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Saraglis G, Khan A, Sharma A, Pyakurel S, Rabbani SFE, Arafa MSA. The linked nail/plate construct for the management of distal femur fractures in the elderly. SICOT J 2024; 10:20. [PMID: 38819290 PMCID: PMC11141519 DOI: 10.1051/sicotj/2024016] [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: 03/03/2024] [Accepted: 04/23/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Distal femoral fractures represent a challenging injury, with many different factors such as the method of fixation, complexity of fracture pattern, and patient co-morbidities affecting the outcome. Lots of surgical treatment options have been described, but recently double construct fixation, using a nail/plate combination, has received lots of attention, a technique that leads to faster weight-bearing, low risk of metalwork failure, and non-union. The purpose of this study was to investigate the effectiveness of the linked nail/plate construct in the management of complex distal femur fractures and to investigate if the above technique leads to faster recovery and earlier radiographic union. MATERIALS AND METHODS In total 15 cases were included in the study, that underwent a combined nail/plate construct for a distal femur fracture between January 2021 and December 2022. Only cases with a linked nail/plate construct were included, with a minimum follow-up of 1 year. Open femur fractures, single implant fixation cases, and revision procedures were excluded. RESULTS In this cohort study, 11 cases were periprosthetic distal femur features, and 4 cases were distal femur fractures around a native knee joint. The mean age group was 74 years, 86.6% of the patients had a BMI > 25 and the mean time to fracture union was 24 weeks (range from 20 to 26 weeks). All cases healed uneventfully and the complication rate was 6.6%, including 1 case of superficial infection which resolved completely with oral antibiotics. CONCLUSION The increasing age population, the complexity of distal femoral fractures along with the increasing physiological demands of the elderly population, drive the need for double fixation constructs that allow early mobilization and enhance fracture stability. In our study, the linked nail/plate construct seems to provide adequate stability and excellent union rates (100%) with no associated increased risk of complications.
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Affiliation(s)
- Georgios Saraglis
- Department of Trauma and Orthopaedics, Bedfordshire NHS Foundation Trust, Bedford Hospital South Wing, Kempston Road Bedford MK429DJ United Kingdom
| | - Anwar Khan
- Department of Trauma and Orthopaedics, Bedfordshire NHS Foundation Trust, Bedford Hospital South Wing, Kempston Road Bedford MK429DJ United Kingdom
| | - Amit Sharma
- Department of Trauma and Orthopaedics, Bedfordshire NHS Foundation Trust, Bedford Hospital South Wing, Kempston Road Bedford MK429DJ United Kingdom
| | - Sagar Pyakurel
- Department of Trauma and Orthopaedics, Bedfordshire NHS Foundation Trust, Bedford Hospital South Wing, Kempston Road Bedford MK429DJ United Kingdom
| | - Sayed Fazal Elahi Rabbani
- Department of Trauma and Orthopaedics, Bedfordshire NHS Foundation Trust, Bedford Hospital South Wing, Kempston Road Bedford MK429DJ United Kingdom
| | - Mohamed Shawky Abdelhamid Arafa
- Department of Trauma and Orthopaedics, Bedfordshire NHS Foundation Trust, Bedford Hospital South Wing, Kempston Road Bedford MK429DJ United Kingdom
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Kheiran A, Elbashir M, McDonald C, Elsayed H, Sheikh N, Plakogiannis C. Total femoral spanning for distal femur "fragility" fractures utilising nail-plate fixation "short-term experience of a district general hospital". EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2003-2013. [PMID: 38509381 DOI: 10.1007/s00590-024-03883-0] [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: 01/10/2024] [Accepted: 02/18/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE Our primary objective was to investigate the time to radiological union following linked nail-plate fixation of distal femur "fragility" fractures. Secondary objectives were to evaluate all-cause reoperations, 90-day mortality, rate of blood transfusion and the impact on quality of life. METHODS In this retrospective study of all adults (≥ 65 years) with native or periprosthetic distal femur fragility fractures, underwent a linked nail-plate fixation, data were retrieved on fracture classifications, clinical frailty score, blood transfusion, length of hospital stay, 90-day mortality, time to radiological union, overall complication rates and EuroQoL-5D. RESULTS In total, 18 out of 23 patients completed sequential follow-up. Radiological union was observed in 14 patients (median 143 days; range 42-414). Three patients underwent reoperations. There were no implant failures or a subsequent periprosthetic fractures. Ninety-day mortality was 17.4%. Eighteen patients required blood transfusion. The QoL was significantly lower after index surgery (0.875 vs. 0.684; p < 0.01). CONCLUSION Based on our observation, with short-term follow-up, the linked nail-plate yields optimal stability to allow immediate weight bearing, in a cohort with moderate frailty. It is reproducible, with variable radiological union rates. The concept of "total femoral spanning" reduces the risk of subsequent periprosthetic fractures. The additional intervention has increased the rates of allogenic blood transfusion. There is significant impact on overall QoL, with almost 50% being more dependent in self-care.
