Management of resistant distal femur non-unions with allograft strut and autografts combined with osteosynthesis in a series of 22 patients

Comparison of radiological and functional results in osteoporotic distal femur fractures operated with single plating, lateral incision, and double plating, anterior paramedial incision: A retrospective study

Treatment of osteoporotic distal femur fractures is often complicated by a high rate of nonunion and varus collapse. For such fractures, lateral plating with lateral incision and double plating with anterior paramedial incision have shown promising results in the recent literature. The hypothesis of this study was that bilateral plating of comminuted distal femur fractures in osteoporotic patients would result in higher union rates and lower revision rates compared to an isolated lateral locking plate. The study included 56 patients (23 males, 33 females) with supracondylar femur fracture. According to the OA/OTA classification, 9 were type A3, 8 were A2, 13 were C1, 16 were C2, and 10 were C3. The mean follow-up period was 12 months, with 29 patients treated using lateral mini-incision, lateral locking plate, and 27 patients treated with anterior paramedial incision, dual plating. The clinical and radiological results were evaluated. The mean duration of radiological union in the studied population was 15 ± 2.1 months (range, 11-21 months) in the single plate group (Group A), and 13.5 ± 2.6 months (range, 9-19 months) in the double plate group (Group B). Mean ROM was 112.3° and flexion contracture 4° in Group A, and ROM 108.3° and flexion contracture 6.7° in Group B. (P = .15). The average Western Ontario and McMaster Universities Arthritis Index (WOMAC) score was 85.6 points in Group A and 83.5 points in Group B (P = .2278). The postoperative anteversion measurement in the operated extremity ranged from -15 to 19 in Group A, and from 5 to 18 in Group B. When the anteversion degrees were compared between the injured and uninjured extremities in the postoperative period, a significant difference was observed within Group A (P = .0018), but no significant difference was observed in Group B (P = .2492). Dual plate fixation using the anterior paramedial approach is an effective operative method for osteoporotic distal femur fractures. This has many advantages such as precise exposure, easy manipulation, anatomic reduction, and stable fixation. However, for surgical indications and medial bone defects > 1 cm, grafting should be performed.

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

BACKGROUND

Management of resistant distal femur nonunions is challenging because patients not only have disability from an unhealed fracture, but also often have a shortened femur, stiff knee, deformities, and bone defects to address during revision surgery. Dual plating of the distal femur in such a setting can maintain stability that allows the nonunion to heal while also addressing bone defects and correcting deformities simultaneously. Dual-plating techniques that have been described lack standardization with regard to the size and type of medial-side implants and configuration of the dual-plate construct.

QUESTIONS/PURPOSES

(1) What proportion of patients achieve radiologic evidence of union after parallel plating of resistant distal femoral nonunions? (2) What improvements in function are achieved with this approach, as assessed by improvements in femoral length discrepancy, knee flexion, and patient-reported outcome scores? (3) What complications are associated with the technique?

METHODS

Between 2017 and 2020, the senior author of this study treated 38 patients with resistant distal femoral nonunions, defined here as nonunions that persisted for more than 12 months since the injury despite a minimum of two previous internal fixation procedures. During the study period, our preferred technique for treating aseptic, resistant distal femoral nonunions was to use dual plates in a parallel configuration augmented with autografts. Of 38 patients, three patients with active signs of infection who underwent resection and reconstruction using bone transport techniques and two patients older than 65 years with deficient distal femur bone stock who underwent endoprosthetic reconstruction were excluded. Of the 33 included patients, 67% (22 of 33) were male. The median age was 40 years (range 20 to 67 years). Nonunion was articular and metaphyseal in 13 patients and metaphyseal only in 20 patients. Our surgical approach was to remove existing implants, perform intraoperative culturing to rule out infection, debride the nonunion, correct the deformity, perform intra-articular and extra-articular lysis of adhesions with quadriceps release, and apply fixation using medial and lateral fixed-angle anatomic locked implants positioned in a parallel configuration. Every attempt to improve length was undertaken, and the defects were filled with autografts. A total of 97% of patients were followed until union occurred (one of 33 was lost to follow-up before union was documented), and 79% (26 of 33) were assessed for functional outcomes at a minimum of 2 years (median 38 months [range 25 to 60 months]) after excluding patients lost to follow-up and those in whom union did not occur after parallel plating. Union was defined as evidence of central trabecular bridging on AP radiographs and posterior cortical bridging on lateral radiographs. These radiologic criteria were defined to overcome difficulties in assessing radiologic healing in patients with lateral and medial plates. With parallel plating, bridging trabecular bone along the posterior cortex on lateral radiographs and the central region on AP radiographs is visualized and can be appreciated and interpreted as evidence of healing in two orthogonal planes. Preoperative and follow-up clinical assessment of knee ROM, the extent of femoral length correction based on calibrated femoral radiographs before and after surgery, and the evaluation of improvement in lower limb function based on the preoperative and follow-up differences in responses to the lower extremity functional scale (LEFS) were studied (the LEFS is scored from 0 to 80, with higher scores representing better function). Complications and secondary surgical procedures to address them were abstracted from a longitudinally maintained trauma database.

