“A Modified Anterolateral Swashbuckler Approach for Distal Femoral Fractures: Description and Outcomes”

doi:10.21203/rs.3.rs-154105/v1

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“A Modified Anterolateral Swashbuckler Approach for Distal Femoral Fractures: Description and Outcomes”

https://doi.org/10.21203/rs.3.rs-154105/v1

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Background: The treatment of distal femur fractures represents a challenging task. General and local factors, including bone quality, articular surface involvement, fracture comminution, associated soft tissue injuries and ultimately fixation system, all play a role in the final clinical outcome. Current surgical approaches often undermine patellar vascularization and integrity of the extensor apparatus, not guaranteeing sufficient visualization of the medial condyle. This technical note presents the efficacy and safety a new surgical technique to address distal femoral fractures.

Methods: The original "swashbuckler" surgical approach was modified in order to obtain a better visualization of the lateral and medial femoral condyles without affecting the knee extensor mechanism and the anastomotic arterial supply of the patella. This modified surgical approach was utilized in a consecutive series of patients presenting with a Müller AO 33 distal femur or periprosthetic fracture of the knee. The final outcome was recorded according to a functional evaluation scoring system.

Results: Twelve patients (2 males and 10 females) with a mean age of 67,8 years (min. 18; max 90 years) were included in this series. The same, modified "swashbuckler" surgical approach was applied in all cases. Multiple internal fixation techniques, including a single lateral plate, a combination of a lateral and medial plate, a single lateral plate associated with lag screws, were used to obtain a satisfactory stabilization of the fracture site. All patients were reviewed at a minimum one-year follow up (median 15 months): all patients regained their level of activities of daily living. No major intraoperative or postoperative complications were recorded.

Conclusions: The modified swashbuckler approach allows anatomical reduction and appropriate fixation with minimal severance of the blood supply to the patella and ensures rapid weight bearing resumption thanks to an intact extensor mechanism.

Surgery

tibial tuberosity osteotomy

swashbuckler

computerized tomography

The treatment of distal femur fractures represents a challenging task, as the outcome is influenced by numerous factors: bone quality, patient’s age, articular surface involvement, presence of small fragments, fixation system and associated soft tissue injuries, all play a role in the final clinical result [1][2]. Traditionally, obtaining an anatomical reduction is a priority that must be achieved without compromising the soft tissues and knee vascularization [3]. In addition to classical fractures, trauma surgeons are often asked to treat complex distal femur periprosthetic fractures or other complicated cases, such as non-unions or malunions. Different strategies have been described to solve these challenges, as the choice of an adequate surgical approach represents the first step to achieve satisfying reduction and fixation [4][5].

The aim of this study it to present a modification of the classical “swashbuckler” approach to the distal femur, highlighting its main features when compared to the other approaches and presenting the clinical results in a retrospective case series.

All patients aged 16 years and older that had presented with a distal femoral fracture at the first author Institution between January 1017 and December 2019 were potentially eligible for study. Patients were identified through a diagnosis registry, including both in-hospital stays and outpatient visits. Only patients with distal femoral fracture who underwent osteosynthesis through a modified “swashbuckler” approach were included.

The pre-operative radiologic images of all the eligible patients were obtained from the Picture Archiving and Communication System (PACS, GE Healthcare, USA) and examined in at least two standard projections (anteroposterior and lateral views of the distal femur and knee) and a computerized tomography (CT) scan allowing 3D reconstruction. The fractures were classified according to the AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification system [6] Periprosthetic fractures of the distal femur were classified according to the Lewis and Rorabeck Classification [7]. Patient characteristics at the time of fracture were obtained from hospital files, including data on age, gender, weight, risk factors and comorbidities.

