Retrograde nailing and compression bolts in the treatment of type C distal femoral fractures

Current Concepts in Management of Distal Femur Fractures

Recent studies report the overall incidence of distal femur fractures as 8.7/100,000/year. This incidence is expected to rise with high energy motor vehicle collisions and elderly osteoporotic fractures in native and prosthetic knees keep increasing. These fractures are more common in males in the younger age spectrum while females predominate for elderly osteoporotic fractures. Surgical treatment is recommended for these fractures to maintain articular congruity, enable early joint motion and assisted ambulation. Over the last two decades, development of minimally invasive and quadriceps sparing surgical approaches, availability of angle stable implants have helped achieve predictable healing and early return to function in these patients. Currently, laterally positioned locked plate is the implant of choice across all fracture patterns. Retrograde with capital implantation of intramedullary nails with provision for multiplanar distal locking is preferred for extra-articular and partial articular fractures. Even with these advancements, nonunion after distal femur fracture fixation can be as high as 19%. Further recent research has helped us understand the biomechanical limitations and healing problems with lateral locked plate fixation and intramedullary nails. This has lead to development of more robust constructs such as nail-plate and double plate constructs aiming for improved construct strength and to minimise failures. Early results with these combination constructs have shown promise in high risk situations such as fractures with extensive metaphyseal fragmentation, osteoporosis and periprosthetic fractures. These constructs however, run the risk of being over stiff and can inhibit healing if not kept balanced. The ideal stiffness that is needed for fracture healing is not clearly known and current research in this domain has lead to the development of smart implants which are expected to evolve and may help improve clinical results in future.

Biomechanical evaluation of intramedullary retrograde nail and dynamic condylar screw used in unstable distal femoral fractures

Distal femur fractures are a common problem in orthopedics. Intramedullary retrograde nails (IRN) and dynamic condylar screws (DCS) are generally used for the treatment of these fractures. In this study, it was aimed to mechanically evaluate and compare these two implants used for the treatment of distal femur fractures. In this study, an AOOTA 33C1.3 fracture was created on the intact femur obtained from computed tomography images. The fractures were fixed with DCS and IRN. Then the created models were imported into the ANSYS Workbench for finite element analysis to determine the most convenient mechanical fixation type. The distal region of the femur was loaded considering 75 kg-f, and the created models were constrained in all directions from the femoral head. The intact femur was also analyzed to compare it with the DCS and IRN fixation models. The von Mises stress, strain, and displacement results were examined to determine the damage risk. According to the results, the risk of damage is lower in the model of fixation with IRN. The normal strain distribution in the model fixed with IRN is closer to the model of an intact femur. For this reason, the risk of stress shielding in IRN fixation is less than in DCS fixation. However, the fracture lines were more stable in the fixation with the DCS. In conclusion, fracture fixation with IRN is mechanically more suitable for distal femur fractures in terms of fracture healing.

Double fixation for complex distal femoral fractures

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.

Dual plating or dual plating combined with compression bolts for bicondylar tibial plateau fractures: a retrospective comparative study

The aim of this study was to compare secondary loss of reduction outcomes in dual plating fixation and dual plating combined with compression bolt fixation for bicondylar tibial plateau fractures (TPFs). We performed a retrospective study from January 2015 to April 2019. A consecutive series of 72 bicondylar TPFs underwent surgical treatment and was divided into two groups: group 1 (dual plating, n = 46) and group 2 (dual plating combined with compression bolts, n = 26). The outcomes collected included demographic characteristics, imaging characteristics, intraoperative indicators, clinical outcomes and reduction quality after surgery. Functional outcome was rated according to the Hospital for Special Surgery (HSS) score and Lysholm score. The secondary loss of reduction rate in group 2 was reduced compared with that in group 1 (P = 0.025), and the mean HSS score of group 2 was higher than that of group 1 (P = 0.013). The rate of complications was 30.4% (14/46) in group 1 and 30.8% (8/26) in group 2 (P = 0.976). Compared with single dual plating fixation, dual plating combined with compressing bolt fixation reduced the secondary loss of reduction rate for patients with bicondylar TPFs and showed better functional outcomes.

