High mortality following distal femur fractures: a cohort study including three hundred and two distal femur fractures

Early and 1-year mortality of native geriatric distal femur fractures: A systematic review and time-to-event meta-analysis

Purpose

Distal femur fractures (DFF) account for 6% of all femoral fractures and predominate in females. The current 1-year mortality of DFF is currently reported to be between 10 and 38%, a wide margin, and confounded by multiple factors including age, high energy mechanisms, pathological and periprosthetic fractures. The purpose of this study was to assess and determine all-cause mortality following geriatric native distal femur fractures at 30 days, six months and one year.

Methods

- The databases Cochrane CENTRAL, MEDLINE, EMBASE and NHS NICE Healthcare Databases Advanced Search Interface were searched in accordance with PRISMA guidelines. Original research articles relevant to mortality outcomes in native geriatric distal femur fractures following low energy trauma were included. A time-to-event data meta-analysis model was used to estimate pooled 30-day, six month and one-year mortality. A random effects meta-regression model was performed to assess potential sources of heterogeneity when studies reported on factors affecting the mortality observed in patients with geriatric distal femur fractures.

Results

- Thirteen studies were included in the meta-analysis with a mean age of 79.6 years. Eight studies reported the 30-day mortality of distal femur fractures in patients as a pooled estimate of 8.14%. Pooled estimate for 6-month mortality reported was 19.5% and the one-year mortality reported by ten studies was 26.10%. Time-to-event modelling showed that risk of mortality at one year in elderly patients with distal femur fractures was significantly higher HR = 4.31 (p < 0.001). When evaluating prognostic predictors, age and Type C fracture were predictive of highest mortality rates.

Conclusions

- This study is the first meta-analysis to evaluate the early and long-term mortality observed in elderly patients presenting with native distal femoral fractures. Through our results we have shown the quantifiable impact patient age and fracture configuration has on one-year mortality in this patient cohort.

Distal femur fractures: basic science and international perspectives

Distal femur fractures are challenging injuries to manage, and complication rates remain high. This article summarizes the international and basic science perspectives regarding distal femoral fractures that were presented at the 2022 Orthopaedic Trauma Association Annual Meeting. We review a number of critical concepts that can be considered to optimize the treatment of these difficult fractures. These include biomechanical considerations for distal femur fixation constructs, emerging treatments to prevent post-traumatic arthritis, both systemic and local biologic treatments to optimize nonunion management, the relative advantages and disadvantages of plate versus nail versus dual-implant constructs, and finally important factors which determine outcomes. A robust understanding of these principles can significantly improve success rates and minimize complications in the treatment of these challenging injuries.

Risk of reverse golf club deformity with medial plating of distal femur fracture

INTRODUCTION

This study described a deformity induced by medial plating of supracondylar distal femur fractures using plates that are precontoured for other anatomic locations.

MATERIALS AND METHODS

OTA/AO 33A fractures were created in 12 sawbone femurs and fixed with either a proximal humerus locking plate (PH), an ipsilateral lateral tibial plateau plate (LTP), or an ipsilateral medial distal tibial plate (MDT). A motion capture system measured changes in length and rotation of the distal femur as the plate was applied. Each plate underwent four trials and the mean and standard deviation (SD) for each measurement was reported. An analysis of variance with post hoc Tukey test compared malreduction measures between plate types.

RESULTS

All plates consistently created a varus deformity. There was lateral lengthening with a compensatory medial shortening and an increase in the lateral distal femoral angle. The distal fracture fragment was laterally translated, and internally rotated. The PH plate had significantly greater lateral length (27.39 mm SD 4.78, p = 0.007), shorter medial length (13.57 mm SD 4.99, p = 0.028), greater lateral translation (28.82 mm SD 5.70, p = 0.010) and greater widening of the lateral distal femoral angle (28.54° SD 4.98, p < 0.001) than the LTP and MDT plates. The MDT plate had significantly greater angulation anteriorly (8.40° SD 1.07, p < 0.001) and laterally (7.63° SD 3.10, p = 0.002) than the PH and LTP plates. There was no significant difference between plates in internal rotation (PH: 3.07° SD 2.79; LTP: 2.05° SD 1.05; MDT 3.81° SD 3.56; p = 0.659).

CONCLUSION

When dual plating supracondylar distal femur fractures, poor plate positioning and a mismatch between plate contour and the slope of the medial distal femur can lead to varus angulation, internal rotation, and lateral translation or a "reverse golf club deformity". After comparing three types of precontoured plates, the authors recommend initial evaluation of the ipsilateral proximal tibial plate when placing a plate along the medial distal femur.

LEVEL OF EVIDENCE

IV.

Bone reconstruction with modified Masquelet technique in open distal femoral fractures: a case series

BACKGROUND

Large bone defects require complex treatment, multidisciplinary resources, and expert input, with surgical procedures ranging from reconstruction and salvage to amputation. The aim of this study was to provide the results of a case series of open comminuted intra-articular distal femoral fractures with significant bone loss that were managed by early fixation using anatomical plates and a modified Masquelet technique with the addition of surgical propylene mesh.

METHODS

This retrospective study included all patients referred to our institution with OTA/AO C3 distal femur open fractures and meta-diaphyseal large bone loss between April 2019 and February 2021. We treated the fractures with irrigation and debridement, acute primary screw and plate fixation in the second look operation, and Masquelet method using shell-shaped antibiotic beads supplemented by propylene surgical mesh to keep the cements in place. The second step of the procedure was conducted six to eight weeks later with bone grafting and mesh augmentation to contain bone grafts. Surprisingly, hard callus formation was observed in all patients at the time of the second stage of Masquelet procedure.

RESULTS

All five patients' articular and meta-diaphyseal fractures with bone loss healed without major complications. The average union time was 159 days. The mean knee range of motion was 5-95 degrees. The average Lower Extremity Functional Score (LEFS) was 49 out of 80.

CONCLUSIONS

Combination of early plate fixation and the modified Masquelet technique with polypropylene mesh is an effective method for managing large bone defects in open intra-articular distal femoral fractures with bone loss, resulting in shorter union time possibly associated with the callus formation process. This technique may also be applicable to the management of other similar fractures specially in low-income and developing areas.

Predictors of in-hospital mortality in older patients undergoing distal femur fracture surgery: A case-control study

INTRODUCTION

Geriatric fractures including distal femur and hip fractures are associated with high mortality rates. Currently, prognostic factors for in-hospital postoperative mortality are not identified. We aimed to evaluate overall in-hospital mortality and related potential risk factors in elderly patients who underwent distal femur fracture surgery.

