Union rates and functional outcome of double plating of the femur: systematic review of the literature

Postoperative early weight-bearing using double plating for periprosthetic, interprosthetic, and interimplant distal femur fractures following total knee arthroplasty: A report of three cases

Background

Distal femur fractures (DFFs) following total knee arthroplasty (TKA) in older patients often require prolonged non-weight-bearing, thereby decreasing their activities of daily living (ADL) and increasing mortality. This report clarifies early weight-bearing safety and utility by using double-plate fixation on medial and lateral sides (LM180 double-plate fixation) for DFFs following TKA.

Case presentation

Three cases of Su Type III periprosthetic, interprosthetic, and interimplant DFFs following TKA, where bone stock was limited, were treated with LM180 double-plate fixation using locking plates through medial and lateral incisions on the distal femur. In interprosthetic and interimplant DFF cases, the proximal section was secured by overlapping the lateral plate +/- medial plate with the proximal femur stem of the intramedullary nail by using monocortical screws and cerclage wires. Early postoperative partial weight-bearing was recommended, and full weight-bearing was allowed 4-5 weeks postoperation. All cases regained independent walking without hardware failure. Average ADL scores, namely, Barthel index (BI) and functional independence measure (FIM), were recovered to 85/100 and 114.7/126, respectively, approaching near-normal values.

Conclusion

LM180 double-plate fixation for DFFs such as Su Type III periprosthetic, Vancouver type C interprosthetic, and interimplant DFFs following TKA with limited bone stock can be used to achieve early weight-bearing without fixation failure and help maintain ADL.

Double plating is a suitable option for periprosthetic distal femur fracture compared to single plate fixation and distal femoral arthroplasty

Aims

The purpose of this study was to compare reoperation and revision rates of double plating (DP), single plating using a lateral locking plate (SP), or distal femoral arthroplasty (DFA) for the treatment of periprosthetic distal femur fractures (PDFFs).

Methods

All patients with PDFF primarily treated with DP, SP, or DFA between 2008 and 2022 at a university teaching hospital were included in this retrospective cohort study. The primary outcome was revision surgery for failure following DP, SP, or DFA. Secondary outcome measures included any reoperation, length of hospital stay, and mortality. All basic demographic and relevant implant and injury details were collected. Radiological analysis included fracture classification and evaluation of metaphyseal and medial comminution.

Results

A total of 111 PDFFs (111 patients, median age 82 years (interquartile range (IQR) 75 to 88), 86% female) with 32 (29%) Su classification 1, 37 (34%) Su 2, and 40 (37%) Su 3 fractures were included. The median follow-up was 2.5 years (IQR 1.2 to 5.0). DP, SP, and DFA were used in 15, 66, and 30 patients, respectively. Compared to SP, patients treated with DP were more likely to have metaphyseal comminution (47% vs 14%; p = 0.009), to be low fractures (47% vs 11%; p = 0.009), and to be anatomically reduced (100% vs 71%; p = 0.030). Patients selected for DFA displayed comparable amounts of medial/metaphyseal comminution as those who underwent DP. At a minimum follow-up of two years, revision surgery for failure was performed in 11 (9.9%) cases at a median of five months (IQR 2 to 9): 0 DP patients (0%), 9 SP (14%), and 2 DFA (6.7%) (p = 0.249).

Conclusion

Using a strategy of DP fixation in fractures, where the fracture was low but there was enough distal bone to accommodate locking screws, and where there is metaphyseal comminution, resulted in equivalent survival free from revision or reoperation compared to DFA and SP fixation.

Radiographic Union Assessment in Surgically Treated Distal Femur Fractures: A Systematic Review

BACKGROUND

Distal femur fractures are known to have challenging nonunion rates. Despite various available treatment methods aimed to improve union, optimal interventions are yet to be determined. Importantly, there remains no standard agreement on what defines radiographic union. Although various proposed criteria of defining radiographic union exist in the literature, there is no clear consensus on which criteria provide the most precise measurement. The use of inconsistent measures of fracture healing between studies can be problematic and limits their generalizability. Therefore, this systematic review aims to identify how fracture union is defined based on radiographic parameters for surgically treated distal femur fractures in current literature.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, Medline, EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science Core Collection databases were searched from inception to October 2022. Studies that addressed surgically treated distal femur fractures with reported radiographic union assessment were included. Outcomes extracted included radiographic definition of union; any testing of validity, reliability, or responsiveness; reported union rate; reported time to fracture union; and any functional outcomes correlated with radiographic union.

