European Journal of Cardiovascular Medicine

Distal femur fractures account for approximately 4–6% of all femoral fractures and pose a significant therapeutic challenge due to their anatomical complexity, frequent comminution, and intra-articular extension. These fractures often result from high-energy trauma such as road traffic accidents in younger individuals or low-energy falls in elderly patients with osteoporotic bone [1,2]. The primary goals in managing distal femur fractures include anatomical reduction, rigid internal fixation, and early mobilization to restore limb function and prevent complications such as joint stiffness, malunion, and post-traumatic arthritis [3].

Over the years, surgical techniques and implant technologies have evolved significantly. The introduction of locking compression plates (LCPs) has revolutionized the internal fixation of periarticular fractures by providing stable fixation even in osteoporotic or comminuted bone [1,4]. Several biomechanical studies have supported the superiority of locking plates over traditional methods in maintaining alignment and promoting union in distal femoral fractures [3]. Additionally, studies have shown promising outcomes using polyaxial locking plates and VA-LCP condylar plates, demonstrating high union rates and acceptable complication profiles [2,6].

Various surgical approaches have been employed to access the distal femur, including the lateral, anterolateral, and medial parapatellar approaches. The Swashbuckler’s approach, a modified anterior approach, offers extensile exposure to both femoral condyles and is particularly advantageous in complex intra-articular fractures. The modified Swashbuckler’s approach further refines this technique by minimizing disruption to the extensor mechanism while allowing precise reduction and implant positioning [5].

Despite these advances, achieving optimal functional outcomes remains challenging. Standardized tools such as the Neer’s scoring system facilitate objective evaluation of postoperative recovery and are essential for guiding clinical decisions and rehabilitation protocols [4,5].

This study was undertaken to assess the functional outcomes, union rates, and complication profile associated with the use of the modified Swashbuckler’s approach in the surgical management of distal femur fractures at a tertiary care center. The findings are intended to support the approach's efficacy and safety in clinical practice.

This was a prospective observational study conducted over a period of 18 months, from September 2022 to february 2024, at the Department of Orthopaedics, Osmania General Hospital, Hyderabad a tertiary care teaching hospital in Telangana.

Study Population

A total of 50 patients with closed distal femur fractures were enrolled in the study after obtaining written informed consent. Ethical clearance was obtained from the Institutional Ethics Committee prior to commencement of the study.

Inclusion Criteria

• Patients aged ≥18 years with closed distal femur fractures (AO/OTA type 33-A, 33-B, 33-C)
• Fractures managed with open reduction and internal fixation via the modified Swashbuckler’s approach
• Willingness to provide informed consent and comply with follow-up protocols

Exclusion Criteria

• Open fractures
• Pathological fractures
• Periprosthetic fractures
• Patients with neurovascular injuries or polytrauma requiring other surgical interventions
• Patients medically unfit for surgery

Surgical Technique

All patients underwent open reduction and internal fixation using distal femoral locking compression plates via the modified Swashbuckler’s approach, which involves a lateral parapatellar incision with careful sub-vastus dissection to provide optimal exposure of the distal femur, while preserving the extensor mechanism and minimizing soft tissue disruption.

Postoperative Protocol

Standard postoperative protocols were followed, including intravenous antibiotics, thromboprophylaxis, and early range of motion exercises. Weight-bearing was initiated based on radiological evidence of union and individual patient progress.

Outcome Measures

Patients were followed up at regular intervals (6 weeks, 3 months, and 6 months). Functional outcomes were assessed using the Neer’s scoring system at 6 months. Data collected included demographic details, fracture classification (AO/OTA), operative time, blood loss, time to radiological union, and postoperative complications.

Data Analysis

All data were compiled and analyzed using Microsoft Excel and SPSS software version 26.0. Descriptive statistics such as mean, standard deviation, and percentages were used to summarize data. Results were presented in tabular and graphical formats.

A total of 50 patients with distal femur fractures were enrolled in this prospective study and managed surgically using the modified Swashbuckler’s approach. The demographic profile revealed a mean patient age of 46.8 ± 13.5 years, with a male predominance (72%, n = 36). The right femur was more commonly involved (58%, n = 29), and the leading mode of injury was road traffic accidents (68%, n = 34), followed by falls from height and domestic falls (Table 1).

Table 1: Demographic and Injury Profile (n = 50)

Fractures were classified according to the AO/OTA system. Type 33-C1 fractures were the most prevalent (36%, n = 18), followed by type 33-A and type 33-C2/C3 fractures (24% each), and type 33-B fractures (16%) (Table 2).