RESULTS

Sixty-seven percent (22 of 33) of nonunions showed radiologic healing by 24 weeks, and another 24% (eight of 33) healed by 36 weeks. Six percent (two of 33) did not unite, and one patient was lost to follow-up before union was documented. In the 79% (26 of 33) of patients available for final functional outcome assessment, the median femoral shortening had improved from 2.4 cm (range 0 to 4 cm) to 1.1 cm (range 0 to 2.3 cm; p < 0.001), and the median knee ROM had improved from 70° (range 20° to 110°) to 100° (range 50° to 130°; p = 0.002) after surgery. The median LEFS score improved to 63 (range 41 to 78) compared with 22 (range 15 to 33; p < 0.001) before surgery. Serious complications, including major thromboembolic events, iliac graft site infection, knee stiffness (flexion < 60°), and medial plate impingement necessitating removal, were seen in 30% (10 of 33) of patients. Secondary surgical interventions were performed in 24% (eight of 33) of patients to address procedure-related complications.

CONCLUSION

Based on our findings, a high likelihood of union and improvements in knee and lower limb function can be expected with parallel plating of resistant distal femur nonunions using anatomic locked plates. However, the increased frequency of complications observed in our study suggests the need for improvements in dual-plating techniques and to explore possible alternative fixation methods through larger multicenter comparative studies.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Resistant distal femoral nonunion treated with combined nail/plate construct and reamer-irrigator-aspirator technique

OBJECTIVE

This study was performed to evaluate the effectiveness of intramedullary nailing and a lateral locking plate combined with the reamer-irrigator-aspirator (RIA) bone grafting technique for resistant distal femoral nonunion.

METHODS

This retrospective observational study was performed from January 2018 to December 2021 and involved five patients who presented with resistant distal femoral nonunion despite undergoing several surgeries. They were treated with intramedullary nailing and a lateral locking plate combined with the RIA bone grafting technique. Postoperative follow-up was performed to observe the healing time, and functional outcomes were evaluated using the Lower Extremity Functional Scale (LEFS).

RESULTS

After the patients had been monitored for a mean of 17.9 months, complete bone healing was observed in every patient (mean healing time of 4.8 months). Postoperative wound failure in an older patient was successfully treated with resuturing and nutritional assistance. At the last follow-up, the mean LEFS score was 71.2/80 and the mean knee flexion was 109 degrees.

CONCLUSIONS

Our study demonstrates that combining intramedullary nailing and a lateral locking plate with the RIA bone grafting technique enhances biological properties, provides good structural support, and achieves good union and functional results in the management of resistant nonunion of the distal femur.

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

PURPOSE

Nonunion is a common complication after a distal femoral fracture (DFF). Standard treatment consists of revision plating and/or bone grafting. Single lateral plating for a distal femoral nonunion can be insufficient in case of a persistent medial gap and compromised bone stock. Alternatively, dual plating can be used to treat a distal femoral nonunion, but to date there is no Gold standard. The aim of our study was to report our results after use of a minimally invasively placed proximal humeral internal locking system (Philos) plate as a medial buttress in the treatment of a distal femoral nonunion.