RESULTS

Sixty articles with 3,050 operatively treated distal femur fractures were included. Operative interventions included lateral locked plate (42 studies), intramedullary nail (15 studies), dynamic condylar screw or blade plate (7 studies), dual plate or plate and nail construct (5 studies), distal anterior-posterior/posterior-anterior screws (1 study), and external fixation with a circular frame (1 study). The range of mean follow-up time reported was 4.3 to 44 months. The most common definitions of fracture union included "bridging or callus formation across 3 of 4 cortices" in 26 (43%) studies, "bony bridging of cortices" in 21 (35%) studies, and "complete bridging of cortices" in 9 (15%) studies. Two studies included additional assessment of radiographic union using the Radiographic Union Scale in Tibial fracture (RUST) or modified Radiographic Union Scale in Tibial fracture (mRUST) scores. One study included description of validity, and the other study included reliability testing. The reported mean union rate of distal femur fractures was 89% (range 58%-100%). The mean time to fracture union was documented in 49 studies and found to be 18 weeks (range 12-36 weeks) in 2,441 cases. No studies reported correlations between functional outcomes and radiographic parameters.

CONCLUSION

The current literature evaluating surgically treated distal femur fractures lacks consistent definition of radiographic fracture union, and the appropriate time point to make this judgement is unclear. To advance surgical optimization, it is necessary that future research uses validated, reliable, and continuous measures of radiographic bone healing and correlation with functional outcomes.

LEVEL OF EVIDENCE

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

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.

Validity of the ACS NSQIP surgical risk calculator as a tool to predict postoperative outcomes in subacute orthopedic trauma diagnoses

Purpose

This retrospective study aimed to validate the ACS NSQIP Surgical Risk Calculator (SCR) to predict 30-day postoperative outcomes in patients with one of the following subacute orthopedic trauma diagnoses; multiple rib fractures, pelvic ring/acetabular fracture, or unilateral femoral fracture.

Methods

Data of patients with these diagnoses treated between January 1, 2015 and September 19, 2020 were extracted from the patients' medical files. Diagnostic performance, discrimination, calibration, and accuracy of the ACS NSQIP SRC to predict specific outcomes developing within 30 days after surgery was determined.

Results

The total cohort of the three diagnoses consisted of 435 patients. ACS NSQIP SRC underestimated the risk for serious complications, especially in patients with multiple rib fractures (8.3% predicted vs 17.2% observed) or pelvic ring/acetabular fracture (6.1% vs 19.8%). Underestimation was more pronounced for the composite outcome 'any complication'. Sensitivity ranged from 16.7% to 100% and specificity from 41.1% to 97.1%. Specificity exceeded sensitivity for pelvic ring/acetabular and femoral fractures. Discrimination was good for predicting death (femoral fracture), fair for readmission (femoral fracture), serious complication (multiple rib fractures), and any complication (multiple rib fractures), but poor in all other outcomes and diagnoses. Calibration and accuracy were adequate for all three diagnoses (p-value for Hosmer-Lemeshow test >0.05 and Brier scores <0.25).

Conclusion

Performance of the ACS NSQIP SRC in the studied cohort was variable for all three diagnoses. Although it underestimated the risk of most outcomes, calibration and accuracy seemed generally adequate. For most outcomes, adequate diagnostic performance and discrimination could not be confirmed.

What Is the Likelihood of Union and Frequency of Complications After Parallel Plating and Supplemental Bone Grafting for Resistant Distal Femoral Nonunions?

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.

Supplementary medial plating in revision surgery for distal femoral fractures: A surgical technique with clinical outcomes

INTRODUCTION

Distal femur fractures (DFF) are common, especially in the elderly and high energy trauma patients. Lateral locked osteosynthesis constructs have been widely used, however non-union and implant failures are not uncommon. Recent literature advocates for the liberal use of supplemental medial plating to augment lateral locked constructs. However, there is a lack of proprietary medial plate options, with some authors supporting the use of repurposing expensive anatomic pre-contoured plates. The aim of this study was to investigate the feasibility of an effective, readily available medial implant option.

METHODS

A retrospective analysis from January 2014 to August 2023 was performed on DFF requiring revision open reduction internal fixation (rORIF) with supplemental medial plating with a Large Fragment Locking Compression Plate (LCP) T-Plate via a medial sub-vastus approach. The T-plate was contoured and placed superior to the medial condyle. A combination of 4.5 mm cortical, 5 mm locking and/or 6.5 mm cancellous screws were used, with oblique screw trajectories towards the distal lateral cortex of the lateral condyle. The primary outcome was union rate.

RESULTS

This technique was utilised on fifteen patients. The mean age was 55±15 (range 23-81); 73 % of cases were male and the median follow-up was 61 weeks (IQR 49-87). The two most common fracture patterns were AO/OTA 33-C3 (n = 5) and 33-A3 (n = 4), and three patients had open fractures. The union rate was 93 % (14/15), with a median time to union of 29 weeks (IQR 18-49). There were two complications: a deep infection requiring two debridements and locally eluding antibiotic insertion, and a prominent screw requiring removal; both patients achieved union. The median range of motion was 0° (IQR 0-5) of extension and 100° (IQR 90-120) of flexion.

