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A Prospective Study On The Functional Outcome Following Open Reduction And Internal Fixation In Supracondylar Intercondylar Fracture Femur

Sudheer U*. Sreejith T.G**, Anwar Marthya***, P.Gopinath****, M.K.Raveendran****.

*Post Graduate trainee
** Lecturer
*** Senior Lecturer
**** Associate Professor 
Department of Orthopedics, Govt. Medical College, Calicut, Kerala, India.

Address for Correspondence:
Dr.Sudheer U 
Post Graduate trainee in Orthopedics
Govt. Medical College
Calicut, Kerala, India.


Introduction: Treatment of Supracondylar intercondylar fractures of the femur was always a challenge to the orthopaedic surgeon because of the poor results obtained with various treatment modalities. Intra articular comminution and lack of post-operative physiotherapy adds to the complexity. Non surgical treatment always results in stiffness due to lack of early mobilisation. In this study we analyse the functional out come of open reduction and rigid internal fixation using various implants and early post-operative rehabilitation in such fractures.
Materials And Methods
: We studied the results of various surgical techniques in 25 patients with supracondylar-intercondylar fracture  of femur over a period of 3 years at our institution from 2003 to 2005. The final outcome is compared with the results available from the latest literature.
: In this study we obtained 68% good or excellent results, which is significantly better than with conservative treatment. We found that, open fractures, articular comminution, infection, lack of rigid internal fixation,and prolonged post operative immobilisation are the major culprits for a poor functional outcome.
:  Early open reduction and internal fixation using AO technique give good results in the hands of experienced surgeon, in patients of any age group, if it is followed by an early active controlled rehabilation programme.

 J.Orthopaedics 2007;4(2)e30


Aim of the present study is to evaluate the results of early open reduction and internal fixation of supracondylar intercondylar fractures of femur done in Calicut Medical college Hospital from 2003 to 2005. Functional results were evaluated with regard to pain, range of motion of knee, limb length discrepancy any persisting deformity, presence and absence of early and late complications etc. Attempts were also made to identify specific causes directly related to the bad results in this series. It is hoped that the results of this study will be of help in more careful selection of patients and implants, and thereby avoiding a large number of complications which are actually the results of inadequate preoperative planning and case selection.

Material and Methods :

For a fracture to be included in this series, part of the fracture line has to extend distal to a horizontal line drawn on the AP roentgenogram 9 cm above the distal articular surface of the femoral condyles. We studied 25 patients presented to our institution from January 1st, 2003   till December 31st 2005 with the above injury. Patient of both sexes above 13 years, Closed and Open fractures, and  Type C fractures were included in the study. Pathological fractures and AO type A & B fractures were excluded.

Initial resuscitation and stabilization of the patients were done.  In terms of the management of open fractures, initial irrigation, debridement, intravenous antibiotic, upper tibial pin traction and delayed wound closures were done routinely. 3 Antibiotics (one for gram positive, one for gram negative an one for anaerobic bacteria) were started and continued till the wounds healed.  From the initial radiographs, all fractures were classified according to ASIF classification.


Skin incision was made through a line connecting greater trochanter to lateral femoral condyle for desired length. Next Interval between the vastus lateralis and anterior border of the lateral intermuscular septum was developed to allow full visualization of the distal part of the femoral shaft.  After analyzing the fragments, temporary reduction was attained with K wire and knee movements were checked. Definitive fixation was done with various implants. Internal fixation devices used were, either dynamic compression screw and side plate, 950 angled blade plate, screws, intramedullary nail or  condylar buttress plate.

Cancellous bone graft was used to fill supracondylar defects at the time of fixation in case of metaphyseal comminution.  Iliac crest was the donor site for cortico-cancellous grafts. The source of the graft was the iliac crest. Post operatively the limb was kept in Bohler Braun splint to prevent contracture of the quadriceps.  After quadriceps and hamstring strengthening exercises, active and active assisted range of motion exercises of the knee were initiated.

