Injury, Int. J. Care Injured 44 (2013) 1826–1831

Open supracondylar femur fractures with bone loss in thepolytraumatized patient – Timing is everything!

Tiffany R. Dugan a, Mark G. Hubert b, Peter A. Siska a,Hans-Christoph Pape c, Ivan S. Tarkin a,*a Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufmann Medical Building, 3471 Fifth Avenue,

Pittsburgh, PA 15213, United Statesb Trinity Mother Frances – Orthopaedic & Sports Medicine, 1327 Troup Hwy, Tyler, TX 75701, United Statesc Deparment of Orthopaedics and Trauma, University of Aachen, Bauwelsstrabe 30, 52074 Aachen, Germany

A R T I C L E I N F O

Article history:

Accepted 18 March 2013

Keywords:

Open fractures

Locking plate

Supracondylar femur

Soft tissue management

Bone morphogenic protein

Bone graft

Polytrauma

A B S T R A C T

Introduction: Open supracondylar femur fractures are rare, complex injuries which occur in polytrauma

patients and are complicated by bone loss, contamination, compromised soft tissues, and poor host

condition. The purpose of this study is to demonstrate a successful treatment protocol for these

challenging injuries.

Methods: A consecutive series of 15 open supracondylar femur fractures in 14 polytrauma patients (ages

16–75, mean 41) were treated at one Level I trauma centre by a single surgeon. Fracture patterns

included seven AO/OTA Type C2 and eight Type C3 fractures. All fractures were open and classified by

Gustillo/Anderson as type IIIA (10 fractures) and type IIIB (five fractures). Stage I was performed within

24 h and included thorough open fracture care and early definitive fixation with a laterally based locking

device and antibiotic bead placement. Stage II was performed several months later (average 3.6 months)

when the soft tissue envelope had revascularized and the polytrauma patient had recovered from their

other injuries. Stage II consisted of either an anterior incision or subvastus approach to the distal femur,

bone grafting, BMP application, and addition of medial column support to create rigid fixation.

Results: All fractures (15/15) healed uneventfully. Union was determined by absence of pain and

radiographic union in 3/4 cortices. Mean time to union was 4 months. There were no deep infections and

alignment was maintained (average tibiofemoral angel of 58 of valgus) although several limbs were

complicated by knee stiffness.

Conclusions: Healing of open supracondylar femur fractures with critical sized bone defects requires

diligent surgical timing in order to optimise the host and wound bed. Thorough initial debridement and

early definitive fixation halt ongoing soft tissue injury, restores length and alignment, and allow for

sterilisation of the wound. After patients have recovered from their other injuries and the soft tissue

sleeve has revascularized, bone grafting with BMP supplementation and medial column plating allows

for rigid fixation of the femur and offers the biology these fracture patterns require for successful union

without infection.

� 2013 Elsevier Ltd. All rights reserved.

Contents lists available at SciVerse ScienceDirect

Injury

jo ur n al ho m epag e: ww w.els evier . c om / lo cat e/ in ju r y

Introduction

Open high energy supracondylar femur fracture with bone lossin the polytrauma patient presents unique therapeutic challengeswhen the pathway of limb salvage surgery is prescribed. Althoughamputation maybe the preferred reconstructive strategy for themultiply injured patient in extremis, limb salvage using a stagedapproach to care should be considered. Management factors to

* Corresponding author. Tel.: +1 412 605 3203; fax: +1 412 687 0802.

E-mail address: tarkinis@upmc.edu (I.S. Tarkin).

0020–1383/$ – see front matter � 2013 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.injury.2013.03.018

consider include the scope of open fracture care, type of skeletalstabilisation, soft tissue coverage, and bone grafting strategy.1

Arguably, however, timing of the reconstructive effort toachieve limb salvage is the most important factor to consider.The physiology of the severely traumatised host and localmusculoskeletal environment deserve special consideration.2

Although, early skeletal stabilisation and open fracture care stopsthe cycle of injury, removes nidus for infection, and halts ongoinghaemorrhage, it may be prudent to delay further reconstructivesurgery until the host and local soft tissue conditions areoptimised.2

The purpose of this study was to determine whether a stagedprotocol using thorough open fracture care, early fixed angle

Fig. 1. Initial injury: open supracondylar femur fracture, AAOS/OTA Type C2.