MATERIALS AND METHODS

A retrospective cohort study of patients older than 60 years, who underwent distal femur fracture surgery between January 01, 2003, and December 31, 2021, was conducted. A case-control study was conducted to compare two age-matched groups of elderly patients of equivalent ages at a 1:4 ratio. The in-hospital mortality rate was calculated and potential confounders were compared between groups.

RESULTS

A total of 170 patients were enrolled; five died during hospital stay after undergoing surgery, yielding a 2.94% in-hospital mortality rate. Twenty patients who did not die were included in the control group. Patients' demographics were similar. The case-control comparison showed that the time from injury to surgery, preoperative hemoglobin level, estimated glomerular filtration rate (eGFR), and white blood cell count were significant factors correlated with in-hospital mortality.

DISCUSSION

The overall in-hospital mortality rate was 2.94%. Significant risk factors for in-hospital mortality included a longer time from injury to surgery, lower preoperative hemoglobin level and eGFR, and higher preoperative white blood cell count. In conclusion, preoperative comprehensive geriatric assessment, including cognitive, nutritional, and frailty status, should also be considered in the elderly fracture care model.

An analytical model of lateral condylar plate working length

BACKGROUND

The locking plate is a common device to treat distal femur fractures. Healing is affected by construct stiffness, thus many surgeon-controlled variables such as working length have been examined for their effects on strain at the fracture. No convenient analytical model which aids surgeons in determining working length has yet been described. We propose an analytical model and compare it to finite element analysis and cadaveric biomechanical testing.

METHODS

First, an analytical model based on a cantilever beam equation was derived. Next, a finite element model was developed based on a CT scan of a "fresh-frozen" cadaveric femur. Third, biomechanical testing in single-leg stance loading was performed on the cadaver. In all methods, strain at the fracture was recorded. An ANCOVA test was conducted to compare the strains.

FINDINGS

In all models, as the working length increased so did strain. For strain at the fracture, the shortest working length (35 mm) had a strain of 8% in the analytical model, 9% in the finite element model, and 7% for the cadaver. The longest working length (140 mm) demonstrated strain of 15% in the analytical model, and the finite element and biomechanical tests both demonstrated strain of 14%.

INTERPRETATION

The strain predicted by the analytical model was consistent with the strain observed in both the finite element and biomechanical models. As demonstrated in existing literature, increasing the working length increases strain at the fracture site. Additional work is required to refine and establish validity and reliability of the analytical model.

Primary and Periprosthetic Distal Femur Fractures in Older Adults: No Difference in 12-Month Mortality and Patient-Reported Outcomes

OBJECTIVES

To compare fracture incidence, mortality, and patient-reported health outcomes at 6 and 12 months postinjury between primary and periprosthetic distal femur fractures in older adults.

METHODS

A registry-based cohort study was conducted including all adults 70 years of age or older registered by the Victorian Orthopaedic Trauma Outcomes Registry who experienced a primary or periprosthetic distal femur fracture between 2007 and 2017. Outcomes included mortality and health status (Three-Level European Quality of Life-Five Dimensions Scale [EQ-5D-3L]) collected at 6 and 12 months postinjury. All distal femur fractures were confirmed by radiological review. Multivariable logistic regression was conducted to report associations between fracture type and mortality and health status.

RESULTS

A final cohort of 292 participants was identified. Overall mortality for the cohort was 29.8%, and no significant differences were found in mortality rate or EQ-5D-3L outcomes between fracture types (ie, primary vs. periprosthetic). A large proportion of participants reported problems across all EQ-5D-3L domains at 6 and 12 months postinjury, with slightly worse outcomes in the primary fracture group.

CONCLUSIONS

This study reports high mortality and poor 12-month outcomes in an older adult cohort with both periprosthetic and primary distal femur fractures. Given these poor outcomes, fracture prevention and a greater focus on long-term rehabilitation is needed in this cohort. In addition, the involvement of an ortho-geriatrician should be considered as a routine component of care.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

How Often Do Complications and Mortality Occur After Operatively Treated Periprosthetic Proximal and Distal Femoral Fractures? A Register-based Study

BACKGROUND

The incidence of periprosthetic femoral fractures is increasing because of an increasing number of primary THAs and TKAs. High rates of complications and mortality are associated with periprosthetic fractures, but few studies have evaluated and compared the population-based incidences of these events after fractures.

QUESTIONS/PURPOSES

(1) What is the annual incidence of periprosthetic fractures treated with surgery in one hospital district in Finland? (2) How are those incidences changing over time? (3) What is the risk of complications, reoperations, and death after those injuries?

METHODS

This register-based study evaluated 2259 patients who underwent revision THA or TKA or any surgery for a femoral fracture between January 2004 and December 2016 at the only hospital in our district where these types of operations are performed. During the study period, the diagnosis and operation codes of the operated-on patients varied greatly, and they were somewhat inaccurate. We thus evaluated radiographs of all 2259 patients one by one, and created inclusion and exclusion criteria based on radiologic findings and medical records. Of those, 12% (279 of 2259) had periprosthetic fractures that met the inclusion criteria, and from these, we formed two study groups (periprosthetic proximal femur fractures, n = 171; periprosthetic distal femur fractures, n = 108). Eighty-eight percent (1980 of 2259) of the patients were excluded because they were treated for a condition other than periprosthetic femoral fracture. The follow-up period ended in December 2019 or at the time the patient died. To evaluate the population-based incidence, we drew the number of individuals with THA or TKA in the hospital district from the Finnish Arthroplasty Register and the Finnish Hospital Discharge Register. The characteristics of patients with operatively treated periprosthetic femoral fractures were evaluated in terms of age, gender, fracture type, implant type, and time from the index operation to periprosthetic fracture. The annual incidences of periprosthetic femoral fractures are summarized per 1000 person-years of individuals living with an implanted THA or TKA and per 100,000 individuals per year living in our hospital district. The risks of death, complications, and reoperations were evaluated for both groups, and comparisons were made in terms of patient characteristics.

