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Thorne TJ, Nelson CT, Lisitano LS, Higgins TF, Rothberg DL, Haller JM, Marchand LS. Dual Plating of Distal Femoral Fractures. JBJS Essent Surg Tech 2024; 14:e23.00018. [PMID: 38903606 PMCID: PMC11186817 DOI: 10.2106/jbjs.st.23.00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2024] Open
Abstract
Background Dual plating of the distal femur is indicated for the treatment of complex intra-articular fractures, supracondylar femoral fractures, low periprosthetic fractures, and nonunions. The aim of this procedure is anatomical alignment of the articular surface, restoration of the articular block, and prevention of varus collapse. Description Following preoperative planning, the patient is positioned supine with the knee flexed at 30°. The lateral incision is made first, with a mid-lateral incision that is in line with the femoral shaft. If intra-articular work is needed this incision can be extended by curving anteriorly over the lateral femoral condyle. Next, the iliotibial band is transected in line with its fibers. The vastus lateralis fascia is incised and elevated off the septum, working distal to proximal. Care should be taken to maintain hemostasis when encountering femoral artery perforating vessels. Once there is adequate exposure, several reduction aids can be utilized, including a bump under the knee, Schanz pins, Kirschner wires, and reduction clamps. A lateral precontoured plate is placed submuscularly, and the most proximal holes are filled percutaneously. The medial incision begins distally at the adductor tubercle and is a straight incision made proximally in line with the femoral shaft. The underlying fascia is transected in line with the skin incision, and the vastus medialis is elevated. Care should be taken to avoid the descending geniculate artery, as well as its articular branch and the muscular branch to the vastus medialis. A lateral tibial plateau plate is contoured and placed. Alternatives Nonoperative treatment of distal femoral fractures is rare, but relative indications for nonoperative treatment include frailty of the patient, lack of ambulatory status, a non-reconstructible fracture, or a stable fracture. These patients are placed in a long-leg cast followed by a hinged knee brace1. There are several other surgical fixation options, including lateral plating, retrograde intramedullary nailing, distal femoral replacement, and augmentation of a retrograde nail with a plate. Rationale Dual plating has several benefits, depending on the clinical scenario. Biomechanical studies have found that dual plating results in increased stiffness and construct strength2,3. Additional construct stability can be offered through the use of locking plates, particularly in osteoporotic bone. Taken together, this increased stability and construct strength can allow for earlier weight-bearing, which is particularly important for fractures in the geriatric population. Furthermore, the increased stiffness and construct strength make this procedure a favorable treatment option for nonunion, and it has been shown to result in lower rates of postoperative nonunion compared with lateral plating alone4-7. Adjunctive use of a medial plate also has been suggested to prevent varus collapse, particularly with metaphyseal comminution and poor bone quality2,3,8. Finally, in the periprosthetic fracture population, dual plating also removes the concern of incompatibility with a retrograde nail. Expected Outcomes The outcomes of dual plating are promising, given the severity of the injury. When comparing operative to nonoperative treatment outcomes, nonoperatively managed patients had worse functional outcomes and higher rates of complications related to immobility1. Dual plating of supracondylar fractures and intra-articular distal femoral fractures yields nonunion rates ranging from 0% to 12.5%, lower than the 18% to 20% reported with lateral locking plates4-7,9-12. This reduction in nonunions has been shown to lead to fewer revisions when compared with single-plating techniques7. In prior studies, 95% of nonunions treated with the dual-plating technique achieved union postoperatively11. One concern when utilizing the medial approach is critical damage to medial vascularity; however, this result has not been reported in the literature, and there is a safe operating window13. Despite the benefits of dual plating, there are relatively high rates of infection following dual plating (0% to 16.7%) compared with lateral plating alone (3.6% to 8.5%)5,14-17. However, many of these studies are small case series, highlighting that a surgeon's comfort and skill with these procedures is paramount to patient outcomes. Important Tips Meticulous placement and contouring of lateral and medial plates are required to prevent malreduction of the articular block that creates a "golf-club deformity."18,19During the medial approach, be aware of descending geniculate artery-particularly its muscular branch, which is ∼5 cm from the adductor tubercle/medial epicondyle, and its root, which enters the compartment at the adductor hiatus at ∼16 cm13.
