Journal List > J Korean Fract Soc > v.31(4) > 1107162

Son, Kim, and Choi: Risk Factors for Knee Stiffness in Distal Femoral Fractures

Abstract

Purpose

The aims of this study were to evaluate risk factors for knee stiffness after the fixation of distal femoral fractures, and to analyze the clinical and radiologic outcomes.

Materials and Methods

This is a retrospective case control study of 104 consecutive patients who have a distal femoral fracture and were treated with a submuscular locking plate. The case group comprised of patients with 12-month postoperative range of motion (ROM) ≤90° or a history of manipulation under anesthesia. The case group was compared with the control group of patients with a 12-month postoperative ROM >90°. The possible risk factors were evaluated by univariate and logistic regression analysis. The postoperative ROM and Knee Society clinical rating system was evaluated for the clinical assessment and the distal femoral angle on a whole-extremity scanogram was measured for radiologic assessments.

Results

Fifty-four patients were included in the study (14 in the case group, 40 in the control group). Univariate analysis showed that comminuted fracture, intra-articular fracture, open fracture, temporary external fixation, severe osteoarthritis, and prolonged immobilization placed patients at an increased risk for knee stiffness. On the other hand, multivariate logistic regression showed that an extensor mechanism injury was the only significant predictor (p=0.001; odds ratio, 42.0; 95% confidence interval, 5.0–350.7). The ROM and Knee Society score were significantly lower in the case group; however, the coronal alignment was similar in the case and control group.

Conclusion

Various factors that delay postoperative knee motion place patients at increased risk of knee stiffness. Understanding these risk factors may help surgeons prevent postoperative knee stiffness after distal femoral fractures. In particular, extensor mechanism injury, such as patella fracture or open quadriceps injury, was found to be an independent predictable factor associated with knee stiffness.

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Fig. 1.
(A, B) A 58-year-old man with an open distal femoral fracture. He had a severe open comminuted distal femoral fracture. (C) The distal femoral segment was not large enough to allow rigid fixation. (D) Spanning temporary external fixation was used for severe soft tissue injury, which was maintained for 12 days. (E, F) Because fracture site instability was observed intraoperatively, cast immobilization was applied for 6 weeks. (G) Although bone union was observed after postoperative 9 months, the range of motion of the knee was not recovered completely.
jkfs-31-123f1.tif
Fig. 2.
(A) A 26-year-old woman with open distal femoral fracture. She had an open fracture and quadriceps muscle injury. A bony fragment penetrated through the skin and the wound was contaminated. (B, C) Preoperative radiographs demonstrating comminuted and intra-articular fractures in the distal femur. After complete debridement and a weak spanning external fixation, the patient underwent auto- and allo-bone graft and firm-plate fixation. Two days later, she started knee exercise. (D) Follow-up radiograph after 3 months demonstrating fracture union. (E, F) The range of motion of the knee was recovered completely through early exercise and firm internal fixation.
jkfs-31-123f2.tif
Table 1.
Demographic Characteristics of the Case and Control Groups
Characteristic Case (n=14) Control (n=40) p-value
Age (yr) 58±13 (37–74) 61±22 (19–95) 0.874
Sex (male:female) 4:10 16:24 0.678
Follow-up (mo) 19±8 (12–36) 18±8 (12–38) 0.957
Open fracture type 10 4  
  Grade I 2 2  
  Grade II 6 2  
  Grade III 2 0  
AO classification      
  A 0 A1: 12, A2: 8, A3: 4  
  B 0 0  
  C C2: 2, C3: 12 C1: 4, C2: 6, C3: 6  

Values are presented as mean±standard deviation (range) or numbe only.

Table 2.
Comparisons of the Frequency of Variables Known to be Risk Factors of Knee Joint Stiffness according to the Range of Motion
Variable Case (n=14) Control (n=40) p-value*
High-energy injury 14 23 <0.001
Comminuted fracture 12 16 0.005
Intra-articular fracture 14 15 <0.001
Extensor injury 10 2 <0.001
Open fracture 10 4 <0.001
Temporary external fixator 8 2 <0.001
Osteoarthritis K-L grade >4 4 2 0.033
Immobilization >3 weeks 8 6 0.004

Values are presented as number only.

* Fisher's exact test,

K-L grade: Kellgren-Lawrence grade.

Table 3.
Clinical and radiologic outcomes of the case and control groups
Variable Case (n=14) Control (n=40) p-value
3-month postoperative ROM (o) 82±8 (70–90) 125±14 (95–145) <0.001*
12-month postoperative ROM (o) 88±17 (70–120) 125±15 (90–145) <0.001*
Knee Society score 79±12 (65–95) 89±6 (72–97) <0.001*
Bone union time (wk) 22±4 (16–28) 14±3 (9–21) <0.001*
Mechanical LDFA (o) 86±1 (85–87) 87±4 (79–93) 0.215
Anatomical LDFA (o) 80±1 (79–82) 80±4 (70–86) 0.155

Values are presented as mean±standard deviation (range) only.

* Significant difference. ROM: range of motion, LDFA: lateral distal femoral angle.

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