O R I G I N A L R E S E A R C H

Swashbuckler approach and surgical technique in

severely comminuted fractures of the distal femur
Mohamed Ashraf Khalil, FRCS, MDa, Weam Farid, MDb and Saad Gad, MDc

a
Department of Orthopedic Surgery and Traumatology, Faculty of Medicine, Mansoura University Hospital, Mansoura
University, Mansoura, Egypt
b
Department of Orthopedic Surgery and Traumatology, Faculty of Medicine, Tanta University Hospital, Tanta University,
Tanta, Egypt
c
Department of Orthopedic Surgery and Traumatology, Faculty of Medicine, Ein Shams University Hospital, Ein Shams
University, Cairo, Egypt

avoided future interference with any total knee arthroplasty

ABSTRACT surgery.
Background:
Multiplanar severely comminuted type C3 distal femoral Key Words
fractures present many challenges in terms of surgical approach Comminution, C3-type femur, fracture, modified anterior
and technique of fixation, which eventually reflect on the final approach, swashbuckler, aggressive rehabilitation, functional
outcome. This prospective study investigates a possible strategy results, knee stiffness.
to overcome these problems and hence improve the outcome
by using a modified anterior approach to anatomically recon-
struct the articular surface, followed by rigid fixation and an early
aggressive rehabilitation program.

Methods:
Nine polytraumatized patients with closed C3-type injuries were INTRODUCTION
included; seven were men, and the mean age was 33.4 yr. The

cause of injury was road traffic accident in seven patients and a
fall from a height in two. Five patients underwent surgery during
the first week and four during the second after injury. The
procedure was an anatomical reconstruction through a Swash-
buckler approach, preserving the integrity of the quadriceps
muscle and extensor mechanism. The mean follow-up was
17.6 mo (14--26 mo).
Results:
All patients had good clinical and radiographic healing without
nonunion or malunion. Mean radiographic healing time was
19.2 wk. Clinically, three patients had excellent results, four had
good results, one had a fair result, and one had a poor result. No
patient developed skin necrosis, deep infection, or implant failure.
However, the two patients with a fair and poor result had limited
knee flexion to 851; one required subsequent quadricepsplasty.
Conclusions:
The use of this anterior approach facilitated anatomical
reconstruction of severely comminuted type C3 distal femoral
fractures while preserving the integrity of the quadriceps muscle
and extensor mechanism. This procedure had fewer than
expected complications, had a favorable clinical outcome, and
Financial Disclosure: The authors report no financial
conflicts of interest.
Reprints: Mohamed Ashraf Khalil, FRCS, MD, King Fahad Hospital, P.O.
Box 41352, Medina 41521, Saudi Arabia
(e-mail: ashrafkhalil1960@gmail.com).
1940-7041 Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
T
reatment of highly comminuted distal femoral
fractures is challenging because these injuries usually
result from high-energy trauma producing commi-
nution, bone loss, intraarticular extension, and unstable
fracture patterns in different planes, in addition to variable
degrees of soft-tissue insult.1 AO-ASIF type C-3 fracture
entails significant articular comminution with fractures in
all planes and remains the most difficult surgical challenge.
Surgery has become the standard of care for displaced
fractures and for patients who must obtain rapid return of
knee function. The goal of surgical management is to
promote early knee motion while restoring the articular
surface, maintaining limb length and alignment, and
preserving the soft-tissue envelope with durable fixation
that allows functional recovery during bone healing.2
The lateral approach to the distal femur (described by
Marcy3 in 1947) is commonly used to treat these fractures;
however adequate reduction and fixation of complex
intercondylar fractures of the distal femur through a lateral
incision can be difficult and demanding. Variable modifica-
tions of the lateral exposure were introduced as well as a
direct anterior approach and a more extensile approach with
tibial tubercle detachment as described by Olerud.4
The surgeon treating these complex fractures can expect a
considerable percentage of his patients (at least 30% even in
the best hands) to develop posttraumatic arthritis, and total
knee arthroplasty often is needed when posttraumatic
arthritis becomes severe;5 however, poorly placed incisions
and their subsequent scars can make total knee arthroplasty