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Affiliation(s)
- Tyler J. Thorne
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - Chase T. Nelson
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | | | - Thomas F. Higgins
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - David L. Rothberg
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - Justin M. Haller
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - Lucas S. Marchand
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
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Nauth A, Haller J, Augat P, Anderson DD, McKee MD, Shearer D, Jenkinson R, Pape HC. Distal femur fractures: basic science and international perspectives. OTA Int 2024; 7:e320. [PMID: 38487402 PMCID: PMC10936154 DOI: 10.1097/oi9.0000000000000320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/21/2023] [Accepted: 12/26/2023] [Indexed: 03/17/2024]
Abstract
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.
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Affiliation(s)
- Aaron Nauth
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Peter Augat
- Paracelsus Medical University in Salzburg, Austria and Institute of Biomechanics at Trauma Centre Murnau, Salzburg, Germany
| | - Donald D. Anderson
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - Michael D. McKee
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ
| | - David Shearer
- Department of Orthopaedic Surgery, University of California, San Francisco, CA
| | - Richard Jenkinson
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Çalbiyik M, Zehir S, Demirezen MO. Comparison of radiological and functional results in osteoporotic distal femur fractures operated with single plating, lateral incision, and double plating, anterior paramedial incision: A retrospective study. Medicine (Baltimore) 2024; 103:e36904. [PMID: 38306559 PMCID: PMC10843363 DOI: 10.1097/md.0000000000036904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/18/2023] [Indexed: 02/04/2024] Open
Abstract
Treatment of osteoporotic distal femur fractures is often complicated by a high rate of nonunion and varus collapse. For such fractures, lateral plating with lateral incision and double plating with anterior paramedial incision have shown promising results in the recent literature. The hypothesis of this study was that bilateral plating of comminuted distal femur fractures in osteoporotic patients would result in higher union rates and lower revision rates compared to an isolated lateral locking plate. The study included 56 patients (23 males, 33 females) with supracondylar femur fracture. According to the OA/OTA classification, 9 were type A3, 8 were A2, 13 were C1, 16 were C2, and 10 were C3. The mean follow-up period was 12 months, with 29 patients treated using lateral mini-incision, lateral locking plate, and 27 patients treated with anterior paramedial incision, dual plating. The clinical and radiological results were evaluated. The mean duration of radiological union in the studied population was 15 ± 2.1 months (range, 11-21 months) in the single plate group (Group A), and 13.5 ± 2.6 months (range, 9-19 months) in the double plate group (Group B). Mean ROM was 112.3° and flexion contracture 4° in Group A, and ROM 108.3° and flexion contracture 6.7° in Group B. (P = .15). The average Western Ontario and McMaster Universities Arthritis Index (WOMAC) score was 85.6 points in Group A and 83.5 points in Group B (P = .2278). The postoperative anteversion measurement in the operated extremity ranged from -15 to 19 in Group A, and from 5 to 18 in Group B. When the anteversion degrees were compared between the injured and uninjured extremities in the postoperative period, a significant difference was observed within Group A (P = .0018), but no significant difference was observed in Group B (P = .2492). Dual plate fixation using the anterior paramedial approach is an effective operative method for osteoporotic distal femur fractures. This has many advantages such as precise exposure, easy manipulation, anatomic reduction, and stable fixation. However, for surgical indications and medial bone defects > 1 cm, grafting should be performed.
