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Leal JA. Medial augmentation of distal femur fractures using the contralateral distal femur locking plate: A technical note. OTA Int 2024; 7:e347. [PMID: 39228878 PMCID: PMC11365623 DOI: 10.1097/oi9.0000000000000347] [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: 01/31/2024] [Revised: 06/03/2024] [Accepted: 07/27/2024] [Indexed: 09/05/2024]
Abstract
Introduction Lateral locking plates are commonly employed for the fixation of distal femur fractures. However, scenarios involving medial comminution, extremely distal fractures, periprosthetic fractures, or nonunion could necessitate medial augmentation. This study explores the possibility of using lateral distal femoral locking plate systems for medial fixation by employing the contralateral plate. Methods This study presents a technical note on the application of lateral distal femur locking systems for medial augmentation in patients as indicated by current literature findings. Postoperative imaging modalities, including radiography and computed tomography (CT), were used to assess the plates' fit to the distal femur. Three cases following the specified technical note are presented. Results The various plate systems, all comprising distal femur locking systems, demonstrated adaptability to the medial femur anatomy as confirmed by intraoperative visualization and postoperative radiographs, including two-dimensional and three-dimensional CT scans. It has also been possible to achieve at least 3 independent fixation points regardless of the size of the medial condyle. Conclusions Locking distal femoral plates can be a viable option for medial augmentation in indicated cases, achieving anatomical adaptation to the distal femur. This provides robust augmentation without the need for additional instruments beyond those used for the lateral cortex.
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Affiliation(s)
- Jaime Andrés Leal
- Department of Orthopedic and Traumatology, Hospital Universitario de la Samaritana and Hospital Universitario Mayor de Méderi, Bogotá, Colombia
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Weinschenk RC, Oldham BM, Nagaraja KM, Alam F, Samade R, Li W. Three-dimensional-printed femoral diaphysis for biomechanical testing-Optimization and validation. J Orthop Res 2024. [PMID: 39101345 DOI: 10.1002/jor.25954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 07/01/2024] [Accepted: 07/13/2024] [Indexed: 08/06/2024]
Abstract
Polylactic acid (PLA) models of normal human femoral diaphyses were designed using three-dimensional (3D) printing technology to create inexpensive, accessible, and reproducible specimens for flexural biomechanical studies. These models were subjected to three-point bending and their response to loading was characterized. The anisotropic mechanical behavior of the 3D-printed femurs and the influence of printing orientations, infill density, wall layers, resolution, and other printing parameters were explored to develop a design space. The objective of the design space was set to emulate the flexural biomechanical response of the normal human femur bones. Results show the 3D-printed PLA diaphyseal femurs with 5% infill density, two-four wall layers, and a resolution of 200 µm resulted in a flexural strength of 184.8 ± 8.18 MPa. Models with 20% infill density and six wall layers resulted in a flexural modulus of 18.54 ± 0.543 GPa. These results emulate the biomechanical response of the normal human femur, as determined by historical target values derived from prior cadaveric and 3D printing data. With further research, inclusive of modeling the proximal and distal femur and more comprehensive biomechanical testing, 3D-printed femurs may ultimately serve as a cheap, accessible biomechanical resource for surgeons and researchers.
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Affiliation(s)
- Robert C Weinschenk
- Department of Orthopaedic Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Biomedical Engineering, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Blaine M Oldham
- Department of Orthopaedic Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kishore M Nagaraja
- Department of Mechanical Engineering, The University of Texas at Dallas, Richardson, Texas, USA
| | - Faiqa Alam
- Department of Mechanical Engineering, The University of Texas at Dallas, Richardson, Texas, USA
| | - Richard Samade
- Department of Orthopaedic Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Biomedical Engineering, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Wei Li
- Department of Mechanical Engineering, The University of Texas at Dallas, Richardson, Texas, USA
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Achudan S, Antony Xavier RP, Tan SE. Medial plating of distal femur: which pre-contoured angular stable plate fits best? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:3297-3308. [PMID: 39152353 DOI: 10.1007/s00590-024-04068-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 08/05/2024] [Indexed: 08/19/2024]
Abstract
PURPOSE Distal femur fractures comprise approximately 4% of all femoral fractures, with lateral plating being a common fixation technique. In recent years, dual plating with an additional medial plate has shown added benefit for Arbeitsgemeinschaft für Osteosynthesefragen C-type fractures, comminuted, osteoporotic distal femur fractures and non-union or malunion complications postsingle lateral plating. However, to our knowledge, there is no commercially available distal femur medial plate for fracture fixation. The aim of our study was to determine which of our current commercially available pre-contoured plates fit the medial distal femur best in an Asian population. METHODS We evaluated 13 different pre-contoured angular plates on standardized sawbone models. The plates were first applied onto the medial distal femur and subsequent anterior-posterior and lateral radiographs were taken postapplication. The appropriateness of the fit of each plate was objectively compared using a scoring system derived from pre-determined plate- and screw-related factors. RESULTS The proximal humerus internal locking system plate had the best anatomical fit with the highest 'best fit score,' followed by the variable angle proximal tibia plate. CONCLUSION While non-anatomical plates may be successfully utilized, in view of the anatomical variations of the femur, ultimately an anatomical plate for the medial distal medial femur should be developed for ease of fixation.
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Affiliation(s)
- Shaam Achudan
- Department of Orthopedics, Tan Tock Seng Hospital, Singapore, Singapore.
| | | | - Sze Ern Tan
- Department of Orthopedics, Tan Tock Seng Hospital, Singapore, Singapore
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Kriechling P, Bowley ALW, Ross LA, Moran M, Scott CEH. Double plating is a suitable option for periprosthetic distal femur fracture compared to single plate fixation and distal femoral arthroplasty. Bone Jt Open 2024; 5:489-498. [PMID: 38862133 PMCID: PMC11166487 DOI: 10.1302/2633-1462.56.bjo-2023-0145.r1] [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] [Indexed: 06/13/2024] Open
Abstract
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.
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Affiliation(s)
| | | | - Lauren A. Ross
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Matthew Moran
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Chloe E. H. Scott
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Orthopaedics, University of Edinburgh, Edinburgh, UK
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Pastor T, Zderic I, Drenchev L, Skulev HK, Berk T, Beeres FJP, Link BC, Gueorguiev B, Stoffel K, Knobe M. Is augmented femoral lateral plating with helically shaped medial plates biomechanically advantageous over straight medial plates? J Orthop Res 2024; 42:886-893. [PMID: 37975265 DOI: 10.1002/jor.25730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/14/2023] [Indexed: 11/19/2023]
Abstract
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.
