Study of outcome of knee joint in patients with fracture distal femur versus fracture ipsilateral femur and tibia

The posture on the two wheeler at the speed we travel, makes knee the vulnerable joint of all in any of the mishaps. We as orthopedic surgeons see the fractures around the knee joint as one of the most studied concept in the subject. This is a prospective study conducted, over 2 years, in Krishna Institute of Medical Sciences, Deemed to be University, Karad. In this study, 20 cases of fracture distal femur and 20 cases of ipsilateral fracture femur and tibia were studied to evaluate outcome of knee joint and post surgical stabilization of fractures. The fractured limb was stabilized with splinting the limb in Thomas splint or plaster slab. The type of fracture, type of fracture ixation, duration of hospital stay, time of union and time to start weight bearing are evaluated. According to Neer’s score, Good outcome was found in both Fracture Distal femur and Ipsilateral Fracture Femur and tibia. The functional outcome was found to be better in diaphyseal fractures femur and tibia treated with intramedullary interlock nailing which allowed early mobilization and weight bearing than in intra-articular fractures treated with plating. Bony union occurred early in closed, diaphyseal and simple transverse or oblique fractures and delayed in open, intraarticular and comminuted fractures.


A
The posture on the two wheeler at the speed we travel, makes knee the vulnerable joint of all in any of the mishaps. We as orthopedic surgeons see the fractures around the knee joint as one of the most studied concept in the subject. This is a prospective study conducted, over 2 years, in Krishna Institute of Medical Sciences, Deemed to be University, Karad. In this study, 20 cases of fracture distal femur and 20 cases of ipsilateral fracture femur and tibia were studied to evaluate outcome of knee joint and post surgical stabilization of fractures. The fractured limb was stabilized with splinting the limb in Thomas splint or plaster slab. The type of fracture, type of fracture ixation, duration of hospital stay, time of union and time to start weight bearing are evaluated. According to Neer's score, Good outcome was found in both Fracture Distal femur and Ipsilateral Fracture Femur and tibia. The functional outcome was found to be better in diaphyseal fractures femur and tibia treated with intramedullary interlock nailing which allowed early mobilization and weight bearing than in intra-articular fractures treated with plating. Bony union occurred early in closed, diaphyseal and simple transverse or oblique fractures and delayed in open, intraarticular and comminuted fractures.

INTRODUCTION
Man is a nomadic animal. Travelling is one of the pursuits of mankind since the early paleolithic era. Since the Industrial revolution, man has brought into use various machine to make the travel cheap and quick. With time the need for personalized travel wagons grew and then came the era of personalized and highly accepted versions of four wheelers. The development of people's interest in this travel industry led to a development of irst petroleum based motorcycle in 1885. Since then mankind has not taken a step back in riding the two wheelers. Speed is now an integral part of riding. The posture on the two wheeler at the speed we travel, makes knee the most vulnerable joint of all in any of the mishaps. We as orthopedic surgeons see the fractures around the knee joint as one of the most studied concept in the subject. The injuries might present with deformities, loss of function and delayed knee mobility.
Ipsilateral fracture of femur and tibia or "Floating knee" includes a combination of Diaphyseal, metaphyseal and intra articular fractures of both Femur and/or Tibia, in various combinations. They usually associated with high energy trauma like road trafic accidents. Mostly, these injuries result in some permanent disability. The incidence of loating knee injuries was reported as 26 % of all fractures (Letts et al., 1986). These high energy traumas are usually associated with other injuries like head Injury, chest injury and abdominal injuries as shown by Veith et al. (1984).
Distal femur fractures -articular or non-articular; upto 9 cm above the distal articular surface of the femoral condyles on radiograph, are also the fractures associated with high energy trauma sustained around the knee joint. The distal femur fractures associated with intraarticular extension need to be managed with maintenance of articular congruency.

To evaluate and categorize the patients with
Fractures around Knee joint 2. To evaluate knee joint range of motion and deformity in patients of distal femur fracture and ipsilateral fracture of femur and tibia 3. To evaluate the time required for union clinically and radiologically in patients with fracture distal femur and ipsilateral fracture femur and tibia Classi ication For Floating Knee 1. Fraser classi ication for loating knee injuries ( Figure 1 and Table 1) (Fraser et al., 1978).

MATERIALS AND METHODS
This is a prospective study conducted, from June 2018 to June 2019; with a year long follow up upto June 2020; in Krishna Institute of Medical Sciences Deemed to be University, Karad. The patients in the study presented to Casualty and Outdoor Patient Department (OPD)who ful illed the criteria. The approval was given by institutional ethics committee.
This study is about the study of Functional Outcome of Ipsilateral Femur & Tibia Fractures (Floating Knee) and Distal Femur Fracture.
For this study 20 patients with ipsilateral femur and tibia fractures (Floating Knee) and 20 patients with distal femur fractures.

