Early Results with the PERI-LOC Plate for Distal Femoral and Proximal Tibial Fractures

Khan AD, Casserly HB.

Department of Trauma & Orthopaedics,
Warrington Hospital,United Kingdom.

Address for Correspondence:
Khan AD
Department of Trauma & Orthopaedics,
Warrington Hospital,
Lovely Lane,
Warrington, Liverpool  WA5 1QG (United Kingdom).

Abstract:

Purpose: To report our early experience with PERI-LOC plate fixation for Distal Femoral and Proximal Tibial Fractures. The study reports on (1) the time to callus formation and radiographic union (2) range of knee motion, (3) the complications and (4) the comparison with early results of LISS plate fixation.
Methods: We retrospectively reviewed the results with PERII-LOC plate (Smith & Nephew Inc) for 11 distal femoral (all closed) and 4 proximal tibial fractures (1 open) between January 2006 and May 2009. The mean follow up was 11 months (Range 6 – 22 months).
Results: In Distal Femoral Fractures, the time to callus formation was 6.5 weeks (Range 5 – 11) and radiographic union 14 weeks (Range 10 – 22 months). The range of motion (knee) was 110 degrees (Range 65 – 135) and the loss of extension 10 degrees (Range 0 – 15).  Two minor complications, one plate irritation, one superficial wound ooze was observed. In Proximal Tibial Fractures, the average time to callus formation was 6 weeks           ( Range 5 – 7 ) and to radiographic union  12 weeks( Range 11 -13 ). The average range of motion (knee) was 115degrees (Range 105 - 125) and the average lack of extension was 10 degrees (Range 5 – 15). There were 2 complications, both plate irritations.
Conclusion: Our study shows that the early results with the PERI-LOC plate for distal femoral and proximal tibial fractures are comparable to that of the LISS plate. We feel that further studies are needed to prove the long term role of the PERI-LOC plates.

J.Orthopaedics 2010;7(2)e12

Keywords:

Distal Femoral Fractures; Proximal Tibial Fractures; Less invasive stabilisation system (LISS), PERI-Loc plates; Minimal invasive surgery; internal fixation.

Introduction:

The management of Distal Femoral and Tibial Plateau Fractures has evolved during the past decade from non-operative treatment to relatively rigid internal fixation ^{(2,5,9,17,19,24)}. The aim is to achieve rapid bony union and allow early mobilisation of the knee joint minimising the risks of joint stiffness. Several implants have been developed to achieve these goals with varying results ^{(34, 35)} Early techniques of   Osteosynthesis emphasized anatomic reduction and rigid fixation. Surgical approaches were often extensive and added to the soft tissue damage already present ^{(11,16,39,40)}  Recently, the optimisation of fracture environment has been the focus of treatment in order to improve fracture healing and to minimise complications. The concept of Indirect Reduction and Minimally Invasive Plate Osteosynthesis (MIPO) has evolved, illustrating the importance of preservation of bone biology ^{(12, 22, 24).} Modern fracture fixation techniques encourage the use of implants which can be inserted with minimal soft tissue dissection, thus preserving bone and soft tissue vascularity. These implants have been designed with sound biomechanical properties allowing early mobilisation and promoting healing before implant failure ^(15).

This study reviews our initial experience with the PERI-LOC plate for the treatment of distal femoral and proximal tibial fractures.

Materials and Methods:

Between January 2006 and May 2009, 15 consecutive patients with 11 distal femoral and 4 proximal tibial fractures had PERI-LOC plates inserted. Criteria for inclusion in the study were: all distal femoral and proximal tibial fractures treated with PERI-LOC plate. All notes and radiographs were retrospectively reviewed independently. Patients were followed up at 1, 2, 6 weeks, 3 months, 6 months and thereafter depending on the clinical and radiological progress. Union was defined as full weight bearing without pain and radiological callus in two planes at right angles to each other. The mean follow up was for 11 months, Tibial Fractures 8 – 14 months, Femoral Fractures 6---22 months.

Surgical technique:    Tibia /Femur

All closed fractures had a closed technique using the PERI-LOC Jig. A limited surgical approach through a curved incision was performed. The Deep Fascia was opened and sub muscular plane developed with a cobb elevator .The articular portion of the was reduced, temporary stabilised with k wires and Cannulated Screws inserted. The plates were inserted sub muscularly and checked with using biplanar Image Intensification. All the patients routinely received 3 doses of IV antibiotics (Cefuroxime) at induction followed by 2 doses postoperatively. CPM was commenced immediately. They were non weight bearing for 2 weeks, Toe-touch bearing for 4 to 6 weeks and full weight bearing depending on the progress of the fracture healing.