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bridge plating, and antibiotic bead usage followed by delayedautogenous bone grafting was an effective strategy for managingthe polytrauma patient with an open supracondylar femur fractureand critical sized bone defect. We contend that a laterally lockedbridge plate will maintain optimal fracture alignment untilconditions are suitable for a bone grafting procedure. Secondly,thorough open fracture care in conjunction with antibiotic beadusage will minimise the chance of septic complication. Third,delayed bone grafting in concert with medial column plating in theoptimised host and musculoskeletal sleeve will encourage optimalrates of bone union.

Methods

Between 2006 and 2012, a consecutive series of 15 supracon-dylar femur fractures with critical sized bone defects in 14polytrauma patients were treated with a staged protocol at a singlelevel one trauma centre. Retrospective analysis of both clinical andradiographic parameters was utilised to determine treatmentoutcomes. Primary outcomes measures included rate/time tounion, alignment, knee functionality, and complication rate.

Limb salvage protocol for open supracondylar femur fractures in the

polytraumatized patient

The multiply injured patient with an open supracondylar femurfracture was brought to the operating theatre within the first 24 hfor thorough open fracture care and immediate skeletal fixation(Fig. 1). Radical soft tissue and bone debridement was performed.The articular block was anatomically fixated with lag screwfixation. The reconstructed articular segment was secured to shaftwith a bridging laterally based locking plate (Fig. 2). Antibioticbeads (with either vancomycin, tobramycin, or both) were placedat the site of critical sized defect. A VAC system was used for softtissue defects defying tension free closure.3

Patients were brought back to operating room for second lookdebridement within 2-3 days in conjunction with antibiotic beadexchange. Subsequently, serial VAC changes were performed in theoperating room until the soft tissues were closed. A reconstructiveplastic surgeon was utilised for the definitive delayed closure orsoft tissue coverage procedure. The decision for closure was basedon maturation of the soft tissue sleeve and improving hostparameters. Additionally, special attention was paid to optimisingour polytrauma patient’s nutrition with protein enhanced supple-ments and high protein meals.

Timing of further reconstructive surgery was determined in theoutpatient setting. Bone grafting combined with medial columnplating was performed once the previous polytrauma patient hadachieved both physical and psychological wellness. As determinedby the general surgery trauma service, the patient was required tohave resolution of associated injuries (head, chest, and abdomen)prior to continuation of orthopaedic reconstruction. Nutrition wasoptimised prior to orthopaedic reconstruction. Further, the local softtissues associated with the previously open supracondylar femurfracture were required to be completely healed and remodelledwhich suggested re-vascularisation of the soft tissue envelopesurrounding the bony injury. Lastly, psychologic disorder, namelytransient depression and/or posttraumatic stress associated withthe polytrauma event, was identified and treatment was initiatedprior to further orthopaedic limb salvage procedure.4

Definitive reconstruction of the supracondylar femur fractureconsisted of retaining the locked lateral bridge plate, antibioticbead removal, cancellous autograft with or without supplementa-tion with allograft chips, bone morphogenic protein application,and medial column plating. Surgical approach was dictated bydegree and location of bone loss. An extensile anterior approach as

described by Henry was used most commonly (Fig. 3). However, amedial subvastus approach was used for more distal fractures withless extensive bone deficit. (Fig. 4).

Cancellous graft was harvested from the iliac crest whenfeasible. Alternative harvest site for autologous bone was usedwith history of previous pelvic or acetabular fracture or when bodyhabitus (BMI > 35) precluded safe harvest from the iliac crest.5 Thegraft was packed into the biologic vascularised envelope leftbehind after antibiotic bead removal (Masquelet technique).6

Allograft chips were used as bone graft extender when necessary.

Fig. 2. Post-op following Stage I treatment.

Fig. 3. Intra-op Stage II – anterior approach: after antibiotic bead removal and

placement of the medial column plate, bone graft, and BMP.

Fig. 4. Intra-op Stage II – subvastus approach.

T.R. Dugan et al. / Injury, Int. J. Care Injured 44 (2013) 1826–18311828

Bone morphogenic protein (BMP) in the form of a BMP-2 sponge(Infuse; Medtronic, Memphis, TN) or BMP-7 powder (OP-1; StrykerBiotech; Hopkinton, MA) was placed over the autogenous graft atthe site of femoral defect prior to closure.