Cases of ipsilateral femur and tibia fractures
and Distal femur fractures 2. Unwillingness to participate in the study.
3. Patients un it for surgery.

Initial management
As the patient presented in hospital -in casualty or Outdoor Patient Department -complete head to toe assessment was done. Initial management involved resuscitation and hemodynamic stabilization of the patient. The fractured limb was stabilized with splinting the limb in Thomas splint or plaster slab. Skeletal traction applied for most of the patients. After the patients was hemodynamically stable, radiographs of the affected limb were done and all routine blood investigations were sent (Lundy and Johnson, 2001). Primary closure of the compound wound was done. Appropriate antibiotics were started and prophylactic tetanus toxoid was given. No patient was left untreated.
The subject was included into the study once a diagnosis of fracture was made. The plan of management for the given patient was made depending on the nature of fracture, location of fracture and associated soft tissue injuries.

Post operative evaluation
Physiotherapy was started from post op day 1 as quadriceps and hamstring strengthening exercises.   All patients were evaluated postoperatively at regular follow up of 6 weeks, 3 months, 6 months, 9 months and 1 year or till radiological union was conirmed. Radiographs and functional assessment of knee joint was carried out at each follow up outpatient clinic itself using the Neer score (Table 4). All the patients were assessed using a prediscussed and decided Proforma.
Knee exercises were started depending upon the fracture pattern and modality of ixation. Non weight bearing walking was started and gradually increasing to partial and full weight bearing depending upon the modality of ixation. The associated injuries and the type of fracture are prognostic indicators in the Floating knee (Rethnam et al., 2007).

RESULTS AND DISCUSSION
In our study, for distal femur fracture the average age was 42.45 years whereas for loating knee was 47.8 years in Tables 5 and 6 and Figure 2. In a study done by Mohamaad Hadi Nouraei et al. in 2012, states that the most frequent age group was 20-29 years with 44.5 % patients of the study falling in the group (Nouraei et al., 2013).
In our study, diaphyseal fractures of ipsilateral femur and tibia was 80%, where 20 % were intraar-ticular metaphyseal fractures, in Table 7. On the other, 60% of the Fracture Distal Femur were intraarticular; and 40 % were Diaphyseal Fractures, in Table 8 and Figure 3. The functional result was poor, as the femoral fracture associated with intaarticular extension and the femur fracture stabilized with internal ixation with plating (Bansal et al., 1984).
All the patients were operated under spinal anesthesia. Average duration of surgery was 100 minutes with a range of 140 to 600 min.            and depending on the age of patient and type of the fracture. Good results were obtained with operative treatment. In this study, according to Neer's score, the outcome for both injuries stands Good with Distal Femur Fracture score 74 and for Floating knee score 78 in Figure 4. The management of the associated injuries, intramedullary nailing of both the fractures and post operative rehabilitation are necessary for good inal outcome (Rethnam et al., 2007).
In the present study, the average Duration of Hospital Stay for Distal Femur Fracture is 14 days where it is 15.7 days for loating knee in Tables 9 and 10 and Figure 5.
The average Bony Union is approximately 7 months(30 weeks) for distal femur fracture whereas 8 months (34 weeks) for loating knee injury, in Figure 6. The average inal arc of motion of the knee was 107 degrees, ranging from 113 degrees to 99 degrees (Siliski et al., 1989).
Distal Femur fracture are isolated injuries; whereas the Floating Knee injuries are high velocity injuries and are associated other bony injuries. Postoperative complications, like infection, knee stiffness, delayed union, non union, mal union, deformity and limb length inequality; are minimal with our hospital setup and regular follow up.
Postoperatively, the average knee lexion for distal Femur fracture was 83 degrees; whereas loating knee show 91.5 degrees lexion on an average, in Tables 11 and 12 and Figure 7.
The average time to start weight bearing for distal femur fracture was 6.65 months; for loating knee injury is 6.8 months, in Tables 13 and 14

CONCLUSION
The functional outcome was found to be better in diaphyseal fractures femur and tibia treated with intramedullary interlocking nail which allowed early mobilization and weight bearing than in intraarticular fractures treated with plating. Bony union occurred early in closed, diaphyseal and simple transverse or oblique fractures and delayed in open, intra articular and comminuted fractures. According to Neer's score, the outcome of Knee joint is Good with Distal Femur Fracture and for Ipsilateral Femur and Tibia Fractures. The average time to start weight bearing for distal femur fracture was earlier than Ipsilateral Fracture Femur and Tibia.
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