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Affiliation(s)
- Murat Çalbiyik
- Hitit University, Faculty of Medicine, Department of Orthopedics and Traumatology, Corum, Turkey
| | - Sinan Zehir
- Hitit University, Faculty of Medicine, Department of Orthopedics and Traumatology, Corum, Turkey
| | - Murat Okan Demirezen
- Hitit University, Faculty of Medicine, Department of Orthopedics and Traumatology, Corum, Turkey
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Gavaskar AS, Tummala NC, Reddy CR, Gopalan H, Srinivasan P. What Is the Likelihood of Union and Frequency of Complications After Parallel Plating and Supplemental Bone Grafting for Resistant Distal Femoral Nonunions? Clin Orthop Relat Res 2024; 482:362-372. [PMID: 37638842 PMCID: PMC10776157 DOI: 10.1097/corr.0000000000002809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/11/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Management of resistant distal femur nonunions is challenging because patients not only have disability from an unhealed fracture, but also often have a shortened femur, stiff knee, deformities, and bone defects to address during revision surgery. Dual plating of the distal femur in such a setting can maintain stability that allows the nonunion to heal while also addressing bone defects and correcting deformities simultaneously. Dual-plating techniques that have been described lack standardization with regard to the size and type of medial-side implants and configuration of the dual-plate construct. QUESTIONS/PURPOSES (1) What proportion of patients achieve radiologic evidence of union after parallel plating of resistant distal femoral nonunions? (2) What improvements in function are achieved with this approach, as assessed by improvements in femoral length discrepancy, knee flexion, and patient-reported outcome scores? (3) What complications are associated with the technique? METHODS Between 2017 and 2020, the senior author of this study treated 38 patients with resistant distal femoral nonunions, defined here as nonunions that persisted for more than 12 months since the injury despite a minimum of two previous internal fixation procedures. During the study period, our preferred technique for treating aseptic, resistant distal femoral nonunions was to use dual plates in a parallel configuration augmented with autografts. Of 38 patients, three patients with active signs of infection who underwent resection and reconstruction using bone transport techniques and two patients older than 65 years with deficient distal femur bone stock who underwent endoprosthetic reconstruction were excluded. Of the 33 included patients, 67% (22 of 33) were male. The median age was 40 years (range 20 to 67 years). Nonunion was articular and metaphyseal in 13 patients and metaphyseal only in 20 patients. Our surgical approach was to remove existing implants, perform intraoperative culturing to rule out infection, debride the nonunion, correct the deformity, perform intra-articular and extra-articular lysis of adhesions with quadriceps release, and apply fixation using medial and lateral fixed-angle anatomic locked implants positioned in a parallel configuration. Every attempt to improve length was undertaken, and the defects were filled with autografts. A total of 97% of patients were followed until union occurred (one of 33 was lost to follow-up before union was documented), and 79% (26 of 33) were assessed for functional outcomes at a minimum of 2 years (median 38 months [range 25 to 60 months]) after excluding patients lost to follow-up and those in whom union did not occur after parallel plating. Union was defined as evidence of central trabecular bridging on AP radiographs and posterior cortical bridging on lateral radiographs. These radiologic criteria were defined to overcome difficulties in assessing radiologic healing in patients with lateral and medial plates. With parallel plating, bridging trabecular bone along the posterior cortex on lateral radiographs and the central region on AP radiographs is visualized and can be appreciated and interpreted as evidence of healing in two orthogonal planes. Preoperative and follow-up clinical assessment of knee ROM, the extent of femoral length correction based on calibrated femoral radiographs before and after surgery, and the evaluation of improvement