Volume 26  Number 3  May/June 2015 Current Orthopaedic Practice 269

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more difficult.6 Moreover, the extensile approaches can injuries as summarized in Table 1. There were seven men and
damage the quadriceps muscle and disturb the extensor two women. The mean age was 33.4 yr (range, 21--49 yr). The
mechanism and may lead to scarring and poor quadriceps cause of injury was road traffic accident (RTA) in seven
function and prolonged rehabilitation.5 patients and a fall from a height in two. All patients were
To overcome these problems the ‘‘swashbuckler’’ modified neurovascularly intact in the affected extremity. Table 2 shows
anterior approach was proposed by Starr et al.5 in 1999. We patient demographics, clinical, and final outcome data.
report our findings using this exposure combined with a Timing of surgery varied according to the general condition
well-tailored technique and aggressive rehabilitation in a of the patient and the associated injuries. Five patients were
series of patients with polytrauma and highly comminuted operated on during the first week, and four during the second
intraarticular distal femoral fractures (Müller type C3). week after injury. Plain anteroposterior and lateral radio-
graphic views and CT scans were obtained to classify the
injury, map the fracture lines, and help with preoperative
MATERIALS AND METHODS surgical planning. Chemical prophylaxis for deep vein
thrombosis with subcutaneous injection of 30 mg enoxaparin
Between February 2009 and September 2012, nine poly-
(low-molecular-weight heparin) once every 12 hr was given in
traumatized adult patients with closed highly comminuted
all patients until they could fully ambulate. At the time of the
intraarticular distal femoral fractures (Müller type C3)7 were
planned surgery, a prophylactic broad-spectrum parenteral
selected to be specifically treated according to a carefully-
antibiotic was given to all patients.
outlined strategy, using the swashbuckler modified anterior
approach as a replacement for the standard lateral approach
and its extensile modifications that is routinely used in
less comminuted fractures. The decision to adopt the Surgical Technique
swashbuckler approach in the selected patients was based
The operation was carried out with the patient supine, with a roll
on our intention to evaluate its efficiency in adequately
under the knee to allow knee flexion. A thigh tourniquet was
exposing the distal femoral condyles, extending the incision
used only if the fracture did not extend too far proximally
proximally as much as needed to expose the distal femur as
because it can prevent medial retraction of the quadriceps
dictated by the fracture pattern to allow reconstruction of
muscle. If autogenous bone grafting was thought to be necessary,
the articular surface and stable fixation. We used a carefully-
the ipsilateral iliac crest was prepared and draped for harvesting
executed surgical technique based on the standard techni-
the graft. A midline incision was made from above the fracture
ques recommended by the AO-ASIF group,8,9 Forster et al.,10
extending distally to below the patella (Figure 1) down to the
and Kregor and Zlowodzki.11
fascia overlying the quadriceps muscle. This fascia was incised in
Informed consent was obtained from all patients; for
line with the skin incision and sharply dissected off the vastus
patients with head injuries, the consent was obtained from
lateralis muscle laterally to its inclusion with the iliotibial band,
the formal guardian. The study was authorized by the local
exposing the quadriceps muscle (Figure 2). The iliotibial band
ethical committee and performed in accordance with the
and quadriceps fascia were retracted laterally, continuing the
ethical standards of the 1964 Declaration of Helsinki as
dissection down to the linea aspera. The lateral parapatellar
revised in 2000.
retinaculum was then incised to separate it from the vastus
All patients had a type C3 fracture according to the
lateralis muscle belly, and a lateral parapatellar arthrotomy was
classification by Müller et al.7 All other types of distal femoral
performed to expose the femoral condyles (Figure 3). A retractor
fractures were excluded because they could be easily treated
was placed under the vastus lateralis and medialis muscles to
with the usual or mini-invasive lateral or lateral parapatellar
expose the distal femur and to evert the patella medially.
approaches without the need for extensive dissection maneu-
Perforating vessels encountered on the lateral aspect of the femur
vers. In all patients, the fracture lines within the condyles ran
were cauterized or ligated. Several retractors were placed under
in the sagittal or oblique planes, in addition to variable
the quadriceps if exposure of the entire distal femur was needed.
degrees of metaphyseal comminution. Four patients had a
Subperiosteal stripping of the distal femur was carefully avoided
coronal ‘Hoffa’ fracture pattern. All patients had associated
and medial bone fragments were, when possible, left undis-
turbed. Meticulous reconstruction of the articular surface using
countersunk screws (when needed) was given priority (Figures 4
TABLE 1. Associated injuries and 5) followed by open reduction and internal fixation of
Number of
condylar and metaphyseal elements using lag screws and locked
Associated injuries patients plating (Figure 6). Severe metaphyseal bone comminution was
augmented using autogenous bone graft or artificial bone
Head injury 3
Chest injury 6
substitute. After open reduction and internal fixation were
Blunt abdominal injury 5 complete, the retractors were removed, thus allowing the intact
Upper extremity injury 3 vastus lateralis muscle to fall back against the lateral intermus-
Another ipsilateral lower extremity injury 2 cular septum. Before starting wound closure, the quality of
Another contralateral lower extremity 3 articular surface reduction and the final alignment of the
injury
Stable spine fracture 2 fractured segment were checked intraoperatively using an image
Stable pelvic fracture 5 intensifier. The tourniquet was released and hemostasis obtained.
The midline split of the quadriceps fascia was repaired, along
TABLE 2. Patients’ demographic, clinical, and final outcome data

Injury Range of Functional

Severity knee result
Patient Age Cause of Fracture Fracture Score Time of motion (Sanders
no. Sex (yr) Occupation injury type side Associated injuries (ISS) surgery Complications (degrees) et al.)

