International Journal of Science and Research (IJSR)

ISSN: 2319-7064
SJIF (2020): 7.803

A Prospective Study of Functional Outcome of

Locking Compression Plate Fixation Over Dynamic
Condylar Screw Fixation in the Treatment of Distal
Femur Fractures
Dr. Vinoth Kumar1, Dr. Ramesh2
1
M. S., (Ortho), D. Ortho
2
M. S., (Ortho), D. Ortho

Abstract: Aim: To analyse and compare the functional outcome of distal femur fractures treated with Locking Compression Plate
fixation and Dynamic Condylar Screw fixation Materials and Methods: Our study is a prospective study conducted in Department of
orthopedics, Government Dharmapuri Medical College and Hospital, Dharmapuri, Tamil Nadu from July 2015 to January 2021.
Patients admitted with distal femur fractures are selected on the basis of inclusion and exclusion criteria. We have followed Muller
Classification for distal femur fractures, based on which treatment modalities determined. Our study sample size is 25 patients, of which
10 patients were treated with dynamic condylar screw and 15 patients with distal femur locking compression plate. We have used
Extensile Lateral approach to fix the fracture with patient supine with sand bag underneath knee. Fractures treated with either LCP
and DCS followed in standard protocol and evaluated in serial follow up. Functional outcome analyzed using standard scoring system
called Hospital for Special Surgery. Result: In our study Males are more affected with 80% and age group 40 - 50 years more
commonly involved with 28%. Mode of injury Road traffic accidents in 76% patients and 24% in accidental fall.11 patients got
associated injuries. Muller sub type C2, C3 accounts for 40% of patients. Open injuries of type I and II accounts for 20% of all
fractures. Distal femur fractures treated with DCS shows 60% excellent and good outcome and 40% shows fair and poor outcome,
whereas those treated with LCP shows 66.6% excellent and good results and 33.3% fair and poor results. Overall in our study 64%
excellent and good outcome and 36% poor outcome. Muller subtype - A fractures with both LCP and DCS showed similar results
whereas for Muller subtype C, LCP showed very good results when compared to DCS.5 Patients shown complications like superficial
wound infection, deep infection. Conclusion: Fractures of distal femur are more common in high velocity injuries and occur in middle
aged men and old age women. Most fractures were comminuted. Locking compression plate [LCP] appears to be technically an ideal
implant for comminuted distal femoral fractures with proper physiotherapy produced excellent results, whereas extra articular distal
femoral fracture with Type A fractures LCP and DCS shown similar results. However large study group and long follow up needed for
accurate functional outcome.

Keywords: Locking Compression Plate, Dynamic Condylar Screw, Distal Femur Fracture

