompared with retrograde intramedullary nails and screws scattered with DCSgroup, bearing in axial load is able to absorb more energy. Firoozbakhsh et al.[8] showed: the retrograde intramedullary nail is weaker than DCS in valgusstress, lateral bending and axial rotation. However, these authors believethat these are non-physiological stress, and arrived at this conclusion: if thephysical stress, for exapmple inverted, and there may be no differencewithin the state flexor.The subject do a series of researches on fracture of the distal femur,from the distal femur bone and the surrounding anatomy, biomechanics andother aspects with an in-depth study, and we design and develop its ownclosed reduction of fracture of the femur with invasive arthroscopic guideinvasive surgical instruments supporting femur nail, which results inminimally invasive treatment of a distal femoral fracture, and postoperativerehabilitation as a result of the research, greatly improving the efficacy.Part oneThree methods of distal femoral fracture fixation was studied inbiomechanicalObjective: To investigate the biomechanical properties of the threecommonly used methods of the distal femoral fracture of: femur fixationnails, dynamic condylar screw (DCS), femoral fixation support, and makea comparision of these methods in biomechanical, and to explore from themechanics, providing a reliable theoretical basis and experiments forinternal fixation.Methods: Selecting six pairs (with 12) of male adult anticorrosionfemurs, then were divided randomly to three groups, each with four. All ofthem were made supracondylar fractures, namely AO: 33-A3 fractures. Supracondylar femoral nails, the dynamic condylar (DCS), femoral fixationsupport for the axial, flexion, flexor, foreign flexor compression wereused, and comparision of the various methods.Results: DCS,condylar buttress plate fixation and retrogradeintramedullary nail specimens housed in the biomechanical test machine wereused on flexion, flexor, outside, past and the vertical stress, the stressof 100N, 200N, 300N, 400N, 500N, 600N and 700N, were recorded inthe stress of displacement. The results showed that when the specimens wereimposed on the vertical stress, the retrograde intramedullary nail samplesbegan to displace when stress is over 400N, with a smaller displacement thanother groups in the same stress. DCS and condylar plate groups have thesame proximity under the same stress. But the displacement of condylar plategroup is larger than that of DCS group. Stress in flexion, DCS Groupdisplacement is larger than the other two groups. The displacement ofretrograde intrame of dullary nails than condy is far than plate group 500Nbelow, and under 600N and 700N condylar plate displacement groupbegan more than retrograde intramedullary nails; After winning thefollowing stress in the 500N and below, condylar plate displacement issignificantly less than the other two groups. When bigger than 500N, thedisplacement increased significantly than the other two groups. Stress within,the displacement of retrograde intramedullary nail was significantly smallerthan the other two groups; Foreign flexor stress, displacement is larger thanthe other two major condylar plate.Conclusion: 1, The retrograde intramedullary nail samples under a fixedflexion, outside, past and the vertical stress was stronger than the other twogroups; 2, DCS Group flexion stress the role of the resistance wassignificantly weaker than the other two groups 3. condylar plate external stresswas significantly weaker than the other two groups, 500N below theresistance of flexion is stronger than the other two. Part twoThe curative effect of closed reduction by self-designed tractor andarthroscopic for retrograde intramedully interlocking nail(RIIN) for femoralsupracndylar fractureObjective: The curative effect of closed reduction by self-designedtractor and arthroscopic for retrograde intramedullary interlocking nails in thetreatment of femoral supracondylar fracture.Methods: A total of 60 patients with femoral fractures underwent eitherclosed arthroscopic (n=30) or open surgeries(n=30).Results: The operation time, surgical blood loss and bone union time inclosed arthroscopic groups was less than that in the open surgerygroup. (p＜0.05). Folow-up of the patients revealed excellent results in 24cases, good 11 cases,, and fair5 cases, poor 0 in the arthoscopic group,according to the Kolmert criteria, while excellent in 14 cases, good 16 cases,and fair 6 cases, poor 4 in the open surgery group, without statisticallysignificances in the rate of excellent or good outcomes between the twogroups.Conclusion: Compared with open surgery RIIN shortens the operationtime, incision length, reduces intraoperative blood loss and accelerats boneunion, thus benefiting the recovery of knee joint functions.Part threeRehabilitation of knee joint function after the treatment of closed arthroscopicsurgerys for retrograde intramedully interlocking nail double-plating fixationto femoral supracondylar fractureObjective: To investigate curative effect of femoral supracondylarfracture by early rehabilitation training after operation.Methods: A total of 80 patients with femoral supracondylar fracture andtreated by closed arthroscopic surgerys for retrograde intramedullyinterlocking nail(RIIN) were reviewed, in that, 40 patients were treated byearly regular rehabilitation, and others were not.Results: The average duration of follow-up was 11 months (rang from 7months to 18 months). According to the Kolmert score standard, The rate ofexcellent or good outcomes is 87.5% in early regular rehabilitation group, theother group is only 65.0%. the result of the rehabilitation training group wasmuch better than that of the non-rehabilitation training group(p＜0.05).Conclusion: The treatment of with femoral supracondylar fracturefemoral fractures and treated by closed arthroscopic surgerys for retrogradeintramedully interlocking nail(RIIN) is stable. After early rehabilitationtraining., the function of knee joint is expecting well.Part fourTreatment of Double-Plating to Serious Comminuted Fracture of DistalPart of the FemurObjective: To explore treatment of double-plating to comminutedserious fracture of distal part of the femur.Methods: From March 2003 to June 2005. The cases of 60 patients whohad a complex fracture of the distal part of the femur and deficentmedial-cortical buttress were reviewed. According to AO classification: 11cases belonged to type C2.3, 9 cases belonged to type C3.3.Stable fixationwas not achieved with the lateral condylar buttress plate alone. Collapse of thefragment into varus angulation was noted intraoperatively. Additionalstabilization with a medial plate and a bone graft from the iliac crest wasapplied in all 60 patients.Results: At an average duration of follow-up of 14 months(rang 12-24months), all fractures had healed. Evaluation of the functional outcomerevealed 25 excellent, 19 good, 9 fair, poor 7.Conclusion: Treatment of double-plating to comminuted fracture ofdistal part of the femur is satisfactory. Part fiveRehabilitation of knee joint function after the treatment of double-platingfixation to serious comminuted fracture of distal part of the femurObjective: To investigate the effect of comminuted serious fracture ofdistal femur by early rehabilitation training after operation.Methods: 60 patients who had a complex fracture of the distal femur andtreated by double-plating fixation were reviewed, in that, 30 patients weretreated by early regular rehabilitation, and others were not.Results: The average duration of follow-up was 14 months (rang from 12months to 18 months). According to the Kolmert score standard, the result ofthe rehabilitation training group was much better than that of thenon-rehabilitation training group(p＜0.001).Conclusion: The treatment of comminuted serious fracture of distalfemur with double-plating fixation is stable. After early rehabilitationtraining., the function of knee joint is expecting well.