1 Male 41 Soldier RTA C3 Left Head injury (GCS 11), 34 Second Delayed union, 0-1151 Good
(Pedes- chest injury, stable week delayed
trian) pelvic fracture response to
Current Orthopaedic Practice

rehabilitation
program
2 Male 24 Car Fall from C3 Right Chest injury, stable 27 First Iliac crest pain, 5-851 Fair
Mechanic height spine fracture, right week Exuberant
lower limb injury callus
formation
3 Female 31 Teacher RTA C3 Left Chest injury, blunt 14 First Iliac crest pain 0-1201 Good
(Passen- abdominal injury, week
ger) stable pelvic
fracture, right lower
limb injury
4 Male 37 Teacher RTA C3 Right Right upper limb 16 First Exuberant callus 0-851 Poor
(Pedes- injury, stable pelvic week formation
trian) fracture, right lower
limb injury
5 Male 21 Student RTA C3 Right Head injury (GCS 12), 17 Second None 0-1301 Excellent
(Passen- chest injury, blunt week
ger) abdominal injury
6 Male 39 Private RTA C3 Left Chest injury, left 25 First Superficial 0-1201 Good
business (Passen- upper limb injury, week wound
ger) left lower limb infection,
injury delayed
response to
rehabilitation
program
7 Female 49 House wife RTA C3 Right Chest injury, blunt 17 Second Delayed wound 0-1201 Excellent
(Passen- abdominal injury, week healing
ger) stable pelvic
fracture
8 Male 36 Tailor RTA C3 Left Head injury (GCS 12), 22 Second None 0-1301 Excellent
(Pedes- blunt abdominal week
trian) injury, stable pelvic
fracture
9 Male 23 Unemployed Fall from C3 Left Blunt abdominal 17 First Delayed union 0-1251 Good
height injury, stable spine week
fracture, right
upper limb injury,
right lower limb
injury

GCS, Glasgow Coma Scale.