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Affiliation(s)
- Amin Kheiran
- Department of Trauma and Orthopaedics, Kettering General Hospital, Rothwell Rd, Kettering, NN16 8UZ, UK
| | - Mohamed Elbashir
- Department of Trauma and Orthopaedics, Kettering General Hospital, Rothwell Rd, Kettering, NN16 8UZ, UK
| | - Colin McDonald
- Department of Trauma and Orthopaedics, Kettering General Hospital, Rothwell Rd, Kettering, NN16 8UZ, UK
| | - Hassan Elsayed
- Department of Trauma and Orthopaedics, Kettering General Hospital, Rothwell Rd, Kettering, NN16 8UZ, UK
| | - Nomaan Sheikh
- Department of Trauma and Orthopaedics, Kettering General Hospital, Rothwell Rd, Kettering, NN16 8UZ, UK
| | - Christos Plakogiannis
- Department of Trauma and Orthopaedics, Kettering General Hospital, Rothwell Rd, Kettering, NN16 8UZ, UK.
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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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Espey R, Stevenson L, Tucker A. Combined nail-plate constructs in the management of osteoporotic native distal femoral fractures: a systematic review of the available evidence. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3215-3223. [PMID: 37106139 DOI: 10.1007/s00590-023-03552-8] [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: 02/21/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE Distal femoral fractures account for 4-6% of fragility fractures. These may be managed using a combined nail-plate construct (NPC). The use of NPCs is gaining traction. Whilst several theoretical advantages exist, there is little evidence reporting on binary or patient-reported outcomes. The aim of the current study was to perform a systematic review of the available literature pertaining to NPCs and their treatment of native distal femoral fractures, appraising the outcomes and focusing on the rationale for their increasing uptake in recent literature. METHODS A comprehensive search of MEDLINE, EMBASE, Clinical Key, PubMed and Cochrane library was performed from date of inception up to in August 9, 2022. All study languages were included initially. A further Google Scholar search review was performed to identify any other studies not identified in the database interrogation. Studies were eligible if they reported on the use of nail-plate constructs in managing distal femoral fractures. Any outcome metric was permitted. The study was conducted in accordance with PRISMA guidelines. Risk of bias was assessed using the Methodological Index for non-randomised Studies tool. Quantitative analysis was performed using a log odds ratio random effects model. The Knapp-Hartung adjustment was utilised if the total number of included studies was < 5. Study effect sizes and appropriate plots were constructed to illustrate the outcomes data. RESULTS A total of four studies were eligible for inclusion. Study data was extracted and summarised with their relevant outcomes presented. The literature review demonstrated that the use of NPCs led to significantly earlier full weight bearing (p < 0.001) and had reduced non-union rates over a single construct, without affecting infection rates (12.5% vs. 5.6%; p = 0.289) and significantly lower implant failure rates (10.5% vs. 0%; p = 0.011). A meta-analysis is performed of available studies and Forrest plots presented. CONCLUSION The use of NPC in the management of native osteoporotic DFFs is gaining traction but the available evidence is of low grade with significant heterogeneity in small cohorts of patients. We suggest that a large-scale, multicentre prospective study should be performed, with agreed functional and radiological outcome metrics, to provide a more robust evidence base.