On follow up. all patients were assessed using Neer’s Criteria and Knee Society Score for functional outcome. We considered a fracture united if there were no pain on palpation or attempted motion, no increase in warmth at the fracture site, no discomfort on full weight bearing and serial roentgenograms demonstrated bone trabaculae crossing the fracture site.  The functional and radiographic results were recorded according to Neer’s criteria.  Functional grading was made depending on pain, walking capacity, mobility and work.  Radiological grading was made based on varus or valgus deformity, shortening, signs of osteoarthritis and union of fracture.

Discussion :

Fractures in the distal femur have posed considerable therapeutic challenges throughout the history of fracture treatment.27,42,36  .  Most of these surgical failures were due to inadequate fixation of the fracture fragments. (Mize et al 1982).23  The prognostic factors for supracondylar fracture included age, intra-articular involvement, methods of treatment, timing of joint motion, etc (Neer et al 1967; Morre 1987).25,27


The present study does not show a biphasic age distribution of the patient population as is usually seen in studies (Bell et al, 1992).1 This is a reflection of the mechanism of injury which was high energy trauma in 72.13% of patients most of whom were younger.  This correlates well with the high degree of associated trauma seen and with the high incidence of open fracture (39.13%) and intercondylar type fractures (74.2%).


Out of 25 cases, 6 (24%) showed excellent results. All were operated within 5 days of which 4 were treated in the 1st day itself. All except one were <55 years. Younger patients had better result than older age group. These fractures were all of C1 type. In all these excellent type of cases implants used were of different types (DCS,CBP,IMN). Selection of implants were based on the decision of the surgeon during the surgery depending on fracture configuration. There cannot be a rule laid down on this matter. Maximum stability with minimum implants was our aim in choosing the implants.  In all cases of excellent results post operative mobilisation was started within 10 days of surgery.


There were 6 (24%) open fractures. 5 of them were treated with external fixator and 1 with Condylar Buttress Plate (CBP).  One of the five cases treated with external fixator and the one with CBP gave satisfactory results. Of the remaining 4, two cases had unsatisfactory and two had failure results. External configuration of knee was always better with surgery; than treated conservatively. In all satisfactory cases there was no weakness or knee instability. Poor result in 4 patients could be attributed to delay in initiating the prescribed post operative mobilisation protocol, due to various reasons. Our results are comparable with the results of a study conducted by John M, Siliski40 et al, where 40% were open fractures, with 40% good results, and the rest poor. They also had the conclusion that rigid internal fixation is far superior to external fixation even in open fractures


All the cases designated as excellent or good in the overall rating were similar per-operatively. Our per operative results were well correlated.


There were 6 (24%) unsatisfactory and 2(8%) failure cases in this study. In a study by Roby D, Mize and Robert Bucholz 23there were 21% poor results which is comparable with the present study. When these cases are closely analysed, many factors are found to be responsible for the bad results. Major contributing factors are:

(1)   Improper fixation  due to a non anatomical reduction or a non-rigid fixation.

(2)   Gross comminution of fragments which prevented a good reconstruction of distal end of femur.

(3)   Delay in starting active exercises also contributed to the bad results.


Delay in surgery is also a factor in contributing bad results (p value 0.0289). Of the 2 failure cases both were open fractures. One had multiple injuries and the other had initial head injury. Both fractures were fixed only in the 3rd week. In a study by Seinshiemer33 there is a positive correlation between time delay and final outcome. According to them surgery should be conducted preferably within a week.         

According to schatzker, in an analysis of supracondylar inter condylar fracture femur, 74% had better results in type-C.  Thus complete articular fractures had poor results compared to the partial articular and extra-articular fractures.36 

In our study the percentage of excellent and good result comprises 68%. This closely matches with that reported by schatzker36.    

On analyzing the results according to the type of internal fixation used dynamic compression screw and side plate and 950 condylar blade plate had good results.  70% in dynamic compression screw and side plate and 66.6% in 950 condylar blade plate had excellent results. The one case treated with IMN gave excellent result. Robbins and Zickel47 in a study noted excellent results in 30 of 33 cases using IMN and bone grafting. None of the fractures treated by external fixation devices had excellent results.  Out of 5 fractures treated by external fixation device, one had unsatisfactory result and 2 had failure results.  Poor results were mainly because of open fractures. In a study conducted by Michael W and Chapman MD, 49 found that when the bone stock is in adequate the better options are either Dynamic Condylar Srew  or Condylar Buttress Plate.