Patients were followed for a minimum of 12 months postoperatively. Each follow up visit consisted of an outpatient consultation with a careful clinical and radiological examination (two weight-bearing anteroposterior and lateral radiographic projections of the distal femur including the knee were performed) at an interval of 1, 3, 6, 12 months postoperatively and thereafter depending on the necessity of further control. Clinical outcomes and complications, such as infections, implant failure, osteolysis, bone collapse, skin necrosis, knee stiffness and quadriceps hypotrophic changes were all recorded. The final outcome was classified according to the functional evaluation scoring system described by Sanders et al [8].

Description of the modified swashbuckler approach

The patient is placed supine onto a radiolucent table; a roll is positioned beneath the knee, to maintain a flexion of approximately 30° of both hip and knee. A radiolucent bump is placed under the ipsilateral buttock to avoid excessive external rotation of the lower limb. In order to prevent quadriceps medial retraction and avoid ischemic damage to the tissues, no tourniquet is used [7]. Starting at the lateral aspect of the tibial tuberosity, a blunt incision, which maintains a distance of about 2 cm from the lateral border of the patellar tendon, is made; at the base of the patella the incision deviated slightly, aiming for the posterior depression of the vastus lateralis until it reached the anterolateral aspect of the thigh, about 5 fingerbreadths from the patella (Fig. 1); the incision continued along thigh anterolateral aspect as proximal as needed.

Subsequently the approach is developed from proximal to distal. The incision is extended deep to the quadriceps fascia, which is incised, exposing the quadriceps muscle belly. The iliotibial band is bluntly separated from the vastus lateralis muscle and retracted laterally. The lateral intermuscular septum, which separates the anterior and posterior compartments of the thigh, usually relates directly to the iliotibial band distally at the level of the patella. A blunt dissection is used to divide the septum from the vastus lateralis until the anterolateral aspect of femoral shaft is exposed and visualized according to the surgeon’s need. After the vastus lateralis has been detached from the lateral intermuscular septum, Hohmann retractors were used to displace the quadriceps muscle medially and to expose distal femur. The superior lateral geniculate artery is easily identified before it joins the anastomotic lateral circle and was ligated.

The distal extension of the subcutaneous dissection must be performed carefully and precisely to minimize the disruption of the patellar arterial supply. Parapatellar arthrotomy is performed at least 2 cm from the lateral patellar margin in order to preserve the integrity of the peripatellar vascular anastomotic ring (Fig. 2). The integrity of the lateral descending and the transverse infrapatellar artery are thought to be pivotal in maintaining patellar vascularization on both sides of the anastomotic ring. The lateral inferior geniculate artery, which crosses the surgical incision perpendicularly at the height of the lateral meniscus, is ligated. We recommend preserving, if possible, the anterior tibial recurrent artery which usually crosses the surgical field at the height of the tibial tuberosity, in order to maintain a better vascularization of the peripatellar anastomotic ring [8, 9].

If a wider visualization of the medial side of the distal femur is required, the vastus intermedius muscle could be stripped from the femoral anterior cortex, as there are no attachments distally. The last step to increase exposure of the medial condyle, was to bend the knee few degrees in association with a medial sliding of the extensor apparatus in order to avoid unnecessary stress at the fracture site. Adductor magnus and biceps femoris brevis muscles usually remain intact at the posterior aspect of the femur, as there is no need to further expose both these structures. A retractor is useful to move the patella medially. Before skin suture, the retinaculum is closed with absorbable sutures with special attention not to damage the lateral circulatory anastomosis of the patellar network.

Postoperative management

A single daily dose of low-molecular-weight heparin12 hours after the operation was administered as a prophylaxis to prevent deep venous thrombosis of lower extremities. No drainage tube was placed in any patient. The skin stitches were removed two weeks after the procedure or later if the surgical wound has not healed. The postoperative weight-bearing status was regulated according to the stability of fracture fixation, the general condition of the patients, and the healing process at the level of the osteosynthesis.