RESULTS

The mean annual incidence of operatively treated periprosthetic proximal femur fractures per 1000 people living with THA implants was 2.3 ± 0.9 (95% confidence interval 1.8 to 2.7) per year, and for those with periprosthetic distal femur fractures with TKA implants, it was 1.3 ± 0.6 (95% CI 1.0 to 1.7). There was an increasing trend in the incidence of periprosthetic proximal femur fractures from 1.6 to 3.8 (95% CI 1.8 to 2.8) per 1000 arthroplasties, and it increased from 0.4 to 1.7 (95% CI 2.4 to 4.4) for periprosthetic distal femur fractures between 2004 and 2016. The mean population-based incidence of periprosthetic proximal femur fractures per 100,000 person-years was 5.3 ± 2.2 (95% CI 4.1 to 6.4) per year, and for periprosthetic distal femur fractures, it was 3.4 ± 1.7 (95% CI 2.5 to 4.4). The incidence of periprosthetic proximal femur fractures related to 100,000 person-years increased from 3.2 to 8.9 (95% CI 3.9 to 6.6), while the incidence of periprosthetic distal femur fractures increased from 1.3 to 4.4 (95% CI 2.4 to 4.8) during the study period. The cumulative incidence of major complications after periprosthetic proximal femur fracture was 8.8% at 1 year (95% CI 5.1% to 13.6%) and 12.3% at 10 years (95% CI 7.5% to 18.4%), and after periprosthetic distal femur fracture, it was 7.4% at 1 year (95% CI 3.5% to 13.4%) and 9.3% at 10 years (95% CI 4.7% to 15.7%). The cumulative incidence of reoperation after periprosthetic proximal femur fracture was 10.5% at 1 year (95% CI 6.5% to 15.7%) and 13.5% at 10 years (95% CI 8.9% to 19.1%), and for periprosthetic distal femur fracture, it was 8.3% at 1 year (95% CI 4.1% to 14.5%) and 13.8% at 10% years (95% CI 7.8% to 21.4%). The cumulative incidence of death after periprosthetic proximal femur fracture was 8.2% at 1 year (95% CI 4.7% to 12.9%) and 47.3% at 10 years (95% CI 38.1% to 55.9%), and after periprosthetic distal femur fractures, it was 14.8% at 1 year (95% CI 8.8% to 22.2%) and 67.8% at 10 years (95% CI 56.3% to 76.9%).

CONCLUSION

The increased use of THA and TKA has led to an increase in the incidence of operatively treated periprosthetic fractures, which means there will be more revisions in the future. Older age, frailty of these patients, and often-complicated fracture patterns are related to a high rate of complications, reoperations, and mortality. Healthcare systems must prepare for a large increase in revisions for periprosthetic fracture, which are morbid events for patients and costly ones for healthcare systems.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Prediction of fracture nonunion leading to secondary surgery in patients with distal femur fractures

Aims

Several previously identified patient-, injury-, and treatment-related factors are associated with the development of nonunion in distal femur fractures. However, the predictive value of these factors is not well defined. We aimed to assess the predictive ability of previously identified risk factors in the development of nonunion leading to secondary surgery in distal femur fractures.

Methods

We conducted a retrospective cohort study of adult patients with traumatic distal femur fracture treated with lateral locking plate between 2009 and 2018. The patients who underwent secondary surgery due to fracture healing problem or plate failure were considered having nonunion. Background knowledge of risk factors of distal femur fracture nonunion based on previous literature was used to form an initial set of variables. A logistic regression model was used with previously identified patient- and injury-related variables (age, sex, BMI, diabetes, smoking, periprosthetic fracture, open fracture, trauma energy, fracture zone length, fracture comminution, medial side comminution) in the first analysis and with treatment-related variables (different surgeon-controlled factors, e.g. plate length, screw placement, and proximal fixation) in the second analysis to predict the nonunion leading to secondary surgery in distal femur fractures.

Results

We were able to include 299 fractures in 291 patients. Altogether, 31/299 fractures (10%) developed nonunion. In the first analysis, pseudo-R2 was 0.27 and area under the receiver operating characteristic curve (AUC) was 0.81. BMI was the most important variable in the prediction. In the second analysis, pseudo-R2 was 0.06 and AUC was 0.67. Plate length was the most important variable in the prediction.

Conclusion

The model including patient- and injury-related factors had moderate fit and predictive ability in the prediction of distal femur fracture nonunion leading to secondary surgery. BMI was the most important variable in prediction of nonunion. Surgeon-controlled factors had a minor role in prediction of nonunion.

Advancing Osteoporosis Evaluation Procedures: Detailed Computational Analysis of Regional Structural Vulnerabilities in Osteoporotic Bone

Osteoporotic fractures of the femur are associated with poor healing, disability, reduced quality of life, and high mortality rates within 1 year. Moreover, osteoporotic fractures of the femur are still considered to be an unsolved problem in orthopedic surgery. In order to more effectively identify osteoporosis-related fracture risk and develop advanced treatment approaches for femur fractures, it is necessary to acquire a greater understanding of how osteoporosis alters the diaphyseal structure and biomechanical characteristics. The current investigation uses computational analyses to comprehensively examine how femur structure and its associated properties differ between healthy and osteoporotic bones. The results indicate statistically significant differences in multiple geometric properties between healthy femurs and osteoporotic femurs. Additionally, localized disparities in the geometric properties are evident. Overall, this approach will be beneficial in the development of new diagnostic procedures for highly detailed patient-specific detection of fracture risk, for establishing novel injury prevention treatments, and for informing advanced surgical solutions.

Risk of pacemaker implantation after femur fracture in patients with and without a history syncope: a Danish nationwide registry-based follow-up study

BACKGROUND

It has previously been described that fall-associated injuries including fractures are commonly observed among patients with bradyarrhythmia. However, knowledge on the risk of pacemaker implantation after admission due to femur fracture from large population-based epidemiologic data is lacking. Therefore, we investigated the risk of pacemaker implantation following femur fracture in patients with and without a history of previous syncope.

METHODS

All patients with femur fracture between 2005-2017 were identified using the Danish Nationwide Patient Registry. Among these, patients already having a pacemaker were excluded. Primary outcome was one-year risk of pacemaker implantation and secondary outcome was one-year all-cause mortality. Multivariable logistic regression was used to obtain absolute and relative risks of the study endpoint in relation to patients with versus without history of syncope and standardized to the age, sex, selected comorbidity and pharmacotherapy distribution of all patients.

RESULTS

Of 93,093 patients with femur fracture, 5508 (5.9%) had a history of syncope within five years. Patients with prior syncope were slightly older (84 vs. 83 years), more often male (33.6% vs. 29.4%), and had more often comorbidities relative to those without history of syncope. All-cause mortality was significantly higher among those with previous history of syncope compared to those without previous syncope (29.9% vs. 28.6%, P = 0.021). The relative mortality risk was 1.05 (95% CI: 1.01-1.09, P = 0.021). A total of 695 (0.8%) patients underwent pacemaker implantation within 5 years following femur fracture, and a significantly higher proportion of patients with syncope had a pacemaker implanted within one year (1.6% vs. 0.7%, P < 0.001; relative risk, 2.01 [95% CI: 1.55-2.46]).