METHODS

Fifteen adult patients with a distal femoral nonunion were prospectively entered in a trauma database and retrospectively assessed. All patients underwent a similar operation, which included removal of failed hardware, nonunion debridement, fixation with a lateral plate, and a medial Philos plate combined with bone grafting. Data collected included union rate, time to union, complications and functional outcome.

RESULTS

In twelve out of fifteen patients (80%), the fracture united after our index operation. Median time to union was 4.8 months (range 1.6-15). Three patients (20%) needed additional bone grafting surgery. One patient underwent a Judet quadricepsplasty.

CONCLUSION

This study suggests that the Philos plate is a safe and effective adjunct as a medial buttress plate for distal femoral nonunions.

Operative treatment of nonunions in the elderly: Clinical and radiographic outcomes in patients at minimum 75 years of age

BACKGROUND

Limited information exists on nonunion treatment in the elderly. This retrospective study evaluates whether results of operative treatment of nonunion of the humerus or femur in patients aged ≥ 75 years are comparable to those in younger patients.

METHODS

We identified patients age ≥ 75 years with a nonunion of humerus or femur treated with open reduction and internal fixation. The Non-Union Scoring System was calculated. Complications, clinical outcome, and radiographic findings were assessed. Primary endpoint was nonunion healing. A literature review compared time to healing of humeral and femoral nonunion in younger populations.

RESULTS

We identified 45 patients treated for a nonunion of humerus or femur with > 12 months follow-up. Median age was 79 years (range 75-96). Median time to presentation was 12 months (range 4-127) after injury, median number of prior surgeries was 1 (range 0-4). Union rate was 100%, with median time to union 6 months (range 2-42). Six patients underwent revision for persistent nonunion and healed without further complications.

CONCLUSIONS

Using a protocol of debridement, alignment, compression, stable fixation, bone grafting and early motion, patients aged 75 years or older can reliably achieve healing when faced with a nonunion of the humerus or femur.

LEVEL OF EVIDENCE

IV.

Role of impaction bone grafting of allografts in the management of benign lesions of the proximal femur

Purpose of study

The use of allografts to reconstruct benign lesions of the proximal femur after curettage has seldom been reported. We report our experience of impaction bone grafting of only allografts combined with osteosynthesis to manage benign lesions involving the proximal femur.

Materials and methods

Between 2013 and 2019, 35 patients of a mean age of 23.8 years (14-41) who had a biopsy proven benign pathology and a median pre-operative Mirels' score of 9 (8-11) were managed using extended curettage, impaction bone grafting of allografts combined with osteosynthesis through a lateral approach. Radiographs were assessed to see for any recurrence at follow-ups, and functional outcomes were assessed using Musculoskeletal Tumour Society (MSTS) score and Harris hip score (HHS).

Results

At a mean follow-up was 41.5 months (23-80), patients demonstrated favorable functional outcomes with a mean MSTS of 28.3 (18-30) and a mean HHS of 94.3 (66-100) at the last follow-up. Two cases (GCT = 1; fibrous dysplasia = 1) had a recurrence of disease. Allografts demonstrated a particular integration pattern on radiographs that involved an intermediate period of lucency followed by consolidation and integration with the parent bone.

Conclusion

Impaction grafting of allografts in benign lesions of the proximal femur allows adequate bony consolidation of the cavity after extended curettage and can be effectively used as a permanent solution to manage such lesions in most cases. The intermediate period of lucency seen on radiographs must not be confused for recurrence, and patients must be followed up continuously.

Study design

Retrospective Case Series.

Level of evidence

Level IV.

The Management of Aseptic Non-unions of Distal Femur Fractures with Anatomical Lateral Locking Plates

Background

Distal femoral non-unions are challenging, and frequently associated with short distal fragments, poor bone stock, and with issues from previous implants.

Materials and methods

A retrospective study of 31 patients admitted with distal femoral non-unions treated using anatomical lateral locking plates. Non-union scores were used. The Knee Society and Neer's scores were used for the comparison of results. The mean follow-up was 39.5 months (from 24 months to 60 months).