CONCLUSION

Supplemental medial plating of DFF with a Large Fragment LCP T-Plate is a feasible, safe, and economical option for rORIF. Further validation on a larger scale is warranted, along with considerations to developing a specific implant in line with these principles.

Nonvascularized fibular graft with locking screw fixation for metaphyseal bone loss of distal femur: biomechanical assessment validated by a clinical case series

BACKGROUND

The optimal modality to surgically treat significant bone loss of distal femur remains inconclusive. The objectives of the present study were to assess the mechanical performance of nonvascularized fibular graft (NVFG) with locking screw fixation in distal femur fixation construct by finite element analysis and to retrospectively describe the outcomes of the present technique in clinical cases.

METHODS

Four constructs which the fractured femur was stabilized by LCP-DF alone, dual plating, LCP-DF combined with NVFG, and LCP-DF combined with NVFG (LCP-DF-NVFG-S) with locking screw were assessed the biomechanical performance under physiological loads. For the clinical case series, 12 patients with open intercondylar fracture with metaphyseal bone loss of distal femur were operated by LCP-DF-NVFG-S. The collected data included fracture consolidation, length of NVFG, perioperative complications and objective clinical results.

RESULTS

LCP-DF-NVFG-S demonstrated lower implant equivalent von Mises stress (EQV) stress and better fracture stability than other constructs. A locking screw presented its essence in maintaining the NVFG in the required position and subsequently enhancing the fracture stability. In regard to the clinical series, all fractures were consolidated with an average duration of 27.8 weeks (range 20-32). An average NVFG length was 7.8 cm (range 6-12). No perioperative complication was demonstrated. By the Knee Society score, 1 was considered to be excellent, 9 to be good and 2 to be poor.

CONCLUSION

Based on the results of mechanical assessment and case series, LCP-DF-NVFG-S can be an effective technique in the management of metaphyseal bone loss of distal femur.

Is augmented femoral lateral plating with helically shaped medial plates biomechanically advantageous over straight medial plates?

Dual plating of comminuted distal femoral fractures allows for early patient mobilization. An additional helically shaped medial plate avoids the medial vital structures of the thigh. The aim of this study is to investigate the biomechanical competence of an augmented lateral locking compression plate distal femur (LCP-DF) using an additional straight versus a helically shaped medial LCP of the same length. Ten pairs of human cadaveric femora were instrumented with a lateral anatomical 15-hole LCP-DF. Following, they were pairwise instrumented with either an additional medial straight 14-hole LCP (group 1) or a 90°-helical shape LCP (group 2). All specimens were biomechanically tested under quasi-static and progressively increasing combined cyclic axial and torsional loading until failure. Initial interfragmentary axial displacement and flexion under static compression were significantly smaller in group 1 (0.11 ± 0.12 mm and 0.21 ± 0.10°) versus group 2 (0.31 ± 0.14 mm and 0.68 ± 0.16°), p ≤ 0.007. Initial varus deformation under static compression remained not significantly different between group 1 (0.57 ± 0.23°) and group 2 (0.75 ± 0.34°), p = 0.085. Flexion movements during dynamic loading were significantly bigger in group 2 (2.51 ± 0.54°) versus group 1 (1.63 ± 1.28°), p = 0.015; however, no significant differences were observed in terms of varus, internal rotation, and axial and shear displacements between the groups, p ≥ 0.204. Cycles to failure and load at failure were higher in group 2 (25,172 ± 6376 and 3017 ± 638 N) compared to group 1 (22,277 ± 4576 and 2728 ± 458 N) with no significant differences between them, p = 0.195. From a biomechanical perspective, helical double plating may be considered a useful alternative to straight double plating, demonstrating ameliorated damping capacities during flexion deformation and safer application as the medial neurovascular structures of the thigh are avoided.

Current standard of care for distal femur fractures in Germany and Switzerland

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.

Periprosthetic Fractures After a Total Knee Arthroplasty

As the number of total knee arthroplasties performed continues to increase, complications such as postoperative periprosthetic fractures are becoming increasingly more common. Femoral periprosthetic fractures are the most common type of fractures around a total knee arthroplasty, whereas tibial and patellar periprosthetic fractures are infrequent. Treatment principles depend on the bone the fracture is located, the status of the implant fixation, bone stock, and the type of implants available. The Vancouver classification allows for a standardized system to describe and manage these injuries, incorporating these factors. A systematic approach is vital in obtaining the best possible outcomes because complications and mortality rates mimic those of hip fractures.

Predictors of nonunion for transverse femoral shaft fractures treated with intramedullary nailing: a SIGN database study

Introduction

Nonunion is a common postfracture complication resulting in decreased quality of life for patients in resource-limited settings. This study aims to determine how age, sex, injury mechanism, and surgical intervention affect the rate of nonunion in transverse femur fractures treated with a SIGN intramedullary nail (IMN).