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Affiliation(s)
- Robert Espey
- Musgrave Park Hospital, Stockmans Lane, Belfast, BT9 7JB, UK
| | - Lewis Stevenson
- Ulster Hospital Dundonald, Upper Newtownards Road, Belfast, BT16 1RH, UK
| | - Adam Tucker
- Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, UK.
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Shi BY, Brodke DJ, O'Hara N, Devana S, Hernandez A, Burke C, Gupta J, McKibben N, O'Toole R, Morellato J, Gillon H, Walters M, Barber C, Perdue P, Dekeyser G, Steffenson L, Marchand L, Shymon S, Fairres MJ, Black L, Working Z, Roddy E, El Naga A, Hogue M, Gulbrandsen T, Atassi O, Mitchell T, Lee C. Nail Plate Combination Fixation Versus Lateral Locked Plating for Distal Femur Fractures: A Multicenter Experience. J Orthop Trauma 2023; 37:562-567. [PMID: 37828687 DOI: 10.1097/bot.0000000000002661] [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: 06/26/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVES To (1) report on clinical, radiographic, and functional outcomes after nail-plate fixation (NPF) of distal femur fractures and (2) compare outcomes after NPF with a propensity matched cohort of fractures treated with single precontoured lateral locking plates. DESIGN Multicenter retrospective cohort study. SETTING Ten Level 1 trauma centers. PATIENTS/PARTICIPANTS Patients with OTA/AO 33A or 33C fractures. INTERVENTION Fixation with (1) retrograde intramedullary nail combined with lateral locking plate (n = 33) or (2) single precontoured lateral locking plate alone (n = 867). MAIN OUTCOME MEASUREMENTS The main outcomes of interest were all-cause unplanned reoperation and presence of varus collapse at final follow-up. RESULTS One nail-plate patient underwent unplanned reoperation excluding infection and 2 underwent reoperation for infection at an average of 57 weeks after surgery. No nail-plate patients required unplanned reoperation to promote union and none exhibited varus collapse. More than 90% were ambulatory with no or minimal pain at final follow-up. In comparison, 7 of the 30 matched lateral locked plating patients underwent all-cause unplanned reoperation excluding infection (23% vs. 3%, P = 0.023), and an additional 3 lateral locked plating patients were found to have varus collapse on final radiographs (10% vs. 0%, P = 0.069). CONCLUSIONS Despite a high proportion of high-energy, open, and comminuted fractures, no NPF patients underwent unplanned reoperation to promote union or demonstrated varus collapse. Propensity score matched analysis revealed significantly lower rates of nonunion for NPF compared with lateral locked plating alone. Larger studies are needed to identify which distal femur fracture patients would most benefit from NPF. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | | | - Nathan O'Hara
- Adams Cowley Shock Trauma Center at the University of Maryland
| | | | | | - Cynthia Burke
- Adams Cowley Shock Trauma Center at the University of Maryland
| | - Jayesh Gupta
- Adams Cowley Shock Trauma Center at the University of Maryland
| | | | - Robert O'Toole
- Adams Cowley Shock Trauma Center at the University of Maryland
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Coheña-Jiménez M, Prieto-Domínguez R, Pérez-Belloso AJ, Muriel-Sánchez JM, Gómez-Carrión Á, Montaño-Jiménez P. Comparison of Resorbable and Non-Resorbable Osteosynthesis Material in Hallux Surgery: A Systematic Review. Life (Basel) 2023; 13:2018. [PMID: 37895399 PMCID: PMC10608219 DOI: 10.3390/life13102018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023] Open
Abstract
There are various pathologies that involve the hallux, among which hallux valgus is the most common. When conservative treatment fails, it is necessary to resort to a surgical approach. The fixation elements for osteotomies in the hallux are usually composed of metallic materials; however, today, there are numerous resorbable materials that offer numerous advantages over conventional materials. In this article, the objective is to analyze the scientific evidence through the systematic analysis of the existing literature in relation to the effectiveness of resorbable versus non-resorbable osteosynthesis material in the surgical correction of hallux deformities and compare the complications as well as the patient satisfaction and quality of life between both fixation methods. A systematic review of the literature available in the PubMed, EMBASE, Web of Science and Scopus databases and 10 studies were included. The documents were chosen following the eligibility and exclusion criteria, including experimental and observational studies evaluated with the Jadad and Newcastle-Ottawa methodological quality scale, respectively. Data were extracted from valid studies for the review, and the variables functionality, pain, angular corrections, complications, satisfaction and quality of life were observed. In conclusion, there is limited scientific evidence regarding the effectiveness of resorbable versus non-resorbable osteosynthesis material in the surgical correction of hallux deformities. All observed variables are similar regardless of the surgical technique and osteosynthesis material used.