Rigid stabilisation of the distal femur was achieved via plateosteosynthesis of the medial column which complimented theexisting lateral support. Plating was performed either directmedially or anteromedially and dictated by the existing indwellinghardware and the size of distal articular block. Small fragmentcombination plates were used most commonly.

Patients were non-weight-bearing for six weeks following bonegraft procedure. Knee physiotherapy was instituted after surgicalwound healing was evident at 2 weeks. Patients were followed tounion with serial radiographic examination.

Union was defined as bridging bone on 3 of 4 cortices andresolution of pain in the supracondylar region (Fig. 5). Inquestionable cases, a computed tomography scan was used toassess uneventful bone healing across the critical sized femoraldefect (Fig. 6).

Alignment was determined by the tibiofemoral angle, which isaccepted to be on average 6 degrees of valgus.7 Tibiofemoral anglesmeasured immediately postoperatively and at final follow up wereall within our acceptable range.

Results

A consecutive series of fourteen polytrauma patients with 15limb threatening open supracondylar femur fractures with bone

Fig. 5. Final AP/lateral of healed supracondylar femur.

Fig. 6. (a) Sagittal CT scan of a patient after Stage I treatment. (b) Sagittal CT scan of

healed supracondylar femur.

T.R. Dugan et al. / Injury, Int. J. Care Injured 44 (2013) 1826–1831 1829

loss were identified from the trauma registry. Near equalproportions of men and woman were studied (8 men and7 women) with an average age of 41 (range 16–75). Each patienthad multisystem injury with associated injuries (ISS � 16).8 Highenergy trauma was causative in all cases (motor vehicle accidentn = 8, motorcycle crash n = 3, high energy fall n = 3, blast n = 1).

All high energy open supracondylar femur fractures had intra-articular involvement. Fracture patterns as defined by AO/OTAclassification system included 7 Type C2 and 8 Type C3 injuries. Allfractures were open and included 10 grade 3a and 5 grade 3binjures according to the Gustillo Anderson classification. After

thorough open fracture care, all supracondylar fractures were leftwith a critical size bone defect averaging 8 cm (range 2.2-11.7 cm).

The average time to the second stage of bone reconstructionwhich included antibiotic bead removal, cancellous bone grafting,BMP application and medial column plating was 3.6 months fromthe first surgery (range 1–6 months.) Successful bone union wasrealised in 100% of our cases (15/15). Time to union was onaverage 4 months (range 2–8 months). Tibiofemoral anglesaveraged 4.8 (�1 to 11) degrees immediately postoperativelyand 5.0 (�6 to 13) at final follow up with an average change of0.46 degrees (�2 to +58).

No cases of infection were identified. Knee stiffness, however,was an undesirable effect of these injuries and our treatmentprotocol with an average motion arc of 2-88 degrees. Range ofextension was 0–108 and flexion from 40-1208.

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Discussion

As improvements have been made in emergency medicalservices and critical care medicine, polytrauma patients aresurviving their life threatening injuries and require functionalorthopaedic reconstruction to promote wellness.9–11 Long-termfunctional outcomes of the multi-system trauma patient are oftenpredicated on extremity trauma management.12,13 Complicationssuch as nonunion, malunion, or infection after lower extremityreconstruction can have a profound negative impact on thisunfortunate patient population.14

In this study, we have demonstrated that optimal union ratescan be realised with staged mindful care of the polytraumatizedpatient with a limb threatening open supracondylar femurfracture with bone loss. Our approach was successful in avoidingboth local and systemic complication by respecting the tenuousnature of the host and local soft tissue environment by delayingdefinitive reconstruction until the patient and soft tissue sleevewere optimised.

The initial care prescribed included thorough open fracture careand usage of antibiotic beads, which was successful in ‘‘sterilising’’the wound bed as evidenced by a 0% incidence of deep infection.Further, usage of a locked lateral precontoured internal fixator atthe index operation was integral for achieving alignment andstability. The plate bridged a critical size metadiaphyseal defect.The precontoured plate was used intraoperatively as a template toachieve adequate coronal alignment of the articular block to theshaft. Locked technology was especially useful for stabilising theoften diminutive articular segment.15,16 Successful use of theinternal fixation strategy was evidenced by no significant changein coronal alignment recorded when comparing immediatepostoperative to final follow-up radiographs.