Methods

A retrospective study was conducted using the SIGN online surgical database. All patients older than 16 years with simple transverse (<30 degrees), open or closed, femur fractures treated using a SIGN IMN between 2007 and 2021 were included. Our primary outcome of nonunion was measured with the modified Radiographic Union Scale for Tibial fractures (mRUST); scores ≤9 of 16 defined nonunion. The secondary outcome was squat depth. Outcomes were evaluated at follow-up appointments between 240 and 365 days postoperatively. Univariate and multivariate analysis were used for statistical comparison.

Results

Inclusion criteria were met for 182 patients. The overall radiographic union rate was 61.0%, and a high proportion (84.4%) of patients could squat with their hips at or below the level of their knees. Older age, retrograde approach, and fracture distraction were associated with nonunion, but sex, injury mechanism, and other surgical variables were not.

Conclusion

Poor reduction with fracture distraction was associated with a higher rate of nonunion. Loss of follow-up may have contributed to our overall union rate; however, we observed high rates of functional healing using the SIGN IMN.

Level of evidence

IV.

Medial augmentation plating of aseptic distal femoral nonunions

BACKGROUND

Distal femur nonunions are well-recognized contributors to persistent functional disability, with limited data regarding their treatment options. In the current study, we asked whether additional medial augmentation plating is a feasible treatment option for patients with aseptic distal femoral nonunion and intact lateral implants.

METHODS

We conducted a single-center, retrospective study including 20 patients treated for aseptic distal femoral nonunion between 2002 and 2017. The treatment procedure included a medial approach to the distal femur, debridement of the nonunion site, bone grafting and medial augmentation plating utilizing a large-fragment titanium plate. Outcome measures were bone-related and functional results, measured by the Hospital for Special Surgery Knee Rating Scale (HSS) and the German Short Musculoskeletal Function Assessment questionnaire (SMFA-D).

RESULTS

Eighteen of 20 nonunions showed osseous healing at 8.16 ± 5.23 (range: 3-21) months after augmentation plating. Regarding functional results, the mean HSS score was 74.17 ± 11.12 (range: 57-87). The mean SMFA-D functional index was 47.38 ± 16.78 (range 25.74-71.32) at the last follow-up. Index procedure-associated complications included two cases of persistent nonunion and one case of infection.

CONCLUSIONS

According to the assessed outcome measures, augmentation plating is a feasible treatment option, with a high proportion of patients achieving bony union and good functional outcomes and a few patients experiencing complications.

Medial and lateral dual plating of native distal femur fractures: a systematic literature review

Introduction

Lateral locked plating (LLP) development has improved outcomes for distal femur fractures. However, there is still a modest rate of nonunion in fractures treated with LLP alone, with higher nonunion risk in high-energy fractures, intra-articular involvement, poor bone quality, severe comminution, or bone loss. Several recent studies have demonstrated both the safety and the biomechanical advantage of dual medial and lateral plating (DP). The purpose of this study was to evaluate the clinical outcomes of DP for native distal femoral fractures by performing a systematic review of the literature.

Methods

Studies reporting clinical outcomes for DP of native distal femur fractures were identified and systematically reviewed. Publications without full-text manuscripts, those solely involving periprosthetic fractures, or fractures other than distal femur fractures were excluded. Fracture type, mean follow-up, open versus closed fracture, number of bone grafting procedures, nonunion, reoperation rates, and complication data were collected. Methodologic study quality was assessed using the Coleman methodology score.

Results

The initial electronic review and reverse inclusion protocol identified 1484 publications. After removal of duplicates and abstract review to exclude studies that did not discuss clinical treatment of femur fractures with dual plating, 101 potential manuscripts were identified and manually reviewed. After final review, 12 studies were included in this study. There were 199 fractures with average follow-up time of 13.72 months. Unplanned reoperations and nonunion occurred in 19 (8.5%) and 9 (4.5%) cases, respectively. The most frequently reported complications were superficial infection (n = 6, 3%) and deep infection (n = 5, 2.5%) postoperatively. Other complications included delayed union (n = 6, 3%) not requiring additional surgical treatment and knee stiffness in four patients (2%) necessitating manipulation under anesthesia or lysis of adhesions. The average Coleman score was 50.5 (range 13.5-72), suggesting that included studies were of moderate-to-poor quality.

Conclusions

Clinical research interest in DP of distal femoral fractures has markedly increased in the past few decades. The current data suggest that DP of native distal femoral fractures is associated with favorable nonunion and reoperation rates compared with previously published rates associated with LLP alone. In the current review, DP of distal femoral fractures was associated with acceptable rates of complications and generally good functional outcomes. More high-quality, directly comparable research is necessary to validate the conclusions of this review.