Results :

Fig 1. Demographic Details

Fig 2   Mobility Pre and Post Surgery

Fig 3   Results of Healing

Distal Femoral Fractures 11 cases

The time to callus formation was 6.5 weeks (Range 5 – 11).  The time to radiographic union was 3.5 months ( Range 2.5 – 5.5 months ). The range of motion at last clinic review was 110 degrees ( Range 65 – 135) and the lack of extension was 10 degrees ( Range  0 – 15). There were 2 minor complications in this group. One patient developed “Plate Irritation” One patient developed a wound discharge. Both settled with time. No plate was removed.

Proximal Tibial Fractue 4 Cases 

Time to callus formation was 6 weeks (Range 5 – 7).  Time to radiographic union was 12 weeks (Range 11 -13). The range of motion at last clinic review was 115 degrees (Range 105 - 125) and the lack of extension was 10 degrees (Range 5 – 15). 2 patients complained Plate Irritation and one plate was removed after 6.5 months. The other case has not had the plate removed yet.

Discussion :

Treatment Methods for Distal Femoral and Proximal Tibial fracture have undergone a major change in the last few years ^{(1,2,5,6,9,10,11,13,17,19,30,31,38)}. External fixation with limited joint line internal fixation is the norm. With the recent development of locking plates more internal fixation has been advocated with a minimal invasive approach (MIPPO). Kruttek et al took this concept further by emphasising the need to obtain relative rather than absolute stability of the fracture. He also suggested minimal interference with the zone of the injury which was achieved by sliding plates in the sub-muscular plane on the lateral side of the femur (minimally invasive percutaneous plate osteosynthesis MIPPO). ^{(4,8,12,18,22,25)} Mast et al first reported the importance of reduced surgical dissection of the fracture site and utilised the surrounding soft tissues for fracture reduction ^(24). He termed this indirect reduction of the fracture. This helps to maintain blood supply to the bone ends and reduces non union rates ^(4,24).

The LISS plate was developed to complement the concept of the MIPPO technique^{(3,7,14,15,20,21,23,26-29,32,33,36,37,41).} It consists of a precontoured plate to the bone block utilising multiple fixed angle screws. Utilising the cantilever principle, the bone – plate interface closely resembles an external fixator. It is not surprising that it has been called an Internal Fixator. Its other main advantage is preservation of bone biology, eliminating the need for bone grafting in most cases. ^(20,21,23)  The PERI-LOC  plate incorporates all the advantages and principles of the LISS  plate with better contouring.

Our Results are comparable to previous LISS studies. To our knowledge, there have been no published results using the PERI-LOC plate for Distal Femoral Fractures. The PERI-LOC plate has specific design features. This plate has a bevelled tip proximally to allow easy sub muscular insertion of the plate. There are scallops distally to allow for the easy placement of independent articular lag screws close to the joint surface. Each hole in the plate can accept 4 different screws 4.5mm non locking screw, 4.5mm locking screw, 5.7mm cannulated locking screw and 6.5mm partially threaded cancellous screw unlike the LISS plate. The contouring in the plate design is more anatomical hence less plate irritation. Our results show comparable time to callus formation and union as the LISS series. The better plate design has lead to fewer complications particularly plate irritation.

Femoral PERI-LOC plate

Fig 4   Distal Femoral   LISS studies

FIG 5   Proximal Tibia / LISS Studies

There have been no published results using the PERI-LOC plate for Proximal Tibial Fractures. PERI-LOC Tibial plates come in two sizes 3.5cm and 4.5cm. The plates   have a scalloped edge which allows for easy placement of independent lag screws for reduction of articular surface. The plate head has a 5 degree posterior tilt and is contoured to match the lateral proximal tibia. There are also 3 additional small holes proximally for meniscal repair. The plate shaft has a 3 degree bend to match the diaphysis of tibia. There is a bevelled tip distally which allows for the easy percutaneous insertion of the plate. Each of the holes can accept 4 different screws 4.5mm non locking screw, 4.5mm locking screw, 5.7mm cannulated locking screw and 6.5mm partially threaded cancellous screws.

Tibial PERI-LOC  Plate

Our hypothesis that the results of the distal femoral and proximal tibial fractures fixed with the PERI-LOC plate are comparable to that of the LISS plate have been affirmed considering the time to callus formation, time to union, range of motion and the incidence of complications. The PERI-LOC plate system is user friendly and no specific technical difficulties were encountered. This plate incorporates the advantages of minimally invasive surgical techniques with a fixed angle device. We believe the better anatomical contouring; bevelling and wider choice of screws gives it an advantage over other similar systems.