The demographic data are illustrated in Table 1. Two males and ten females with a mean age of 67,8 (18 ~ 90) years were included in our study. All were closed fractures. The median delay from injury to surgical procedure was 2,8 (1 ~ 6) days. None of the patients had any neurological or vascular deficit at the time of admission. After a median follow-up of 14,9 (12 ~ 24) months, all patients regained their activities of daily living. No cases of major complications as infections, plate breakage or loosening, varus collapse, bone reabsorption were recorded. Three patients were treated with lateral plating, three patients with medial plating and lag screws and 6 patients with double plating (lateral and medial) of the distal femur. Two patients who sustained a periprosthetic fracture complained of anterior knee pain since the 1 month follow-up consultation. When asked about the pain, both patients reported that it was present in the months following the TKA procedure. All incisions healed by first intention.

The postoperative joint function was graded according the functional evaluation scoring system described by Sanders: 4 cases excellent, 8 cases good, no cases with fair or poor scores. The mean score was 34,8 (30 ~ 40). Among them, 7 patients had maximal flexion of more than 120°, 5 patients had flexion between 90° and 120°, no patient showed a flexion below 90°.

This study showed that the modification of the classical “swashbuckler approach” has allowed for an appropriate internal fixation of distal femoral fractures: the rate of complications, related to the surgical approach, was very low.

Displaced or comminuted distal femur fractures require anatomic reduction of the articular surface since literature agrees that articular incongruity leads to poor outcomes [9]. In order to achieve this goal, the surgeon must be able to fully visualize and address the proximal end of the knee joint. Historically, the direct lateral access proposed by Marcy in 1947 [10] has represented the gold standard in a distal femoral fracture scenario. Unfortunately, this approach lacks the visualization of the entire medial condyle and trochlea as well as the severance of multiple perforating arteries: its association with a medial parapatellar incision can be tempting but the soft tissue vascularization is exposed to a high risk of necrosis; moreover, its proximal extension is laborious and time wasting. The Olerud approach [11] guarantees visualization but the current authors believe that prolonged post-operative immobilization is not recommended for an elderly patient. Nevertheless, tibial tuberosity osteotomy (TTO) ensures wide intercondylar visualization but the integrity of the extensor apparatus is essential for weightbearing and early mobilization [11][12]. Starr et al [13] claimed that their "swashbuckler" approach allowed for wide visualization of the distal femur without damaging the extensor apparatus. Dugan et al. [14] reported poor knee ROM after this approach was applied to a series of patients; interestingly, Khalil and Ayoub [15] reported multiple complications, including infections, non-unions, delayed tibial tuberosity osteotomy healing, in several young patients who sustained 33-C3 fractures. On the other side, a TTO is useful in a periprosthetic fracture scenario but several authors reported severe complications [16][17] [18].

Beltran et al. [19] proposed a minimally invasive version of the classical “Swashbuckler approach”: this modification significantly reduced the length of the skin incision and quadriceps stripping from the meta-diaphyseal bone but it was found not useful in fractures with meta-diaphyseal extension. Several case reports and case series have confirmed the validity of the “Swashbuckler approach” proposed by Starr [20][21][22][3].

The main drawback of the “Swashbuckler approach” in all its modified versions is the inclusion of a lateral parapatellar arthrotomy which may undermine the lateral supply to the anastomotic patellar ring [23]. In fact, recent literature has identified poor vascularization as one of the etiologies of postoperative anterior knee pain as well as patellar necrosis and stress fractures [24][25][26][27][28]. The current authors developed a modification of the “Swashbuckler approach” with the primary intention of not reducing blood flow to the patella while maintaining the ability to mobilize the extensor mechanism and gain access to the medial condyle. Lazaro et al [29] in their cadaveric study, defined patellar anastomotic ring “safety margins” while performing a knee arthrotomy: they found that a tissue cuff greater than 15 mm, both medially and laterally, ensured the patellar blood supply not be damaged. Based on these findings, the current authors decided to perform the arthrotomy with a minimum 2 cm margin. This choice did not lead to a reduction in the mobility of the extensor apparatus allowing the surgeon to perform double plates synthesis if indicated (Fig. 3a, 3b, 4a, 4b, 5a, 5b)s. In light of recent literature, internal fixation with a medial and lateral plate appears to be the gold standard in the treatment of distal femur fractures in the elderly population, which may benefit from early loading and mobilization in terms of lower mortality, inferior morbidity and overall better function [1][30][31] [32][33][34][35][36]. On the other side, if a TKA will be subsequently indicated, the surgeon could decide whether to perform a more familiar medial approach or a lateral one being not afraid of ischemic complications involving the patella and the adjacent soft tissues. The current authors made the same considerations with an inverse temporal order regarding double plating of periprosthetic fractures. Knowing that the anastomotic circle has been interrupted from the medial side, the authors were able to safely visualize and instrument the entire fracture by incising laterally, keeping the previously described arthrotomy margin [29].