Novel classification system for periprosthetic distal femoral fractures: a consideration for comminution

PURPOSE

Comminution is an aspect of periprosthetic distal femoral fractures (PDFFs) that can influence postoperative outcomes and treatment selection, but is not included in current classification systems. We propose a new classification system for PDFFs based on comminution and cortical reads. This study aims to prove its reliability and efficacy to predict fracture severity and guide treatment.

METHODS

A retrospective chart review of patients treated with single or dual locking plates for PDFFs was performed. Two fellowship-trained orthopedic joint reconstruction specialists used available imaging to classify each PDFF as either type 1 (minimal or no comminution allowing for reconstruction of medial and lateral cortices), type 2 (comminution reasonably allowing for reconstruction of either medial or lateral cortex), and type 3 (extensive comminution not allowing reasonable reconstruction of medial or lateral cortex). Each PDFF was then analyzed for radiographic outcomes including lateral distal femoral angle (LDFA) and the posterior distal femoral angle (PDFA).

RESULTS

Interobserver reliability assessed by Cohen's Kappa statistic was 0.707, and average intraobserver reliability was 0.843, showing substantial reliability. Type 3 PDFFs had greater varus deformity than type 1 (p = 0.0457) or 2 (0.0198).

CONCLUSION

The proposed classification system accounts for comminution, demonstrates strong interobserver and intraobserver reliability, and can be used to guide treatment in regard to single versus dual plating.

LEVEL OF EVIDENCE

Retrospective comparative study, Level IV.

Short-term outcomes of periprosthetic compared to native distal femur fractures, a national database study

BACKGROUND

Distal femur fractures (DFFx) are highly morbid injuries with a complication rate comparable to hip fractures. Rising rates of total knee arthroplasty (TKA) have led to increasing rates of periprosthetic DFFx (pDFFx). We sought to determine how pDFFx complication rates differed from native DFFx (nDFFx).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used to identify patients who sustained pDFFx or nDFFx between 2012 and 2018. Patients were further stratified by operative treatment: open reduction internal fixation (ORIF) or distal femur replacement (DFR). Multivariate logistic regression was used to compare 30-day complication rates between pDFFx versus nDFFx and, among pDFFx patients, ORIF versus DFR or revision TKA (rTKA).

RESULTS

563 patients with pDFFx and 2259 patients with nDFFx were identified between 2012 and 2018. pDFFx patients had significantly lower rates of ORIF than nDFFx patients (36.4 vs 95.4%, p < 0.001). On multivariate analysis, pDFFx were associated with a higher rate of surgical site complications (OR 2.48, p = 0.009) compared to nDFFx. There were no differences in mortality, reoperations, major complications, rate of blood transfusion, venous thromboembolism and disposition. In patients with pDFFx, patients undergoing DFR/rTKA were more likely to be discharged home versus a rehab facility, compared to those undergoing ORIF (OR 2.62, p < 0.001).

CONCLUSIONS

In this first large registry study comparing pDFFx and nDFFx, we find similar outcomes between these groups in the first 30 days after surgery. Patients with pDFFx did have higher rates of surgical site complications, including infection and dehiscence. In pDFFx patients, those undergoing DFR were more likely to return home post-operatively.

Modified use of the proximal humeral internal locking system (PHILOS) plate for distal femoral nonunions

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.

Dual plating for fixation failure of the distal femur: Finite element analysis and a clinical series

BACKGROUND

The optimal technique for managing distal femur fixation failure remains inconclusive. The author studied the efficacy of a combined proximal humerus locking compression plate (LCP-PH) and 3.5 mm reconstruction plate (LCP-RP) by finite element (FE) analysis and retrospectively described the clinical outcomes of the present technique in such difficult circumstances.

METHODS

Biomechanical study setting included FE models of the distal femur with remaining holes from previous distal femur LCP (LCP-DF) fixation stabilized with three different constructs i.e., LCP-DF alone, LCP-DF-and-LCP-RP, as well as LCP-PH-and-LCP-RP. All settings were analyzed by using FE under physiological loads. Regarding the clinical series, the outcomes of 8 LCP-DF fixation failures operated on by the present technique were retrospectively reviewed.

RESULTS

High Implant stress of 911.2 MPa and elastic strain at fracture site of 200.8 µɛ were found when stabilized with LCP-DF. The constructs of LCP-DF-and-LCP-RP, and LCP-PH-and-LCP-RP presented lower implant stress compared to LCP-DF, 511.5, and 617.5 MPa, respectively. The elastic strain of both dual plating constructs was also 4-5 times lower than LCP-DF and differed from each other by approximately 10 µɛ. Regarding the clinical series, bony consolidation was achieved in all cases with a mean duration of 28.5 weeks (range 24-36). An average ROM of the affected knee was 115° (range 105-140). Regarding the KSS, 1 was determined to be excellent and 7 to be good.