In this study we had 8 cases of age >55, of which only 1 had excellent result, 2 had satisfactory results and the rest are either unsatisfactory or failure Some studies have shown a less satisfactory outcome in elderly patients with rigid internal fixation, presumably because of poor quality bone stock (Seinsheimer, 1980) 33. 

When a femoral fracture involves the knee or quadriceps mechanism or both, some loss of motion of the knee seems to be inevitable in most patients, whether they are treated non-operatively or by internal fixation.  Acceptable knee flexion following treatment ranges from 650 in one study (Brown et al, 1971) 5 to 1170 in another study (Shelbourne et al, 1982).38  The average post-operative range of motion of 91.30 in our series compares very favourably with these figures (p value 0.0213).  The average range of motion in type-C were 70.590 .  The average range of motion in closed fractures were 98.40 whereas it was only 77.730 in open fractures. In this study, average range of motion in type C was 72 degree and in open fractures it was 58 degrees.  Thus intra-articular fractures lead to intra-articular stiffness, decreased range of motion and poor result and open fractures results in extra-articular stiffness.

In our study male to female ratio is 3:1which is very close to the study by Muller ME,Algower M26

In this study ,we obtained 55%fractures in right side and 45%in left side which closely resembles the results obtained by Neer CS where they got 60% rightside and 40% left side.27

Average age under this studyis47.9 yrs(ranging from 24 to 62). Pritchett JW in their study got an average of 28.5 yrs. This could be because of the inclusion of fractures with epiphysis still open.29

77.5% of the fractures are because of road traffic accidents,15% due to fall from height and the rest 7.5%is due to domestic fall. Most of the studies agree with us(shewring DJ,Silisky JM,Wiss DA)39

In this study C1 includes48%, C2 includes32% and C3 includes20% of the fracture.

Average hospital stay was 15 day which ranges from 10 days to 81 days. Some studies(Stewart MJ)42 states an average of 30 days. In a study by Muller26, average was 20 days, whereas by Neer27 it was 21 days. This disparity is because, most of the cases in our study underwent surgery on the same day or next day itself, whereas in the other study most of the patients had 2weeks of preoperative traction..


The significant morbidity resulting from complications of supracondylar fractures are well documented (Moore et al, 1987)25.  In this study, 2 cases of chronic osteomyelitis and 2 non unions were encountered.  Giles et al14 (1982) with 5 open fractures of 26 had an infection rate of 0%, by Pritchett29 from Arizona reported a 5.2% rate, Pritchett (1984)29 and Mize et al (1982)23 a 6.6% deep infection rate.  In our series, 2 out of 25 fractures (8%) had chronic infection and all 2 were open fractures.  None of the closed fractures treated operatively had chronic infection. Thus the infection rate  is just above current literature values. We use a combination of third generation cephalosporin (cephasolin 1g) and an aminoglycoside (gentamicin 80mg) one hour prior to surgery and 3 days postoperatively. Metronidazole 500 mg added to above regime if fracture is open.


In a study by Roby D, Robert W and Bucholz  post op infection rate was 7%54. In our study we got an infection rate of 8%. Both of these 2 cases presented with open contaminated fractures.


Deformities were more common in non-operative methods of management. In our study angulation >5degrees was reported in none. In a similar study by James B and Giles MD, they have got a similar result in 26 patients53


Nonunion in the distal third of femur is and should be relatively rare for the bone is primarily cancellous and has an excellent vascular supply with good local osteogenic properties.  The incidence of this complication seems to vary according to the method with which the fracture was treated.  In two large series (Neer et al, 1967; Butler et al 1991)27,7 involving both open and closed methods of treatment, there was nonunion in 19 of 315 (6.5%) and 16 of 110 (15%) cases respectively (Conolly et al, 1973)11.  Therefore all forms of treatment have had nonunion as a significant complication.


In our series, there were only 2 cases of delayed union (8%). They were treated by bone grafting.  Non union in non-operative group may be due to distraction of the fracture fragments in skeletal traction.  Traction must be applied carefully and good quadriceps muscle tone must be maintained to prevent distraction.  The length of follow up evaluation is insufficient to allow calculation of the incidence of late degenerative joint disease.