The limitation of our study is the relatively small number of patients included Also it is a retrospective study and there is no control group. This is a preliminary report of results of a new system of osteosynthesis. Longer term follow up may add findings that lead to additional conclusions. The strengths of conclusions would certainly be enhanced with a randomised prospective study to prove the long term role of PERI-LOC in the management of distal femoral and proximal tibial fractures.

Conclusion:

Our study shows that the early results with the PERI-LOC plate for Distal Femoral and Proximal Tibial fractures are comparable to that of the LISS plate. We feel that further studies are needed to prove the long term role of the PERI-LOC plate.

Reference :

1. Benirschke SK, Agnew SG, Mayo KA, Santoro VM, Henley MB. Immediate internal fixation of open complex tibial plateau fractures: treatment by a standard protocol. J Orthop Trauma 1992; 6:78-86.

2. Blokker CP, Rorabeck CH, Bourne RB. Tibial plateau fractures. An analysis of the results of treatment in 60 patients. Clin Orthop Rel Res 1984; 182:193.

3. Boldin C, Fankhauser F, Hofer HP, Szyszkowitz R. Three year results of proximal tibia fractures treated with the LISS. Clin Orthop Rel Res 2006; 445:222-29.

4. Bolhofner B, Carmen B, Clifford P. The results of open reduction and  internal fixation of distal femur fractures using the a biologic reduction technique. J Orthop Trauma 1996; 10:372-7.

5. Burri C, Gartzke G, Coldewey J, Muggler E. Fractures of the tibial plateau. Clin Orthop Rel Res 1979; 138:84.

6. Butt M, Krikler S, Ali M. Displaced fractures of the distal femur in elderlypatients.Operative versus non operative treatment. J Bone Joint Surg 1996;78B:110-4.

7. Cole PA, Zlowodski M, Kregor PJ. Treatment of proximal tibia fractures using the Less invasive stabilisation system. J Orthop Trauma 2004; 18:528-34.

8. Collinge C, Sanders R, DiPasquale T. Treatment of complex tibial periarticular fractures using percutaneous techniques. Clin Orthop Rel Res 2000;375:69.

9. Connolly J, Dehne E, Lafollette B. Closed reduction and early cast brace ambulation in treatment of femoral fractures. Results in one hundered and forty three fractures. J Bone Joint Surg 1973; 55A:1581-99.

10. Dendrinos GK, Kontos S, Katsenis D, Dalas A. Treatment of high energy tibial plateau fractures by the Ilizarov circular fixator. J Bone Joint Surg 1996; 78:710.

11. Duwelius PJ, Rangitsch MR, Colville MR, Woll TS. Treatment of tibial plateau fractures by limited internal fixation. Clin Orthop Rel Res 1997;339-47.

12. Farouk O, Krettek C, Miclau T, Schandelmaier P, Guy P, Tscherne H. Minimally invasive plate osteosynthesis: does percutaneous plating disrupt femoral blood supply less than the traditional technique? J Orthop Trauma 1999; 13:401-6.

13. Firoozbaksh K, Behzadi K, Decoster TA, Moneim M, Naragi F. mechanics of retrograde nail versus plate fixation for supracondylar femur fractures. J Orthop Trauma 1995; 9:152-7.

14. Frankhauser F, Gruber G, Schippinger G, Boldin C, Hofer HP, Greechenig W, Szyszkowitz R. Minimal invasive treatment of distal femoral fractures with the LISS. Acta Orthop Scand 2004; 75:56-60.

15. Frigg R, Appenzeller A, Christensen R, Frenk A, Gilbert S, Schavan R. The  Development of the distal femoral LISS. Injury 2001; 32(3):24-31.

16. Gaudinez RF, Mallik AR, Szporn M. Hybrid external fixation of comminuted tibial plateau fractures. Clin Orthop 1996; 328:203-210.

17. Giles JB, DeLee JC, Heckman JD, Keever JE. Supracondylar – intercondylar fractures of femur treated with a supracondylar plate and lag screw. J Bone Joint Surg 1982; 64A:864-870.

18. Goesling T, Frenk A, Appenzeller A, Garapati R, Marti A, Krettek C. LISS plate: design, mechanical and biomechanical characteristics. Injury 2003; 34:11-15.