Results

Stable union was accomplished in all. There was a significant improvement in the average Neer's score (24 preoperative to 82 post-operatively at final follow-up), the Part 1 Knee Society score from an average of 46 preoperatively to 84 post-operatively, and Part 2 Knee Society score from 36 preoperatively to 80 post-operatively.

Conclusion

Optimal stability, good compression at the non-union site (either by lag screws or a compression device or both), maintaining the axial alignment strictly, freshening of bone ends, using an adequate amount of cortico-cancellous bone graft, respecting the biology along with the correct choice of the implant (including the size) are essential to achieve union at the fracture site.

Clinical significance

Paying attention to the basic principles of management, good contact, stability and maintaining biology is essential in the treatment of non-union.

How to cite this article

Mukhopadhaya J, Ranjan R, Sinha AK, et al. The Management of Aseptic Non-unions of Distal Femur Fractures with Anatomical Lateral Locking Plates. Strategies Trauma Limb Reconstr 2022;17(3):137-143.

Cortical allograft strut augmented with platelet-rich plasma for the treatment of long bone non-union in lower limb- a pilot study

Background

The autogenous iliac bone graft is the first choice of surgical treatment for long bone non-union. However, many factors limit the use of autogenous bone, such as insufficient bone harvest and complications in the donor site. This study aimed to pilot-test the effectiveness of the cortical allograft strut augmented with Platelet-rich plasma (PRP) on long bone non-union in the lower limb.

Method

This study was a one-armed pilot trial, with thirteen men and four women patients scheduled for surgery. Revision surgery for managing long bone non-union included debridement, internal fixation of the cortical allograft strut, and adding PRP in the fracture site. After surgery, outcome measurements of healing rate, healing time, the incidence of revision, and complications, were assessed at least one-year follow-up.

Results

Fourteen of seventeen participants completed all follow-ups. The mean age of 14 patients was 35.9 years (range, 18–56 years), and the mean BMI was 22.44 ± 1.53 kg/m². All nonunions united after the operation. The mean healing time was 4.6 ± 0.7 months. There was no revision or complication.

Conclusion

Cortical allograft strut augmented with PRP led to healing long bone non-union in the lower limb. More clinical research is required before widespread use.

Updates in postoperative imaging modalities following musculoskeletal surgery

Postoperative imaging following orthopaedic surgeries is essential in assessing complications post-surgery and also helps plan further treatment. Combining a high degree of clinical insight with appropriate imaging can guide the treating clinician to the correct diagnosis. Imaging is quite challenging because of surgery-related soft tissue changes, especially in the early postoperative period and the presence of metal implants resulting in image scatter and metal artifacts. Newer modalities and advances in imaging have helped overcome shortcomings and assess better, especially in procedures that involve implants. Collaborative decision-making involving radiologists and clinicians has shown to be beneficial and is the way forward. This narrative review discusses the utility of imaging in evaluating postoperative complications following musculoskeletal surgeries with specific relation to trauma, arthroplasty, and tumour by discussing commonly encountered clinical scenarios.

Infected Non-Union of the Distal Femur

The reported levels of non-union in the lateral locking plate differ widely, with some early studies showing rates of less than 6% and up to 17%-21% in more recent studies. We report a case where better results were shown by a non-union treated with distal femoral nailing with allogenic grafting.

Atypical periprosthetic femoral fractures of the hip: characterisation of three cases

INTRODUCTION

Long-term use of bisphosphonates (BPs) has been associated with a specific type of tensile side femoral stress fracture known as Atypical Femoral Fracture (AFF). Theoretically periprosthetic femoral fractures (PFF) should be excluded from the diagnosis of AFF. However, emerging evidence correlates prolonged BPs use with the occurrence of a type of PFF with an atypical pattern (atypical PFF, APFF). The aim of the present study is to report 3 cases of APFF treated at a single centre.

METHODS

Clinical and radiographic records of PFF that occurred between January 2016 and August 2018 were retrospectively reviewed. All patients meeting the American Society for Bone and Mineral Research (ASBMR) criteria for definition of PFF were included. Management strategies for APFF and patient outcomes, including fracture healing and hip function (assessed by the Oxford Hip Score [OHS]) were collected.