CONCLUSIONS

In patients with femur fracture, a history of syncope was significantly associated with a higher one-year risk of pacemaker implantation.

Investigation of distal femur microarchitecture and factors influencing its deterioration: An ex vivo high-resolution peripheral quantitative computed tomography study

While fractures of the distal femur are often considered as fragility fractures, detailed knowledge of the bone microarchitecture at this skeletal site is largely unavailable. Initial evaluation of a patient cohort with distal femur fractures showed a markedly increased occurrence in elderly women. The purpose of this study was to determine the extent to which demographic characteristics of distal femur fractures are reflected by general age- and sex-specific variations in local microarchitectural parameters. Fifty cadaveric femora were collected from 25 subjects (12 females, 13 males, age 25-97 years). A volume of interest within 3 cm proximal to the condyles was analyzed using high-resolution peripheral quantitative computed tomography (HR-pQCT), which revealed impaired trabecular and cortical bone microarchitecture in women compared to men as well as in osteoporotic compared to normal or osteopenic subjects, as classified by dual-energy X-ray absorptiometry (DXA) T-score. Linear regression analyzes showed negative associations between age and HR-pQCT parameters in women (e.g., cortical thickness -14 µm/year, 95% CI: -21 to -7 µm/year), but not in men (e.g., cortical thickness 1 µm/year, 95% CI: -12 to 14 µm/year). HR-pQCT parameters showed strong positive associations with areal bone mineral density (aBMD) determined by DXA at the hip in both sexes. Taken together, our findings suggest that female sex, advanced age, and low aBMD represent major risk factors for impaired microarchitecture at the distal femur. Both the diagnostic value of DXA for predicting distal femur fractures and the efficacy of bone-specific agents on fracture risk reduction should be investigated in the future.

Effect of Age on the Patterns of Traumatic Femoral Fractures: Seven Years of Experience at a Regional Tertiary Hospital

Objective

Femoral fractures are a common cause of mortality and functional loss, mainly among older people, and there are few studies about the age in relation to traumatic femoral fractures. The aim of this study was to investigate the effect of age on the patterns of traumatic femoral fractures in patients presenting to our regional tertiary hospital.

Methods

The records of 2020 patients who presented with traumatic femoral fractures between 2013 and 2019 were retrospectively reviewed. The patients' clinical and radiographic records were reviewed. Univariate and multivariable logistic regression were used to identify independent risk factors for associated injuries and complications.

Results

The patients were divided into a child group (CH group, n = 342) aged under 18 years, a young adult group (YA group, n = 484) aged 18–60 years, and an older people group (OP group, n = 1194) aged 60 years and over. There were significant differences among the three groups in several indexes, such as sex ratio (χ² = 301.699, p < 0.001), osteoporosis (χ² = 375.463, p < 0.001), injury time of day (χ² = 114.913, p < 0.001), injury cause (χ² = 748.187, p < 0.001), injury location (χ² = 490.153, p < 0.001), fracture side (χ² = 57.000, p < 0.001), fracture site (χ² = 806.650, p < 0.001), associated injuries (χ² = 322.921, p < 0.001), coma after injury (χ² = 147.814, p < 0.001), non‐surgery‐related complications (χ² = 7.895, p = 0.019), and surgery‐related complications (χ² = 82.186, p < 0.001). The YA group had a significantly higher percentage of patients with surgery‐related complications than the OP group. The OP group had a higher frequency of non‐surgery‐related complications than the YA group and CH group. The most common non‐surgery‐related complications were pneumonia (7.1%) in the OP group and deep venous thrombosis (6.4%) in the YA group. Multivariable logistic regression showed that young adults, high‐energy injury, outdoors, coma after injury, and fracture sites except for the proximal region were independent risk factors for associated injuries. Older age, male, and fracture site except for the proximal region were independent risk factors for complications.

Conclusions

Traumatic femoral fractures are mostly the result of low‐energy trauma and predominantly affect the proximal site of the femur among older people. A higher rate of shaft fractures, fractures occurring outdoors, and associated injuries were observed among young adults and children than among older people.

Does distance from joint line influence complications after distal femur fractures in native and periprosthetic knees?

BACKGROUND

Distal femur fractures are projected to increase in incidence secondary to an aging population and growing utilization of total knee arthroplasty. Surgical management is the standard of care, but optimal treatment for far distal fractures is still unclear. Our study investigates if there are distal femur fractures too distal to be treated with lateral locked plating in periprosthetic fractures.

METHODS

One hundred and ten consecutive patients treated with locked plating for distal femur fractures around a total knee replacement were identified using CPT codes. Fractures were classified by length of the distal fracture segment and Su classification. Complications studied were nonunion, malunion, infection, further fracture related surgery, readmission within 90 days, and mortality within 1 year of surgery. Sixty six fractures met inclusion criteria of 180 days of follow-up or sustaining a complication prior to180 days.

RESULTS

The size of the distal fracture segment and Su classification did not correlate with increased complication rate in periprosthetic distal femur fractures.

CONCLUSIONS

There was no difference between complications following lateral locked plating of distal femur fractures based on the size of the distal fracture segment in periprosthetic fractures. Lateral locked plating is an effective treatment modality for these fractures regardless of how distal the fracture extends.

Comparable Outcomes Between Native and Periprosthetic Fractures of the Distal Femur

Despite the rising prevalence of arthroplasty and aging population, limited data exist regarding differences in periprosthetic fracture clinical outcomes compared with native counterparts. This study compares differences in hospital treatment, morbidity, and mortality associated with periprosthetic distal femur fractures at an urban level 1 trauma center. We retrospectively reviewed all adult AO/OTA type 33 fractures (526) that presented to our institution between 2009 and 2018. In total, 54 native and 54 periprosthetic fractures were matched by age and gender. We recorded demographics, operative measures, length of stay (LOS), discharge disposition, and mortality. We used McNemar's and paired t-tests for analysis where appropriate (p < 0.05) (IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY; IBM Corp.). The average age at injury was 74 years ± 12 (native) compared with 73 years ± 12 (periprosthetic). After 1:1 matching, the groups had similar body mass index (31.01 vs. 32.98, p = 0.966 for native and periprosthetic, respectively) and mechanisms of injury with 38 native and 44 periprosthetic (p = 0.198) fractures from low-energy falls. Both groups had 51/54 fractures managed with open reduction internal fixation with a locking plate. The remaining were managed via amputation or intramedullary nail fixation. Mean operative time (144 minutes (±64) vs. 132 minutes (±62), p = 0.96) and estimated blood loss (319 mL (±362) vs. 289 mL (±231), p = 0.44) were comparable between the native and periprosthetic groups, respectively. LOS: 9 days ± 7 (native) versus 7 days ± 5 (periprosthetic, p = 0.31); discharge disposition (to skilled nursing facility/rehab): n = 47 (native) versus n = 43 (periprosthetic, p = 0.61); and mortality: n = 6 (native) versus n = 8 (periprosthetic, p = 0.55). No significant differences were observed. We found no statistical differences in morbidity and mortality in periprosthetic distal femur fractures treated over 10 years at a level 1 trauma center. Native and periprosthetic AO/OTA type 33 distal femur fractures are serious injuries with similar outcomes at a level 1 trauma center.