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Affiliation(s)
- Manuel Coheña-Jiménez
- Podiatry Department, University of Seville, 41009 Seville, Spain; (M.C.-J.); (R.P.-D.); (P.M.-J.)
| | - Raquel Prieto-Domínguez
- Podiatry Department, University of Seville, 41009 Seville, Spain; (M.C.-J.); (R.P.-D.); (P.M.-J.)
| | - Ana Juana Pérez-Belloso
- Podiatry Department, University of Seville, 41009 Seville, Spain; (M.C.-J.); (R.P.-D.); (P.M.-J.)
| | | | | | - Pedro Montaño-Jiménez
- Podiatry Department, University of Seville, 41009 Seville, Spain; (M.C.-J.); (R.P.-D.); (P.M.-J.)
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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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Bianco Prevot L, Nannini A, Mangiavini L, Bobba A, Buzzi S, Sinigaglia F, Peretti G. What Is the Best Treatment of the Femoral Shaft Nonunion after Intramedullary Nailing? A Systematic Review. Life (Basel) 2023; 13:1508. [PMID: 37511883 PMCID: PMC10381168 DOI: 10.3390/life13071508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/30/2023] Open
Abstract
Nonunion (NU) is one of the most feared complications of femoral shaft fracture treatment. Femoral shaft fracture treatment is often linked with poor bone stock and reduced bone metabolism. In this paper, the goal is to carefully analyze the best treatment options for patients who developed nonunion after the intramedullary nailing of a femoral shaft fracture. A systematic review of the literature available in the PubMed, EMBASE and Cochran library databases was carried out, and 16 studies were included. Exclusion criteria included case reports and case series that do not have data about clinical outcomes or functional outcomes and included fewer than 10 patients. The reviewed data provide evidence for very good results about the treatment of this pathology with exchanging intramedullary nails or the implantation of a plate and screws (general healing rate of 96.3%). Moreover, the data support the utilization of autologous bone graft in order to stimulate the healing process. In conclusion, the choice between these two types of treatment must be guided by the type of pseudarthrosis that the patient presents. Additionally, bone grafting or growth factors promote bone regenerative processes, especially in patients with oligo-atrophic pseudoarthrosis.
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Affiliation(s)
- Luca Bianco Prevot
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
| | - Alessandra Nannini
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
| | - Laura Mangiavini
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
| | - Andrea Bobba
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
| | - Sara Buzzi
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
| | - Federico Sinigaglia
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
| | - Giuseppe Peretti
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
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Zhang JH, Liu H, Cai TY, Lin YZ, Wu J. Resistant distal femoral nonunion treated with combined nail/plate construct and reamer-irrigator-aspirator technique. J Int Med Res 2023; 51:3000605231187945. [PMID: 37498625 PMCID: PMC10387779 DOI: 10.1177/03000605231187945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Abstract
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.
