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01-04-2020 | Femoral Fracture | Letter to the Editor
Letter to the editor on “Functional outcome of open distal femoral fractures managed with lateral locking plates”
Published in: International Orthopaedics | Issue 4/2020
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I read with interest the article titled “Functional outcome of open distal femoral fractures managed with lateral locking plates” by Jain et al. and would like to congratulate the authors for their study [1]. Although they have touched a highly pertinent topic in a scientific manner, certain queries need to be addressed:
1.
The authors have included all open distal femoral fractures in their present study. The cohort included in the study had around eight patients of Gustilo type 1 and 2, a total of 23.52%. These patients are supposed to have comparatively lesser soft tissue injuries and may form a comparatively “healthy cohort,” which may skew the results. It would have been more interesting to see how the patients with Gustilo type 3a and 3b fractures compared with these patients as the latter are supposed to have severe soft tissue damage.
2.
Although the authors suggest that 55.8% of patients were AO/OTA type C3, they have not mentioned whether any of the patients treated with primary plating needed any primary bone grafting. In these severely comminuted fractures, maintenance of length of the femur may require the use of fibular struts at the time of primary fixation. The use of bone grafting in 16 patients suggested by the authors is all in the external fixator group or in established non-unions.
3.
A total of nine patients had injuries to the ipsilateral knee including patella fractures. Exposure and fixation of these fractures (like patella or comminuted proximal tibia fractures) would require some modification in the approach, and it is difficult to understand that all the fractures were fixed through the lateral approach. There is evidence in the literature which describes the use of parapatellar approaches for the fixation of severely comminuted AO/OTA type C3 injuries [2].
4.
The authors have mentioned that the definitive fixation was done after adequate healing of all soft tissues after external fixation. It would be important to know how many of the Gustilo type 3b fractures required any additional soft tissue procedure like flaps and skin grafting for the healing of the soft tissues, as this would affect the surgical approach used for fixation of these fractures.
5.
As the authors rightly mention that it is prudent to be proactive with bone grafting, it would also help to know the type of bone grafting which was used in their cases. The number of patients needing fibular strut grafts and cancellous bone grafts would add further value to the results.
6.
It is extremely important to know the time duration between the presentation and the primary definitive fixation of the fractures. Dugan et al. have mentioned the importance of early definitive fixation of the distal femoral fractures so that the soft tissue damage from the fracture ends is minimized and soft tissue sleeve is vascularized faster [3]. The authors mention the time gap between presentation and external fixation, but a similar mention of the gap between presentation and primary definitive fixation of the fracture is not mentioned.