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FIGURE 1. Midline skin incision.
with the lateral parapatellar arthrotomy (Figure 7). The skin and
subcutaneous tissues were then closed.5,12
FIGURE 2. Incision of quadriceps fascia and exposure of quadriceps
muscle.
Volume 26  Number 3  May/June 2015
FIGURE 3. Exposure of both femoral condyles with preservation of
periosteum.
Because a continuous passive motion (CPM) machine was
not available, the limb was placed postoperatively in a
hinged knee immobilizer with the hinges unlocked to allow
assisted gradual range of motion as tolerated under
physiotherapy control. Crutch-assisted partial weight-bear-
ing was progressive, with full weight-bearing being post-
poned until there was radiographic evidence of bony union
(minimum of 12 wk postoperatively). Postoperatively, the
quality of reduction was checked radiographically taking
FIGURE 4. Reconstruction of the articular surface.
Current Orthopaedic Practice
FIGURE 5. Reconstruction of the articular surface (completed).
note of the amount of articular surface step-off and the
degree of any angular malalignment especially varus tilt of
the distal segment, while the presence of any significant
shortening was detected clinically.
Follow-up
The stability of hardware fixation and the progress of
fracture healing were examined radiographically and clin-
ically during the regular follow-up visits. Osseous healing
was defined radiographically as the presence of at least three
of four healed cortices, with bridging callus formation and
crossing bone trabeculae on anteroposterior and lateral
radiographs. Clinical healing was defined as the absence of
functional pain and local tenderness at the fracture site.13
Mean follow-up was 17.6 mo (range 14--26 mo). At the end
of the follow-up period, functional results were evaluated
according to the method of Sanders et al.,1 which depends
on range of motion (0-9 points), pain (0-10 points),
deformity (0-6 points), walking ability (0-9 points), and
return to work (0-6 points) as parameters for clinical scoring.
Accordingly, patients with 36-40 points, 26-35 points, 16-25
FIGURE 6. Internal fixation with lag screws and locked plate.
www.c-orthopaedicpractice.com | 273
FIGURE 7. Realignment of quadriceps muscle and extensor mechanism
before final closure.
points, or 0-15 points had excellent, good, fair, or poor
results, respectively.
RESULTS
None of the patients had a nonunion or malunion. Radio-
graphic signs of healing correlated with clinical signs of
healing (absence of pain or functional pain over the fracture
site). Reductions were near anatomic (< 2 mm step-off, <51
angular deformity, <1 cm shortening) in all patients. Mean
radiographic healing time was 19.2 wk (range, 13--27 wk), as
two patients initially had delayed union for more than
24 wk. Both these patients had a good final result. Clinically,
three patients had an excellent result (Figure 8), four patients
had a good result, one patient had a fair result, and one
patient had a poor result. The unsatisfactory (fair and poor)
results were because of restricted knee motion, in addition to
pain of variable degree, walking disability in both, and
change of job in one. No patient had skin necrosis or deep
infection. However, controlled superficial infection was
recorded in one patient who had a good result. No implant
failure or bone collapse occurred in any patient. In addition
to the above-mentioned residual knee stiffness, approach-
related complications, and delayed fracture union, two
patients had mild pain at the iliac crest bone graft donor
site, and two had a delayed response to the rehabilitation
program that necessitated manipulation under general
anesthesia at 3 and 4 wk from their date of surgery,
respectively. Both these patients had a good final result.
The two patients with considerable restriction of knee
flexion (fair and poor result) initially had severe comminu-
tion of the metaphyseal segment that required extensive
bone grafting; radiographic follow-up revealed excessive
callus formation. One of them underwent quadricepsplasty
surgery after 13 mo.
DISCUSSION
Intraarticular distal femoral fractures (especially type C3)
present a treatment challenge. Surgical treatment with
open reduction and internal fixation (ORIF) has been
274 | www.c-orthopaedicpractice.com
FIGURE 8. Patient no. 8 (A and B) Coronal and sagittal three-dimensional (3D) CT reconstruction showing AO type C3 fracture of the distal end of the left
femur. (C) Axial CT view showing intraarticular comminution. (D and E) Anteroposterior and oblique radiographic views at last follow-up showing complete
fracture healing and bone remodeling.
recommended since the 1960s and has been shown to be
superior to nonsurgical treatment. The goal of surgical
treatment is anatomical reconstruction of the articular
surface followed by stabilization of the articular condyles
to the diaphysis of the femur with appropriate length,
rotational, and axial alignment, and preserving the soft-
tissue envelope. The adopted stabilization must be estab-
lished by durable fixation that allows functional recovery
and promotes early knee motion during bone healing.2,14
Achieving this goal entails a great compromise between
adequate visibility to ensure perfect articular reduction and
acceptable anatomic reconstruction of the highly commin-
uted distal femoral segment, and the unacceptable high
extensile-approach-related complications, mainly wound
healing problems, bone fragments devitalization, nonunion,
arthrofibrosis, quadriceps scarring, and interference with
future total knee arthroplasty surgery that may be needed in
many of these patients.5,15
A vast array of surgical techniques and exposures have
been described to treat these fractures and ensure better
outcomes, including the common lateral approach with its
modifications, the double incision (lateral and medial)
Volume 26  Number 3  May/June 2015
approach, direct anterior (Henry) approach, extensile ap-
proaches with tibial tubercle osteotomy, minimally invasive
percutaneous techniques, retrograde distal femoral nailing,
and different external fixation techniques, all with short-
comings.2,5,10,16
Seeking a reasonable compromise for this dilemma, we
thought that adopting a certain surgical strategy might be
rewarded with better functional outcomes and fewer
complications. Our strategy involved using the swashbuckler
approach recommended by Starr et al.5 to expose the entire
articular surface of both femoral condyles and as much as
needed to expose the distal femoral metaphysis and lower
