What is the step by step procedure for treating a patient with a fracture of the distal femur using Open Reduction Internal Fixation (ORIF) with plating?

ORIF with Plating for Distal Femur Fractures: Detailed Surgical Procedure

Open reduction and internal fixation with distal femoral locking plates is the standard surgical approach for distal femur fractures, providing rigid angular stability that allows early mobilization and weight-bearing without increased risk of fixation failure. 1, 2

Preoperative Planning

Patient Assessment

• Obtain upright radiographs (AP and lateral views) to accurately assess fracture displacement and comminution 3
• Evaluate the entire femur length on imaging to identify any proximal extension or associated injuries that would alter surgical planning 4
• Classify the fracture using AO/OTA system (Type 33-A for extra-articular, 33-B for partial articular, 33-C for complete articular) to guide fixation strategy 2, 5
• Assess bone quality particularly in elderly patients where osteoporosis may compromise fixation 6, 2

Surgical Planning

• Select appropriate distal femoral locking plate with sufficient length to span the fracture with at least 3-4 cortices of fixation proximally and distally 6, 2
• Plan approach - lateral approach is standard for most distal femur fractures 2
• Determine fixation strategy for intra-articular fractures requiring anatomic reduction of articular surface first 2

Surgical Technique

Patient Positioning and Approach

• Position patient supine on radiolucent table with bump under ipsilateral hip 2
• Make lateral incision extending from lateral femoral condyle proximally along lateral intermuscular septum 2
• Develop interval between vastus lateralis and lateral intermuscular septum 2
• Identify and protect the common peroneal nerve if dissection extends distally 2

Fracture Reduction

For Intra-articular Fractures (AO/OTA 33-C)

• Reduce articular fragments first using pointed reduction forceps to achieve anatomic joint surface restoration 2
• Provisionally fix articular block with 2.0mm or 2.7mm lag screws perpendicular to fracture lines 2
• Verify articular reduction with direct visualization and fluoroscopy in AP and lateral planes 2

For Metaphyseal/Diaphyseal Component

• Use indirect reduction techniques to minimize soft tissue stripping and preserve blood supply 6
• Restore length, alignment, and rotation using manual traction and/or femoral distractor 2
• Avoid extensive periosteal stripping - biological fixation principles are critical for healing 6

Plate Application

Plate Positioning

• Position distal femoral locking plate on lateral cortex of distal femur 6, 2
• Ensure plate sits flush against bone without gaps that could compromise fixation 2
• Verify plate position with fluoroscopy - the distal end should be 5-10mm proximal to joint line 2

Distal Fixation

• Insert distal locking screws in multiple planes to capture condylar fragments 2
• Use at least 4-6 distal locking screws to achieve adequate purchase in metaphyseal bone 6, 2
• Add lag screws through plate if needed for interfragmentary compression of articular fragments 2
• Verify screw length with fluoroscopy to avoid intra-articular penetration 2

Proximal Fixation

• Achieve bicortical purchase with at least 3-4 screws proximally, spanning minimum 8 cortices 6, 2
• Use combination of locking and non-locking screws proximally based on bone quality 6
• Ensure adequate working length between proximal and distal screw clusters to avoid stress concentration 2

Bone Grafting Considerations

• Primary bone grafting is NOT routinely required when using biological fixation techniques with locked plating 6
• Consider bone grafting only for significant metaphyseal bone loss or defects >2cm 2
• Autograft or allograft can be used if needed, though minimally invasive techniques often obviate this need 6

Final Verification

• Confirm reduction and fixation with fluoroscopy in AP, lateral, and oblique views 2
• Assess knee range of motion intraoperatively to ensure no mechanical block 2
• Verify stability of construct before closure 2

Closure and Postoperative Management

Wound Closure

• Close in layers - repair vastus lateralis to intermuscular septum, subcutaneous tissue, and skin 2
• Place drain if significant dead space or concern for hematoma 2

Immediate Postoperative Care

• Multimodal pain management using regional blocks, NSAIDs, and judicious opioid use 4
• Prophylactic antibiotics for 24 hours postoperatively 4
• DVT prophylaxis with chemical and mechanical methods 4
• Monitor for compartment syndrome in first 48 hours, particularly in high-energy injuries 2

Weight-Bearing Protocol

• Allow immediate weight-bearing as tolerated - there is no evidence that early weight-bearing increases risk of fixation failure or fracture displacement with locked plating 1
• Restrictive weight-bearing may actually delay healing and increase risk of complications 1
• Use assistive devices (walker, crutches) for safety and comfort, not for fracture protection 1

Rehabilitation

• Begin knee range of motion exercises immediately on postoperative day 1 to prevent stiffness 4, 2
• Initiate quadriceps strengthening as soon as pain allows 4
• Progress to full weight-bearing typically within first 2 weeks based on patient comfort 1
• Continue physical therapy for 3-6 months focusing on strength and functional mobility 4

Follow-Up and Monitoring

Radiographic Follow-Up

• Obtain radiographs at 2 weeks, 6 weeks, 12 weeks, and then every 6 weeks until union 4, 3
• Assess for loss of reduction, implant failure, or delayed union 2

Expected Outcomes

• Union typically occurs at 4-6 months - closed fractures unite faster (4.25 months) than open fractures (5.86 months) 2
• Minimally invasive biological techniques result in faster union (4.6 months) compared to open reduction with bone grafting (6.4 months) 6

Common Complications and Management

Infection

• Occurs in approximately 8% of cases 2
• Treat with irrigation, debridement, and culture-directed antibiotics 2

Knee Stiffness

• Most common complication occurring in 12% of patients 2
• Prevented by early aggressive range of motion exercises 4, 2
• May require manipulation under anesthesia if severe and refractory to therapy 2

Nonunion/Delayed Union

• Higher risk with extensive soft tissue stripping and inadequate fixation 6
• Biological fixation techniques reduce this risk 6
• May require revision surgery with bone grafting if nonunion develops 2

Implant Failure

• Occurs more frequently with non-weight-bearing protocols (6 failures in restricted group vs 0 in early weight-bearing group) 1
• Salvage with distal femoral replacement is possible but technically demanding 7