Abstract
Background:
High-energy traumatic fractures represent a challenge for orthopaedic surgeons because there are a great variety of morphologic patterns and associated injuries1. Although the incidence is higher in developing countries, these fractures pose a major financial burden all over the world because of their considerable hospital length of stay, time away from work, rate of failure to return to work, complications, and cost of treatment2-4. Since the fracture patterns are so variable, some cases may have a lack of available specific osteosynthesis implants, despite recent advancements in implant engineering5. However, experienced surgeons are capable of using their knowledge and creativity to treat challenging lesions with use of preexisting plates while following the principles of fracture fixation and without compromising outcomes. In 2012, Hohman et al. described for the first time the use of a calcaneal plate to treat distal femoral fractures6. In 2020, Pires et al. further expanded the indications for use of a calcaneal plate5. This technical trick is widely utilized in our trauma center, especially in comminuted fractures around the knee. The present video article provides a stepwise description of the off-label use of a calcaneal plate in a medial distal femoral fracture.
Description:
The key principles of this procedure involve following common fundamentals during open reduction and internal fixation, approaching the fracture, preserving soft-tissue attachments of the comminution, and reducing the main fragments. Afterwards, the off-label use of a calcaneal plate adds the special feature of being able to contain fracture fragments with plate contouring. If necessary and if osseous morphology allows, bone grafting through the plate may also be performed.
Alternatives:
Multiple fixation implants can be utilized in medial distal femoral fractures. Surgeon-contoured plates (i.e., locking compression plates or low-contact dynamic compression plates), multiple mini-fragment plates, cortical screws alone, cannulated cancellous screws alone, or proximal humeral plates are among the alternatives5-9. However, the lack of specific implants for fixation of fractures involving the medial femoral condyle is notable, even in developed countries10.
Rationale:
The small-fragment calcaneal plate is a widely available and cheaper implant compared with locking compression plates, which is especially important in developing countries. Additionally, this plate has a lower profile, covers a greater surface area, and allows multiple screws in different planes and directions. The use of this plate represents a great technical trick for surgeons to contain comminution.
Expected Outcomes:
Patient education regarding fracture severity is mandatory, and it is important to highlight that there is no current gold standard to treat these fractures because of the wide variability of morphological patterns. To our knowledge, all studies reporting the use of a calcaneal plate to treat these fractures have shown promising results, including good functional outcomes and 100% fracture healing with no cases of nonunion, infection, or implant failure5,6,10-14. In the largest case series to date, Shekar et al. performed an interventional prospective study of 30 patients undergoing calcaneal plating for distal femoral unicondylar fractures14. They reported a mean range of motion of 108° ± 28.27° at 6 months, with excellent or satisfactory results in 80% of patients as measured with use of the Neer scoring system14.
Important Tips:
Preserve the blood supply by performing minimal soft-tissue dissection.
Do not detach comminuted fragments from the soft tissues, which will help fracture reduction.
Reduce the main fragments anatomically and fix as necessary.
Contain the comminution using the spanning property and large covering area of the calcaneal plate.
Perform bone grafting through the plate as necessary.
Acknowledgments
Note: The authors thank Mr. Ricardo Julião and AMGS Comércio e Representações Ltda for providing photos and illustrations of the orthopaedic implants shown in this manuscript.
Published outcomes of this procedure can be found at: Am J Orthop (Belle Mead NJ). 2012 Mar;41(3):140-3, Eur J Orthop Surg Traumatol. 2021 Feb;31(2):275-82, and J West Afr Coll Surg. 2023 Jul-Sep;13(3):59-64
Investigation performed at Hospital Risoleta Tolentino Neves, FUNDEP, Belo Horizonte, Minas Gerais, Brazil
Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSEST/A456).
Contributor Information
Túlio Vinícius de Oliveira Campos, Email: tuliovoc@gmail.com.
Santiago Enrique Sarmiento Molina, Email: santiago_m16@hotmail.com.
Gustavo Scarpelli Martins da Costa, Email: gustavoscarpelli2@gmail.com.
André Guerra Domingues, Email: agdandre@gmail.com.
Paulo de Tarso Cardoso Gomes, Email: ptcardosogomes@gmail.com.
Marco Antônio Percope de Andrade, Email: marcoapercope@gmail.com.