Conceptualizing Biological Aging and Frailty in Orthopaedics: A Framework for Clinical Practice

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Biological aging can best be conceptualized clinically as a combination of 3 components: frailty, comorbidity, and disability.

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Despite advancements in the understanding of senescence, chronological age remains the best estimate of biological age. However, a useful exercise for practitioners is to look beyond chronological age in clinical and surgical decision-making.

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A chronologically aging person does not age biologically at the same rate.

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The best way to understand frailty is to consider it as a physical phenotype.

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Physical optimization should parallel medical optimization before elective surgery.

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The poorer the host (both in terms of bone quality and propensity for healing), the more robust the implant construct must be to minimize reliance on host biology.

Practical approach to the native distal femur fractures in the elderly: A rapid review over the recent trends

Significant work has been done in recent years on treatment strategies for distal femur fractures. Inclusive reviews on periprosthetic fractures of distal femur have been carried out recently, but there is a lack of such reviews on the subject of native distal femur fractures in the recent literature. In this narrative review, we are set out to address the latest updates on geriatric non-periprosthetic distal femur fractures, and perform a rapid review over different treatment options, arriving at a summarized proposed treatment algorithm.

[Distal femoral fractures]

CLINICAL ISSUE

Fractures of the distal femur represent rare but serious injuries with a high 1‑year mortality. An increasingly older patient population requires adapted treatment concepts.

STANDARD TREATMENT PROCEDURE

Surgical treatment using angular stable plating and retrograde nailing is the standard procedure. Conservative treatment is only indicated in cases of low demands and high perioperative risks of the patient.

TREATMENT INNOVATIONS

Primary double plate osteosynthesis and primary implantation of a distal femoral replacement represent new treatment procedures and show promising initial results in the collective of geriatric patients.

DIAGNOSTIC WORK-UP

Conventional radiographs in 2 planes and computed tomography with multiplanar and 3D reconstructions should be performed to enable an adequate assessment of the indications and treatment planning.

PERFORMANCE

Nonunion rates of plate and nail osteosyntheses range from 4% to 10%. No significant differences in long-term results can be observed. The results regarding double plate osteosynthesis and distal femoral replacement so far do not show any disadvantages compared to the existing procedures but there is still insufficient data for general recommendations.

ASSESSMENT

Complex fractures with extensive reconstructive procedures and treatment by distal femoral replacement should be performed in specialized centers.

PRACTICAL RECOMMENDATIONS

The gold standard is still surgical treatment by means of minimally invasive angular stable plate or retrograde nail osteosynthesis. Complex fracture forms require individual treatment planning considering all currently available treatment options.

Distal femur complex fractures in elderly patients treated with megaprosthesis: Results in a case series of 11 patients

BACKGROUND

Surgical treatment of complex fractures of the distal femur in the elderly is controversial. Osteoporosis and pre-existent osteoarthritis are common comorbidities in the elderly which add to the need for early walking and rapid restoration of function and also pose significant obstacles to achievement of satisfactory results with standard fixation techniques. Recently, several authors have suggested that primary arthroplasty could be a viable alternative option to standard fixation techniques in selected patients with complex distal femur fractures.

AIM

To present our experience with 11 cases of distal femur fractures treated with knee arthroplasty and large femoral resection in a population of patients over the age of 85.

METHODS

Data from 11 consecutive patients (10 females, 1 male) presenting with acute intra-articular supracondylar or intercondylar distal femur fractures and with pre-existent primary osteoarthritis who were treated with primary knee arthroplasty were recorded. We collected standard demographic data, comorbidities and patient reported outcomes including Visual Analogical Scale (VAS), Oxford Knee Score (OKS) and Barthel's Index. Post-operative joint range of motion (ROM) and standard radiographic data were also collected.

RESULTS

At a mean follow-up of 23.2 mo, all of the implants were well-positioned and osteointegrated. Furthermore, all the patients were alive and walking either independently or with walking aids. There was a marked improvement in pain (VAS 4.5 postop vs 1.9 at the last follow-up), OKS score (29.5 postop vs 36.81 at the last follow-up), ROM (96.2° postop vs 102° at the last follow-up) and restoration of pre-injury ambulatory status (average Barthel Index 77.3). The radiographic evaluations showed good restoration of the articular geometry. No deaths and no complications were recorded.

CONCLUSION

In conclusion, we believe that knee megaprosthesis in the case of complex fractures of the distal femur is a valid surgical choice. This is particularly true in elderly patients with severe osteoporosis and pre-existing osteoarthritis. It is important to note that this surgery should be performed by surgeons with proven experience in prosthetic hip and knee surgery and that a scrupulous selection of the cases is completed.

Predictive factors for mortality after distal femoral fractures in the elderly: A retrospective multicenter (TRON group) study

PURPOSE

This retrospective multicenter study aimed to assess the 1-year mortality rate in elderly patients with distal femoral fractures (DFFs) and identify potential risk factors for mortality.

METHODS

We analyzed 321 patients aged 65 years and older with DFFs treated surgically between 2012 and 2019 in 13 hospitals. Patient demographics and surgical characteristics were extracted from medical records and radiographs. We used univariable and multivariable Cox regression analyses to identify the factors affecting mortality.

RESULTS

The mortality rate for DFFs in elderly patients at 1 year was 9.0%. Multivariable Cox regression analysis revealed older age, male sex, underweight (body mass index [BMI] <18.5 kg/m²), bedridden status, and nursing home residency to be independent predictors for mortality (older age: hazard ratio [HR] 1.07, 95% confidence interval [CI] 1.03-1.11, P<0.001; male sex: HR 3.08, 95% CI 1.23-7.71, P=0.015; underweight: HR 1.93, 95% CI 1.01-3.68, P=0.045; bedridden status: HR 4.59, 95% CI 1.61-13.07, P=0.0042; and nursing home residency: HR 2.63, 95% CI 1.18-5.83, P=0.017). None of the factors associated with surgery including types of fixation, time from initial visit to surgery, blood loss during operation, and operation time was an independent predictor for mortality.