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Affiliation(s)
- Torsten Pastor
- AO Research Institute Davos, Davos, Switzerland
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
| | - Ludmil Drenchev
- Bulgarian Academy of Sciences, Institute of Metal Science "Acad. A. Balevski", Sofia, Bulgaria
| | - Hristo K Skulev
- Bulgarian Academy of Sciences, Institute of Metal Science "Acad. A. Balevski", Sofia, Bulgaria
| | - Till Berk
- AO Research Institute Davos, Davos, Switzerland
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Frank J P Beeres
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
- Department of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Björn-Christian Link
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | | | - Karl Stoffel
- Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland
| | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
- Medical Faculty, RWTH Aachen University Hospital, Aachen, Germany
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Thorne TJ, DeKeyser GJ, Clapp I, Haller JM. Risk of reverse golf club deformity with medial plating of distal femur fracture. Arch Orthop Trauma Surg 2024; 144:1211-1220. [PMID: 38265463 DOI: 10.1007/s00402-023-05173-6] [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: 06/22/2023] [Accepted: 12/04/2023] [Indexed: 01/25/2024]
Abstract
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.
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Affiliation(s)
- Tyler J Thorne
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | | | - Ian Clapp
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Justin M Haller
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
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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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Jitprapaikulsarn S, Chantarapanich N, Gromprasit A, Mahaisavariya C, Sukha K, Rungsakaolert P. Nonvascularized fibular graft with locking screw fixation for metaphyseal bone loss of distal femur: biomechanical assessment validated by a clinical case series. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:659-671. [PMID: 37684357 DOI: 10.1007/s00590-023-03710-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023]
Abstract
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.
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Affiliation(s)
| | - Nattapon Chantarapanich
- Department of Mechanical Engineering, Faculty of Engineering at Sriracha, Kasetsart University, Sriracha, Chonburi, Thailand.
| | - Arthit Gromprasit
- Department of Orthopedics, Buddhachinaraj Hospital, Phitsanulok, Thailand
| | - Chantas Mahaisavariya
- Golden Jubilee Medical Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kritsada Sukha
- Department of Orthopedics, Buddhachinaraj Hospital, Phitsanulok, Thailand
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Pereira S, Bidolegui F, Garabano G, Pesciallo CA, Giordano V, Pires RE, Mariolani JR, Belangero WD. Does the type of medial plate fixation matter for supplemental fixation of distal femur fractures manage with a lateral pre-contoured locked plate? A Biomechanical study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:605-612. [PMID: 37661241 DOI: 10.1007/s00590-023-03685-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/13/2023] [Indexed: 09/05/2023]
Abstract
INTRODUCTION Fixation of distal femur fractures with a lateral pre-contoured locking plate provides stable fixation and is the standard treatment in most cases, allowing early range of motion with a high rate of union. However, in situations, the stability achieved with the lateral plate alone may be insufficient, predisposing to fixation failure. The objective of the study was to compare, in synthetic bone models, the biomechanical behaviour of the fixation with a distal femur lateral pre-contoured locking plate solely and associated with a 3.5 mm proximal humeral locking plate applied upside down or a 4.5 mm helical locking compression plate on the medial side. MATERIAL AND METHODS A total of 15 solid synthetic left femur samples were used. A metaphysical defect at the level of the medial cortex was simulated. The samples were randomly distributed into three groups equally. All groups received a 4.5/5.0 mm single lateral 9-hole distal femur lateral pre-contoured locking plate. Group 1 had no supplementary plate. Group 2 received a supplementary 6-hole 3.5 mm proximal humeral locking plate and Group 3 received a supplementary 4.5/5.0 mm helical 14-hole narrow locking compression plate. RESULTS Both supplementary plate types used in groups 2 and 3 contributed to increase the apparent stiffness of the construct, but pairwise comparison showed statically significant difference only between group 1 and 3. No significant difference was observed between groups 2 and 3. CONCLUSION Both supplementary plates might be considered for improving the fixation in distal femur fracture in selected cases.
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Affiliation(s)
- Sebastián Pereira
- Servicio de Ortopedia y Traumatologia, Sanatorio San Lucas, Belgrano 369, B1642, San Isidro, Buenos Aires, Argentina.
- Servicio de Ortopedia y Traumatologia, Hospital Sirio-Libanes, Campana 4658, C1419, Buenos Aires, Argentina.
| | - Fernando Bidolegui
- Servicio de Ortopedia y Traumatologia, Hospital Sirio-Libanes, Campana 4658, C1419, Buenos Aires, Argentina
- Servicio de Ortopedia y Traumatologia, Sanatorio Otamendi Miroli, Azcuénaga 870, C1115, Buenos Aires, Argentina
| | - Germán Garabano
- Servicio de Ortopedia y Traumatologia, Hospital Británico de Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
| | - Cesar Angel Pesciallo
- Servicio de Ortopedia y Traumatologia, Hospital Británico de Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
| | - Vincenzo Giordano
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Robinson Estevez Pires
- Departamento do Aparelho Locomotor, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - José Ricardo Mariolani
- Biomaterials Laboratory in Orthopedics (LABIMO), Faculty of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - William Dias Belangero
- Biomaterials Laboratory in Orthopedics (LABIMO), Faculty of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
- Department of Orthopedics, Faculty of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
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Liu J, Huang Z, Qi Y, Long Y, Zhang Y, Liu N, Zuo G, Wang W. Biomechanical analysis of bridge combined fixation system as a novel treatment for the fixation of type A3 distal femoral fractures. Front Surg 2023; 10:1264904. [PMID: 38033528 PMCID: PMC10687203 DOI: 10.3389/fsurg.2023.1264904] [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: 07/21/2023] [Accepted: 10/25/2023] [Indexed: 12/02/2023] Open
Abstract
Background To compare the biomechanical parameters of AO/OTA type A3 distal femoral fractures fixed bilaterally with a bridge combined fixation system (BCFS) and lateral locking compression plate + locking reconstruction plate (LCP + LRP). Methods Twelve A3 distal femoral fracture models with medial cortical defects of the distal femur were created using synthetic femoral Sawbones. BCFS and LCP + LRP were used for bilateral fixation, with six in each group. Axial compression and torsion tests were performed on the two groups of fracture models to determine their stiffness during axial compression and the Torsional stiffness during torsion tests. Axial compression failure tests were performed to collect the vertical loads of the ultimate failure tests. Results In the test conducted on the fixed type A3 distal femoral fracture models, the axial stiffness in the BCFS group (group A) (1,072.61 ± 113.5 N/mm) was not significantly different from that in the LCP + LRP group (group B) (1,184.13 ± 110.24 N/mm) (t = 1.726, P = 0.115), the Torsional stiffness in group A (3.73 ± 0.12 N.m/deg) was higher than that in group B (3.37 ± 0.04 N.m/deg) (t = 6.825, P < 0.001),and the ultimate failure test of type A3 fracture model showed that the vertical load to destroy group A fixation (5,290.45 ± 109.63 N) was higher than that for group B (3,978.43 ± 17.1 N) (t = 23.28, P < 0.05). Notably, intertrochanteric fractures occurred in groups A and B. Conclusions In the fixation of type A3 distal femoral fractures, the anti-axial compression of the BCFS group was similar to that of the LCP + LRP group, but the anti-torsion was better.