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Affiliation(s)
- Jin-Hui Zhang
- Department of Orthopaedics, the 909th Hospital, School of Medicine, Xiamen University, Zhangzhou, China
| | - Hui Liu
- Department of Orthopaedics, the 909th Hospital, School of Medicine, Xiamen University, Zhangzhou, China
| | - Tao-Yi Cai
- Department of Orthopaedics, the 909th Hospital, School of Medicine, Xiamen University, Zhangzhou, China
| | - Yong-Zhi Lin
- Department of Orthopaedics, the 909th Hospital, School of Medicine, Xiamen University, Zhangzhou, China
| | - Jin Wu
- Department of Orthopaedics, the 909th Hospital, School of Medicine, Xiamen University, Zhangzhou, China
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Nail plate combination in fractures of the distal femur in the elderly: A new paradigm for optimum fixation and early mobilization? Injury 2023; 54:288-291. [PMID: 36400628 DOI: 10.1016/j.injury.2022.11.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Distal femoral fractures in elderly or osteoporotic patients constitute a challenging injury, especially in the settings of fracture comminution or periprosthetic fractures. A recent trend in the treatment of these difficult injuries is the double fixation with a nail and a plate, a strategy that comes with advantages including faster weight-bearing and lower risk for non-union. Although biomechanical studies have demonstrated the superiority of nail-plate constructs, there is a paucity in the literature regarding the indications and results of treatment. A review of the literature to date was carried out to identify which group of patients would benefit the most from this type of reconstruction and to evaluate the clinical outcomes.
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11
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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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12
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Treatment of Femoral Shaft Pseudarthrosis, Case Series and Medico-Legal Implications. J Clin Med 2022; 11:jcm11247407. [PMID: 36556022 PMCID: PMC9787375 DOI: 10.3390/jcm11247407] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/14/2022] [Accepted: 12/13/2022] [Indexed: 12/15/2022] Open
Abstract
Pseudarthrosis (PSA) is a possible complication of femoral shaft fracture treatment. It is often associated with reduced bone quality and can, therefore, adversely affect quality of life. Its treatment poses a major challenge for orthopaedic surgeons. Several authors have set forth different surgical approaches for the treatment of pseudarthrosis, such as internal fixation with plate and screws, replacement of an intramedullary nail or prosthetic replacement. In cases associated with bone loss, osteopenia, or comminution of fracture fragments, autologous or homologous bone grafts may also be used. The chronic outcomes of the surgical treatment of femoral shaft pseudarthrosis, even when consolidation is achieved, are linked to disabling sequelae of clinical-functional relevance, deserving an adequate medico-legal evaluation. The purpose of this retrospective study is to analyse a clinical case series of patients treated for atrophic femoral shaft pseudarthrosis at the IRCCS Orthopaedic Institute Galeazzi, Milan, Italy, from 2014 to 2020 and their orthopaedic-traumatological and medico-legal implications.
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13
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Li QW, Wu B, Chen B. Modified fixation for periprosthetic supracondylar femur fractures: Two case reports and review of the literature. World J Clin Cases 2022; 10:12328-12336. [PMID: 36483801 PMCID: PMC9724516 DOI: 10.12998/wjcc.v10.i33.12328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 09/16/2022] [Accepted: 10/26/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Periprosthetic supracondylar femoral fractures (PSFs) present a challenge in terms of optimizing fixation in patients with poor bone quality. Surgical treatment and peri-operative management of PSFs in the elderly remain a burden for orthopedic surgeons. Among different treatment options, locking plate (LP) and retrograde intramedullary nail (RIMN) have shown favorable results. However, reduced mobility and protected weight-bearing are often present in the postoperative older population. With a purpose of allowing for early weight-bearing, a modified nail plate combination (NPC) was redesigned for PSF management.
CASE SUMMARY In our cases, two elderly osteoporotic female underwent total knee arthroplasty (TKA), and then suffered from low energy trauma onto their knees after falling to the floor. Plain radiographs or computed tomography scans demonstrated oblique or transverse PSFs, both of which occurred at the distal femur above TKA. The modified NPC technique was performed for treatment of PSFs. The patient was made foot flat weight bearing in 1 wk. At 6-mo follow-up, the union was ultimately achieved using modified NPC with satisfactory implant outcomes.
CONCLUSION Neither LP nor RIMN alone may provide adequate support to allow for union in circumstances where the patient has severely osteopenic bone. Therefore, developing a modified implant offer an alternative choice for treating PSFs. These two cases revealed that this technique is a viable option for the geriatric osteoporotic PSFs, offering safe, early weight bearing and favorable clinical outcomes.