in lower limb function based on the preoperative and follow-up differences in responses to the lower extremity functional scale (LEFS) were studied (the LEFS is scored from 0 to 80, with higher scores representing better function). Complications and secondary surgical procedures to address them were abstracted from a longitudinally maintained trauma database. RESULTS Sixty-seven percent (22 of 33) of nonunions showed radiologic healing by 24 weeks, and another 24% (eight of 33) healed by 36 weeks. Six percent (two of 33) did not unite, and one patient was lost to follow-up before union was documented. In the 79% (26 of 33) of patients available for final functional outcome assessment, the median femoral shortening had improved from 2.4 cm (range 0 to 4 cm) to 1.1 cm (range 0 to 2.3 cm; p < 0.001), and the median knee ROM had improved from 70° (range 20° to 110°) to 100° (range 50° to 130°; p = 0.002) after surgery. The median LEFS score improved to 63 (range 41 to 78) compared with 22 (range 15 to 33; p < 0.001) before surgery. Serious complications, including major thromboembolic events, iliac graft site infection, knee stiffness (flexion < 60°), and medial plate impingement necessitating removal, were seen in 30% (10 of 33) of patients. Secondary surgical interventions were performed in 24% (eight of 33) of patients to address procedure-related complications. CONCLUSION Based on our findings, a high likelihood of union and improvements in knee and lower limb function can be expected with parallel plating of resistant distal femur nonunions using anatomic locked plates. However, the increased frequency of complications observed in our study suggests the need for improvements in dual-plating techniques and to explore possible alternative fixation methods through larger multicenter comparative studies. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Von Rehlingen-Prinz F, Eggeling L, Dehoust J, Huppke C, Strahl A, Neumann-Langen MV, Glaab R, Frosch KH, Krause M. Current standard of care for distal femur fractures in Germany and Switzerland. Injury 2023; 54:110936. [PMID: 37516571 DOI: 10.1016/j.injury.2023.110936] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/09/2023] [Accepted: 07/10/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND Distal femur fractures occur with an incidence of 4.5/100,000 and show a prevalence of 0.4%. Causes include low-impact trauma in older patients and high-impact trauma in younger patients without pre-existing medical conditions. The aim of this study was to perform a comprehensive evaluation of trauma mechanisms, trauma-promoting factors, comorbidities, medication history and type of surgical care to provide an overview of the causes of injury and the most appropriate therapeutic approach. METHODS In this multicenter cohort study a retrospective analysis of 229 patients who sustained a distal femur fracture between January 2011 and December 2020 was performed. Individual fracture patterns, fracture predisposing factors, concomitant disease profiles, medication history, treatment strategy and associated complications were analyzed. RESULTS 229 patients were included in the retrospective analysis. A total of 113-type 33 A, 50-type 33 B and 66-type 33 C fractures were diagnosed, of whom 92% received a lateral locking plate osteosynthesis. There was a complication in 14.4% of all cases, of which 6.1% were attributable to infection. Significant risk factors for developing a complication were an increased BMI (29.9 ± 8.5 kg/m2; p = 0.04), fracture displacement of over half a shaft width (p < 0.001) and AOC fractures (p < 0,016), specifically C2 fractures (p < 0,008). CONCLUSION In this multicenter retrospective cohort study, lateral locking plate osteosynthesis was the method of choice and was selected in over 90% of cases, regardless of the fracture classification and risk factors. A complication rate of 14.4% emphasizes the necessary analysis of patient- and care-specific risk factors and a resulting adjustment of the therapy strategy. An increased BMI (29.9 ± 8.5 kg/m2; p = 0.04), fracture displacement of over half a shaft width (p < 0.001) and AOC fractures (p < 0,016), specifically C2 fractures (p < 0,008) increase the risk of developing a complication and should prompt an early switch to a treatment strategy that provides more stability.
