Reconstruction of complex distal femur open fracture with distal femoral locking plate and primary autologous free fibular graft

Rajagopal H. P., Madan Mohan M., Anoop Pilar, Keith Behram Tamboowalla


Background: Distal femur fractures are high velocity injuries which accounts for 7-10% of all femoral fractures. These injuries are complex injuries which are difficult to manage. Despite advances in techniques and implants, treatment remains a challenge, in many situations.

Methods: We present a retrospective review of 8 cases, involved in high velocity road traffic accident who presented to emergency department at St. John’s Medical College, Bangalore, Karnataka, India between September 2011 to December 2015, with complex open fracture of the distal femur with bone loss. All were managed with initial wound debridement and skeletal traction. Subsequently fractured femur was reconstructed with distal femoral locking plate stabilization, along with autogenous non vascularised fibular graft and cortical-cancellous graft bridging the bone defect. Radiological union, functional outcome measured with Tegner and Lyslom scores, KOOS score and complications were assessed.

Results: At average 5 years follow up, all the fractures have united well, with good functional outcome. X-ray showing united fracture with incorporation of the fibular graft. According to Tegner and Lyslom scoring, 6 patients had good rating, 2 had satisfactory rating. Average KOOS score was 82.15. Shortening of 2 cm and 4 cm in couple of patients was the major complication.

Conclusions: Delayed primary surgery, using autologous non vascularised free fibular graft in conjunction with a locking compression plate, with autogenous cortico-cancellous graft is an effective, less technically demanding and cost effective means of reconstruction option to manage bone defects in complex open fractures of the distal femur. An overall acceptable results in terms of fracture union, fibular incorporation, adequate restoration of knee motion and early rehabilitation can be expected.


Complex open fractures, Distal femur, Distal femoral locking plate, Fibular

Full Text:



Arneson TJ, Melton LJ, Lewallen DG, O’Fallon WM. Epidemiology of diaphyseal and distal femoral fractures in Rochester, Minnesota. 1965-1984. Clin Orthop Relat Res. 1988;234:188-94.

Schütz M, Müller M, Krettek C, Höntzsch D, Regazzoni P, Ganz R, et al. Minimally invasive fracture stabilization of distal femoral fractures with the LISS: a prospective multicenter study. Results of a clinical study with special emphasis on difficult cases. Injury. 2001;32(3):48–54.

Virk JS, Garg SK, Gupta P, Jangira V, Singh J, Rana S. Distal Femur Locking Plate: The Answer to All Distal Femoral Fractures. JCDR. 2016;10(10):1-5.

Ramesh LJ, Rajkumar SA, Rajendra R, Rajagopal HP. Ilizarov ring fixation and fibular strut grafting for C3 distal femoral fractures. J OrthopSurg (Hong Kong). 2004;12(1):91-5.

Gawri V, Garg Y, Singh D, Garg RS, Choudhary N. Complex open distal femur fracture managed by primary autogenous fibular graft in conjunction with dflp- a case report. J Clin Diag Res. 2015;11:1-3.

Lawal YZ, Garba ES, Ogirima MO, Dahiru IL, Maitama MI, Abubakar K. Use of non-vascularized autologous fibula strut graft in the treatment of segmental bone loss. Ann Afr Med. 201;10(1):25-8.

Yajima H, Tamai S, Mizumoto S, Ono H. Vascularised fibular grafts for reconstruction of the femur. J Bone Joint Surg Br. 1993;75(1):123-8.

Muramatsu K, Ihara K, Shigetomi M, Kawai S. Femoral reconstruction by single, folded or double free vascularised fibular grafts. Br J Plast Surg. 2004;57(6):550-5.

Gustilo RB, Mendoza RM, Williams DN. Problems in management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984;24:742–6.

Muller ME. The comprehensive classification of fractures of long bones. New York: Springer-Verlag; 1990.

Marsh JL, Slongo TF, Agel J, Broderick JS. Fracture and dislocation classification compendium – 2007: Orthopaedic Trauma Association Classification, Database and Outcomes Committee. J Orthop Trauma. 2007;21(10):1-133.