**4. Management of intraarticular fractures**

Articular involvement should be addressed with anatomical restoration of the joint as a prime objective. Open reduction is often required. Additional fixation of

#### *Management of Distal Femoral Fractures DOI: http://dx.doi.org/10.5772/intechopen.110692*

the articular segment to the femoral diaphysis can be achieved by different methods, either "minimally invasive" or open. As mentioned previously, considerations for the planning of the approach and the selection of implants shall consider the amount of fracture comminution, the quality of the bone, the age and physiological needs of the patient, and -for articular fractures- whether there is previous joint arthritis.

Currently, with modern RIMN and anatomical locking plates, either simple or complex articular fractures can be properly managed in terms of initial fixation and alignment (**Figure 9**) [46–50]. However, comminuted articular fractures -as well as those with metaphyseal comminution, as mentioned before-, together with other specific fracture patterns, have been associated with a high rate of nounion and hardware failure [15, 26, 51, 52]. Recently, Nino et al. published on 16 patients with articular comminution, that were treated with articular screw fixation and RIMN, with a high degree of success in terms of fracture healing, without the need of additional procedures to promote union [53]. However, 38% of patients had a complication, most commonly knee stiffness. To minimize the risk of fixation failure and nonunion in cases of comminution and/or poor bone quality, and as mentioned before, the advent of techniques such as coupling intramedullary devices to laterally placed plates or locked "washers", as well as the addition of medial plates as a supporting medial strut, have come into play, with clinical evidence supporting their use (**Figure 10**).

Articular involvement—even with comminution—is not an impediment for the use of RIMN. Proper articular reduction and fixation can be undertaken with small-diameter screws (2.7 or 3.5 mm. cortical screws), which provide sound fixation of articular fragments, and leave space for the insertion of a nail. RIMN becomes a supporting column placed in the mechanical axis of the femur, therefore resisting axial and bending forces, acting as a load-sharing device. "Augmentation", by the addition of a lateral locking plate—or an interlocking "washer"—adds significant resistance to mechanical failure, with a higher endurance of the construct until bone healing occurs.

#### **Figure 9.**

*C1 fracture, treated with open parapatellar approach, reduction and fixation of the condyles with 3.5 mm. cortical screws, and RIMN as definitive fixation. Callus formation and healing is seen after 6 months.*

#### **Figure 10.**

*High-energy floating knee (Fraser type IIB) in a patient with a previously healed tibial fracture, and an osteoarticular defect of the lateral femoral condyle, due to trauma 9 years before the actual scenario. The articular distal femoral fracture was managed with 3.5 mm. cortical screws, and a 3.5 mm. wrist T plate for reduction to the diaphysis, followed by nail and plate combination. The tibial fracture was fixed with a percutaneous plate, due to absence of displacement, and because the tibial canal was assumed to be occluded by the previous fracture.*

## *Management of Distal Femoral Fractures DOI: http://dx.doi.org/10.5772/intechopen.110692*

The presence of joint arthritis, especially in older patients, should be a main consideration when planning surgical treatment. In such patients, distal femoral replacement with a distal femoral megaprosthesis and a rotating hinge, has been advocated as an excellent treatment method, allowing for swift functional recovery [54–58]. Internal fixation—whichever the method—is subjected to high rotational and bending forces due to joint stiffness, which is often aggravated by poor bone quality, as well as the difficulty (as previously mentioned) in restricting function postoperatively in order to decrease the risk of hardware failure. In addition, older patients with distal femoral fractures share similar epidemiological characteristics with those having proximal femoral fractures, including mortality rates [59], so

#### **Figure 11.**

*C3 distal femoral fracture in a 70 year-old patient. X-rays and CT show extensive articular comminution, and signs of knee arthritis. A resection of the distal femur and reconstruction with a modular tumor endoprosthesis and rotating hinge was done. Swift postoperative recovery and return to funtion was possible.*

considerations for operative treatment and early return to function should be the same As such, primary treatment with distal femoral resection and replacement by a rotating hinged prosthetic knee is a very valuable alternative (**Figure 11**). Aside from the aforementioned advantages, complications or re-interventions in distal femoral replacements are not higher than those reported with fracture fixation techniques.