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Affiliation(s)
- F Von Rehlingen-Prinz
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - L Eggeling
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Klinikum Hamburg, Bergedorfer Str. 10, 21033 Hamburg, Germany
| | - J Dehoust
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Klinikum Hamburg, Bergedorfer Str. 10, 21033 Hamburg, Germany
| | - C Huppke
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Strahl
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - M V Neumann-Langen
- Klinikum Konstanz, Department of Orthopaedic and Trauma Surgery, Mainaustrasse 35, 78464 Konstanz, Germany
| | - R Glaab
- Departmet of Traumatology, Cantonal Hospital Aarau, Tellstrasse 25, CH-5001, Aarau, Switzerland
| | - K H Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Klinikum Hamburg, Bergedorfer Str. 10, 21033 Hamburg, Germany
| | - M Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Poelmann J, Kloen P. Modified use of the proximal humeral internal locking system (PHILOS) plate for distal femoral nonunions. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:425-433. [PMID: 35061100 PMCID: PMC9930358 DOI: 10.1007/s00590-022-03203-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/29/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Nonunion is a common complication after a distal femoral fracture (DFF). Standard treatment consists of revision plating and/or bone grafting. Single lateral plating for a distal femoral nonunion can be insufficient in case of a persistent medial gap and compromised bone stock. Alternatively, dual plating can be used to treat a distal femoral nonunion, but to date there is no Gold standard. The aim of our study was to report our results after use of a minimally invasively placed proximal humeral internal locking system (Philos) plate as a medial buttress in the treatment of a distal femoral nonunion. METHODS Fifteen adult patients with a distal femoral nonunion were prospectively entered in a trauma database and retrospectively assessed. All patients underwent a similar operation, which included removal of failed hardware, nonunion debridement, fixation with a lateral plate, and a medial Philos plate combined with bone grafting. Data collected included union rate, time to union, complications and functional outcome. RESULTS In twelve out of fifteen patients (80%), the fracture united after our index operation. Median time to union was 4.8 months (range 1.6-15). Three patients (20%) needed additional bone grafting surgery. One patient underwent a Judet quadricepsplasty. CONCLUSION This study suggests that the Philos plate is a safe and effective adjunct as a medial buttress plate for distal femoral nonunions.
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Affiliation(s)
- Josje Poelmann
- Department of Orthopedic Surgery, Amsterdam University Medical Center, Meiberdreef 9, Amsterdam, 1105AZ, The Netherlands.
| | - Peter Kloen
- grid.509540.d0000 0004 6880 3010Department of Orthopedic Surgery, Amsterdam University Medical Center, Meiberdreef 9, Amsterdam, 1105AZ The Netherlands
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van Trikt CH, Donders JCE, Klinger CE, Wellman DS, Helfet DL, Kloen P. Operative treatment of nonunions in the elderly: Clinical and radiographic outcomes in patients at minimum 75 years of age. BMC Geriatr 2022; 22:985. [PMID: 36539691 PMCID: PMC9764700 DOI: 10.1186/s12877-022-03670-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Limited information exists on nonunion treatment in the elderly. This retrospective study evaluates whether results of operative treatment of nonunion of the humerus or femur in patients aged ≥ 75 years are comparable to those in younger patients. METHODS We identified patients age ≥ 75 years with a nonunion of humerus or femur treated with open reduction and internal fixation. The Non-Union Scoring System was calculated. Complications, clinical outcome, and radiographic findings were assessed. Primary endpoint was nonunion healing. A literature review compared time to healing of humeral and femoral nonunion in younger populations. RESULTS We identified 45 patients treated for a nonunion of humerus or femur with > 12 months follow-up. Median age was 79 years (range 75-96). Median time to presentation was 12 months (range 4-127) after injury, median number of prior surgeries was 1 (range 0-4). Union rate was 100%, with median time to union 6 months (range 2-42). Six patients underwent revision for persistent nonunion and healed without further complications. CONCLUSIONS Using a protocol of debridement, alignment, compression, stable fixation, bone grafting and early motion, patients aged 75 years or older can reliably achieve healing when faced with a nonunion of the humerus or femur. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Clinton H. van Trikt
- grid.509540.d0000 0004 6880 3010Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Johanna C. E. Donders
- grid.509540.d0000 0004 6880 3010Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Craig E. Klinger
- grid.5386.8000000041936877XOrthopaedic Trauma Service, Hospital for Special Surgery and New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY USA
| | - David S. Wellman
- grid.260917.b0000 0001 0728 151XOrthopaedic Trauma Service, Westchester Medical Center, New York Medical College, Valhalla, NY USA
| | - David L. Helfet
- grid.5386.8000000041936877XOrthopaedic Trauma Service, Hospital for Special Surgery and New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY USA