19. Henry SL. Supracondylar femur fractures treated percutaneously. Clin Orthop  2000; 375:51-9.

20. Kregor PJ, Hughes JL, Cole PA. Fixation of distal femoral fractures above total knee arthroplasty utilising LISS. Injury 2001; 32:64-75.

21. Kregor PJ, Stannard J, Zlowodski M, Cole PA, Alonso J. Distal femoral fracture fixation utilising the less invasive stabilisation system: the technique and early results. Injury 2001; 32:32-47.

22. Krettek C, Muller M, Miclau T. Evolution of minimally invasive plate osteosynthesis in the femur. Injury 2001; 32:14-23.

23. Marti A, Frankhauser C, Frenk A, Cordey J, Gasser B. Biomechanical evaluation of the less invasive stabilisation system for the internal fixation of distal femoral fractures. J Orthop Trauma 2001; 15:482-7.

24. Mast J, Jakob R, Ganz R. Planning and reduction techniques in fracture surgery. New York: Springer-Verlag; 1989.

25. Miclau T, Holmes W, Martin RE, Krettek C, Schandelmaier P. Plate osteosynthesis of the distal femur: surgical technique and results. J South Orthop Assoc 1998; 7:161-70.

26. Panasiuk M, Kmieciak M. Treatment of periprsthetic fractures of the distal femur with the LISS system. Chir Narzadow Ruchu Orthop Pol 2004; 69:369-71.

27. Ricci WM, Rudzki JR, Borrelli J. Treatment of complex proximal tibia fractures with the less invasive stabilisation system. J Orthop Trauma 2004; 18:521-27.

28. Schandelmaier P, Krettek C, Miclau T. Stabilisation of distal femoral fractures using the LISS. Tech Orthop 1999; 14:230-46.

29. Schandelmaier P, Partenheimer A, Koenemann B, Grun OA, Krettek C. Distal femoral fractures and LISS stabilisation. Injury 2001; 32:55-63.

30. Schatzker J. Fractures of the distal femur revisited. Clin Orthop 1998; 347:43-56.

31. Schatzker J, Lambert DC. Supracondylar fractures of the femur. Clin Orthop1979; 138:77-83.

32. Schutz M, Muller M, Kaab M, Haas N. LISS in the treatment of distal femoral fractures. Acta Chir Orthop Traumatol Cech 2003; 70:74-82.

33. Schutz M, Muller M, Krettek C, Hontzsch D, Regazzoni P, Ganz R, Haas N. Minimally invasive fracture stabilisation of distal femoral fractures with the LISS: a prospective multicenter study. Injury 2001; 32:48-54.

34. Siliski JM, Mahring M, Hofer HP. Supracondylar – intercondylar fractures of the femur. Treatment by internal fixation. J Bone Joint Surg Am 1989; 71A:95-104.

35. Slatis P, Ryoppy S, Huittinen VM. AO osteosynthesis of fractures of the distal third of the femur. Acta Orthop Scand 1971; 42:162-72.

36. Stannard JP, Wilson TC, Volgas DA, Alonso JE. Fracture stabilisation of proximal tibial fractures with the proximal tibial LISS: Early experience. Injury 2003; 34:36-42.

37. Syed AA, Agarwal M, Giannoudis PV, Matthews SJ, Smith RM. Distal femoral fractures: long term outcome following stabilisation with the LISS. Injury 2004; 35:599-607.

38. Tees JD. Fracture of the lower end of the femur. Am J Surg 1937; 38:656-9.Waddell JP, Johnston DW, Neidre A. Fractures of the tibial plateau: a review of  ninety five patients and comparison of treatment methods. J Trauma 1981; 21:376-381.

39. Watson JT. High energy fractures of the tibial plateau. Orthop Clin North Am. 1994; 25:723-52.

40. Wong MK, Leung F, Chow SP. Treatment of distal femoral fractures in the elderly using a less invasive plating technique. Int Orthop 2005; 29:117-20.

This is a peer reviewed paper 

Please cite as: Khan ADi: Early Results with the PERI-LOC Plate for Distal Femoral and Proximal Tibial Fractures

J.Orthopaedics 2010;7(2)e12

URL: http://www.jortho.org/2010/7/2/e12

ANNOUNCEMENTS

Arthrocon 2011


Refresher Course in Hip Arthroplasty

13th March,  2011

At Malabar Palace,
Calicut, Kerala, India

Download Registration Form

For Details
Dr Anwar Marthya,
Ph:+91 9961303044

E-Mail:
anwarmh@gmail.com

Powered by
VirtualMedOnline