There are a number of weaknesses in the present study. The authors sample size is small in order to draw conclusions applicable to the general population: although they did not encounter any difficulties in patellar mobilization during the surgical procedures, this statement should be verified and supported by future cadaveric studies [37]. In support of the authors conclusions, a contrast enhanced knee MRI study could be useful to verify the integrity of the peri-patellar circulation and a doppler ultrasound study could verify the intra-patellar blood flow [38][39]. Another limitation of the current study is the difference in the skin incision between the current authors and Starr et al [13] and by Beltran et al [19]: the current authors decided to make a skin incision 2 cm lateral to the patellar tendon. However, we do not believe that this can constitute a substantial difference in comparison with the other authors, although it makes a subsequent medial knee incision more feasible.

Fractures of the distal femur, whether on native bone or prosthetic implant, are increasing in number and their mortality is equal to those of the proximal femur. The authors believe that this modified approach represents a solution to meet the modern demands for robust fixation and early mobilization without incurring in ischemic damage to the patella and the periarticular soft tissues.

TTO: tibial tuberosity osteotomy; AO/OTA: AO Foundation/Orthopaedic Trauma Association; CT: computerized tomography

Ethics approval and consent to participate

This study was approved by the Department of Orthopedic Surgery, San Carlo Borromeo Hospital, Milano, Italy. Written informed consent was obtained from each patient and the study was conducted in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Availability of data and material

The datasets used and/or analyzed in the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

No funding was obtained for this study.

Authors’ contributions

SG: Analysis of data and writing the manuscript; GT: Study conceptualization

and design. GA: Study conceptualization and design, Reviewing and editing

the draft manuscript; ET: Data collection and analysis; BV: Reviewing and editing the draft manuscript. PFI: Analysis of data and writing the manuscript; All authors agreed to submit the manuscript for publication in this journal. All authors read and approved the final manuscript.

Acknowledgements

The authors thank all clinical researchers involved in this study.

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Table 1. General information of the patients

Table 2

Injury characteristics of the patients
Case	Age (Years)	Gender	Diagnosis	Treatment Follow-up (months)		Major complications	Sanders Scoring System
1	18	M	AO 33 C1	Lateral plate	24	None	40
2	64	F	AO 33 B2	Media plate & lag screws	20	None	37
3	66	F	LR 2	Lateral & medial plate	16	Anterior Knee Pain	34
4	36	M	AO 33 A3	Lateral & medial plate	14	None	40
5	72	F	AO 33 B2	Media plate & lag screws	12	None	36
6	74	F	AO 33 A3	Lateral plate	20	None	33
7	90	F	LR 2	Lateral & medial plate	12	Anterior Knee Pain	34
8	82	F	AO 33 C3	Lateral & medial plate	12	None	37
9	90	F	AO 33 A3	Lateral & medial plate	12	None	28
10	88	F	LR2	Media plate & lag screws	12	None	34
11	45	F	AO 33 A3	Lateral plate	12	None	35
12	89	F	AO 33 A2	Lateral & medial plate	13	None	30

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“A Modified Anterolateral Swashbuckler Approach for Distal Femoral Fractures: Description and Outcomes”

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