References
- 1.Court-Brown CM, Clement ND. The Epidemiology of Musculoskeletal Injury. In: Tornetta P III, Ricci WM, Ostrum RF, McQueen MM, McKee MD, Court-Brown CM, editors. Rockwood and Green’s Fractures in Adults. 9th ed. Philadelphia: Wolters Kluwer; 2019. [Google Scholar]
- 2.Myatt RW, Miles J, Matharu GS, Cockshott S, Kendrew J. The financial cost of managing tibial plateau fractures at a major trauma centre. Trauma. 2015;17(1):33-8. [Google Scholar]
- 3.Schade AT, Khatri C, Nwankwo H, Carlos W, Harrison WJ, Metcalfe AJ. The economic burden of open tibia fractures: A systematic review. Injury. 2021. Jun;52(6):1251-9. [DOI] [PubMed] [Google Scholar]
- 4.Herteleer M, Van Brandt C, Vandoren C, Nijs S, Hoekstra H. Tibial plateau fractures in Belgium: epidemiology, financial burden and costs curbing strategies. Eur J Trauma Emerg Surg. 2022. Oct;48(5):3643-50. [DOI] [PubMed] [Google Scholar]
- 5.Pires RE, Giordano V, Boni G, Campos TVO, Lopes MTC, de Andrade MAP. Expanding the indications for calcaneal plates beyond foot fractures: a technical trick and case series. Eur J Orthop Surg Traumatol. 2021. Feb;31(2):275-82. [DOI] [PubMed] [Google Scholar]
- 6.Hohman DW, Affonso J, Budny J, Anders MJ. Calcaneal plate fixation of distal femoral fractures. Am J Orthop (Belle Mead NJ). 2012. Mar;41(3):140-3. [PubMed] [Google Scholar]
- 7.Mierzwa AT, Toy KA, Tranovich MM, Ebraheim NA. Surgical Approaches, Postoperative Care, and Outcomes Associated with Intra-Articular Hoffa Fractures: A Comprehensive Review. JBJS Rev. 2019. Aug;7(8):e8. [DOI] [PubMed] [Google Scholar]
- 8.Neumann-Langen MV, Eggeling L, Glaab R, von Rehlingen-Prinz F, Kösters C, Herbst E. Hoffa fractures are associated with concomitant soft tissue injures and a high postoperative complication rate. Arch Orthop Trauma Surg. 2024. Feb;144(2):747-54. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Li Z, Chen Z, Wang X, Li J, Jing L, Li Z, Cao X. Locking Plate Alone or in Combination with Cannulated Screws for Hoffa Fractures: A Retrospective Study. Orthop Surg. 2022. Mar;14(3):492-500. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Upadhyay P, Syed F, Ramoutar DN, Ward J. The missing piece of the trauma armoury-medial femoral condyle plate. Injury. 2022. Mar;53(3):1237-40. [DOI] [PubMed] [Google Scholar]
- 11.Loesch EC, Bamne AB, Kwon JY. A Novel Technique for Fixation of a Medial Femoral Condyle Fracture using a Calcaneal Plate. The Orthopaedic Journal at Harvard Medical School. 2015. Jun;16:102-6. [Google Scholar]
- 12.Silva R, Moreira E, Branco R, Ferreira F, Areias M, Oliveira C, Alpoim B. Calcaneal Plate for Medial Femoral Condyle Fractures-Is This It? A Clinical Case. Surg J (N Y). 2021. May 25;7(2):e59-61. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Meena A, Kumar S, Joshi N, Rathore M. Outcome Analysis of Open Reduction and Internal Fixation with Calcaneal Plate: An Observational Study Among Unicondylar Fracture of Distal Femur. Int J Contemp Med Res. 2016;3(5):1535-8. [Google Scholar]
- 14.Shekar DD, Meena RC, Sharma SL, Vijayan KT, Nayak S, Singhal A. Management of Distal Femur Unicondylar Fractures by Calcaneal Buttress Plating: A Prospective Interventional Study. J West Afr Coll Surg. 2023. Jul-Sep;13(3):59-64. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Boni G, Pires RE, Sanchez GT, Dos Reis FB, Yoon RS, Liporace FA. Use of a stainless steel locking calcaneal plate for quadrilateral plate buttress in the treatment of acetabular fractures. Eur J Orthop Surg Traumatol. 2019. Jul;29(5):1141-5. [DOI] [PubMed] [Google Scholar]