1. Introduction recognized that operative fixation with the ability to

maintain anatomical reduction of the joint surface, restoring
Fractures affecting the distal femur are very complex axial alignment and early range of motion presents clear
injuries that pose a challenge to every orthopaedic surgeon. advantages over closed means of treatment. Numerous
It involves about 7% of all femur fractures. It commonly devices have been proposed for the treatment of these
occurs during high velocity trauma in younger group of fractures. The principles of internal fixation must be met
patients and frequently are associated with other skeletal regardless of the choice of fixation. These include
injuries and concomitant other system injuries. In contrast to anatomical reduction of the distal femoral articular surface,
this, elderly patients with severe osteopenia might sustain stable internal fixation, minimal soft tissue stripping and
isolated distal femur fractures from trivial trauma such as a early active mobilization.
simple slip and fall. Treating the elderly individuals with
relatively weak bone quality is night mare to surgeons. 2. Aim and Objectives
Though well advanced Technologies and modern diagnostic
imaging modalities versatile implants available in market, The aim of this study is comparing the functional outcome
makes this fractures more amenable to treat satisfactorily. of the Patients who sustained the Distal femoral fractures
Despite all these modalities, treatment of distal femur treated with Locking Compression Plate fixation against
fractures are not without of complications, since most of this Dynamic Condylar Screw fixation.
fractures located very proximity to traversing neurovascular
structures, hence they are more prone for injury to popliteal Study Place: Government Dharmapuri Medical College and
vessels and badly comminuted fragments and bone loss, Hospital, Dharmapuri. Study Design: Both Prospective and
displacement of fragments all these components make this Retrospective
fractures difficult to fixation. Since fractures involving
juxtaarticular location in relation to knee joint, the Study
movement of this joint affected very early and recovery of
the lost knee movement is delayed unless followed good Study Period: July 2015 to July 2021
physiotherapy and gradual mobilization exercises. It is
Volume 10 Issue 11, November 2021
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Licensed Under Creative Commons Attribution CC BY
Paper ID: SR211031220803 DOI: 10.21275/SR211031220803 137
 International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2020): 7.803
Study Sample Size: 25 outcomes were analyzed using scoring system of
HOSPITAL FOR SPECIAL SURGERY.
3. Materials and Methods
Majority of injured patients were males (80%) and Highest
This study pattern is prospective & retrospective study with number of patients were in their 4th decade (28%), Road
study sample of 25 patients with supracondylar and distal traffic accident was the most common mode of injury (76%)
femur fractures treated with either Locking Compression 2 patients had associated distal radius fracture, one patient
Plate fixation or Dynamic Condylar Screw at Government had ipsilateral clavicle and one patient had ipsilateral pubic
Dharmapuri medical college and hospital, Dharmapuri, rami fracture, one patient had ipsilateral tibial condyle and 2
Tamil Nadu from July 2016 to December 2021. Patients patients had ipsilateral tibial shaft fracture making a total of
were selected from among the admissions to the 11 patients (43%) with associated fractures Most of the
Orthopaedic ward in the Department of Orthopaedics, patients, reported within 1st week of injury to the hospital.20
Government Dharmapuri medical college and hospital, out of 25 patients had closed injury. Type C2 and C3 muller
Dharmapuri and recruited into the study prospectively based fracture was the most common fracture type 12 out of 25
on the following criteria. patients (48%). The shortest follow up period was 3 months
and the longest follow up period was 16 months. The
Inclusion Criteria average range of knee flexion achieved was about 0 to 98°.
Maximum gain in knee flexion was 120° and minimum gain
All patients above 18 years with closed fractures of about 60°. The average knee score 76.55% was rated using
supracondylar & distal femur fractures extending up to 15 HSS functional score.
cm from distal articular surface.
Early complications were encountered in 4 patients and
Fractures Include these were superficial wound infection, wound gaping, pin
1) Closed distal femoral fractures & nonunion site infection and mild transfusion reaction. Late
2) Muller type A1 A2 & A3 fractures. complications were observed like mal - union with varus in
3) Muller type C1 C2 &C3 fractures. 3 patients, knee stiffness in 9 patients. The average stay in
4) Presence of distal 3rd femoral fractures which needs to hospital was about 28days.
be internally fixed in displaced Muller’s type A and
Type C fractures
5) Grade I and Grade II compound injuries
6) Patients who give consent to be included in the study.
7) Patient who is preoperatively mobile.

Exclusion Criteria
1) AO type B1 B2 & B3 fractures.
2) Grade III open fractures
3) Pathological fractures
4) Fractures in children with Skeletal immaturity with
open physics.
5) Undisplaced fracture patterns needing only conservative
management.

4. Results and Statistics

In our study, 25 cases of distal femur fracture were operated
Postoperative immobilization with knee brace was advised
with Open Reduction with internal fixation with Dynamic
for severely comminuted fractures, for 3 weeks, although
Condylar screw and Locking compression plate.10 patients
gentle physiotherapy. Exercises were started earlier.
of distal femur fractures operated with DCS and 15 patients
Autogenousipsilateral iliac graft was harvested based on the
were operated with locking compression plate. Patients were
intra operative on table bone loss, there were used in 10 out
followed up every 3 weeks till fracture united and thereafter
of 25 patients. Patients were followed at regular intervals
at 3 months, 5 months and 1 year. The minimum follow up
(i.e., once in a month for the first 3 months and once every 3
period in our study was 3 months and maximum follow up
months thereafter). The minimum follow up period was 3
period was 16 months.
months and the maximum follow up was 12 months. The
mean follow up period in this study was 8.46 months. In our
Clinically, tenderness at fracture site, knee pain, limb length
study Average healing of the fractures was 14.5 weeks. The
discrepancy, range of movements, any varus or valgus
mal-alignment was found in the cases of intra articular
deformity were assessed at each follow up. The results were
fractures. None had a step>2mm or more. The average knee
analyzed with standard anteroposterior and lateral
flexion in our series was 95 degrees ranging from15° - 120
radiographs. Clinical and radiological signs of union were
degrees, the knee flexion varied according to the sub type of
analyzed at each follow up. The fracture was said to be
the fracture. Shortening less than 1cm was recorded in 8
radiologically united if callus was seen in at least 3 cortices
cases and shortening of 2cm and more was recorded in 7
in anteroposterior and lateral views. The functional
cases. All the patients remained painless in the post