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Affiliation(s)
- Jianke Liu
- Shandong First Medical University & Shandong Academy Medical Sciences, Jinan, China
| | - Zhaozhao Huang
- Tianjin Walkman Biomaterial Co., Ltd. Newton Laboratory, Tianjin, China
| | - Yubin Qi
- Department of Orthopaedics, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Yuntao Long
- Shandong First Medical University & Shandong Academy Medical Sciences, Jinan, China
| | - Yanhui Zhang
- Department of Orthopaedics, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Na Liu
- Tianjin Walkman Biomaterial Co., Ltd. Newton Laboratory, Tianjin, China
| | - Guilai Zuo
- Department of Orthopaedics, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Wen Wang
- Department of Orthopaedics, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
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11
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Liu CH, Tsai PJ, Chen IJ, Yu YH, Chou YC, Hsu YH. The double-plate fixation technique prevents varus collapse in AO type C3 supra-intercondylar fracture of the distal femur. Arch Orthop Trauma Surg 2023; 143:6209-6217. [PMID: 37347253 PMCID: PMC10491700 DOI: 10.1007/s00402-023-04953-4] [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: 03/13/2023] [Accepted: 06/15/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Varus collapse followed by osteosynthesis for distal femoral fractures with conventional implants has been well documented but is seldom mentioned in fractures managed with locking plates. The purpose of this study was to assess the incidence of varus collapse after treating complex supra-intercondylar fractures of the distal femur (AO type C3) using a Single Plate (SP) or Double Plate (DP) fixation technique. MATERIALS AND METHODS We retrospectively reviewed 357 patients with distal femoral fractures who were treated at our hospital between 2006 and 2017. After excluding cases of infection, malignancy, periprosthetic fracture, revision surgery, pediatric fracture, and extra-articular fracture, 54 patients were included in the study. All demographic data and radiological and clinical outcomes were reviewed and analyzed. RESULTS There were 54 patients enrolled into this study with age from 15 to 85 years old (mean 41.6, SD = 19.9), and 32 of them were open fractures (59%). The patients were further divided into either an SP (n = 15) or a DP group (n = 39). Demographics, including age, sex, injury severity score, and open fracture type, were all compatible between the two groups. The overall nonunion rate was 25.9% (n = 14; 6 from the SP and 8 from the DP group; p = 0.175). The varus collapse rate was 9.3% (n = 5; 4 from the SP and 1 from the DP group (p = 0.018). CONCLUSIONS The varus collapse rate after osteosynthesis with a single lateral locking plate could be as high as 26.7% in AO type C3 fractures of the distal femur, which would be decreased to 2.6% by adding a medial buttress plate. Surgeons should consider DP fixation to avoid varus collapse in severely comminuted complete intra-articular fractures of the distal femur.
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Affiliation(s)
- Chang-Heng Liu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fusing St., Gueishan Dist., Taoyuan City, 333423, Taiwan (ROC)
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan (ROC)
| | - Ping-Jui Tsai
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fusing St., Gueishan Dist., Taoyuan City, 333423, Taiwan (ROC)
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan (ROC)
| | - I-Jung Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fusing St., Gueishan Dist., Taoyuan City, 333423, Taiwan (ROC)
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan (ROC)
| | - Yi-Hsun Yu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fusing St., Gueishan Dist., Taoyuan City, 333423, Taiwan (ROC)
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan (ROC)
| | - Ying-Chao Chou
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fusing St., Gueishan Dist., Taoyuan City, 333423, Taiwan (ROC)
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan (ROC)
| | - Yung-Heng Hsu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fusing St., Gueishan Dist., Taoyuan City, 333423, Taiwan (ROC).
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan (ROC).
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12
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Hong CC, Pearce CJ, Lau ETC, Gardner A. Augmented fixation in distal femur fractures: how does it fare? Singapore Med J 2023; 64:634-639. [PMID: 35739631 PMCID: PMC10645003 DOI: 10.11622/smedj.2022086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 07/28/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Choon Chiet Hong
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore
| | - Christopher Jon Pearce
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore
| | - Eugene Tze-Chun Lau
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore
| | - Antony Gardner
- Department of Orthopaedic Surgery, Ng Teng Fong General Hospital, National University Health System, Singapore
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13
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Zdero R, Gide K, Brzozowski P, Schemitsch EH, Bagheri ZS. Biomechanical design optimization of distal femur locked plates: A review. Proc Inst Mech Eng H 2023; 237:791-805. [PMID: 37366552 DOI: 10.1177/09544119231181487] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
Clinical findings, manufacturer instructions, and surgeon's preferences often dictate the implantation of distal femur locked plates (DFLPs), but healing problems and implant failures still persist. Also, most biomechanical researchers compare a particular DFLP configuration to implants like plates and nails. However, this begs the question: Is this specific DFLP configuration biomechanically optimal to encourage early callus formation, reduce bone and implant failure, and minimize bone "stress shielding"? Consequently, it is crucial to optimize, or characterize, the biomechanical performance (stiffness, strength, fracture micro-motion, bone stress, plate stress) of DFLPs influenced by plate variables (geometry, position, material) and screw variables (distribution, size, number, angle, material). Thus, this article reviews 20 years of biomechanical design optimization studies on DFLPs. As such, Google Scholar and PubMed websites were searched for articles in English published since 2000 using the terms "distal femur plates" or "supracondylar femur plates" plus "biomechanics/biomechanical" and "locked/locking," followed by searching article reference lists. Key numerical outcomes and common trends were identified, such as: (a) plate cross-sectional area moment of inertia can be enlarged to lower plate stress at the fracture; (b) plate material has a larger influence on plate stress than plate thickness, buttress screws, and inserts for empty plate holes; (c) screw distribution has a major influence on fracture micro-motion, etc. Recommendations for future work and clinical implications are then provided, such as: (a) simultaneously optimizing fracture micro-motion for early healing, reducing bone and implant stresses to prevent re-injury, lowering "stress shielding" to avoid bone resorption, and ensuring adequate fatigue life; (b) examining alternate non-metallic materials for plates and screws; (c) assessing the influence of condylar screw number, distribution, and angulation, etc. This information can benefit biomedical engineers in designing or evaluating DFLPs, as well as orthopedic surgeons in choosing the best DFLPs for their patients.