| | - Peter Kloen
- grid.509540.d0000 0004 6880 3010Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
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Rajasekaran RB, Jayaramaraju D, Palanisami DR, Agraharam D, Thippeswamy PB, Rajasekaran S. Role of impaction bone grafting of allografts in the management of benign lesions of the proximal femur. J Orthop 2022; 34:189-195. [PMID: 36104992 PMCID: PMC9465316 DOI: 10.1016/j.jor.2022.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose of study The use of allografts to reconstruct benign lesions of the proximal femur after curettage has seldom been reported. We report our experience of impaction bone grafting of only allografts combined with osteosynthesis to manage benign lesions involving the proximal femur. Materials and methods Between 2013 and 2019, 35 patients of a mean age of 23.8 years (14-41) who had a biopsy proven benign pathology and a median pre-operative Mirels' score of 9 (8-11) were managed using extended curettage, impaction bone grafting of allografts combined with osteosynthesis through a lateral approach. Radiographs were assessed to see for any recurrence at follow-ups, and functional outcomes were assessed using Musculoskeletal Tumour Society (MSTS) score and Harris hip score (HHS). Results At a mean follow-up was 41.5 months (23-80), patients demonstrated favorable functional outcomes with a mean MSTS of 28.3 (18-30) and a mean HHS of 94.3 (66-100) at the last follow-up. Two cases (GCT = 1; fibrous dysplasia = 1) had a recurrence of disease. Allografts demonstrated a particular integration pattern on radiographs that involved an intermediate period of lucency followed by consolidation and integration with the parent bone. Conclusion Impaction grafting of allografts in benign lesions of the proximal femur allows adequate bony consolidation of the cavity after extended curettage and can be effectively used as a permanent solution to manage such lesions in most cases. The intermediate period of lucency seen on radiographs must not be confused for recurrence, and patients must be followed up continuously. Study design Retrospective Case Series. Level of evidence Level IV.
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Affiliation(s)
- Raja Bhaskara Rajasekaran
- Department of Orthopaedics & Trauma, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
| | - Dheenadhayalan Jayaramaraju
- Department of Orthopaedics & Trauma, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
| | - Dhanasekara Raja Palanisami
- Department of Orthopaedics & Trauma, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
| | - Devendra Agraharam
- Department of Orthopaedics & Trauma, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
| | - Pushpa Bhari Thippeswamy
- Department of Radiology, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
| | - Shanmuganathan Rajasekaran
- Department of Orthopaedics & Trauma, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
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Bhowmick K, Jepegnanam TS, Inja DB, Karuppusami R, Nithyananth M. The outcomes of surgical treatment for lateral Hoffa fracture nonunions. Arch Orthop Trauma Surg 2022; 143:2509-2517. [PMID: 35723709 DOI: 10.1007/s00402-022-04503-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 05/28/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Lateral Hoffa nonunion are rare injuries. A significant percentage of these nonunions are due to missed acute lateral Hoffa fractures. Operative management of these injuries is difficult and complicated by the presence of bone loss, infection, and soft-tissue contractures. In this study, the aim was to assess clinical and functional outcome in our group of patients with lateral Hoffa nonunion who had undergone operative management and to determine whether variables such as fracture type, infection, and previous surgery affect nonunion/complication rates. MATERIALS AND METHODS Data were analyzed for patients with lateral Hoffa nonunion who underwent surgical fixation from January 2008 to December 2020 at a tertiary-care referral center. Patients with lateral condyle Hoffa nonunion and having a minimal follow-up of 1 year were included in this study. Patients with medial Hoffa nonunion, pathological fractures, and children aged less than 16 years were excluded from the study. The fractures were classified by the AO/OTA and Letenneur classification systems. Clinical and functional outcomes were assessed by the Knee society score (KSS) and the lower extremity functional scale (LEFS). RESULTS All the 12 patients had united in our series. One patient had reduction failure at 3 months who united after re-fixation. The union rate in our patients was 100%, with a loss of reduction rate of 7.7%, and post-traumatic arthrosis of 7.7%. The average follow-up period was 52.16 ± 27.7 months. The mean knee flexion obtained at the final follow-up was 104.5° (80°-130°). The average KSS clinical score was 80.6 (65-88). The average KSS functional score was 92 (70-100). The average LEFS score was 71 (47-79). There is a statistically significant improvement in the knee range of motion in our patients (p = 0.001). However, no correlation could be detected between variables like type of fracture, infection, and previous surgeries and outcomes. CONCLUSIONS Lateral Hoffa nonunion can be managed with careful planning of surgical approaches and fixation techniques.
