Date: Wed, 17 May 2000 19:01:15 +0100

From: chris wilson

Subject: supracondylar femoral fracture in elderly

Can I get the views of list members on their chosen ways of managing low supracondylar femoral fractures in the elderly osteoporotic(usually) female patient? We have found these a real problem, and in the 8 over 70's we've had this year, have found the bone quality to be such that the fractures are unfixable, by nail or plate.Previous attempts at conservative management of this type of fracture were similarly disastrous.Newer devices from the AO group are being used in the USA but still rely on the bone being of a certain quality. I've begun to think in terms of treating them with stemmed , semiconstained or constrained TKA. Any views or experience?

Kind Regards,

Chris Wilson, Consultant Trauma and Orthopaedic Surgeon, University Hospital Cardiff

Date: Wed, 17 May 2000 16:05:11 -0400

From: William Obremsky

I would agree that a retograde IMNB does not work well in this patient population especially if the fx is low. We have been using a blade plate w/ decent results. The blade has to be pefectly parallel to the joint or they have too much valgus. I have been more cautious in early ROM as I have had one begin to pull off the bone, but healed by holding ROM. A TKA is an option as salvage if blade fails. We have had one t-intercondylar fx completely collapse into the lateral conyle and needs to be revised. These are tough problems that we are just beginning to see the problems.

Bill Obremskey MD MPH, University of North Carolina

Date: Thu, 18 May 2000 12:55:15 -0500

From: Adam Starr

Chris,

I don't have any personal experience with the technique, but some of the total joint surgeons in our town report good results with immediate total knee replacement. In some cases, a constrained knee is used. Other cases require a large "tumor" prosthesis with an intramedullary stem.

I've had plenty of experience with the crummy bone that won't hold screws. I agree that it is a difficult problem.

I'll see if I can find any literature on TKR for distal femur fracture.

Adam Starr, Dallas, Texas

Date: Thu, 18 May 2000 13:26:33 -0500

From: Steven Rabin

I would fix them. In very osteoporotic and medically fragile patients I still use the occassional Zickel Rods because they can be done very quickly with very little blood loss and essentially percutaneously and they act as a nice internal splint for early mobilization (accepting that there will be some varus deformity and shortening)........In the osteoporotic and medically healthy elderly patients, I do ORIF with indirect reduction techniques as much as possible with either DCS, or blade, or condylar buttress plate depending on the fracture configuration and supplement with cement. I think the LISS plate system will be an excellent option as it becomes more available because it will allow plating with less soft tissue damage. I think total knee replacement is a lot more difficult in these patients acutely due to lack of stable bone to anchor the prosthesis and technical difficulties in determining the alignment, so i wouldn't do immediate replacement. (perhaps because i am primarily a trauma surgeon so i do have a bias toward fixing instead of replacing.) Many times these patients do fairly well even if the final alignment is not perfect.

Date: Thu, 18 May 2000 23:22:42 -0400

From: Bill Burman

Chris

In the mid 80's we started a small series of Zickel supracondylar devices applied to osteoporotic supracondylar fractures at Peterborough, Cambs, UK. Glyn Pryor, who succeeded me there, reported them in Injury 1988 Nov;19(6):410-4

The modification of the Zickel technique used follows.

Bill Burman, MD, HWB Foundation, www.hwbf.org

-----------------------------------

We modified the Zickel technique in the following ways:

• 1) With the fracture reduced over a translucent knee bolster on a radiolucent or fracture table, the implants were introduced percutaneously just above the joint line medially and laterally. Since these were generally low energy injuries we could reduce most of them closed. Intracondylar components were provisionally fixed with percutaneous wires.
• 2) If the channels for the implants could not be easily and gently made with a Kuntscher awl, they were developed with reamers over a bulb tip guide wire.
• 3) The implants were interlocked with a nutted single long 4.5 mm screw (like a Barr bolt) which went from the distal locking hole on one device to the other. A knee ligament jig guided precise drilling. This kept the implants from backing out.
• 4) Small "snowshoe" 3-4 hole plates (a la Anoch Lewert who used the Modny nail for supracondylar fxs) could be used on either end of the 4.5 screw to prevent the implants from sinking into the soft bone with intercondylar compression secondary to nut tightening.
• 5) A percutaneous medial-lateral diaphyseal blocking screw could be placed just above the proximal tip of the implants to prevent shortening.
• 6) An anteroposterior diaphyseal blocking screw could be placed along side the implant blades to prevent rotation.
  

Date: Tue, 23 May 2000 06:48:15 +0530

From: dr. navin thakkar

dear dr chris,

i have experience to treat such fractures in elderly , i get resonably good results with enders nails passed from tip of greater trochanter to medulary canal of lat condyle and medial condyle - two in each condyle gives good stability for early mobilisation

dr navin thakkar m.s. (ortho), ahmedabad, gujarat india

Date: Tue, 23 May 2000 09:43:09 -0500

From: Naftaly Attias,MD

Dear Dr Navin Thakkar

What do you consider to be reasonably good result?

Naftaly attias, MD Trauma Fellow, Houston

Date: Tue, 23 May 2000 10:33:30 -0500

From: Steven Rabin

this wasn't addressed to me, but i think the definition of reasonably good result is defined by the patient and their pre-fracture activity level, and medical condition. In the fragile sedentary patient a good result is painless mobility without infection or pulmonary or other compllication. In such patients who may be limited ambulators pre-fracture, the goal is optimal nursing care and shortening or malalignment is acceptable if it avoids a prolonged operation with significant risks. In the active alert but elderly patient, then a good result is the same as with any other patient. It is worth taking more surgical risks to achieve an anatomic reduction of the joint and good mechanical alignment of the bone without shortening. Be flexible and choose the surgery that fits the patient.