RESULTS

3 patients in the study period were identified as APFF (1 incomplete, 2 complete). All patients were females with a mean age of 83.3 years. All patients were treated with lateral plating. The application of a contralateral strut allograft resulted in fracture healing in cases of complete fractures. Mean OHS at final follow-up was 34.3.

CONCLUSIONS

Despite occurring around a hip stem like PFF, APFF had peculiar clinical and radiographic features, making them more similar to AFF. Therefore, the orthopaedic surgeon should also consider the natural history and healing problems associated with AFF prior in order to choose the most appropriate management for APFF.

The effects of dual plating on the vascularity of the distal femur

AIMS

Dual plating of distal femoral fractures with medial and lateral implants has been performed to improve construct mechanics and alignment, in cases where isolated lateral plating would be insufficient. This may potentially compromise vascularity, paradoxically impairing healing. This study investigates effects of single versus dual plating on distal femoral vascularity.

METHODS

A total of eight cadaveric lower limb pairs were arbitrarily assigned to either 1) isolated lateral plating, or 2) lateral and medial plating of the distal femur, with four specimens per group. Contralateral limbs served as matched controls. Pre- and post-contrast MRI was performed to quantify signal intensity enhancement in the distal femur. Further evaluation of intraosseous vascularity was done with barium sulphate infusion with CT scan imaging. Specimens were then injected with latex medium and dissection was completed to assess extraosseous vasculature.

RESULTS

Quantitative MRI revealed a mean reduction of 21.2% (SD 1.3%) of arterial contribution in the lateral plating group and 25.4% (SD 3.2%) in the dual plating group (p = 0.051); representing a mean decrease in arterial contribution of 4.2%. The only significant difference found between both experimental groups was regionally, at the lateral aspect of the distal femur with a mean drop in arterial contribution in the lateral plating group of 18.9% (SD 2.6%) versus 24.0% (SD 3.2%) in the dual plating group (p = 0.048), representing a mean decrease in arterial contribution of 5.1%. Gross dissection revealed complete destruction of periosteal vessels underneath either medial or lateral plates in both groups. The network of genicular branches contributing to the posterior and distal femoral condyles was preserved in all specimens. A medial vascular pedicle was found dividing from the superficial femoral artery at a mean 12.7 cm (SD 1.7) proximal to the medial epicondyle and was undisrupted in the dual plating group.

CONCLUSION

Lateral locking-plate application resulted in mean 21.2% reduction in distal femur vascularity. Addition of medial plates did not further markedly decrease vascularity. As such, the majority of the vascular insult occurred with lateral plating alone. Supplemental medially based fixation did not lead to marked devascularization of the distal femur, and should therefore be considered in the setting of comminution and poor bone stock in distal femoral fractures. Further clinical research is required to confirm the results of this study. Cite this article: Bone Joint J 2020;102-B(4):530-538.

A Three-Dimensional Printed Polycaprolactone Scaffold Combined with Co-Axially Electrospun Vancomycin/Ceftazidime/Bone Morphological Protein-2 Sheath-Core Nanofibers for the Repair of Segmental Bone Defects During the Masquelet Procedure

Introduction

Masquelet proposed a new solution for the healing of segmental bone defects, thus minimizing the disadvantages associated with traditional bone grafting. However, a major factor leading to the failure of this technique pertains to be the residual infection. Accordingly, we developed an antibiotic- and osteo-inductive agent-loaded composite scaffold to solve this problem.

Methods

A mesh-like polycaprolactone scaffold was prepared using a lab-exploited solution-type three-dimensional printer, and hybrid sheath-core structured poly(lactic-co-glycolic-acid) nanofibers were fabricated using co-axial electrospinning technology. Vancomycin, ceftazidime, and bone morphological protein (BMP)-2 were employed. The in vitro and in vivo (rabbit fracture model) release patterns of applied agents from the composite scaffold were investigated.

Results

The results revealed that the drug-eluting composite scaffold enabled the sustainable release of the medications for at least 30 days in vitro. Animal tests demonstrated that a high concentration of medications was maintained. Abundant growth factors were induced within the bioactive membrane stimulated by the applied scaffold. Finally, satisfactory bone healing potential was observed on radiological examination and biomechanical evaluation.