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Affiliation(s)
- Kaushik Bhowmick
- Department of Orthopaedics, Christian Medical College, Vellore, India
| | | | - Dan Barnabas Inja
- Department of Orthopaedics, Christian Medical College, Vellore, India
| | - Reka Karuppusami
- Department of Biostatistics, Christian Medical College, Vellore, India
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Stoffel K, Sommer C, Lee M, Zhu TY, Schwieger K, Finkemeier C. Double fixation for complex distal femoral fractures. EFORT Open Rev 2022; 7:274-286. [PMID: 35446259 PMCID: PMC9069857 DOI: 10.1530/eor-21-0113] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
For complex distal femoral fractures, a single lateral locking compression plate or retrograde intramedullary nail may not achieve a stable environment for fracture healing. Various types of double fixation constructs have been featured in the current literature. Double-plate construct and nail-and-plate construct are two common double fixation constructs for distal femoral fractures. Double fixation constructs have been featured in studies on comminuted distal femoral fractures, distal femoral fracture with medial bone defects, periprosthetic fractures, and distal femoral non-union. A number of case series reported a generally high union rate and satisfactory functional outcomes for double fixation of distal femoral fractures. In this review, we present the state of the art of double fixation constructs for distal femoral fractures with a focus on double-plate and plate-and-nail constructs.
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Affiliation(s)
- Karl Stoffel
- Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland
| | - Christoph Sommer
- Department of Surgery, Kantonsspital Graubuenden, Chur, Switzerland
| | - Mark Lee
- Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, California, USA
| | - Tracy Y Zhu
- AO Innovation Translation Center, AO Foundation, Davos, Switzerland
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Tripathy SK, Mishra NP, Varghese P, Panigrahi S, Purudappa PP, Goel A, Sen RK. Dual-Plating in Distal Femur Fracture: A Systematic Review and Limited Meta-analysis. Indian J Orthop 2022; 56:183-207. [PMID: 35140850 PMCID: PMC8789962 DOI: 10.1007/s43465-021-00489-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/13/2021] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Although lateral locking plate has shown promising results in distal femur fracture, there are high rates of varus collapse and implant failure in comminuted metaphyseal and articular fractures. This systematic review evaluates the functional outcomes and complications of dual plating in the distal femur fracture. MATERIALS AND METHODS Manual and electronic search of databases (PubMed, Medline Embase and Cochrane Central Register of Controlled Trials) was performed to retrieve studies on dual plate fixation in the distal femur fracture. Of the retrieved 925 articles, 12 were included after screening. RESULTS There were one randomized-controlled, four prospective and seven retrospective studies. A total of 287 patients with 292 knees were evaluated (dual plating 213, single plating 76, lost to follow-up 3). The nonunion and delayed union rates following dual plate fixations were up to 12.5% and 33.3%, respectively. The mean healing time ranged from 11 weeks to 18 months. Good to excellent outcome was observed in 55-75% patients. There was no difference between the single plate and dual plate fixation with regards to the functional outcomes (VAS score, Neer Score and Kolmert's standard) and complications. Pooled analysis of the studies revealed a longer surgical duration (MD - 16.84, 95% CI - 25.34, - 8.35, p = 0.0001) and faster healing (MD 5.43, 95% CI 2.60, 8.26, p = 0.0002) in the double plate fixation group, but there was no difference in nonunion rate (9.2% vs. 0%, OR 4.95, p = 0.13) and blood loss (MD - 9.86, 95% CI - 44.97, 25.26, p = 0.58). CONCLUSION Dual plating leads to a satisfactory union in the comminuted metaphyseal and articular fractures of the distal femur. There is no difference between the single plate and dual plate with regards to nonunion rate, blood loss, functional outcomes and complications. However, dual fixation leads to faster fracture healing at the cost of a longer surgical duration.