Delayed bone grafting optimises the likelihood of cancellousbone graft incorporation at site of bone defect after opensupracondylar femur fracture. Each case in our series requiredonly one bone grafting procedure to achieve union with defects upto 11 cm in size. The merits of delayed bone grafting have beenrecognised by Fisher and Gustillo et al.17 They identify that re-epithelialisation and vascularisation of the wound bed increasesthe rate of uneventful osseous integration after bone grafting.Several others have also concluded that maturation of thedamaged soft tissues prior to bone grafting procedure providessuperior incorporation of the graft with a diminished occurrence ofinfection.18–20

Usage of antibiotic beads as described in the Masquelettechnique6 prepares the site of bone defect with a vascularisedpouch ideal for cancellous autograft. Gardner et al. describesuccessful union in 9/10 open AO/OTA Type C3 pilon fractures withsegmental bone loss utilising antibiotic beads for woundsterilisation.18 Donegan et al. also demonstrated successful useof antibiotic spacers in a heterogenous study including patientswith both acute open fractures with bone loss as well as chronicinfected and noninfected nonunions in the femur and tibia.19 Theydemonstrated successful, aseptic union in 10/11 patients identify-ing the versatility of this method to sterilise a wound bed andprovide a useful biomembrane for implantation of bone graft at alater date. Further, Ostermann et al. describes the usefulness oflocal antibiotic therapy as evidenced by a decrease in chronicinfection rates from 12% to 3% with the use of antibiotic beads in alarge heterogenous population of Gustilo and Anderson grade I-IIIbopen upper and lower extremity fractures.21

Creating a rigid biomechanical environment at the second stageof care is integral for uneventful union and bone graft incorpo-ration as evidenced by our reported 100% union rate. Addition of amedial plate to the distal femur creates bicolumnar fixation, whichprevents deformity and promotes graft integration. Wang and

Weng demonstrated the importance of stabilising the medialcolumn to prevent varus, but they recreated it with corticalallograft struts.22 Chapman et al. used bicolumnar plate fixation in15 patients treated for supracondylar nonunion with a union rateof a 100%.23

Bone morphogenic proteins were used in our study tosynergistically provide osteoinductive activity to the bone graftmatrix.24–28 The cost and potential carcinogenic potential of BMPwas balanced against the limb threatening nature of the fracturestreated. Despite their profound bone forming capabilities, bonemorphogenic proteins must be used judiciously given emergingrisks. Bone morphogenic proteins have been implicated as a cancercausing agent with new reports from the FDA indicating anincreased rate of cancer in patients treated with BMP2 as opposedto controls.29,30 It is crucial to make patients aware of the emergingrisk when discussing use BMP as a potential treatment adjunct.

Despite the encouraging results demonstrated with our limbsalvage protocol, certain limitations of this treatment paradigmdeserve attention. Due to the staged approach prescribed, anextended treatment course is inevitable. The time course frominjury to union averaged 8.5 months. With nearly a year of lifespent attempting to salvage their limb, this process proved taxingfor most patients. Further, despite a united well-aligned limb, kneedysfunction precluded normality in most patients. Final knee rangeof motion ranged from 0-10 degrees of extension and 40-120degrees of flexion.

Conclusion

We have demonstrated the union of 15/15 open supracondylarfemur fractures with critical sized bone defects in polytraumapatients. With thorough initial debridement, antibiotic beadplacement for wound sterilisation, and restoration of length andalignment with a lateral locking plate at the time of initial surgery,we removed any nidus for infection and halted ongoing injury tothe already tenuous soft tissues. Patients were then allowed to healtheir other injuries in addition to their traumatic and surgicalorthopaedic wound. After patients achieved physiologic andmental wellness and the soft tissues had revascularized sufficient-ly, bone grafting was performed in addition to medial columnplating to achieve rigid fixation and prevent the femur fromcollapsing into varus. The combination of these orthopaedicprinciples in addition to diligent operative timing providedsufficient biology for all our patients to achieve union with noseptic complications.

Conflict of interest statement

None of the authors of this manuscript have any conflicts ofinterest to report, including employment, consultancies, stockownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding.

Acknowledgement

The authors give a special thanks to Dana Farrell for herassistance in the data collection and construction of thismanuscript.

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