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Affiliation(s)
- Radovan Zdero
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada
| | - Kunal Gide
- Department of Mechanical Engineering, George Mason University, Fairfax, VA, USA
| | - Pawel Brzozowski
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada
| | - Emil H Schemitsch
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada
- Division of Orthopaedic Surgery, Western University, London, ON, Canada
| | - Z Shaghayegh Bagheri
- Department of Mechanical Engineering, George Mason University, Fairfax, VA, USA
- Kite Research Institute, Toronto Rehab Institute, University Health Network, Toronto, ON, Canada
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14
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Chen S, Zheng Z, Guo J, Hong S, Zhou W, Xie J, Wang W. Three-dimensional computed tomography mapping techniques in the morphometric analysis of AO/OTA 33A and 33C distal femoral fractures: a retrospective single-center study. Front Bioeng Biotechnol 2023; 11:1162214. [PMID: 37397967 PMCID: PMC10311492 DOI: 10.3389/fbioe.2023.1162214] [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: 02/09/2023] [Accepted: 06/05/2023] [Indexed: 07/04/2023] Open
Abstract
Purpose: Complex distal femoral fractures involve a challenging set of considerations that must be known to provide optimal management. This study aimed to determine the location and frequency of fracture lines and comminution zones in AO/OTA types 33A and 33C distal femoral fractures using three-dimensional computed tomography mapping. Methods: Seventy-four consecutive eligible patients were included. Fracture fragments for each patient were reconstructed, virtually reduced, and adjusted to match the distal femoral template. Then, all fracture lines and comminuted areas were extracted in transparent mode, and corresponding heat maps were constructed. Finally, these maps, along with the quantitative analysis findings of the counts and volumes of each fragment, were used to summarize the characteristics of the fractures. Results: Thirty-four females and 40 males [average age, 58 years (range, 18-92 years)] presented with a distal femoral fracture. There were 53 AO/OTA type 33A fractures, and 21 AO/OTA type 33C fractures. These two patterns differed significantly on fracture fragment count, comminuted zone fracture fragment count, and mean comminuted zone fracture fragment volume (p < 0.05). Most of the fracture line heat zones were in the femoral epiphysis, intercondylar notch of the femur, and patellofemoral joint. The comminuted area heat regions were mostly found on the lateral, anterior, and posterior femoral diaphysis, with less involvement on the medial side. Conclusion: Our findings may serve as a guide for the surgical approach selection of complex distal femur fractures, the placement strategy of the internal fixation, and the optimization of the osteotomy plan for biomechanical studies.
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Affiliation(s)
- Song Chen
- *Correspondence: Song Chen, ; Jun Xie, ; Wei Wang,
| | | | | | | | | | - Jun Xie
- *Correspondence: Song Chen, ; Jun Xie, ; Wei Wang,
| | - Wei Wang
- *Correspondence: Song Chen, ; Jun Xie, ; Wei Wang,
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15
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Chen SR, Shaikh H, Turvey BR, Moloney GB. Technical Trick: Supplemental Medial Column Screw Fixation of Distal Femur Fractures Treated With a Laterally Based Locked Plate. J Orthop Trauma 2023; 37:e175-e180. [PMID: 36001898 DOI: 10.1097/bot.0000000000002475] [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] [Accepted: 08/15/2022] [Indexed: 02/02/2023]
Abstract
SUMMARY Given known failure rates after lateral plating of distal femur fractures, there is an increasing interest in augmenting fixation to improve outcomes. The addition of medial plates or intramedullary nails have been described with promising results, decreasing nonunion and varus collapse rates. However, the use of dual implants increases implant costs, adds surgical complexity, and requires a second surgical approach that may increase morbidity. A supplemental, percutaneously placed, medial column screw may provide a less invasive means of improving stability and achieving fracture union compared with lateral plating alone.
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Affiliation(s)
- Stephen R Chen
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA
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16
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Medial and lateral dual plating of native distal femur fractures: a systematic literature review. OTA Int 2023; 6:e227. [PMID: 36760659 PMCID: PMC9904193 DOI: 10.1097/oi9.0000000000000227] [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: 11/24/2021] [Accepted: 10/02/2022] [Indexed: 01/18/2023]
Abstract
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.
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17
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Prophylactic Femoral Neck Fixation in an Osteoporosis Femur Model: A Novel Surgical Technique with Biomechanical Study. J Clin Med 2023; 12:jcm12010383. [PMID: 36615182 PMCID: PMC9821729 DOI: 10.3390/jcm12010383] [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: 11/16/2022] [Revised: 12/28/2022] [Accepted: 01/01/2023] [Indexed: 01/05/2023] Open
Abstract
Intramedullary nailing (IMN) is a popular treatment for elderly patients with femoral shaft fractures. Recently, prophylactic neck fixation has been increasingly used to prevent proximal femoral fractures during IMN. Therefore, this study aimed to investigate the biomechanical strength of prophylactic neck fixation in osteoporotic femoral fractures. An osteoporotic femur model was created to simulate the union of femoral shaft fractures with IMN. Two study groups comprising six specimens each were created for IMN with two standard proximal locking screws (SN group) and IMN with two reconstruction proximal locking screws (RN group). Axial loading was conducted to measure the stiffness, load-to-failure, and failure modes. There were no statistically significant differences in stiffness between the two groups. However, the load-to-failure in the RN group was significantly higher than that in the SN group (p < 0.05). Femoral neck fractures occurred in all specimens in the SN group. Five constructs in the RN group showed subtrochanteric fractures without femoral neck fractures. However, one construct was observed in both subtrochanteric and femoral neck fractures. Therefore, prophylactic neck fixation may be considered an alternative biomechanical solution to prevent proximal femoral fractures when performing IMN for osteoporotic femoral fractures.
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18
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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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19
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Muacevic A, Adler JR, Raithatha H, Shah S. Study of Clinical Results and Functional Outcome of Patients With Distal Femur Fracture Treated With Dual Plating. Cureus 2023; 15:e34182. [PMID: 36843752 PMCID: PMC9951124 DOI: 10.7759/cureus.34182] [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] [Accepted: 01/25/2023] [Indexed: 01/27/2023] Open
Abstract
Introduction Distal femur fracture has been routinely fixed with a single lateral locking plate. This method of fixation in intra-articular distal femur fractures has proved to give a higher outcome of varus collapse as well as higher rates of mal-union due to inadequate fixation of the medial aspect of the distal femur. To address this drawback of single lateral plating, the use of medial assisted plating (MAP) has been introduced recently, which was proposed to give better stability to the medial fragments. This Is a prospective case series of 50 patients with distal femur fractures treated with dual plating. Materials and methods Fifty cases of patients with distal femur fractures were treated with dual plating between August 2020 and September 2022. Patients were followed up postoperatively till the third month, when patients were assessed clinically and radiologically. Range of motion of the knee, postoperative fracture displacement, limb shortening, and signs of union and infection were checked. Neer's scoring and Kolmet's scoring were used to grade the outcome for the patients. Results The mean age of the patients was 39. Only 12% of the cases were open fractures. Eighty-four percent of the cases did not have fixed flexion deformity (FFD) and only 4% had FFD of 15 degrees; 72% of the cases achieved flexion of the knee beyond 120 degrees. Eighty-four percent of patients had normal walking ability by the 12th week postoperatively; 16% of the cases had a postoperative displacement of more than 1.6 cm, with the maximum being 2.5 cm. Conclusion From the study, we have concluded that outcomes were better for fractures of distal femur when treated with dual fixation, probably due to superior fixation and earlier postoperative mobilization.