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Affiliation(s)
- Sujit Kumar Tripathy
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019 India
| | - Narayan Prasad Mishra
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019 India
| | - Paulson Varghese
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019 India
| | - Sibasish Panigrahi
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019 India
| | | | - Akshay Goel
- Joan C Edwards School of Medicine, Marshall University, Huntington, WV USA
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12
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Grecula MJ. CORR Insights®: What Is the Likelihood of Union After Coronal Limb Realignment Using Revision Osteosynthesis and Concurrent TKA in Patients with Advanced Arthritis and Loss of Fixation After Distal Metaphyseal Femur Fractures? Clin Orthop Relat Res 2021; 479:1262-1264. [PMID: 33760758 PMCID: PMC8133273 DOI: 10.1097/corr.0000000000001742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/02/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Michael J Grecula
- M. J. Grecula, Department of Orthopedics, University of Texas Medical Branch at Galveston, Galveston, TX, USA
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Rajasekaran RB, Palanisami DR, Natesan R, Jayaramaraju D, Rajasekaran S. Reply to "Megaprosthesis in distal femur nonunions in elderly patients-experience from twenty-four cases: a letter to editor". INTERNATIONAL ORTHOPAEDICS 2020; 44:2191-2192. [PMID: 32377782 DOI: 10.1007/s00264-020-04586-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/27/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Raja Bhaskara Rajasekaran
- Department of Orthopaedics & Trauma, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam road, Coimbatore, India.
| | - Dhanasekara Raja Palanisami
- Department of Orthopaedics & Trauma, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam road, Coimbatore, India
| | - Rajkumar Natesan
- Department of Orthopaedics & Trauma, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam road, Coimbatore, India
| | - Dheenadhayalan Jayaramaraju
- Department of Orthopaedics & Trauma, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam road, Coimbatore, India
| | - Shanmuganathan Rajasekaran
- Department of Orthopaedics & Trauma, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam road, Coimbatore, India
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Sain A, Sharma V, Farooque K, V M, Pattabiraman K. Dual Plating of the Distal Femur: Indications and Surgical Techniques. Cureus 2019; 11:e6483. [PMID: 31903313 PMCID: PMC6935741 DOI: 10.7759/cureus.6483] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Dual-plating of the distal femur is required in some cases to achieve stable fixation. The indications of a medial plate in addition to the lateral plate are medial supracondylar bone loss, low trans-condylar bicondylar fractures, medial Hoffa fracture, peri-prosthetic distal femur fractures, non-union after failed fixation with single lateral plate, poor bone quality and comminuted distal femur fractures (AO type C3). We recommend orthogonal plate configuration with locked plates by a single incision or dual incision approach as per surgeon choice.
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Affiliation(s)
- Arnab Sain
- Orthopaedics, All India Institute of Medical Sciences, New Delhi, IND
| | - Vijay Sharma
- Orthopaedics, All India Institute of Medical Sciences, New Delhi, IND
| | - Kamran Farooque
- Orthopaedics, All India Institute of Medical Sciences, New Delhi, IND
| | - Muthukumaran V
- Orthopaedics, All India Institute of Medical Sciences, New Delhi, IND
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