Discussion

The developed composite scaffold may facilitate bone healing by inducing bioactive membrane formation and yielding high concentrations of antibiotics and BMP-2 during the Masquelet procedure.

Modified Capanna's Technique (Vascularized Free Fibula Combined with Allograft) as a Single-Stage Procedure in Post-traumatic Long-Segment Defects of the Lower End of the Femur: Outcome Analysis of a Series of 19 Patients with an Average Gap of 14 cm

Objectives  Salvage and reconstruction of posttraumatic defects of the long bone are complex due to the multiple procedures involved and increased chances of poor outcomes. We present the outcomes of the modified Capanna’s technique—a reliable single-stage procedure of combining allograft and free vascularized fibular graft—in treating large posttraumatic bone defects in the distal third of the femur.

Study Design  This is a retrospective analysis.

Materials and Methods  Between April 2012 and September 2016, 19 patients with an average age of 33.8 years (range: 18–49 years) and an average defect of 14.5 cm (range: 9.5–20 cm) in the distal femur were managed by the modified Capanna’s technique. Bone union time and functional outcome using lower extremity functional score (LEFS) after union were noted.

Outcomes and Results  Eighteen grafts went onto achieve bony union at an average of 6.6 months (range: 5–9), with an average knee flexion of 80 degrees (range: 45–110 degrees) and an average LEFS of 63 (range: 46–72). One patient had a nonunion with graft resorption at 8 months following persistent infection and was revised with debridement and augmenting the vascularized fibula from the other leg which went on to achieve union. Three patients had superficial infection, and three patients had delayed union.

Conclusion  The modified Capanna’s technique provided increased biology and enhanced structural stability and therefore is a good single-stage procedure in the reconstruction of posttraumatic long-segment defects of the distal femur.

Level of Evidence  Level 4.

Level of Clinical Care  Level I tertiary trauma center.

[Research progress of augmentation plate for femoral shaft nonunion after intramedullary nail fixation]

Objective

To review the history, current situation, and progress of augmentation plate (AP) for femoral shaft nonunion after intramedullary nail fixation.

Methods

The results of the clinical studies about the AP in treatment of femoral shaft nonunion after intramedullary nail fixation in recent years were widely reviewed and analyzed.

Results

The AP has been successfully applied to femoral shaft nonunion after intramedullary nail fixation since 1997. According to breakage of the previous nailing, AP is divided into two categories: AP with retaining the previous intramedullary nail and AP with exchanging intramedullary nail. AP is not only suitable for simple nonunion, but also for complex nonunion with severe deformity. Compared with exchanging intramedullary nail, lateral plate, and dual plate, AP has less surgical trauma, shorter healing time, higher healing rate, and faster returning to society. However, there are still some problems with the revision method, including difficulty in bicortical screw fixation, lack of anatomic plate suitable for femoral shaft nonunion, and lack of postoperative function and quality of life assessment.

Conclusion

Compared with other revision methods, AP could achieve higher fracture healing rate and better clinical prognosis for patients with femoral shaft nonunion. However, whether patients benefit from AP in terms of function and quality of life remain uncertain. Furthermore, high-quality randomized controlled clinical studies are needed to further confirm that AP are superior to the other revision fixations.

Megaprosthesis in distal femur nonunions in elderly patients-experience from twenty four cases

Purpose of the study

To evaluate the outcomes and complications using cemented megaprosthesis in elderly patients with distal femur nonunions (DFN).

Materials and methods

Between 2012 and 2016, 24 patients of DFN with an average age of 71.8 years (66–83) and an average 1.9(1–3) prior surgery was managed with distal femur replacement using cemented modular endoprosthesis. Outcomes were analysed on the following criteria: implant status, complications, knee range of motion, Knee Society Score (KSS) and Musculoskeletal Tumor Society (MSTS) score.