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Affiliation(s)
- Alexander Muacevic
- Orthopaedics, Dr. D.Y. (Dnyandeo Yashwantrao) Patil Medical College and Hospital, Pune, IND
| | - John R Adler
- Orthopaedics, Dr. D.Y. (Dnyandeo Yashwantrao) Patil Medical College and Hospital, Pune, IND
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20
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Zhang J, Liang J, Wang J, Tang X. Comminuted distal femur fracture fixation with intramedullary and extramedullary plates: A rare case report. Asian J Surg 2022:S1015-9584(22)01780-8. [PMID: 36577580 DOI: 10.1016/j.asjsur.2022.12.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 12/14/2022] [Indexed: 12/27/2022] Open
Affiliation(s)
- Jian Zhang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, 116011, China
| | - Jiahui Liang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, 116011, China
| | - Jingshu Wang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, 116011, China.
| | - Xin Tang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, 116011, China.
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21
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Oransky M, Galante C, Cattaneo S, Milano G, Motta M, Biancardi E, Grava G, Johnson EE, Casiraghi A. Endosteal plating for the treatment of malunions and nonunions of distal femur fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03458-x. [PMID: 36539626 DOI: 10.1007/s00590-022-03458-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 12/12/2022] [Indexed: 06/17/2023]
Abstract
PURPOSE To describe the surgical technique and the outcome of a case series of nonunion and malunion of distal femur fractures treated with an endosteal medial plate combined with a lateral locking plate and with autogenous bone grafting. METHODS We retrospectively analyzed a series of patients with malunion or nonunion of the distal femur treated with a medial endosteal plate in combination with a lateral locking plate, in a period between January 2011 and December 2019, Database from chart review was obtained including all the clinical relevant available baseline data (demographics, type of fracture, mechanism of injury, time from injury to surgery, number of previous surgical procedures, type of bone graft, and type of lateral plate). Time to bone healing, limb alignment at follow-up and complications were documented. RESULTS Ten patients were included into the study: 7 male and 3 female with mean age of 48.3 years (range 21-67). The mechanism of trauma was in 8 cases a road traffic accident and in 2 cases a fall from height. According to AO/OTA classification 5 fractures were 33 A3, 3 were 33 C1, 1 was 33 C2 and 1 was 33 C3. The average follow up was 13.5 months. In all cases but one bony union was achieved. Bone healing was observed in average 3.3 months after surgery. No intraoperative or postoperative complications were reported. CONCLUSION A medial endosteal plate is a useful augmentation for lateral plate fixation in nonunion or malunion following distal femur fractures, particularly in cases of medial bone loss, severe comminution, or poor bone quality. LEVEL OF EVIDENCE Level IV (retrospective case series).
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Affiliation(s)
- Michel Oransky
- Department of Bone and Joint Surgery, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Claudio Galante
- Department of Bone and Joint Surgery, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Stefano Cattaneo
- Department of Bone and Joint Surgery, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Giuseppe Milano
- Department of Bone and Joint Surgery, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Viale Europa 11, 25123, Brescia, BS, Italy
| | - Marcello Motta
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Viale Europa 11, 25123, Brescia, BS, Italy.
| | - Elena Biancardi
- Department of Bone and Joint Surgery, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Giuseppe Grava
- Department of Bone and Joint Surgery, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Eric E Johnson
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA Center for the Health Sciences, Los Angeles, CA, 90095-6902, USA
| | - Alessandro Casiraghi
- Department of Bone and Joint Surgery, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
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22
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Immediate Weight-Bearing Following Biplanar Plating of Periprosthetic Femoral Fractures. Tech Orthop 2022. [DOI: 10.1097/bto.0000000000000612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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23
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Biomechanical and anatomical considerations for dual plating of distal femur fractures: a systematic literature review. Arch Orthop Trauma Surg 2022; 142:2597-2609. [PMID: 34097123 DOI: 10.1007/s00402-021-03988-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/28/2021] [Indexed: 12/27/2022]
Abstract
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.
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Pastor T, Beeres FJP, Kastner P, Gehweiler D, Migliorini F, Nebelung S, Scaglioni MF, Souleiman F, Link BC, Babst R, Gueorguiev B, Knobe M. Anatomical analysis of different helical plate designs for distal femoral fracture fixation. Injury 2022; 53:2636-2641. [PMID: 35346508 DOI: 10.1016/j.injury.2022.03.033] [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: 10/23/2021] [Revised: 02/22/2022] [Accepted: 03/18/2022] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Torsten Pastor
- AO Research Institute Davos, Davos, Switzerland; Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Frank J P Beeres
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Philipp Kastner
- AO Research Institute Davos, Davos, Switzerland; Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University, Linz, Austria
| | | | - Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH, University of Aachen Hospital, Aachen, Germany
| | - Sven Nebelung
- Department of Radiology, University of Aachen Medical Center, Aachen, Germany
| | - Mario F Scaglioni
- Department of Plastic and Hand Surgery, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Firas Souleiman
- AO Research Institute Davos, Davos, Switzerland; Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Björn-Christian Link
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | | | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
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Kim JH, Kim KI, Park KC, Shon OJ, Sim JA, Kim GB. New Classification for Periprosthetic Distal Femoral Fractures Based on Locked-Plate Fixation Following Total Knee Arthroplasty: A Multicenter Study. J Arthroplasty 2022; 37:966-973. [PMID: 35121090 DOI: 10.1016/j.arth.2022.01.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/18/2022] [Accepted: 01/22/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This study aimed to establish a new classification using locked-plate fixation for periprosthetic distal femoral fracture (PDFF) following total knee arthroplasty (TKA) and to determine when dual locked-plate fixation is necessary through defining this classification. METHODS One-hundred fifteen consecutive PDFFs that underwent operative treatment were reviewed from 2011 to 2019 with minimum 1-year follow-up. Most PDFFs were fixed with single or dual locked-plate fixations using the minimally invasive plate osteosynthesis technique. Based on preoperative radiographs, PDFFs were classified according to the level of main fracture line relative to the anterior flange of femoral component: type I and II, main fracture line located proximal and distal to the anterior flange; and type III, component instability regardless of fracture line requiring revisional TKA. Furthermore, type II fractures were subclassified based on the direction of fracture beak as follows: type IIL, lateral-beak; type IIM, medial-beak. The incidence, treatment methods, and complications were analyzed according to the classification. RESULTS Incidences of type I, IIL, IIM, and III were 64.4%, 8.7%, 24.3%, and 2.6%, respectively. Meanwhile, most PDFFs in type I and II were treated with lateral single locked-plate fixations, except for type IIM, which was treated with either single or dual locked-plate fixations. Overall complications were significantly higher in type II (28.9%) than in type I (10.8%, P = .019). In type IIM, bone union-related complications were significantly higher in single locked-plate fixation (50.0%) than in dual locked-plate fixation (5.6%; P = .013). CONCLUSION The new classification provides practical and obvious strategies for the treatment of PDFF following TKA using locked-plate fixation. For type IIM fracture, dual plate fixation is necessary to prevent fixation failure or nonunion.
