Surgical Tips and Tricks for Distal Femur Plating

Christopher Lee, MD; Dane Brodke, MD; Ajay Gurbani, MD


J Am Acad Orthop Surg. 2021;29(18):770-779. 

In This Article


The choice of approach is often dictated by the degree of articular involvement and consequent need to visualize the joint. For extraarticular patterns or fractures with minimal articular displacement, a direct lateral approach can be used. The iliotibial band is incised and the vastus lateralis retracted anteriorly and medially, with care taken to cauterize perforating vessels. Retractor placement over the top of the metaphyseal region is avoided so as to minimize soft-tissue dissection. This approach allows for direct visualization of the comminuted metaphyseal region in addition to lateral Hoffa fragments. This approach is often combined with minimally invasive techniques for plate application.

Fractures with notable articular comminution often require more extensile approaches, including the "swashbuckler" or anterolateral approach.[14] This approach involves a lateral parapatellar arthrotomy with either a direct anterior or a curved anterolateral incision. This approach can be extended cranially in a subvastus fashion and can expose the articular block in addition to the femoral shaft. In intraarticular distal femur fractures, especially with medial Hoffa fragments, a midline incision with a lateral parapatellar arthrotomy is the authors' preferred approach (Video 1). Care should be taken to minimize soft-tissue stripping, with only the lateral soft tissue elevated from the distal femur to facilitate final plate application. When using a curved anterolateral approach, an oblique incision through the tendinous portion of the quadriceps can be done to increase medial exposure, although this must be repaired at the conclusion of the surgery (Supplemental Digital Content, Video E1, dual plate fixation of a comminuted intra-articular distal femur fracture,