Perioperative adverse events in distal femur fractures treated with intramedullary nail versus plate and screw fixation

Which fixation produces the best outcome for distal femoral fractures? Meta-analysis and systematic review of retrograde nailing versus distal femoral plating in 2432 patients and 33 studies

PURPOSE

The distal femur comprises a wide intramedullary cavity and thin cortical bone. Firm internal fixation of comminuted fractures with displacement is challenging. Although many comparative studies have reported retrograde intramedullary nailing (RIN) and distal femoral plating (DFP) as the usual fixation methods for distal femoral fractures, no clear conclusion has been reached. Therefore, a meta-analysis and systematic review of the clinical and radiological results were conducted to determine the appropriate treatment method for distal femoral fractures.

METHODS

A systematic search of the PubMed, Embase, Scopus, and Cochrane Library databases from their inception to December 19, 2022, was performed using predefined criteria. Studies comparing the effects of RIN and DFP were considered. The analyzed outcome measures included duration of surgery, blood loss, time to union, delayed union, nonunion, malalignment, implant failure, infection, reoperation, limb length discrepancy, range of motion, persistent anterior knee pain, knee stiffness, and functional scores. Meta-analysis of pooled data was conducted using a random-effects model to determine the standard mean difference (SMD) or odds ratio (OR) with 95% confidence intervals (CIs).

RESULTS

Thirty-three studies with 2,432 patients were included. Compared to DFP, RIN was associated with a shorter time to fracture union (SMD, 1.83 months; 95% CI - 2.76 to - 0.90; P < 0.001) and a lower incidence of postoperative infection (OR 0.54; 95% CI 0.31-0.94; P = 0.03). Pooled analysis revealed no significant differences in other outcome measures between the two treatment modalities.

CONCLUSION

In distal femoral fractures, RIN had a shorter bone union time and was more resistant to infection than DFP. However, there were no significant differences in the other clinical parameters. Therefore, the characteristics, strengths, and weaknesses of RIN and DFP should be carefully identified, and appropriate treatment should be provided based on the patient's medical condition and fracture pattern.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Locked Plating Versus Retrograde Intramedullary Nailing for Distal Femur Fractures: a Systematic Review and Meta-Analysis

Modern advances in techniques and implants have allowed for a better operative fixation for distal femoral fractures. Both locked plating and retromedullary nail have allowed surgeons to stabilize these fractures with minimal soft tissue dissection and preserve blood supply. Although both the implants have been used extensively for such types of fractures, the superiority of one implant over the other is still doubtful. Therefore, we conducted this meta-analysis to compare locked plating and retrograde intramedullary nailing in distal femoral fractures. Based on prisma guidelines, electronic databases, including PubMed, Embase, Scopus, and Ovid Medline were searched using a well-defined search strategy. Outcome measures which were studied included blood loss, implant failure, infection, knee range of motion, malunion, non-union, pain, surgical duration and union time Surgical duration (95% CI 2.90 to 17.13, p <0.01) and blood loss (95% CI 69.60 to123.18, p <0.01) favoured plating group and the difference is significant. But while analysing parameters like implant failure, knee range of motion, non-union and union time, our analysis favoured nailing group, but the difference is not significant. Overall, both locked plating and retrograde intramedullary nailing are comparable with respect to union and complications in distal femur fractures, but we need further larger and high quality randomized studies to evaluate the difference.

Comparing Intramedullary Nailing Versus Locked Plating in the Treatment of Native Distal Femur Fractures: Is One Superior to the Other?

INTRODUCTION

Distal femur fractures make up < 1% of all fractures and 3-6% of all femur fractures. In the literature, both intramedullary nailing (IMN) and locked plating (LP) have shown favorable results, but there is no consensus on a gold standard. The purpose of this systematic review is to compare outcomes of native distal femur fractures treated via IMN versus LP in an effort to determine if one is superior to the other.

METHODS

Systematic review of MEDLINE, EMBASE, and Cochrane Library databases was conducted according to PRISMA guidelines. Only articles published within the last ten years were included. Evidence and study quality were evaluated with the MQOE and Oxford Criteria.

RESULTS

Forty-six articles were included in the review. Fractures treated with IMN were found to have a 93.9% union rate, an average time to union of 19.2 weeks, an average arc of motion of 105.1 degrees, with an average of 14.4 degrees of malalignment. Fractures treated with LP were found to have a 90.2% union rate, an average time to union of 20.5 weeks, an average arc of motion of 104 degrees, with an average of 12.6 degrees of malalignment.

CONCLUSION

Compiled data comparisons revealed no differences in union rate, malalignment, time to union, average arc of motion, or complication rates requiring a return to the operating room. Until higher level randomized data is available, either IMN or LP are acceptable methods of treatment for native distal femur fractures.