Open reduction and internal fixation, right femur using a Smith & Nephew supracondylar locking plate

PREOPERATIVE DIAGNOSIS:                Comminuted right distal femur fracture.

POSTOPERATIVE DIAGNOSIS:             Comminuted right distal femur fracture.

PROCEDURES:                                          1.  Removal of hardware, right femur.

2.  Open reduction and internal fixation, right femur using a Smith & Nephew supracondylar locking plate.

ANESTHESIA:                                             Spinal.

INDICATIONS:                                             The patient is a woman who presented to the Emergency Room on 12/01/08 because of pain after a fall.  The initial x-rays showed evidence of a greater trochanter fracture.  Subsequent x-rays showed evidence of a significant spiral displaced femoral shaft fracture.  I discussed and explained this with the patient and explained that given the osteopenia as well as the fact that it is a displaced fracture, clearly a surgical stabilization is indicated here.

PROCEDURE IN DETAIL:                        After the smooth induction of anesthesia, the patient was given intravenous Ancef antibiotic prophylaxis.  The right lower extremity was prepped and draped in usual sterile manner.  A curved incision was made starting at the mid shaft of the femur extending down distally and across the anterior lateral aspect of the knee.  It was carried down through the subcutaneous tissue.  The deep fascia was split.  Once the knee joint was opened, fracture hematoma was evacuated.  The vastus lateralis was reflected anteriorly.  The fracture site was identified and the wound was aggressively irrigated and curetted and hematoma evacuated.  Reduction was performed initially using a Verbrugge clamp.  However, this was not allowing for placement of the definitive plate fixation.  A single cerclage wire was now placed around the mid shaft of the femur stabilizing the fracture.  Various plates were trialled in order to get adequate fixation proximal to the fracture site, the cerclage wire had to be removed that had been placed during previous surgery.  At this point, a combination of locking screws and compression screws were used to perform anatomical reduction of the multiple screws both proximal and distal to the fracture.  The fixation was stable.  Biplanar fluoroscopic control was used to confirm anatomical alignment of the fracture with appropriate positioning of the internal fixation.  The knee was placed through range of motion and noted to be stable.  The wound was aggressively irrigated with pulsatile lavage system.  Muscle was reapproximated with #1 Vicryl over a Hemovac drain, which had been brought out through a separate stab wound proximal to the incision site.  Deep fascia was now closed with #2 Vicryl.  Subcutaneous tissue closed with 2-0 Vicryl.  Skin was closed with staples.  The wound was washed, dried, and a sterile compression dressing applied.  Anesthesia reversed.  The patient brought to the recovery room, having tolerated the procedure well without complications.  Sponge count and needle counts were correct.  The estimated blood loss was 500 mL.  No intraoperative complications.