CONCLUSION

The 1-year mortality rate in elderly patients with DFFs was relatively low at 9.0%. Older age, lower BMI, and nursing home residency were associated with mortality after surgery for DFFs. Factors associated with the surgical procedure were not significant predictors.

Low body mass index is a risk factor for increased post-operative mortality and poor functional improvement in distal femur fractures among patients aged over 65: A multicentre (TRON) study

BACKGROUND

Distal femur fractures have been reported to have a mortality rate comparable to hip fractures, but the risk is still unknown. Recent studies have reported that low body mass index (BMI) is a risk factor for mortality in the elderly. We investigated the efficacy of low BMI for predicting the risk of mortality in distal femur fractures in patients aged over 65 within 18 months after injury and its impact on postoperative clinical outcomes and mortality.

METHODS

Data from patients followed for more than six months were obtained from our trauma research group's database. We investigated risk factors for increased mortality using Cox proportional hazards models. We divided the analysed cases into low (<18.5 kg/m²) and high (>18.5 kg/m²) BMI groups. We adjusted the background characteristics of the groups by patient matching, and evaluated the postoperative mortality, complication rate, and knee society score (KSS).

RESULTS

We identified 216 patients, including 58 (26.9%) with low BMI values. Low BMI was an independent risk factor for mortality in all models (Hazard Ratio: 2.9, p = 0.011). The overall survival rate of the low BMI group at 18 months was significantly lower than that of the high BMI group (70.7% vs. 89.1%; p = 0.003). The complication rates of the low BMI and high BMI groups were not significantly different (33.3% vs. 22.2%; p = 0.283). The mean KSS values at 3, 6, and 12 months in the low BMI group was significantly worse than that in the high BMI group (78.7 ± 16.2 vs. 84.8 ± 13.1; p = 0.035, 82.2 ± 16.9 vs. 89.7 ± 8.9; p = 0.005, 86.4 ± 13.0 vs. 91.4 ± 8.4; p = 0.020, respectively).

CONCLUSIONS

Our study indicated that low BMI was independent associated with increased mortality and impaired postoperative functional recovery in distal femur fractures of the elderly patients.

Associations between Early Surgery and Postoperative Outcomes in Elderly Patients with Distal Femur Fracture: A Retrospective Cohort Study

Previous literature has provided conflicting results regarding the associations between early surgery and postoperative outcomes in elderly patients with distal femur fractures. Using data from the Japanese Diagnosis Procedure Combination inpatient database from April 2014 to March 2019, we identified elderly patients who underwent surgery for distal femur fracture within two days of hospital admission (early surgery group) or at three or more days after hospital admission (delayed surgery group). Of 9678 eligible patients, 1384 (14.3%) were assigned to the early surgery group. One-to-one propensity score matched analyses showed no significant difference in 30-day mortality between the early and delayed groups (0.5% versus 0.5%; risk difference, 0.0%; 95% confidence interval, −0.7% to 0.7%). Patients in the early surgery group had significantly lower proportions of the composite outcome (death or postoperative complications), shorter hospital stays, and lower total hospitalization costs than patients in the delayed surgery group. Our results showed that early surgery within two days of hospital admission for geriatric distal femur fracture was not associated with a reduction in 30-day mortality but was associated with reductions in postoperative complications and total hospitalization costs.

30-day and 1-year mortality after skeletal fractures: a register study of 295,713 fractures at different locations

Background and purpose - Few studies have reported the mortality rate after skeletal fractures involving different locations, within the same population. We analyzed the 30-day and 1-year mortality rates following different fractures.Patients and methods - We included 295,713 fractures encountered in patients 16-108 years of age, registered in the Swedish Fracture Register (SFR) from 2012 to 2018. Mortality rates were obtained by linkage of the SFR to the Swedish Tax Agency population register. The standardized mortality ratios (SMR) at 30 days and 1 year were calculated for fractures in any location and for each of 27 fracture locations, using age- and sex-life tables from Statistics Sweden (www.scb.se).Results - The overall SMR at 30 days was 6.8 (95% CI 6.7-7.0) and at 1 year 2.2 (CI 2.2-2.2). The SMR was > 2 for 19/27 and 13/27 of the fracture locations at 30 days and 1 year, respectively. Humerus, femur, and tibial diaphysis fractures were all associated with high SMR, at both 30 days and 1 year.Interpretation - Patients sustaining a fracture had approximately a 7-fold increased mortality at 30 days and over 2-fold increased mortality at 1 year as compared with what would be expected in the general population. High mortality rates were seen for patients with axial skeletal and proximal extremity fractures, indicating frailty in these patient groups.

Mortality after distal femur fractures in the elderly

INTRODUCTION

the frequency of distal femur fractures in the elderly is rapidly increasing. A study of these fractures was conducted in our center in order to evaluate the comorbidities and the mortality associated with this entity.

MATERIAL AND METHODS

all the distal femur fractures by low energy in patients over 65 years old at a tertiary center were included, between January 2010 and December 2016. Baseline characteristics, the type of fracture, comorbidities, and functional status before admission, were collected. The relationship of each of these variables to the final functional class, immediate and late complications and mortality during the follow-up. Fifty-nine patients were included, with a median age of 85.3 years (IQR 78.6-91.6). Fifty-one patients were women. In 10 patients, the fractures were atraumatic (postural change mainly in non-walking patients), and in 54 of the cases were treated surgically (6 with retrograde intramedullary nailing and 48 with lateral locking plate). The median time to surgery was 4.5 days (IQR 2-6) and 14 patients were operated within 48 hours. The median follow-up was 26.3 months.

RESULTS

fourteen patients died during the first year of follow-up. Factors independently associated with death during the first year after the fracture were: conservative treatment, and the inability to ambulate before the episode. The absence of certain comorbidities, such as chronic heart disease, and cancer, and an age under 80 years, behaved as protective factors.

CONCLUSION

low-energy distal femur fractures comprise a severe injury in the elderly and are associated with high mortality. Surgical treatment showed better outcomes in terms of survival, with no significant differences depending on the type of fracture, the type of implant or the median time to surgery.

Distal femur fractures have a higher mortality rate compared to hip fractures among the elderly: Insights from the National Trauma Data Bank

INTRODUCTION

The comparison of mortality and morbidity between distal femur (DF) and hip fracture in the old age is rarely reported in the literature. We aim to analyze a nationwide database among the elderly to compare the outcomes between hip fractures and distal femur fractures in the United States.