Volume 10 Issue 11, November 2021

www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
Paper ID: SR211031220803 DOI: 10.21275/SR211031220803 138
 International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2020): 7.803
operative period, except for 2 cases which had wound 5 patients who shown poor and fair outcome mainly of C3
infection. Functionally all the patients discarded walking aid type with highly comminuted intra articular involvement
by16 weeks and one patient was using heel and sole rise. with knee stiffness and knee pain and varus and valgus
deformity.

5. Discussion
Treatments of the distal femoral fractures have been a
controversial subject over the decade 37, 38, 39. There have
been changing philosophies towards surgical treatment of
supra condylar fractures of femur. Close management of
these fractures was the treatment of choice until 1970. This
was due to non - availability of appropriate implants and
lack of proper techniques. Apart from the usual problems of
confining elderly patient to bed, conservative methods at any
7 patients treated with Dynamic Condylar Screw for type A age may be complicated by knee stiffness, mal union and
Muller fractures showing excellent and good results in 5 nonunion.
patients and poor and bad results in 2 patients. Overall
71.4% for positive and 28.6% of poor results given by DCS, Early surgical stabilization can facilitate care of the soft
in this same category 4 cases treated with Locking tissue, permit early mobility and reduces the complexity of
compression screw fixation, all 4 cases good and excellent nursing care. Open reduction and internal fixation has been
results. As per HSS Scoring system type A Muller fractures advocated, using implants, including angled blade plate,
LCP shows outstanding results when compare to DCS. fickle devices, Rush rods, Ender nails, Dynamic condylar
screw, condylar buttress plate and interlocking nails, locking
2 cases in Type A Muller show poor results, of which one compression plate.
case had post operative wound infection, considered as
superficial wound infection and treated with parentral The use of fixed angle devices such as condylar blade plate
antibiotics. Patients discharged after wound found to be along with dynamic condylar screw (DCS) require certain
silent and healthy. He didn’t come for follow up for first 3 amount of good bone stock should be there to insert Lag
months. After 4th month of follow up presented with infected screw and also its entry makes significant amount of bone
wound and sprouting granulation tissue from the operative loss from lag screw entry site which itself compromise
scar and diagnosed as infected Implant and Wound already fractured condyles hence it limits their use in some
debridement and implant exit done. Fracture found be in fracture type of intra articular fracture. This lead to the
good alignment and sticky he treated with supportive development of condylar buttress plates for comminuted
posterior splint and appropriate antibiotics. Another patient fractures. However with standard buttress plating, these
had varus deformity of the operated limb and FFD of 30 and fractures often fall into varus deformity.
knee stiffness.
Biomechanical studies revealed that gross loosening of
Out of 25 patients 14 had type C Muller fractures of which 3 standard condylar buttress plate and DCS occurred because
patients were treated with DCS and 11 Patients were treated of the toggle at the screw - plate interface, which leads early
with LCP.6 patients out of 11 shown excellent and good implant loosening results in breakage of implant and varus
results and 5 patients shown poor results. /valgus collapse of distal fragment. To address these issues,
a first generation locking condylar plate was designed

A locking plate decreases the screw - plate toggle and

motion at the bone - screw interface and provides more rigid
fixation 6, 7, 8, 9. Rigid fixation is felt to be one key to the
successful treatment of these fractures. The conventional
plates are associated with their own demerits such as screw
pullout, implant failure and unstable fixation needing
postoperative immobilization8.