Results

All patients were extremely satisfied with their outcomes. At an average 22.1 months (10–43) follow-up, patients had an average 69.5° (40°-110°) knee flexion, an average KSS of 75.7 (63–88) and an average MSTS score of 19.3 (17–25). Four patients died at an average 21.3 months after surgery due to causes unrelated to the fracture. One patient (4.1%) had implant-related complication; deep infection which required debridement and intravenous antibiotics. There were no late amputations or peri-operative deaths and no patient had aseptic loosening of components.

Conclusion

By permitting immediate full weight-bearing ambulation and with most patients returning to an acceptable functional status, cemented megaprosthesis is a viable and useful single-stage management option in elderly patients with DFN.

Locking plate fixation versus antegrade intramedullary nailing for the treatment of extra-articular distal femoral fractures

INTRODUCTION

The current study aimed to retrospectively analyze locked plating (LP) and antegrade intramedullary nailing (AIN) for the treatment of extra-articular distal femoral fractures.

PATIENTS AND METHODS

Between January 2000 and March 2015, 97 patients (49 male, 48 female) underwent surgery for extra-articular distal femoral fractures in our clinic. Patients were grouped based on their method of treatment (69 (71.1%) with locked plate (LP group) and 28 (28.9%) with antegrade intramedullary nailing (AIN group)), and the groups were analyzed with regards to fracture types, associated trauma, hospital stay, Injury Severity Score (ISS), nonunion, reoperation rate and Lysholm Functional Knee Score.

RESULTS

The LP and AIN groups had no significant differences with regards to age and gender. Sixteen patients (16.4%) experienced nonunion; all of these (5 (5.1%) in the AIN group and 11 (11.3%) in the LP group) required a secondary procedure (p = 0.773). ISS was significantly higher in the AIN group (p = 0.033). There were no significant differences between the two groups with regards to hardware failure, postoperative malreduction, reoperation rate, deep infection, and nonunion. However, the AIN group (mean 88) had a significantly higher Lysholm Functional Knee Score than the LP group (mean 75.9) (p = 0.019).

CONCLUSION

In our study we encountered less nonunion in AIN group. Both fixation methods offer good results; however, functional outcomes in the AIN group were significantly better than those in the LP group.

A surgical algorithm for the management of recalcitrant distal femur nonunions based on distal femoral bone stock, fracture alignment, medial void, and stability of fixation

BACKGROUND

Recalcitrant distal femur nonunions (RDFN) are a challenge in management due to factors including poor bone stock, multiple surgeries, metaphyseal bone loss, and joint contractures. There are no specific guidelines in the management of cases of RDFN. Based on our experience, we devised an algorithm and we present the results of 62 cases of RDFN managed following it.

MATERIALS AND METHODS

Our algorithm was formulated after analyzing 34 cases of RDFN and it involved four factors which were hypothesized to influence outcomes namely: distal femoral bone stock, extent of medial void, alignment of the fracture, and stability of fixation. Each factor was addressed specifically to achieve a good outcome. Between 2012 and 2015, 62 patients with RDFN at a mean age of 47.4 years (26-73) and 2.3 prior surgeries (2-6) were managed following the algorithm.

INTERVENTION

58 patients required revision osteosynthesis to improve alignment and achieve a stable fixation. 4 elderly patients with poor bone stock were managed with arthroplasty. Extent of medial void was found to significantly influence surgical decision making. Five patients without medial void required only cancellous autograft bone grafting, 47 patients with < 2 cm void were treated with an allograft fibular strut inserted in the metaphysis and 6 patients with a void > 2 cm were managed with medial plating.

OUTCOMES AND RESULTS

57 patients treated with osteosynthesis achieved union at an average of 7.4 months (6-11) and the 4 patients managed with arthroplasty also had a favourable outcome. One patient who was managed with revision osteosynthesis had a nonunion with an implant failure and needed an arthroplasty procedure. The average LEFS (lower extremity functional score) of all our patients was 67 (51-76) at an average follow-up of 18.2 months (12-33).

CONCLUSION

Our stepwise surgical algorithm would help surgeons to identify the factors that need to be addressed and guide them towards the interventions that are necessary to achieve a successful outcome while managing cases of RDFN.

LEVEL OF EVIDENCE

III.

LEVEL OF CLINICAL CARE

Level I Tertiary trauma centre.