MATERIALS AND METHODS

A retrospective analysis of the National Trauma Data Bank was queried between 2007-2014 to identify distal femur (DF) and hip fracture patients greater than 65 years of age. Outcomes analyzed included in-hospital mortality, total hospital length of stay(LOS), intensive care unit length of stay(ICU-LOS), length of ventilation use and hospital discharge disposition. Multivariable regression models were performed to adjust for potential confounders. Statistical significance was established at p < 0.001.

RESULTS

26,325 (10.1%) and 233,213 (89.9%) patients reported a diagnosis of DF and hip fracture, respectively. The inpatient mortality rate was significantly higher in the distal femur fracture group (8.3% vs. 6.7%), with significantly longer LOS (7.87 vs. 6.65), ICU-LOS (1.50 vs. 0.73), and required ventilation days (0.74 vs. 0.27). Multivariable analyses demonstrated that hip fracture patients had a lower mortality (adjusted odds ratio [aOR], 0.80; 95% CI [0.76, -0.85]; p < 0.001), shorter LOS ([aOR], -0.31; 95% CI [-0.39, -0.23]; P < 0.001), and more likely to be discharged home ([aOR], 0.88; 95% CI, 0.85, 0.91; P < 0.001, compared to DF fracture patients.

CONCLUSION

After adjusting for potential factors, DF fracture patients have a significantly higher mortality, longer LOS, and less likely to be discharged home compared to hip fractures among the elderly. These results may suggest clinicians and caregivers for closely monitoring of clinical conditions for these patients.

LEVEL OF EVIDENCE

III.

Hybrid locked medial plating in dual plate fixation optimizes the healing of comminuted distal femur fractures: A retrospective cohort study

OBJECTIVES

Dual plate fixation has been reported to be effective in the treatment of comminuted distal femur fractures (DFFs). However, optimized use of the medial plate and screws is less studied. This study aimed to evaluate the effect of a hybrid configuration of the medial plate in dual plate fixation of comminuted DFFs in promoting fracture healing.

MATERIALS AND METHODS

We retrospectively analyzed 62 patients with comminuted DFFs (AO/OTA 33-A3/33-C2/33-C3) from January 2015 to March 2020, who were either fixed with lateral locked plating augmented with hybrid locked medial plating (LP-HLMP, n = 32) or lateral locked plating (LLP, n = 30) alone. Specifically, compression screws were applied in the middle of the medial plate and flanked by locking ones at both ends. Baseline characteristics, radiological and clinical outcomes were reviewed and analyzed. Multivariate logistic regression analysis was used to identify predictive factors for early fracture healing, and risk factors for delayed union/nonunion.

RESULTS

Demographics including age, gender, smoking, diabetes, and injury mechanism were comparable between the two groups. Reduction quality was better in the LP-HLMP group (p < 0.001). Although the LP-HLMP group experienced longer duration of surgery (125 min vs. 100 min, p < 0.001), sign of healing at 3 months was more obvious in this group (75%, 24/32 vs. 30%, 9/30; p < 0.001). The LP-HLMP group also presented with higher union rate (93.8%, 30/32 vs. 56.7%, 17/30; p = 0.001) and lower reoperation rate (0%, 0/32 vs. 13.3%, 4/30; p = 0.049). Kolment score showed no statistical significance between the two groups. Multivariate analysis revealed that younger age (< 60 years) (OR 5.99, 95%CI 1.16 - 31.03; p = 0.001) and LP-HLMP fixation (OR 45.90, 95% CI 4.78 - 440.56; p = 0.001) predict early healing; while smoking (OR 17.80, 95% CI 2.41 - 131.49; p = 0.01) and fracture translation (OR 3.49, 95% CI 1.46 - 8.32; p = 0.01) were identified as risk factors for delayed union/nonunion.

CONCLUSION

Hybrid locked medial plating in this study favors the healing of comminuted DFFs and reduces reoperation. Additionally, smoking and suboptimal reduction (translation) predict delayed union/nonunion.

Finite element analysis of biomechanical effects of residual varus/valgus malunion after femoral fracture on knee joint

OBJECTIVE

Post-operative femoral shaft fractures are often accompanied by a residual varus/valgus deformity, which can result in osteoarthritis in severe cases. The purpose of this study was to investigate the biomechanical effects of residual varus/valgus deformities after middle and lower femoral fracture on the stress distribution and contact area of knee joint.

METHODS

Thin-slice CT scanning of lower extremities and MRI imaging of knee joints were obtained from a healthy adult male to establish normal lower limb model (neutral position). Then, the models of 3°, 5°, and 10° of varus/valgus were established respectively by modifying middle and lower femur of normal model. To validate the modifying, a patient-specific model, whose BMI was same to former and had 10° of varus deformity of tibia, was built and simulated under the same boundary conditions.

RESULT

The contact area and maximum stress of modified models were similar to those of patient-specific model. The contact area and maximum stress of medial tibial cartilage in normal neutral position were 244.36 mm² and 0.64 MPa, while those of lateral were 196.25 mm² and 0.76 MPa. From 10° of valgus neutral position to 10° of varus, the contact area and maximum stress of medial tibial cartilage increased, and the lateral gradually decreased. The contact area and maximum stress of medial meniscus in normal neutral position were 110.91 mm² and 3.24 MPa, while those of lateral were 135.83 mm² and 3.45 MPa. The maximum stress of medial tibia subchondral bone in normal neutral position was 1.47 MPa, while that of lateral was 0.65 MPa. The variation trend of medial/lateral meniscus and subchondral bone was consistent with that of tibial plateau cartilage in the contact area and maximum stress.

CONCLUSION

This study suggested that varus/valgus deformity of femur had an obvious effect on the contact area and stress distribution of knee joint, providing biomechanical evidence and deepening understanding when performing orthopedic trauma surgery or surgical correction of the already existing varus/valgus deformity.

How deadly is a fracture distal to the hip in the elderly? An observational cohort study of 11,799 femoral fractures in the Swedish Fracture Register

Background and purpose - Unlike hip fractures, diaphyseal and distal femoral fractures in elderly patients have not been widely studied. We investigated the demographics, comorbidities and mortality of patients with femoral fractures at any anatomical level with a focus on early mortality.Patients and methods - We analyzed 11,799 patients ≥ 65 years with a femoral fracture registered in the Swedish Fracture Register from 2011 to 2014. The cohort was matched with the National Patient Register to obtain data on comorbidities classified according to the Charlson Comorbidity Index (CCI). Generalized linear models were fitted to estimate the adjusted relative risk of mortality.Results - Mean age of the cohort was 83 years and 69% were women. Patients with distal femoral fractures had the lowest degree of comorbidity, with 9% having a CCI of ≥ 3 compared with 14% among those with proximal and 16% among those with diaphyseal fractures. Unadjusted 90-day mortalities were 13% (95% CI 9.4-16) after fractures in the distal, 13% (CI 10-16) in the diaphyseal, and 15% (CI 14-15) in the proximal segment. The adjusted relative risk for 90-day mortality was 1.1 (CI 0.86-1.4) for patients with distal and 0.97 (CI 0.76-1.2) for patients with diaphyseal femoral fractures when compared with patients with hip fractures.Interpretation - Elderly patients with femoral fractures distal to the hip may have similar adjusted early mortality risks to those with hip fractures. There is a need for larger, preferably prospective, studies investigating the effect of rapid pathways and geriatric co-management for patients with diaphyseal and distal femoral fractures.