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Affiliation(s)
- Qin-Wen Li
- Department of Orthopedics, The People's Hospital of Three Gorges University, The First People's Hospital of Yichang, Yichang 443000, Hubei Province, China
| | - Bin Wu
- Department of Orthopedics, The People's Hospital of Three Gorges University, The First People's Hospital of Yichang, Yichang 443000, Hubei Province, China
| | - Bo Chen
- Department of Orthopedics, The People's Hospital of Three Gorges University, The First People's Hospital of Yichang, Yichang 443000, Hubei Province, China
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14
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ON Path: outpatient nonunion pathway for lower-extremity nonunions. OTA Int 2022; 5:e218. [PMID: 36569112 PMCID: PMC9782313 DOI: 10.1097/oi9.0000000000000218] [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: 10/04/2021] [Revised: 06/03/2022] [Accepted: 07/06/2022] [Indexed: 11/05/2022]
Abstract
Objectives The purpose of this study was to assess the safety and efficacy of outpatient and short-stay surgical nonunion treatment by incorporating minimally invasive surgical techniques, multimodal pain control, and a modernized postoperative protocol. Design Retrospective case series. Setting Tertiary referral hospital and hospital outpatient department. Patients All consecutive nonunion surgeries performed by 1 surgeon between 2014 and 2019 were identified. Outpatient and short-stay surgeries for patients with nonunion of the tibia and femur were eligible (n = 50). Intervention Outpatient and short-stay surgical nonunion treatment by incorporating minimally invasive surgical techniques, multimodal pain control, and a modernized postoperative protocol. Main Outcome Measurements Length of stay, postoperative emergency department visits, all complications, reoperations, and time to union. Results Fifty patients were eligible, with 32 male patients (64%) and an average age of 46.5 years. The patient cohort consisted of 28 femur (56%) and 22 tibia (44%) nonunions. The average length of stay was 0.36 days. Seven patients (14%) required reoperation, 6 patients because of deep infection and 1 patient because of painful implant removal. Four patients (8%) presented to the emergency department within 1 week of surgery. One patient requiring amputation and patients lost to follow-up were excluded from the union rate calculation. For the remaining patients (46/50), 100% (46/46) united their nonunion. The average time to radiographic union was 7.82 months. Conclusions An outpatient pathway is safe and effective for medically appropriate patients undergoing nonunion surgery. Outpatient nonunion surgery is a reasonable alternative that achieves similar outcomes compared with inpatient nonunion studies in the published literature. Level of Evidence IV.
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15
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Jacobs RC, Schmitz MW, Swiontkowski MF. Intramedullary Nail and Plate Combination Technique for Peri-Implant Both-Bone Forearm Fractures. Cureus 2022; 14:e28828. [PMID: 36225435 PMCID: PMC9535688 DOI: 10.7759/cureus.28828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2022] [Indexed: 11/05/2022] Open
Abstract
A 35-year-old female patient with cerebellar ataxia presented with a right periprosthetic both-bone forearm fracture after a ground-level fall. Her surgical history was significant for multiple both-bone forearm fractures treated by open reduction and internal fixation. Subsequent treatment with a combination of intramedullary nailing and plate fixation for each bone provided successful fracture union while allowing immediate return to weight-bearing and range of motion. This case report demonstrates that intramedullary nailing and plate fixation of both-bone forearm fractures provides complete protection of the radius and ulna in recurrent, peri-implant both-bone forearm fractures. This technique is a valuable treatment option in the setting of a patient at risk for recurrent injury of the forearm.