Transient retrograde interfragmentary compression technique in AO/OTA type 33-C distal femur fractures: A surgical technique and short-term radiographic follow up results

Surgical treatment of AO/OTA type 33-C fractures is a therapeutic challenge despite advances in surgical instruments and techniques. We introduce a novel surgical technique named transient retrograde interfragmentary compression (TRIC) to help intraarticular fragment reduction in AO/OTA type 33-C fracture. We inserted a partial threaded 7.0-cannulated screw with a washer along the transepicondylar axis from the medial femoral epicondyle during the articular block reduction process of AO/OTA type 33-C fractures to strengthen the compressive force between the condylar fragments and to enhance the handling of the articular block fragment in the alignmental correction stage. Following the provisional reduction and fixation using lateral distal femur locking compression plate, TRIC screw was removed. Fifteen AO/OTA type 33-C distal femoral intraarticular fractures of thirteen patients were surgically treated using the TRIC technique. We analyzed the radiographic result of the patients by measuring the horizontal gap and vertical step-off in the postoperative radiographs. Mean horizontal fracture gap was 0.34 mm and mean vertical step-off between bicondylar fragments was 0.63 mm. The median value of the horizontal fracture gap and vertical step off was 0 and 0.46 mm, respectively. Mean time to union in the bicondylar fracture fragment was 9 week. TRIC is considered to be a valuable surgical reduction technique in the treatment of the AO/OTA 33-C type fractures.

The antegrade angle-stable locking intramedullary nail for type-C distal femoral fractures: a thirty four case experience

INTRODUCTION

This is a retrospective study that provides initial experience and verifies the effectiveness of the newly-designed antegrade interlocking angle-stable intramedullary nail (IAIN) combined with half-threaded cancellous screws in the management of type-C (AO/OTA classification) distal femoral fractures.

METHODS

During a period of 30 months, 34 patients (mean age 43.1 years) with type-C (AO/OTA classification) fractures of the distal femur were treated with IAIN and half-threaded cancellous screws were reviewed. Peri-operative and post-operative parameters were analyzed.

RESULTS

All of the fractures healed in a mean time of 12.6 weeks with no incidences of malunion, nonunion or infection. No secondary failure of fixation occurred. Partial weight bearing was initiated in an average of 7.4 weeks post-operatively, with full weight bearing initiated in 13.8 weeks. All of the patients, except for one, gained full extension. The mean flexion of the knee joint was 110.1°, while the mean Hospital for Special Surgery (HSS) knee score was 85.2.

CONCLUSION

The IAIN and half-threaded cancellous screws provided a reliable fixation that facilitated uncomplicated outcomes and uneventful early mobilization in treating type-C fractures of the distal femur.

Minimally invasive internal fixation of distal femur fractures

Fractures of the distal femur remain a daunting challenge. Since 1970, operative treatment has been recommended. Unfortunately, it is fraught with complications, and techniques have been developed to limit incidence of non-union, infection and stiffness. A soft-tissue friendly approach is the key point, with minimally invasive surgery as the ultimate goal: its biological and anatomical advantages have been demonstrated, but clinical studies have been less convincing, being based on historical series. At present, retrograde nailing and minimally invasive percutaneous plate osteosynthesis (ideally by locking plate) are the two main techniques. Unfortunately, reports tend to compare implants rather than operative techniques, hindering solid conclusions. Lastly, the delineation of "distal femur fracture" is quite variable, sometimes situated well above the AO epiphyseal square. Meta-analyses find almost no difference between the two implants in minimally invasive procedures. The main advantage of the plate is its versatility, whereas nailing can be impossible in case of certain hip or knee prostheses, compound articular fracture or medullary canal obstruction by fixation material (nail, stem, screw, etc.). The role of arthroscopy is limited. Only a few case reports describe its use in reduction of epiphyseal fracture. In the last analysis, the surgeon's experience is more relevant to outcome than any particular implant.