More than a reposition tool: additional wire cerclage leads to increased load to failure in plate osteosynthesis for supracondylar femoral shaft fractures

INTRODUCTION

Surgical treatment of supracondylar femoral fractures can be challenging. An additional wire cerclage is a suggested way to facilitate fracture reduction prior to plate osteosynthesis. Denudation to the periosteum remains a problematic disadvantage of this procedure. This study analyzed the effect of an additional wire cerclage on the load to failure in plate osteosynthesis of oblique supracondylar femoral shaft fractures.

MATERIALS AND METHODS

On eight pairs of non-osteoporotic human femora (mean age 74 years; range 57-95 years), an unstable AO/OTA 32-A2.3 fracture was established. All specimens were treated with a polyaxially locking plate. One femur of each pair was randomly selected to receive an additional fracture fixation with a wire cerclage. A servohydraulic testing machine was used to perform an incremental cyclic axial load with a load to the failure mode.

RESULTS

Specimens stabilized with solely plate osteosynthesis failed at a mean load of 2450 N (95% CI: 1996-2904 N). In the group with an additional wire cerclage, load to failure was at a mean of 3100 N (95% CI: 2662-3538 N) (p = 0.018). Compression deformation with shearing of the condyle region through cutting of screws out of the condylar bone was the most common reason for failure in both groups of specimens. Whereas axial stiffness was comparable between both groups (p = 0.208), plastic deformation of the osteosynthesis constructs differed significantly (p = 0.035).

CONCLUSIONS

An additional wire cerclage significantly increased the load to failure. Therefore, an additional cerclage represents more than just a repositioning aid. With appropriate fracture morphology, a cerclage can significantly improve the strength of the osteosynthesis.

The Treatment of Periprosthetic Distal Femoral Fractures After Total Knee Replacement: A Critical Analysis Review

Periprosthetic distal femoral fracture after total knee arthroplasty carries substantial morbidity and mortality regardless of fixation technique. Surgical treatment is favored in most patients compared with conservative therapy because of high rates of nonunion, malunion, and reoperation after casting or bracing. Internal fixation techniques including retrograde intramedullary nailing and locked plating are favored for surgical treatment in most fractures when bone stock in the distal fragment allows for appropriate fixation. In the setting of deficient distal femoral bone stock or femoral component loosening, revision arthroplasty with distal femoral replacement is the favored technique. Further studies with regard to the use of intramedullary nailing, locked plating, and distal femoral replacement are necessary to refine the indications for each technique and to define the use of combinations of these fixation techniques.

MODERN ASPECTS OF THE PROBLEM OF FRACTURES OF THE PROXIMAL FEMULAR

The purpose of the study is to study the current global clinical and epidemiological features of proximal hip fractures and the risks of their development and spread. The paper identifies the main aspects of the spread and treatment of fractures of the proximal femur; main world modern epidemiological characteristics of hip fractures and levels of risks of their development and spread. The relationship between comorbidities in patients with proximal hip fractures and the risk of various treatment complications is shown. The main types of treatment tactics are identified, the groups of the most common comorbidities in such patients are given. As a result of the work it was established: the percentage of fractures of the proximal thigh is 9.00–45.00 % among all skeletal fractures in the older age group and among all age categories – 17.00–24.00 %; global annual morbidity is 1.7 million people, and mortality – 11.00–23.00 % in 6 months and 22.00–29.00 % in a year; increase in the frequency of these fractures with age with doubling after 50 years every ten years; average age of patients – 75–79 years; predominance of women over men in 2-3 times; the lowest annual age-standardized cases among women are in Nigeria, South Africa, Tunisia and Ecuador, and the highest are in Denmark, Norway, Sweden and Austria, which is also typical for men; significant economic burden of treatment and high levels of fractures with osteoporosis, cardiovascular disease, diabetes, chronic obstructive pulmonary disease and more; the advantage of surgical treatment over conservative.

[Distal femoral fractures]

With a prevalence of approximately 0.4%, distal femoral fractures are a rare entity. Nevertheless, due to the high mortality rates, which are comparable to proximal femoral fractures, these fractures are highly important. The clinical symptoms are often quite striking. In combination with preoperative computed tomography (CT) and if necessary, supplemented by CT angiography, the morphological situation can be assessed and the decision making facilitated. There are several different treatment options and the appropriate one should be selected for each individual case. The use of external fixation of the complete knee joint in the sense of damage control surgery, is useful. For definitive treatment retrograde intramedullary nailing and locking plates with angle stable screws are the main options. Modern angle stable and anatomically preformed implants enable surgical treatment using minimally invasive approaches to protect the soft tissues, with a better overall outcome.

Management of neglected distal femur epiphyseal fracture-separation

INTRODUCTION

Neglected epiphyseal fracture-separations of the distal femur are rare. Still reported in developing countries, they lead to therapeutic issues. The objective of the study is to describe their characteristics and to propose treatment options.

MATERIALS AND METHODS

Ten years of ongoing study was held in our orthopedics department. All patients with a neglected epiphyseal fracture-separations of the distal femur after a knee trauma were included in the study. Pre-operative and post-operative data were collected and analyzed.

RESULTS

A total of 13 cases of neglected traumatic epiphyseal fracture-separations of the distal femur were found among 8616 in-patients of the department. It was mainly boys (9M/4F) around 16 years that were received 14 weeks after knee trauma. Most of the injuries were an AO-type 33-E/2.1 (Simple Salter-Harris' type II) (n=12) distal femur malunion (n=10). Associated complications were cutaneous opening (n=7), superficial infection (n=4), deep infection (n=4). Fractures were management surgically (n=12) by an open osteoclasis procedure (n=9), debridement (n=7) and a thigh amputation (n=1). The outcome was better if an open osteoclasis procedure was early performed in closed distal femur mal-union with a complementary rehabilitation program.

CONCLUSION

Specialized trauma care facilities must be increased, and trauma education programs must be undertaken to avoid neglected epiphyseal fracture-separations of the distal femur in developing countries.