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16
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Revision Surgery Using Retrograde Nail versus Replating in Nonunion Distal Femur Fracture Treated with Plate. Adv Orthop 2022; 2022:5742743. [PMID: 35694104 PMCID: PMC9184226 DOI: 10.1155/2022/5742743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 04/27/2022] [Accepted: 05/19/2022] [Indexed: 11/17/2022] Open
Abstract
Articular distal femur fractures represent 4% to 6% of femur fractures. Locking compression plates (LCPs) are the main treatment option. Nevertheless, a reoperation rate of 12.9% has been reported; nonunion is reported at 4.8%, delayed union at 1.6%, and malunion at 0.6%. Treatment of nonunions can be challenging as no unanimous consensus regarding the best surgical technique has been reached. The aim of this study was to evaluate and compare two types of revision surgery as treatment of LCP-treated articular distal femoral fracture nonunion: retrograde nail or replating. A retrospective cohort study of patients admitted from January 2015 to February 2017 for nonunion of AO/OTA 33C2 fractures previously treated with a lateral LCP was conducted. Patients were treated either with intramedullary nailing (Group A) or with replating (Group B). One independent observer performed clinically and radiographically followed up at 1, 3, 6, 9, 12, 24, and 36 months after surgery. The nonunion scoring system (NUSS) was used. Nine patients were included in our study. The mean follow-up was 2 years. Five patients were treated with intramedullary nailing and four with replating. The NUSS score was 24.2 ± 6.8 in the nailing group and 37.3 ± 3 in the replating group (P=0.03). In the nailing group, radiographic consolidation was obtained in all cases. In the replating group, nonunion was found in 3 patients and failure of osteosynthesis in one patient. Therefore, four patients (Group B) underwent implant removal and retrograde femoral nailing, obtaining radiological healing. The union time was 7.6 months in the nailing group. Retrograde intramedullary nailing can be used as an effective treatment of aseptic AO-33C distal femoral nonunion following primary locking plating.
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17
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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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18
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Garala K, Ramoutar D, Li J, Syed F, Arastu M, Ward J, Patil S. Distal femoral fractures: A comparison between single lateral plate fixation and a combined femoral nail and plate fixation. Injury 2022; 53:634-639. [PMID: 34836629 DOI: 10.1016/j.injury.2021.11.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/07/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Distal femoral fractures occur in patients with osteoporotic bone and also as a consequence of high energy trauma. The recognised treatment options include closed or open reduction of the fracture and fixation using a locking plate or a femoral nail. Both these fixation modalities have some drawbacks. There is a risk of metalwork failure with single lateral locking plates and limited distal fixation with intramedullary nails. Since January 2018, we started using augmented fixation of distal femoral fractures using a combination of a retrograde femoral nail and a lateral locking plate. This study compares the outcomes of single lateral femoral plating (SLP) and combined nail-plate fixation (NPF). METHODS This is a single centre retrospective case control study including all patients who sustained distal femoral fractures (OTA 33-A2, 33-A3, 33-C, 33-V3B and 33-V3D) over the study period. Outcomes for SLP were compared to NPF. The principal outcome measure was fracture union. Secondary outcome measures were reoperation rate, mortality and post-operative weight bearing status. RESULTS 67 distal femoral fractures were included in the study. 19 patients had peri‑prosthetic fractures. 40 were treated by SLP, 27 were managed with NPF. 23 (58%) patients in the SLP group were given instructions to non-weight bear or Toe touch weight bear for 6 weeks post-surgery compared to 1 (4%) in the NPF group (p = 0.000004). 7 (18%) patients treated with SLP had metalwork failure due to a non-union compared to none treated with NPF (p = 0.04). 11 fractures in the SLP group failed to unite compared to no non-unions in the NPF group (p = 0.01). These differences were magnified when assessing older (>50 years old) patients. CONCLUSIONS Augmented fixation of distal femoral fractures using a nail plate fixation provided significantly higher union and enabled early weightbearing compared to single plate fixation. We recommend nail plate fixation for the treatment of distal femoral fractures, particularly in osteoporotic fractures.
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Affiliation(s)
- Kanai Garala
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry. CV2 2DX, United Kingdom.
| | - Darryl Ramoutar
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry. CV2 2DX, United Kingdom.
| | - James Li
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry. CV2 2DX, United Kingdom.
| | - Farhan Syed
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry. CV2 2DX, United Kingdom.
| | - Mateen Arastu
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry. CV2 2DX, United Kingdom.
| | - Jayne Ward
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry. CV2 2DX, United Kingdom.
| | - Sunit Patil
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry. CV2 2DX, United Kingdom.