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Affiliation(s)
- Jun-Ho Kim
- Department of Orthopaedic Surgery, Center for Joint Diseases, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Kang-Il Kim
- Department of Orthopaedic Surgery, Center for Joint Diseases, Kyung Hee University Hospital at Gangdong, Seoul, Korea; Department of Orthopaedic Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Ki Chul Park
- Department of Orthopaedic Surgery, Hanyang University Guri Hospital, Gyeonggi-do, Korea
| | - Oog-Jin Shon
- Department of Orthopaedic Surgery, Yeungnam University Medical Center, Daegu, Korea
| | - Jae Ang Sim
- Department of Orthopaedics Surgery, Gachon University College of Medicine, Incheon, Korea
| | - Gi Beom Kim
- Department of Orthopaedic Surgery, Yeungnam University Medical Center, Daegu, Korea
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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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Upadhyay P, Syed F, Ramoutar DN, Ward J. The missing piece of the trauma armoury-medial femoral condyle plate. Injury 2022; 53:1237-1240. [PMID: 34839895 DOI: 10.1016/j.injury.2021.11.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 10/16/2021] [Accepted: 11/14/2021] [Indexed: 02/02/2023]
Abstract
Fixation of distal femoral fractures is often challenging due to the fracture configuration and associated poor bone quality. Dual plating (lateral and medial) has become an acceptable option to provide improved stability versus a single plate fixation. Though there are several commercially available anatomically designed plates for the lateral femoral condyle, there is no anatomic plate available in UK specifically for medial fixation of distal femur fractures. Our aim is to determine the best suited pre-contoured plate for stabilising the medial femoral condyle (MFC). Right sided femur sawbones were used to determine how well 18 different pre-contoured anatomical plates (Depuy Synthes, Leeds, UK) fit the medial femoral condyle. Some of these had variable angle (VA) option. Lift off, fit and notch penetration were assessed and recorded independently by 4 orthopaedic trauma surgeons. The number and distribution of screws in the MFC that each plate allowed was also determined. To do this the MFC was divided into quadrants: Proximal anterior (PA), distal anterior (DA), proximal posterior (PP) and distal posterior (DP). The ipsilateral anterolateral proximal tibial (VA and 4.5 mm non-VA), PHILOS, posteromedial proximal tibial and ipsilateral lateral extra-articular distal humeral plate offered good sagittal fit, less than 2 mm lift off at the condyles and no diaphyseal lift off. Plate positioning in the PA quadrant offered the best fit. The ipsilateral anterolateral proximal tibial plates (VA) and PHILOS allowed at least 4 screws to be placed in the PA and 2 in the PP quadrant with no notch penetration. The Tomofix provided good fit, but all 4 screws were in PA quadrant, with distal screws causing notch penetration. The non-VA and PHILOS plates did not offer the VA advantage. The ipsilateral anterolateral proximal tibial VA plates provided the best anatomical fit for the MFC with the greatest number of screws in the condylar quadrants with the option of variable angle screw placement.
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Affiliation(s)
- Piyush Upadhyay
- University Hospital of Coventry & Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK; School of Engineering, University of Warwick, Coventry CV4 7AL
| | - Farhan Syed
- University Hospital of Coventry & Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK.
| | - Darryl N Ramoutar
- University Hospital of Coventry & Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Jayne Ward
- University Hospital of Coventry & Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK
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Inacio JV, Schwarzenberg P, Yoon R, Kantzos A, Malige A, Nwachuku C, Dailey H. Boundary Conditions Matter - Impact of Test Setup On Inferred Construct Mechanics in Plated Distal Femur Osteotomies. J Biomech Eng 2022; 144:1136733. [PMID: 35171212 DOI: 10.1115/1.4053875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Indexed: 11/08/2022]
Abstract
The mechanics of distal femur fracture fixation has been widely studied in bench tests that employ a variety of approaches for holding and constraining femurs to apply loads. No standard test methods have been adopted for these tests and the impact of test setup on inferred construct mechanics has not been reported. Accordingly, the purpose of this study was to use finite element models to compare the mechanical performance of a supracondylar osteotomy with lateral plating under conditions that replicate several common bench test methods. A literature review was used to define a parameterized virtual model of a plated distal femur osteotomy in axial compression loading with four boundary condition sets ranging from minimally to highly constrained. Axial stiffness, longitudinal motion, and shear motion at the fracture line were recorded for a range of applied loads and bridge spans. The results showed that construct mechanical performance was highly sensitive to boundary conditions imposed by the mechanical test fixtures. Increasing the degrees of constraint, for example by potting and rigidly clamping one or more ends of the specimen, caused up to a 25x increase in axial stiffness of the construct. Shear motion and longitudinal motion at the fracture line, which is an important driver of interfragmentary strain, was also largely influenced by the constraint test setup. These results suggest that caution should be used when comparing reported results between bench tests that use different fixtures and that standardization of testing methods is needed in this field.
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Affiliation(s)
- Jordan V Inacio
- Department of Mechanical Engineering & Mechanics, Lehigh University, Packard Laboratory, 19 Memorial Drive West, Bethlehem, PA 18015, USA
| | - Peter Schwarzenberg
- Department of Mechanical Engineering & Mechanics, Lehigh University, Packard Laboratory, 19 Memorial Drive West, Bethlehem, PA 18015, USA
| | - Richard Yoon
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, 377 Jersey Ave, Suite 130, Jersey City, NJ 07302, USA
| | - Andrew Kantzos
- Department of Orthopaedic Surgery, St. Luke's University Health Network, 801 Ostrum, 12 Street, Bethlehem, PA 18015, USA
| | - Ajith Malige
- Department of Orthopaedic Surgery, St. Luke's University Health Network, 801 Ostrum, 12 Street, Bethlehem, PA 18015, USA
| | - Chinenye Nwachuku
- Department of Orthopaedic Surgery, St. Luke's University Health Network, 801 Ostrum, 12 Street, Bethlehem, PA 18015, USA
| | - Hannah Dailey
- Department of Mechanical Engineering & Mechanics, Lehigh University, Packard Laboratory, 19 Memorial Drive West, Bethlehem, PA 18015, USA
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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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Finite element analysis of different medial fixation strategies in double-plate osteosynthesis for AO type 33-C2 fractures. Injury 2022; 54 Suppl 2:S86-S94. [PMID: 35219538 DOI: 10.1016/j.injury.2022.01.003] [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: 09/16/2021] [Revised: 12/04/2021] [Accepted: 01/02/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES In this study, we evaluated the biomechanical characteristics of different locations of medial fixation strategies in double-plate osteosynthesis for fixing AO/ASIF type 33-C2 fractures by means of finite element analysis. METHODS We used 3-matic software and UG-NX software to construct AO/ASIF type 33-C2 fractures and lateral less invasive stabilization system (LISS) plates, medial plates (MPs), and medial support pads (MSPs), respectively. Then, the LISS, MP and MSP were assembled into the fracture model separately to form three fixation models: MSP+LISS, anteromedial plate (AMP+LISS), and MP+LISS. In the next procedure, we performed finite element analysis using ANSYS software after meshing the elements of the models in HyperMesh 11.0 software. Loading conditions including lateral-medial four-point bending, anterior-posterior four-point bending, axial loading, and torsional loading were applied to evaluate the biomechanical advantages among the three fixation types. We observed the peak Von Mises Stress (VMS) value, maximum displacement, bending angle in the coronal plane of the fracture, and torsional angle of the fracture to assess the degree of plate deformation and fixation stability. RESULTS Our results showed that in both lateral-medial four-point bending and anterior-posterior four-point bending, the calculations of MP+LISS were marginally better than those of AMP+LISS. However, with the action of axial loading and torsional loading, the deformation of MP+LISS was distinctly smaller than that of AMP+LISS, and the fixation stability of MP+LISS was also prominently better. Under lateral-medial four-point bending, the VMS on the lateral plate of MSP+LISS (59.977 MPa) was approximately half of the two double-plate models. Under anterior and posterior four-point bending, the 38.209 MPa peak VMS of MSP+LISS was still superior to the other two double-plate models. Under torsional loading, the peak VMS (347.75 MPa), the maximum torsional angle of the femoral head (7.852 °), and the torsional angle of fracture (0.036 °) of MSP+LISS preceded those of the other two models. However, under axial loading, the peak VMS (76.376 MPa) and the maximum displacement (3.1798 mm) of MSP+LISS were slightly higher than those of MP+LISS. CONCLUSION The MSP+LISS model showed better biomechanical performance than the double-plate models, which might be an effective solution for the treatment of comminuted distal femur fractures.