Table 2: Fracture Classification (AO/OTA)

Figure 1. Fracture Classification (AO/OTA)

All patients underwent open reduction and internal fixation via the modified Swashbuckler’s approach.

The mean operative time was 112 ± 18 minutes, with an average intraoperative blood loss of 310 ± 70 mL. Radiological union was achieved in most cases within an average of 17.3 ± 2.4 weeks. Delayed union was observed in 3 patients (6%), while there were no cases of non-union (Table 3).

Table 3: Intraoperative and Postoperative Parameters

Figure 2. Intraoperative and Postoperative Parameters

Postoperative complications were minimal. Superficial wound infection occurred in 4 patients (8%), all of whom responded well to local wound care and antibiotics. Knee stiffness was noted in 6 patients (12%), and implant irritation was reported by 2 patients (4%), requiring implant removal in one case (Table 4).

Table 4: Postoperative Complications

Figure 3. Postoperative Complications

Functional outcomes were assessed at 6 months using the Neer’s scoring system. An excellent outcome was achieved in 24 patients (48%), good in 17 patients (34%), fair in 7 patients (14%), and poor in 2 patients (4%) (Table 5).

Table 5: Functional Outcome (Neer’s Score at 6 Months)

Figure 4. Functional Outcome (Neer’s Score at 6 Months)

Distal femur fractures, although relatively uncommon, pose significant challenges in terms of surgical exposure, anatomical reduction, and restoration of function. These challenges are amplified in fractures involving intra-articular extension and comminution. The evolution of locking compression plates (LCPs) and advanced surgical approaches has significantly improved the outcomes of these injuries. The modified Swashbuckler’s approach offers a practical extensile anterior route that enables effective visualization of both condyles while minimizing soft tissue disruption, particularly beneficial in complex intra-articular fractures [10–12].

In the present study of 50 patients, the majority were males (72%) in the young to middle-aged group, with road traffic accidents accounting for 68% of cases. These findings are consistent with previously reported epidemiological data from Indian and global studies [7,8]. The most frequent fracture pattern was AO/OTA type 33-C1, reflecting the common intra-articular involvement in high-energy injuries.

The mean operative time was 112 ± 18 minutes, with an average intraoperative blood loss of 310 ± 70 mL, which aligns with findings in similar series evaluating LCP-based fixation through modified or extensile approaches [9–11]. Union was achieved in all patients, with a mean radiological union time of 17.3 ± 2.4 weeks. Delayed union occurred in only 6% of cases, while no instance of non-union was observed, suggesting the biological and mechanical integrity of the modified Swashbuckler technique [7,8].

The complication rate in this study was low, with superficial wound infections seen in 8% and knee stiffness in 12%. These figures are in line with those reported by Tsegaye et al. and Shah et al., who also used LCP fixation and reported acceptable complication profiles [8,9]. Implant irritation was reported in 4% of patients, with one requiring removal.

Functional outcomes, measured using the Neer’s scoring system at six months, revealed excellent or good results in 82% of patients. This outcome corresponds well with studies by Agrawal et al. and Touloupakis et al., who evaluated the Swashbuckler and modified anterolateral approaches and emphasized their effectiveness in achieving anatomical reduction and early mobilization [10,11]. The preservation of the extensor mechanism and minimal quadriceps disruption likely contributed to the favorable functional recovery in our cohort.

Additionally, a systematic review by Raja et al. supports the utility of the Swashbuckler approach in providing extensile exposure and improved access to medial and lateral condylar fragments in bicondylar distal femur fractures [12]. Compared to traditional lateral or medial routes, the modified Swashbuckler approach appears to offer better visualization and comparable, if not superior, clinical outcomes with lower morbidity.

Despite these positive findings, the present study is limited by its relatively small sample size, lack of a comparative control group, and short-term follow-up duration. Further randomized controlled trials comparing the Swashbuckler approach to lateral or medial-based exposures with longer-term functional evaluation are recommended to confirm these results and establish definitive surgical guidelines.

The modified Swashbuckler’s approach provides excellent surgical exposure for distal femur fractures, particularly in cases with intra-articular involvement. In this prospective study, it resulted in high union rates, minimal complications, and favorable functional outcomes, with 82% of patients achieving excellent to good Neer’s scores at six months. The approach allowed for precise fracture reduction while preserving soft tissue integrity and facilitating early mobilization. Its adaptability and safety profile make it a valuable technique in the orthopedic surgeon’s armamentarium. However, further studies with larger sample sizes and longer follow-up periods are warranted to validate its long-term efficacy and compare it with alternative surgical approaches.

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