Mechanical Construct Characteristics Predisposing to Non-union After Locked Lateral Plating of Distal Femur Fractures

OBJECTIVES

To identify discrete construct characteristics related to overall construct rigidity that may be independent predictors of nonunion after lateral locked plate (LLP) fixation of distal femur fractures.

DESIGN

Retrospective case-control study.

SETTING

Three level-1 urban trauma centers.

PATIENTS/PARTICIPANTS

Two hundred and seventy-one supracondylar femoral fractures treated with LLP at 3 affiliated level 1 urban trauma centers between August 2004 and December 2010.

METHODS

Nonunion was defined as a secondary procedure for poor healing. Construct variables included: (1) combined plate design and material variable, (2) Plate length, (3) # screws proximal to fracture, (4) total screw density (TSD), (5) proximal screw density (PSD), (6) presence of a screw crossing the main fracture, and (7) rigidity score multivariable analysis was performed using logistic regression to identify independent risk factors for nonunion.

INTERVENTION

LLP fixation.

MAIN OUTCOME MEASURE

Nonunion.

RESULTS

Nonunion rate was 13.3% (n = 36). There was a significant association between plate design/material and nonunion with 41% of stainless constructs and 10% of titanium constructs resulting in a nonunion (P < 0.001). Rigidity scores reached significance (P = 0.001) with constructs resulting in a nonunion having higher scores. No significant univariate differences with respect to number of proximal screws, plate length, total screw density, or proximal screw density were observed between healed fractures and those with nonunion. Results of the multivariate analysis confirmed that the primary significant independent predictor of nonunion was plate design/material (odds ratio, 6.8; 95% CI, 2.9-16.1; P < 0.001).

CONCLUSIONS

When treating distal femur fractures with LLP, combined plate design and material variable has a highly significant influence on the risk of nonunion independent of any other construct variable.

LEVEL OF EVIDENCE

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

Retrograde nailing for distal femur fractures in the elderly

Introduction: We report the results of treating a series of 56 fractures in 54 elderly patients with a distal femur fracture with a retrograde femoral nail.

Methods: Fifty-four of the nails were inserted percutaneously with a closed reduction. After surgery all patients were allowed to weight bear as tolerated. Four fractures were supported in a temporary external splint.

Results: The mean age of patients was 80.6 years (range 51–103 years), 52/54 (96%) were females. There were no cases of nail related complications and no re-operations were required. One patient was lost to follow up. The 30-day mortality was 5/54 (9.3%) and the one year mortality was 17/54 (31.5%).

Conclusions: Distal femoral nail fixation provides a good method of fixation allowing immediate mobilisation for this group of patients.

Management of distal femur fractures with modern plates and nails: state of the art

Fractures of the distal femur, even those with articular extension, are well suited to surgical fixation with modern precontoured anatomic plates and nails. Numerous adjuvant techniques are available to the treating surgeon to obtain and maintain reduction while preserving fracture biology. Yet despite their proven track record and benefits over older implants, technical errors are common and must be overcome with proper preoperative planning and intraoperative attention to detail. This review summarizes the current state of the art regarding distal femur fractures, with an emphasis on relevant modern plate and nail surgical techniques, tempered by our current understanding of implant biomechanics, fracture healing, and long-term outcomes.

Use a simple lower limb outrigger frame in intramedullary nailing fixation of a floating knee

Closed intramedullary nailing is a classical therapeutic approach for floating knee injuries. An appropriate positioning is critical for a successful surgery. However, there is a lack of an ideal auxiliary device to facilitate the implantation of intramedullary nail. The authors developed a simple lower limb outrigger frame (SLLOF), which is made of nylon, to facilitate the nail implementation process. The SLLOF could be radiolucent and autoclavable. A total of 31 patients with floating knee injury underwent the closed intramedullary nailing assisted by SLLOF. The average operative duration was 91.0 min, and all tibial and femur fractures reached bony union. The SLLOF could assist well insertion of intramedullary nail for the treatment of floating knee injuries, with the advantages of simple operation, less manpower, easy imaging access but less radiation exposure, and more cost-effectiveness.