CONCLUSION

By the biomechanical analysis and the clinical results, the construct of LCP-PH-and-LCP-RP could be an effective technique for revision surgery of LCP-DF fixation failure.

Treatment of Femoral Shaft Pseudarthrosis, Case Series and Medico-Legal Implications

Pseudarthrosis (PSA) is a possible complication of femoral shaft fracture treatment. It is often associated with reduced bone quality and can, therefore, adversely affect quality of life. Its treatment poses a major challenge for orthopaedic surgeons. Several authors have set forth different surgical approaches for the treatment of pseudarthrosis, such as internal fixation with plate and screws, replacement of an intramedullary nail or prosthetic replacement. In cases associated with bone loss, osteopenia, or comminution of fracture fragments, autologous or homologous bone grafts may also be used. The chronic outcomes of the surgical treatment of femoral shaft pseudarthrosis, even when consolidation is achieved, are linked to disabling sequelae of clinical-functional relevance, deserving an adequate medico-legal evaluation. The purpose of this retrospective study is to analyse a clinical case series of patients treated for atrophic femoral shaft pseudarthrosis at the IRCCS Orthopaedic Institute Galeazzi, Milan, Italy, from 2014 to 2020 and their orthopaedic-traumatological and medico-legal implications.

Surgical outcomes of dual-plate fixation for periprosthetic femur fractures around a stable hip arthroplasty stem

INTRODUCTION

The incidence of periprosthetic femur fractures is increasing. Multiple treatment methods exist to treat fractures surrounding stable hip arthroplasty implants including locking plate fixation, cable fixation, allograft augmentation, and revision arthroplasty. No consensus regarding optimal treatment has been reached, and significant complications remain. Recently, biomechanical studies have demonstrated the benefits of orthogonal dual-plate fixation, but little clinical data exist. The purpose of the current study was to investigate the clinical and radiographic outcomes of dual-plated periprosthetic femur fractures around stable hip stems.

MATERIALS AND METHODS

Patients with periprosthetic femur fractures following hip arthroplasty with a stable femoral stem treated with dual-plate fixation were identified through chart review at a single institution. Fracture classification, fixation characteristics, radiographic outcomes, clinical outcomes and complications including re-operation were recorded.

RESULTS

Over a 12-year period, 31 patients (mean age 77 years at surgery, range 48-94) underwent dual plating by three traumatologists for implant-stable periprosthetic femur fractures surrounding a hip arthroplasty stem. There were 27 Vancouver B1-type and 9 inter-prosthetic fractures. Average follow-up was 2 years. Of the 26 patients with minimum 6-month follow-up, 24 (92%) united after index surgery (mean time to union 6.0 months, range 1.5-14.0). Mean time to full weight-bearing post-operatively was 2.6 months (range 1.5-4.0 months). Two patients required secondary surgery to address nonunion.

CONCLUSIONS

Dual-plating achieved high union rates with an acceptable complication profile for the treatment of periprosthetic femur fractures surrounding a stable hip arthroplasty stem. Our preferred fixation construct involves a lateral plate spanning the entire femur secured with non-locking bicortical screws supplemented with an anteriorly based reconstruction plate. Additional prospective research is required to confirm the results of this study.

The technique of "autologous bone grafting through channels" combined with double-plate fixation is effective treatment of femoral nonunion

PURPOSE

The aims of this retrospective study were to evaluate the effective treatment of femoral nonunion using the technique of "autologous bone grafting through channels" combined with double-plate fixation.

METHODS

In this study, 186 patients with nonunion fracture of femur who underwent surgery using the technique of "autologous bone grafting through channels" combined with double-plate fixation in Hong Hui Hospital from May 2010 to July 2020 were enrolled. Totally, 122 males and 64 females with mean age of 44 years were evaluated. These patients were evaluated for the full clinical and radiological union time, duration of follow-up, levels of post-operative limb shortening, and range of motion of adjacent joints, and incidence of serious complications.

RESULTS

The mean follow-up time was 22 ± 6.2 months (range 12-44 months). Mean union time from surgery using our technique to full clinical and radiological union was 7.6 ± 1.2 months (range 4-9 months). All patients have achieved the union after one operation or two operations using the technique. The one-operation union rate is 98.4%. Post-operative severe complications were seen in seven patients which included deep vein thrombosis; the surgical site infection and the fracture nonunion. The range of motion in the adjacent joint of 17.7% (33/186) in all patients have an effect to the limb function. Six patients have the limb shortening more than 10 mm after surgery.

CONCLUSION

The technique of "autologous bone grafting through channels" combined with double-plate fixation is showed to be safe, effective, and easy to master and operate surgical option for treating the femoral nonunion.