Delay in postoperative mobilization results in stiffness of the

knee which is an indicator of poor outcome. Fixation in
osteoporotic and comminuted fractures which was difficult
previously was addressed with the invention of locking
3 patients of DCS one patient shown good results and 2
condylar buttress plate. So now with the evolution of
shown poor results
locking compression plating for distal femoral fractures
especially for the comminuted intra – articular fractures
Overall comparative results in concern with type C intra
many of the older demerits could be addressed which
articular fractures treated with LCP and DCS, LCP shown
includes the increased stability due to locking compression
comparatively good functional outcome in 55 % patients and
plating principle, multiple screw options in the distal
DCS shown 33 % good results and 67% poor results. Of the
fragment providing option for fixing the multiple fragments
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Licensed Under Creative Commons Attribution CC BY
Paper ID: SR211031220803 DOI: 10.21275/SR211031220803 139
 International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2020): 7.803
restoring the anatomical congruity and providing stable compression plate [LCP] appears to be technically an
fixation of the distal fragment with the proximal fragment ideal implant for comminuted distal femoral fractures
with resulting increased stability allowing for early with proper physiotherapy produced excellent results.
mobilization.
 Dynamic condylar screw [DCS]appears to be relatively
Current fracture patterns which we encounter are complex easy construct to fix in the distal femur fracture, however
comminuted types due to the prevalence of high speed bulky implant, mandatory of 2 to 4cm Intact femoral
vehicles mainly due to the high two wheeler population in condyle for lag screw insertion and varus collapse of
countries like India. Improved healthcare results in a longer medial fragment in case of comminuted fractures, made
life span and subsequently presents us with more this good implant only for Muller type A, and type B.
osteoporotic fractures which were previously treated using  In Type C comminuted intra articular distal femur
conservative methods. fractures LCP superior to DCS in functional outcome. In
Type A, B fractures both LCP and DCS, produced
The LCP is a single beam construct where the strength of its similar functional results.
fixation is equal to the sum of all screw - bone interfaces  Infection, knee stiffness and mal alignment of fractures
rather than a single screw’s axial stiffness and pullout were the common complication we encountered in our
resistance in unlocked plates30. Its unique biomechanical series in both LCP and DCS, of which comparative
function is based on splinting rather than compression analysis shows relatively higher incidence complications
resulting in flexible stabilization, avoidance of stress found in the DCS, which could be tackled by surgical
shielding and induction of callus formation. It can also be expertise, meticulous soft tissue handling, judicious use
used as biological fixation without disturbing the fracture of antibiotics.
site.  Outcome of patient treated with Distal
 Femur LCP at 10 months follow-up
The Distal Femur - LCP is a further development from the
LISS, which was introduced in the mid to late 1990’ The
main difference between the Distal Femur - LCP and the
LISS is that the LISS utilizes an outrigger device for shaft
holes, functioning essentially as a locking guide jig, which is
attached to the distal part of the plate and guides the
placement of the proximal locking screws. The shaft holes
on the Distal Femur - LCP are oval allowing for the options
of a compression screw or a locking screw. This leads to a
more precise placement of the plate, as it is able to be
compressed more closely to the bone. Although Distal
Femur - LCP is designed to fit the anatomy of the distal
femur, we were worried about the fit in our local Asian
population where shorter and smaller femurs are the norm.
During fixation in delayed cases especially if there was
severe comminution maintaining the reduction in good
alignment and applying the initial screw were difficult. The
average time of union was 15.3 weeks which is similar to
the other modes of fixation and there is no additional benefit Outcome of patient treated with Distal femur LCP at 10
of early healing. However, thus far, our limited numbers months follow-up
demonstrate that this is not an issue.
 In conclusion locking compression plate [LCP] produces
Comparable studies utilizing the Distal femur LCP better results and appears to be a good method of choice
demonstrate only short term results. Although the follow - for management of fractures of distal femur.
up period of our series was short, studies have shown that
 However, Large study sample and long term follow up
early function is comparable to final long term outcome. The
needed for accurate analysis of functional outcome of
outcome seems to correlate with fracture severity, anatomic
this fractures.
reduction, etiology, bone quality, length of time elapsed
from injury to surgery, concomitant injuries and the exact
positioning and fixation of the implant.

Furthermore, the initial severe concomitant cartilage damage

may predispose to early osteoarthritis although there is no
evidence of that yet.

6. Conclusion
 Fractures of distal femur are more common in high
velocity injuries and occur in middle aged men and old
age women. Most fractures were comminuted. Locking
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Paper ID: SR211031220803 DOI: 10.21275/SR211031220803 140
 International Journal of Science and Research (IJSR)
ISSN: 2319-7064
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Paper ID: SR211031220803 DOI: 10.21275/SR211031220803 141