Bone grafting was done in 13 fractures, out of which 6 were of type-C fractures.  Out of 6, primary bone grafting was done in 4 fractures  The remaining 2 bone grafting was done for delayed union  .  Thus, displaced and comminuted type-C fractures required open reduction and rigid internal fixation with bone grafting. According to Michael M and Chapman MD, comminuted articular and metaphyseal fractures give better results with bone grafting49


According to Benum 2, bone cement is not required in osteoporotic or highly comminuted fractures for early posy-operative mobilisation.2 In none of our cases we have done cementing technique.


Thus, analysis of the results of the supracondylar fracture shows that it is a good option to treat displaced fractures (Type-A and C) by operative methods and undisplaced fractures (Type-B) by non-operative methods.


3 of 25 patients in our study had post op pain even after an average follow up of 18 months  other than due to knee stiffness and infection.  Two of them were due to projecting nail tip medially and 1 due to implant failure. In a study by schatzker36 in 78 patients for a follow-up of 10 years implant failure rate was14.6%. In our study it is 4%, difference could be due to shorter follow-up.

By analysig the gait  4 of the 25 patients had short limbed gait.,maximum shortening being 3.5 cm,which was treated with shoe modification. Shortening less than 2 cm were not given any form of treatment.

In our study ,in the early followup period, quadriceps wasting and resultant weakness was present in 20 of 25 patients. This was mainly due to lack of doing quadriceps exercises by the patients because of pain. But in the later follow-up 15 of them regained good power. Those  who had not regain power were  with open fractures

Since  supracondylar inter condylar fractures of femur is associated with high velocity trauma it also has got associated injuries.In our study we had 6 knee instabilities, 3fracture patella, 2 ipsilateral fracture tibia(floating knee), 1 neck of femur fracture  and 1 case of fracture spine(L2). In a similar study by Schartzker and Lambert36  there were 2cases of fracture talus and calcaneum,8 cases of floating knee, 5 cases of central fracture dislocation of ipsilateral hip, 8cases of PCL and medial collateral ligament tear and 3cases of both spine and patella. (out of total 64 cases) . Such a significant number of associated injury could be due to very high velocity trauma occurring in western countries.

Complications of surgery in early stages are never problematic. There was insignificant number of cases with non-union or articular stenosis. Articular stenosis was measured using condylar width index (CWI) which is assessed with a condylar notch view x-ray. In this series follow-up period was of comparatively short duration.

Necessity of early fixation, anatomic and stable reduction with early motion as advocated earlier by Cassebaum56 is once again reiterated through the present study.


Results are generally good in patients of younger age group.Results are good even in elderly with early internal fixation.Preoperative reduction and stability is an important factor in determining the end result.Earlier the surgery, better the results.

No arbitrary rule can be laid down regarding the implants to be used, which depends entirely on the fracture geometry studied at the time of surgery. Hence different types of implants must be available during the surgery.

Comminution of the fracture adversely affects the results.Intra articular communition is not unsuitable for internal fixation. Unstable and incongruent  reduction resulted in poor outcome.Early open reduction with internal fixation can be done in open uncontaminated fractures.AO technique of  fixation offers good compression and adequate stability.

 Surgeon must be well versed in the AO technique and should adhere to the principles throughout fixation. Earlier the mobilisation, earlier the restoration of movement and better is the final outcome.Active mobilisation is the key stone in determining long term functional outcome.

Undisplaced fractures had good results comparing displaced fractures.Displaced fractures with intra-articular extension had bad prognosis, irrespective of the method of treatment adopted.However, incidence of complication was less, when displaced fractures were treated operatively.Open fractures always carry a poor functional outcome

Primary or secondary bone grafting is often necessary with severely comminuted fractures.Rigid internal fixation and early post op rehabilitation are the key factors for a better functional outcome.  Complications like neurovascular injury, non union, traumatic arthritis, significant mal union etc. are rare after ORIF.

Incidence of infection  is more and is a reason  for concern.                                   

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This is a peer reviewed paper 

Please cite as :Sudheer U : A Prospective Study On The Functional Outcome Following Open Reduction And Internal Fixation In Supracondylar Intercondylar Fracture Femur

J.Orthopaedics 2007;4(2)e30





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