these fractures are difficult to treat and operative treatment is usually recommended for favorable outcome [ 14 ] .
these are associated with high energy trauma ( in the youngsters ) and osteoporotic bones ( in the elderly )   and are frequently comminuted and intra - articular .
current generation of distal femoral locking compression plates is precontoured based on the average bony anatomy of the adult population and they form a fixed angled construct .
the pull - out strength of locking screws is higher than the conventional screws and is particularly useful in osteoporotic bones .
these plates are designed to apply in minimally invasive fashion to preserve local biology and avoid problems with fracture healing and infection [ 6 , 7 ] .
the purpose of this study was to evaluate functional outcome , fracture healing , and the complications of distal femoral intra - articular fractures using locking compression plates .
we reviewed 46 consecutive distal femoral fractures treated with distal femoral locking compression plates between 2009 and 2012 .
ao synthes distal femoral locking compression plate and zimmer periarticular distal femoral locking plate were used in 19 and 27 patients , respectively .
there were 36 men and 10 women with mean age of 35 years ( range 2072 ) .
inclusion criteria were as follows : ( i ) type c distal femoral fractures and ( ii ) patients older than 18 years of age . pathological fractures and types a and b distal femoral fractures were excluded from the study .
10 patients had intra - articular fractures involving both condyles ( 33c-1 ) , 12 patients had metaphyseal comminution ( 33c-2 ) , and 24 patients had articular comminution ( 33c-3 ) .
13 patients with multiple injuries and open fractures were treated within 3  wks after temporary application of external fixator .
all surgeries were carried out at our tertiary care level 1 trauma centre with patient placed supine on the radiolucent table .
appropriate - sized distal femoral locking plate was slid in distal to proximal direction submuscularly over lateral aspect of distal femur .
usually we prefer minimum length of the plate which is three times the fracture comminution segment .
first a standard 4.5  mm cortical screw was placed in the femoral diaphysis and tightened lightly . for proximal fixation 3 or 4 bicortical screws
one or more partially threaded cancellous screws were used in intercondylar region whenever required to achieve compression ( figure 2 ) .
small incision was given towards the end of the plate to confirm approximation of plate to the bone .
suction drain was used in 20 patients and was removed after 24 to 48  hrs .
static quadriceps exercises with active hip and knee mobilization were started from 1st postoperative day .
follow - up radiographs were taken after 6  wks , 12  wks , 6 months , 9 months , and 12 months after surgery .
gradual weight bearing was started based on the evidence of bridging callous on follow - up radiographs .
radiological union was defined as the presence of cross trabeculation on both ap and lateral radiographs .
clinical and functional outcomes were assessed using the knee society score   ( table 2 ) .
one case required autogenous iliac crest bone grafting and the other case required bone grafting along with refixation using longer plate due to breakage of proximal screws with broken proximal screws ( figure 3 ) .
one patient required arthroscopic arthrolysis with implant removal due to severe restriction of movement and hardware prominence .
no cases of infection and rotational or angular deformity more than 5 degrees was noted ( table 1 ) .
2 patients had limb length discrepancy of < 2  cm and no treatment was needed . at the latest
follow up rom > 120 is noted in 32 patients , 90120 in 10 patients , and 7090 in 2 patients .
to maintain the fracture biology and to minimize the soft tissue trauma , minimally invasive plating techniques have been developed for the fixation of distal femoral fractures .
the main goals of the above - mentioned techniques are to maintain the important anatomy and to promote early fracture healing . locking plate systems such as the liss  
liss has a lower risk of early implant loosening than the dynamic condylar screw   and promotes early mobilization [ 15 , 16 ] and rapid healing without bone grafting   with low risk of infection [ 15 , 16 ] and less blood loss .
the lcp differs from the liss in that the lcp has combination holes and does not have a jig .
pain over lateral aspect of the distal femur following fixation with liss has been attributed to the jig .
previous studies have demonstrated successful early results and relatively low complication rates using minimally invasive plating techniques for the fractures of distal femur [ 12 , 17 , 18 ] .
we have used minimally invasive plate fixation technique using standard lateral approach for the fixation of simple intra - articular fractures ( c1 ) . however , more extensive approaches are needed for fixation of complex intra - articular fractures ( c2/c3 ) . in these fractures
this articular block was fixed to the femoral shaft using indirect plate fixation technique . in our series of 44 patients
, there were no cases of infection and varus / valgus alignment of more than 5 degrees .
we noted 2 cases of nonunion , out of which one case required autogenous iliac crest bone grafting and the other case required bone grafting along with refixation using longer plate due to breakage of proximal screws . one case required arthrolysis with implant removal due to severe restriction of rom and hardware prominence . as reviewed by miclau et al .  
. relatively low rate of bone grafting in our series is probably due to improved surgical technique with better soft tissue handling .
early experience with the liss for distal femoral fractures in multicentric study in europe demonstrated a 20% incidence of varus / valgus deformity greater than 5 degrees .
our relatively low incidence of deformity is probably because of improved surgical expertise along with better understanding of fracture anatomy
. limitations of the study include ( i ) all the drawbacks pertaining to its retrospective nature and ( ii ) small sample size .
strength of our study is that we included only intra - articular fractures ; most of these were complex which require adequate surgical expertise .
the results of our study suggest that use of standard lateral approach for simple intra - articular distal femoral fractures ( c1 ) and transarticular / minimally invasive techniques for complex intra - articular fractures ( c2/c3 ) results in improved exposure of the knee joint and better union rates with low incidence of bone grafting
 
 background . 
 intra - articular fractures of distal femur present a huge surgical challenge . the aim of this study is to evaluate functional outcome , fracture healing , and the complications of distal femoral intra - articular fractures using locking compression plates . 
 material and methods . 
 we reviewed 46 distal femoral fractures treated with distal femoral locking compression plates between 2009 to 2012 . 
 there were 36 men and 10 women with mean age of 35 years ( range 2072 ) . 
 more than half of the patients were of type c3 ( ao classification ) and had been caused by high energy trauma with associated injuries . 
 results . 
 2 patients were lost to follow - up . of the remaining 44 patients , the mean follow - up period was 25 months ( range 1836 ) . 
 the mean time for radiological union was 12 weeks ( range 1018 ) except 2 patients which had gone for nonunion . at the latest 
 follow up rom > 120 is noted in 32 patients , 90120 in 10 patients , and 7090 in 2 patients . 
 38 patients ( 86% ) had good / excellent outcome . conclusion . 
 use of standard lateral approach for simple intra - articular distal femoral fractures ( c1 ) and transarticular / minimally invasive techniques for complex intra - articular fractures ( c2/c3 ) results in improved exposure of the knee joint and better union rates with low incidence of bone grafting . 
1. Introduction
2. Material and Methods
3. Results
4. Discussion