Biomechanical and anatomical considerations for dual plating of distal femur fractures: a systematic literature review

INTRODUCTION

Distal femur fractures are challenging injuries historically associated with high rates of nonunion and varus collapse with operative management. As a result, clinical and research interest in dual plating (DP) of distal femur fractures has seen a dramatic increase in recent years. The purpose of this study was to systematically review the literature regarding vascular anatomy and biomechanics of distal femur fractures treated with DP constructs.

MATERIALS AND METHODS

A systematic literature review of two medical databases (PubMed & Scopus) was performed to identify peer-reviewed studies on the anatomy and biomechanics regarding DP of distal femur fractures. A total of 1,001 papers were evaluated and 14 papers met inclusion criteria (6 anatomy and 8 biomechanics). Methodological quality scores were used to assess quality and potential bias in the included studies.

RESULTS

In the biomechanical studies, DP constructs demonstrated greater axial and rotational stiffness, as well as less displacement and fewer incidences of failure compared to all other constructs. Vascular studies showed that the femoral artery crosses the mid-shaft femur approximately 16.0-18.8 cm proximal to the adductor tubercle and it is located on average 16.6-31.1 mm from the femoral shaft at this location, suggesting that medial plate application can be achieved safely in the distal femur. The methodological quality of the included studies was good for biomechanical studies (Traa score 79.1; range 53-92.5) and excellent for anatomical studies (QUACs score 81.9; range 69.0-88.5).

CONCLUSIONS

Existing biomechanics literature suggests that DP constructs are mechanically stronger than other constructs commonly used in the treatment of distal femur fractures. Furthermore, medial distal femoral anatomy allows for safe application of DP constructs, even in a minimally invasive fashion. Dual plating should be considered for patients with distal femur fractures that have risk factors for instability, varus collapse, or nonunion.

Anatomical analysis of different helical plate designs for distal femoral fracture fixation

PURPOSE

Helical plates potentially avoid the medial neurovascular structures of the thigh. Two implant designs for additional medial 90° helical plate in double plate constructs for geriatric patients and 180° helical plate for single plating in young patients are potential alternatives to widely used standard straight plates.

AIMS

(1) assess the distances to adjacent anatomical structures being at risk when applying medial 90° and 180° helical plates with MIPO technique to the femur, (2) compare these distances with medial straight plates, and (3) correlate measurements performed during surgical dissection with CT angiography.

METHODS

MIPO was performed in ten human cadaveric femoral pairs using either a 90° helical 14-hole LCP (Group 1) or a 180° helical 15-hole LCP-DF (Group 2). Using CT angiography, distances between femoral arteries and plates as well as distances between plates and perforating vessels were evaluated. Following, specimens were dissected and distances determined again. All plates were removed and measurements were repeated with straight medial plates (Group 3).

RESULTS

Overall closest distances between plates and femoral arteries were 14.5 mm (11-19 mm) in Group 1, 21.6 mm (15-24 mm) in Group 2 and 6.5 mm (5-8 mm) in Group 3, with significant differences between Group 3 and both other groups (p < 0.001). Distances to the nearest perforating vessels were 22.4 mm (15-30 mm) in Group 1 and 1.2 mm (1-2 mm) in Group 2. Measurement techniques (visual after surgical disection and CT angiography) demonstrated a strong correlation (p < 0.010).

CONCLUSIONS

Inserting 90° and 180° helical plates with MIPO technique is safe, however, attention must be paid to the medial neurovascular structures with 90° helical plates and to the proximal perforating vessels with 180° helical plates. Helical plates can avoid irritation of medial neurovascular structures - compared with straight plates - although care must be taken during their distal insertion. Measurements during surgical dissection correlate with CT angiography.

Comminuted periprosthetic distal femoral fractures have greater postoperative extension malalignment

INTRODUCTION

Comminution is a significant aspect of periprosthetic distal femoral fracture characterization and may influence post-surgical outcomes. Existing classification systems that guide treatment decisions do not take into account comminution and current literature is unclear on which surgical approach is optimal. We hypothesize that fractures with comminution will have poorer quality post-reduction alignment, especially with a lateral approach.

MATERIALS AND METHODS

37 study patients were identified with billing codes designating a distal femoral periprosthetic fracture. A retrospective chart review was performed to categorize fractures by absence or presence of comminution and medial parapatellar versus lateral surgical approach. These patients underwent an imaging evaluation for the primary outcome of reduction quality including the anatomic lateral distal femoral angle (LDFA) and the posterior distal femoral angle (PDFA). Differences in radiographic outcomes were analyzed with Wilcoxon/Kruskal-Wallis tests, and analysis by approach was through Fisher's exact test.

RESULTS

Patients with comminuted fractures had significantly greater extension of the fragment (PDFA = 95.4° vs 90.0°, p = 0.018) and similar coronal alignment (LDFA = 85.3° vs 86.3°, p = 0.83) of the knee compared to non-comminuted fractures after surgical reduction. This difference was more prominent amongst those treated with a lateral approach (PDFA = 96.1° vs 89.4°, p = 0.032) than with a medial approach (PDFA = 93.7° vs 91.5°, p = 0.41) (Table 1).

