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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.
References
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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.
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.
Table 1.
Demographic Characteristics of the Case and Control Groups
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 |
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 |
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