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Matsushita T, Akiyama T, Osano K, Yokoyama Y, Okazaki K. Biomechanical analysis of the role of hinge support fixators on hinge stability in medial closing wedge distal femoral osteotomy. Clin Biomech (Bristol, Avon) 2022; 91:105528. [PMID: 34808426 DOI: 10.1016/j.clinbiomech.2021.105528] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 11/07/2021] [Accepted: 11/09/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study aimed to examine the hinge-stabilizing biomechanical effects of hinge support fixators, applied for lateral hinge fractures sustained following distal femoral osteotomy. METHODS Medial closing wedge distal femoral osteotomy was performed using a locking plate on 10 cadaveric limbs. The limbs were divided into two groups: the non-fracture group and the lateral hinge fracture group. A cyclic axial load of 400 N was applied to the knee to keep it extended and flexed at 45°. The hinge-stabilizing effects of adding a screw or a short support plate to the lateral fracture site were examined by measuring the translation and rotational angles of the anterodistal and posterodistal hinge positions as well as the surface strains of the medial locking plate. FINDINGS Translation and rotation in the fracture group were significantly more pronounced than in the non-fracture group, at the anterodistal and posterodistal positions. Translations at both positions were significantly reduced, by adding the support plate, during both extension and 45-degree flexion in the fracture group. The rotation at the posterodistal position upon extension and the anterodistal position upon 45-degree flexion was significantly reduced by the support plate. The surface strain of the medial plate in the fracture group was significantly reduced by the support plate upon both extension and 45-degree flexion. INTERPRETATION Lateral hinge fractures caused abnormal hinge movements, which were significantly reduced by the short support plate. A short support plate could be used if a hinge fracture occurs during distal femoral osteotomy, to improve lateral hinge stability.
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Affiliation(s)
- Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.
| | | | - Kei Osano
- Joint Reconstruction Center, Fukuoka Mirai Hospital, Fukuoka, Japan
| | | | - Ken Okazaki
- Department of Orthopaedic Surgery, Tokyo Women's Medical, Tokyo, Japan
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32
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Impact on periosteal vasculature after dual plating of the distal femur: a cadaveric study. OTA Int 2021; 4:e131. [PMID: 34746663 PMCID: PMC8568473 DOI: 10.1097/oi9.0000000000000131] [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: 11/04/2020] [Revised: 02/03/2021] [Accepted: 03/07/2021] [Indexed: 11/26/2022]
Abstract
Although dual plating of distal femur fractures has been described for injuries at risk of varus displacement, the vascular insult to the medial distal femur utilizing this technique is unknown. The aim of this study was to evaluate the perfusion of the medial distal femoral periosteal arteries after supplemental medial plating of the distal femur. Methods Fifteen human fresh-frozen cadaveric femora were thawed and randomized to lateral locked plating alone or with supplemental medial plate fixation. Conventional submuscular medial plating was performed using a 12-hole small fragment plate and multiple cortical screws. The superficial femoral artery was injected with latex dye. Specimens were dissected. The patency of the medial distal femoral periosteal vessels was evaluated. Results Four vessels were consistently observed traversing the distal medial femur: the transverse and descending (d-MMPA) branches of the medial metaphyseal periosteal artery, and the transverse and longitudinal branches of the descending geniculate artery. The anterior longitudinal arch (ALA) was present in 13 of 15 specimens and was fed by the d-MMPA. The median number of periosteal arteries occluded by the medial plate was 2 (6 out of 8 specimens). The d-MMPA was occluded in 6 of 8 medially plated femurs, resulting in a complete lack of perfusion of the ALA. Conclusions Submuscular medial plating of the distal femur compressed the d-MMPA in the majority of specimens. This vessel gives rise to the ALA, which lacked perfusion in these specimens. This vascular insult could affect the healing of metaphyseal distal femur fractures treated with dual plating.
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Henry Goodnough L, Salazar BP, Chen MJ, Storaci H, Guzman R, Heffner M, Tam K, DeBaun MR, Gardner MJ. Supplemental medial small fragment fixation adds stability to distal femur fixation: A biomechanical study. Injury 2021; 52:1670-1672. [PMID: 33985754 DOI: 10.1016/j.injury.2021.04.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Bridge plating of distal femur fractures with lateral locking plates is susceptible to varus collapse, fixation failure, and nonunion. While medial and lateral dual plating has been described in clinical series, the biomechanical effects of dual plating of distal femur fractures have yet to be clearly defined. The purpose of this study was to compare dual plating to lateral locked bridge plating alone in a cadaveric distal femur gap osteotomy model. MATERIALS AND METHODS Gap osteotomies were created in eight matched pairs of cadaveric female distal femurs (average age: 64 yrs (standard deviation ± 4.4 yrs); age range: 57-68 yrs;) to simulate comminuted extraarticular distal femur fractures (AO/OTA 33A). Eight femurs underwent fixation with lateral locked plates alone and were matched with eight femurs treated with dual plating: lateral locked plates with supplemental medial small fragment non-locking fixation. Mechanical testing was performed on an ElectroPuls E10000 materials testing system using a 10 kN/100 Nm biaxial load cell. Specimens were subject to 25,000 cycles of cyclic loading from 100-1000 N at 2 Hz. RESULTS Two (2/8) specimens in the lateral only group failed catastrophically prior to completion of testing. All dual plated specimens survived the testing regimen. Dual plated specimens demonstrated significantly less coronal plane displacement (median 0.2 degrees, interquartile range [IQR], 0.0-0.5 degrees) compared to 2.0 degrees (IQR 1.9-3.3, p = 0.02) in the lateral plate only group. Dual plated specimens demonstrated greater bending stiffness compared to the lateral plated group (median 29.0 kN/degree, IQR 1.5-68.2 kN/degree vs median 0.50 kN/degree, IQR 0.23-2.28 kN/degree, p = 0.03). CONCLUSION Contemporary fixation methods with a distal femur fractures are susceptible to mechanical failure and nonunion with lateral plates alone. Dual plate fixation in a cadaveric model of distal femur fractures underwent significantly less displacement under simulated weight bearing conditions and demonstrated greater stiffness than lateral plating alone. Given the significant clinical failure rates of lateral bridge plating in distal femur fractures, supplemental fixation should be considered, and dual plating of distal femurs augments mechanical stability in a clinically relevant magnitude.