DISCUSSION

Current classification systems and treatment guidelines for periprosthetic distal femoral fractures do not adequately address several issues that may influence treatment outcomes, especially comminution. Comminuted fractures had greater post-reduction extension malalignment, falling outside the recommended PDFA range of 87-90°, especially with a lateral approach. Consideration should be given to surgical approach and techniques to reduce excessive extension when treating comminuted periprosthetic distal femoral fractures.

Use of the Locking Attachment Plate for Internal Fixation of Periprosthetic Femur Fractures

Introduction

The locking attachment plate (LAP) can be added to a locking compression plate (LCP) to allow the fixation of locking screws bicortically around a femoral implant. We aimed to examine surgical and fracture characteristics associated with healing for periprosthetic femur fractures (PPFFx) treated with constructs employing LAP fixation. We hypothesize that the addition of an LAP provides stable peri-implant fixation.

Materials &Methods

We retrospectively reviewed a consecutive series of 28 PPFFx surgically treated with LCP-LAP constructs by 4 surgeons from 2015-2020. Fractures were classified and grouped using the Vancouver Classification System and included 12 B1, 2 B2, 11 C fractures, and 3 fractures around other stemmed implants. Primary outcome measures included hardware failure such as screw pullout, broken screws, and plate fracture. Clinical complications including infection, non-union, malunion, and reoperation were recorded.

Results

No LAP failures, screw pullout, or broken screws were observed. Two fractured plates (7.1%) occurred in patients with Vancouver C fracture types. Overall complication rate was 17.9% and included 3 non-unions, 1 deep infection, and 1 implant loosening with painful hardware, each requiring reoperation. Differences were observed between unions and nonunions for total number of screws (12.4 vs 14.7, P = .005) and number of locking screws used (8.04 vs 11.3, P = .03).

Conclusion

The LAP provides adequate fixation and low failure rates where fixation is required around a well-fixed stem. When failures occur, it is from plate breakage and not due to failure of fixation at the area of plate-stem overlap.

[Medicine for people with disabilities : Special features of trauma surgical care of extremity injuries in people with severe mental and physical disabilities]

Die von Bodelschwinghschen Stiftungen Bethel blicken auf eine über 150-jährige Tradition in der Behandlung von Menschen mit Behinderungen. Das traumatologische Patient*innenkollektiv ist dabei regelmäßig durch schwerste geistige und körperliche Entwicklungsstörungen und (Mehrfach‑)Behinderungen, mit und ohne Verhaltensstörungen, und internistische Begleiterkrankungen charakterisiert. Diese besondere Kombination erfordert ärztlich wie pflegerisch eine Therapie und Indikationsstellung, welche in allen Behandlungsschritten spezifisch abgewogen und angepasst werden muss. Behandlungsrichtlinien oder Empfehlungen zu diesem Patientenkollektiv existieren in der Literatur nicht. Des Weiteren kann die Behandlung von Frakturen bei Menschen mit Behinderungen nicht immer nach etablierten Konzepten erfolgen. Aufgrund einer hohen postoperativen Komplikationsrate kommt der konservativen Therapie eine entscheidende Rolle zu. Die Entscheidung zur operativen Therapie muss interdisziplinär und individuell unter Berücksichtigung sämtlicher Faktoren getroffen werden. Spezielles Augenmerk muss dabei auf das zu wählende Verfahren (Stabilität, funktionelle Bedürfnisse) gerichtet werden.

Treatment of B1 Distal Periprosthetic Femur Fractures

The burden of periprosthetic distal femoral fractures is projected to increase accordingly with the increase in total knee arthroplasties (TKAs) performed globally in the future. Less invasive plating and intramedullary (IM) nailing techniques still seem to provide similar outcomes based on current literature. Double-plating and combination techniques may prove to be beneficial in the future pending further large-scale studies but currently have not demonstrated superiority over single plating and IM nailing based on current evidence. Distal femoral replacement may provide a useful option for future treatment, provided it is performed by a trained knee arthroplasty surgeon.

[What constitutes a good osteosynthesis?]

What constitutes a "good osteosynthesis"? Although the question seems trivial, on closer inspection there are manifold influencing factors that affect fracture healing, so that this question is ultimately not that easy to answer. The first steps are already set with taking the patient history and initial diagnostics. An adequate analysis of the fracture with a coherent preoperative concept for stabilization based on the latest scientific findings and a subsequent adequate implementation of the planning in the operating room make the success of an osteosynthesis and thus a "good osteosynthesis". Digital support is playing an increasingly important role in this field. This review article deals with the topic in depth and summarizes the most important elements of the necessary cascade.