diaphysis. Meticulous articular surface reconstruction was
performed to obtain as near anatomical as possible distal
femoral realignment followed by rigid fixation with variably
directed interfragmental screws, locked plating and, in severe
medial comminution, a low-profile medial buttress plate.
Extensive metaphyseal comminution and bone defects were
augmented with bone graft. This surgical procedure was
complemented by early aggressive rehabilitation program.
Intraoperatively, we found that the swashbuckler ap-
proach greatly facilitated exposure of both femoral condyles
Current Orthopaedic Practice
and as much as needed of the distal metaphysis and even the
lower diaphysis without compromising the extensor mecha-
nism, thus allowing an early aggressive rehabilitation program.
Similar to literature findings, late bone devitalization and
collapse secondary to blood supply impairment did not
occur in this series.4,17 This might be due to the extensive
primary bone grafting and the fact that the blood supply of
the bone in this part of the femur is mainly posterior
through the major soft tissue attachments.
We believe and agree with Baker et al.18 that CT is essential
and extremely helpful for mapping complex intraarticular
fractures of the distal femur and detection of the commonly
missed coronal ‘Hoffa’ fractures, aiding very much in the
preoperative planning.
The distal femur locked plate has the disadvantage of
uniaxial screw direction, which was overcome by prior
application of separate lag screws. Biomechanically, Koval
et al.19 found that the locked buttress plate provided
significantly greater fixation stability than the standard plate
or blade plate, both before and after cycling in axial loading.
Buttressing severe medial comminution with a low-profile
medial plate in this study, increased the rigidity of fixation
construct, facilitated graft impaction, and encouraged early
rehabilitation without loss of reduction. Sanders et al.1 reported
the efficacy of a medial plate and bone graft in maintenance of
reduction during loading in early active motion without loss of
reduction or loosening of the implants. Also, Jazrawi et al.20
found that the locked double-plate construct provided signifi-
cantly greater fixation stability than the standard double-plate
construct. In spite of the proven biomechanical advantage of
locked plates over standard plates for fixation of unstable distal
femoral fractures, some recent reports claimed high rates of
defective callus formation, delayed union, nonunion, malrota-
tion, and implant failure, especially in severely comminuted
cases, despite use of a single lateral, mini-invasive lateral or
anterolateral approach.21--24 This could be explained on the
basis of a mechanical problem related to application of these
plates, particularly in the absence of fragment compression and
primary bone grafting. In our study, the lateral locked plate was
applied in all patients with 100% union rate, which might be
attributed to the preservation of periosteal blood supply, the
use of separate multidirectional lag screws, the medial buttress
plating for severe medial comminution, and primary bone
grafting, although the latter added a second site of potential
morbidity in two patients.
As regards knee stiffness, this type of injury is notorious
for having a relatively high incidence with extensile
approaches in which knee stiffness has been reported to
occur in as many as 25--33.3%.1,4,17 Ziran et al.25 believed
that extensive damage to suprapatellar tissues and lack of
immediate motion contributed largely to arthrofibrosis and
knee stiffness. In our series, stiffness of the knee with a
maximum of 851 flexion occurred in two patients. Both had
initially severe comminution of metaphyseal segment that
required extensive bone grafting, and the result was plagued
by exuberant callus formation. However, our incidence of
stiffness was lower than that found in the literature, perhaps
due to meticulous soft-tissue dissection, anatomical restora-
tion of the distal end of the femur with rigid internal
fixation and early aggressive rehabilitation.
www.c-orthopaedicpractice.com | 275
Deep infection is a well-known serious complication in
this type of injury that reaches up to 25% in some series.26
However, no patient developed this disastrous complication
in our study. This could be due to the absence of open
injuries, the use of prophylactic antibiotic, and the metic-
ulous dissection and soft-tissue handling. Similarly, Mize
et al.,17 in spite of using an extensile approach, applied the
same principle in eight of their patients with no recorded
infection or skin problems among them.
In comparison to our adopted surgical approach, Hier-
holzer et al.27 in a retrospective study reported 35 (Müller
type C) injuries some of which were type C3 fractures. These
were treated with a Less Invasive Stabilization System (LISS)
using an extensile lateral J-shaped approach with tibial
tubercle osteotomy. Their Knee Injury and Osteoarthritis
Outcome Score (KOOS)28 for the type C group was 218.
Their nonunion rate was 12%, hardware malposition 7%,
and infection 9%.
Lately, Kumar et al.29 published their clinical experience in
using Locking Compression Plate (LCP) in distal femoral
intraarticular fractures type C in 44 patients, 22 of whom
were type C3. They used an extensile anterolateral para-
patellar approach for C2 and C3 fractures. At latest follow-up
38 patients (86%) had good or excellent outcomes using the
Knee Society Score30 and 36 patients (82%) returned to their
preinjury functional level. These results are fairly comparable
to our results despite the different details of approach and
surgical technique and different scoring system.
The main weakness of this study is the rather small
number of patients, the lack of long-term follow-up, and the
lack of head-to-head comparison with a similar group of
patients treated with an alternative method of fixation such
as limited open reduction combined with retrograde intra-
medullary nailing. However, our results clearly demonstrate
that the surgical strategy presented here is a valid option that
ensures perfect articular surface reconstruction, reasonable
distal femoral anatomical realignment with rigid internal
fixation while preserving the periosteal sleeve, maintaining
the integrity of the extensor mechanism, respecting the
future total knee replacement surgery incision, and allowing
an essential aggressive postoperative rehabilitation program.
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