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Affiliation(s)
- L Henry Goodnough
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, 300 Pasteur Drive, Room R144, Stanford CA, United States.
| | - Brett P Salazar
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Room R144, Stanford CA, United States
| | - Michael J Chen
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Room R144, Stanford CA, United States
| | - Hunter Storaci
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Room R144, Stanford CA, United States
| | - Robert Guzman
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Room R144, Stanford CA, United States
| | - Michael Heffner
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Room R144, Stanford CA, United States
| | - Kaysie Tam
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Room R144, Stanford CA, United States
| | - Malcolm R DeBaun
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, 300 Pasteur Drive, Room R144, Stanford CA, United States
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, 300 Pasteur Drive, Room R144, Stanford CA, United States
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Liu JF, Zhou ZF, Hou XD, Chen YX, Zheng LP. Hybrid locked medial plating in dual plate fixation optimizes the healing of comminuted distal femur fractures: A retrospective cohort study. Injury 2021; 52:1614-1620. [PMID: 33461771 DOI: 10.1016/j.injury.2021.01.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/31/2020] [Accepted: 01/03/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Dual plate fixation has been reported to be effective in the treatment of comminuted distal femur fractures (DFFs). However, optimized use of the medial plate and screws is less studied. This study aimed to evaluate the effect of a hybrid configuration of the medial plate in dual plate fixation of comminuted DFFs in promoting fracture healing. MATERIALS AND METHODS We retrospectively analyzed 62 patients with comminuted DFFs (AO/OTA 33-A3/33-C2/33-C3) from January 2015 to March 2020, who were either fixed with lateral locked plating augmented with hybrid locked medial plating (LP-HLMP, n = 32) or lateral locked plating (LLP, n = 30) alone. Specifically, compression screws were applied in the middle of the medial plate and flanked by locking ones at both ends. Baseline characteristics, radiological and clinical outcomes were reviewed and analyzed. Multivariate logistic regression analysis was used to identify predictive factors for early fracture healing, and risk factors for delayed union/nonunion. RESULTS Demographics including age, gender, smoking, diabetes, and injury mechanism were comparable between the two groups. Reduction quality was better in the LP-HLMP group (p < 0.001). Although the LP-HLMP group experienced longer duration of surgery (125 min vs. 100 min, p < 0.001), sign of healing at 3 months was more obvious in this group (75%, 24/32 vs. 30%, 9/30; p < 0.001). The LP-HLMP group also presented with higher union rate (93.8%, 30/32 vs. 56.7%, 17/30; p = 0.001) and lower reoperation rate (0%, 0/32 vs. 13.3%, 4/30; p = 0.049). Kolment score showed no statistical significance between the two groups. Multivariate analysis revealed that younger age (< 60 years) (OR 5.99, 95%CI 1.16 - 31.03; p = 0.001) and LP-HLMP fixation (OR 45.90, 95% CI 4.78 - 440.56; p = 0.001) predict early healing; while smoking (OR 17.80, 95% CI 2.41 - 131.49; p = 0.01) and fracture translation (OR 3.49, 95% CI 1.46 - 8.32; p = 0.01) were identified as risk factors for delayed union/nonunion. CONCLUSION Hybrid locked medial plating in this study favors the healing of comminuted DFFs and reduces reoperation. Additionally, smoking and suboptimal reduction (translation) predict delayed union/nonunion.
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Affiliation(s)
- Jun-Feng Liu
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Zi-Fei Zhou
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Xiao-Dong Hou
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Yi-Xing Chen
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Long-Po Zheng
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China; Shanghai Trauma Emergency Center, Shanghai, 200072, China; Orthopedic Intelligent Minimally Invasive Diagnosis & Treatment Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.
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Excellent outcomes after double-locked plating in very low periprosthetic distal femoral fractures. Arch Orthop Trauma Surg 2021; 141:207-214. [PMID: 33128096 DOI: 10.1007/s00402-020-03655-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/15/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Very low periprosthetic distal femur fractures (PPDFFs) are rare injuries and often have a relatively high failure rate after single lateral locked plating. The double plating technique yields good outcomes in osteoporotic fractures of the distal femur. To date, there is limited information on double-locked plate fixation of very low PPDFFs. This study aimed to evaluate the outcomes and complications of surgically treated very low PPDFFs using double-locked plate fixation. MATERIALS AND METHODS Between January 2013 and December 2018, sixty-one consecutive patients with PPDFFs have been conducted. Only Su type III PPDFFs with double-locked plate fixation through a lateral minimally invasive approach and a medial subvastus approach to the distal femur were analyzed. Patients were encouraged to perform straight leg raising exercises and active knee motion on the second postoperative day. Assisted weight bearing from the early postoperative days was supported, and full weight-bearing was allowed after healing the fracture site. All patients were evaluated according to the time to union, limb alignment, range of knee motion, Knee Society Score, and presence of complications. RESULTS Twenty one patients (17 females and 4 males, mean age 76 years, range 56-90) were included in the study. There were 10 of 33-A1, 6 of 33-A2 and 5 of 33 A3 fractures, according to the AO classification. Of 21 patients, 20 achieved union at an average of 14 weeks postoperatively. Postoperative limb alignment was satisfactory in all cases, with an average mechanical distal lateral femur angle of 89° and average mechanical posterior distal femur angle of 86°. All patients recovered the knee joint motion similar to that of the contralateral side, and daily life pre-injury. The average knee and function scores were 94 and 89, respectively. There were one case of non-union and three cases of superficial wound infection, which resolved after intravenous antibiotic therapy. CONCLUSIONS Double locked plating showed excellent radiographic and functional outcomes with few complications in patients with very low PPDFFs. Based on these promising results, we propose the consideration of double-locked plate fixation in the treatment of very low PPDFFs.
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Giannoudis PV. Injury Golden Issue: Even small studies can have an impact on patient care. Injury 2019; 50:1585. [PMID: 31690404 DOI: 10.1016/j.injury.2019.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Peter V Giannoudis
- Academic Department of Trauma @ Orthopedic Surgery, School of Medicine, University of Leeds, Leeds, UK.
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