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19
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Landrino M, Alberio RL, Clemente A, Grassi FA. The Reamer-Irrigator-Aspirator (RIA) System for the treatment of aseptic femoral nonunions: Report of two cases and literature review. Orthop Rev (Pavia) 2022; 14:37889. [PMID: 36213618 PMCID: PMC9534743 DOI: 10.52965/001c.37889] [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: 02/05/2023] Open
Abstract
Femoral shaft nonunions are disabling complications of fractures, with relevant socioeconomic and psychological impact. The incidence of femoral shaft nonunions is not negligible, ranging between 1% and 10% after intramedullary nailing, but can exceed 20% in case of subtrochanteric fractures. Treatment options are influenced by pathomechanical, anatomical, and clinical factors. Hypertrophic nonunions are usually treated by enhancing stability of fixation, while atrophic nonunions require additional biological stimulation to achieve bone union. The Reamer-Irrigator-Aspirator (RIA) System® was developed to reduce intramedullary pressure and heat generation during intramedullary reaming, thus preventing thermal necrosis and decreasing the risk of fat embolism. The RIA System allows to provide large volumes of high-quality morselized autologous bone, that has shown high osteogenetic and osteoinductive properties. Therefore, its use has been expanded as a valuable source of autologous bone graft for the treatment of large bone defects of different nature. In this article, we present two cases of complex femoral nonunions treated with the use of the RIA System. A review of the published literature on the treatment of femoral nonunions with RIA was also performed. Core tip: In case of atrophic nonunions, the RIA System can be used to obtain biologically active tissue to enhance bone healing. Despite the absence of high-quality studies focused on femoral nonunions, the efficacy of RIA is well-known and orthopaedic surgeons should be aware of this powerful tool.
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Affiliation(s)
- Marco Landrino
- Department of Health Sciences, University of East Piedmont, Novara (Italy)
| | | | - Alice Clemente
- Department of Health Sciences, University of East Piedmont, Novara (Italy)
| | - Federico Alberto Grassi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia (Italy); IRCCS Hospital San Matteo, Pavia (Italy)
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20
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Ward TRW, Garala K, Riemer B. Failure of dual plating in a complex open distal femur fracture as the result of major trauma. BMJ Case Rep 2021; 14:e245362. [PMID: 34853043 PMCID: PMC8638131 DOI: 10.1136/bcr-2021-245362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2021] [Indexed: 11/03/2022] Open
Abstract
A 61-year-old polytrauma patient was admitted with a right distal comminuted metaphyseal femoral fracture with intra-articular extension (Orthopaedic Trauma Association 33C2.3 classification) among other injuries. Due to the high degree of comminution and massive bone loss, this was initially managed with a dual plating open reduction internal fixation. Dual plating has shown to be a superior fixation method than single variable angle locking compression plate (VA-LCP) plating providing greater fixation in metaphyseal bone. Our case reports the failure of dual plating which required removal of metalwork and subsequent fixation using intramedullary nail and plate technique. Failure of dual plating is not well documented in the literature. The most recent radiographs taken 15 months postrevision surgery show that the bone has started to heal with evidence of callus formation.
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Affiliation(s)
| | - Kanai Garala
- Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Bryan Riemer
- Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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21
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Chua K, Lee VK, Chan C, Yew A, Yeo E, Virshup DM. Hematopoietic Wnts Modulate Endochondral Ossification During Fracture Healing. Front Endocrinol (Lausanne) 2021; 12:667480. [PMID: 34108937 PMCID: PMC8181731 DOI: 10.3389/fendo.2021.667480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 04/09/2021] [Indexed: 11/29/2022] Open
Abstract
Wnt signaling plays a critical role in bone formation, homeostasis, and injury repair. Multiple cell types in bone have been proposed to produce the Wnts required for these processes. The specific role of Wnts produced from cells of hematopoietic origin has not been previously characterized. Here, we examined if hematopoietic Wnts play a role in physiological musculoskeletal development and in fracture healing. Wnt secretion from hematopoietic cells was blocked by genetic knockout of the essential Wnt modifying enzyme PORCN, achieved by crossing Vav-Cre transgenic mice with Porcnflox mice. Knockout mice were compared with their wild-type littermates for musculoskeletal development including bone quantity and quality at maturation. Fracture healing including callus quality and quantity was assessed in a diaphyseal fracture model using quantitative micro computer-assisted tomographic scans, histological analysis, as well as biomechanical torsional and 4-point bending stress tests. The hematopoietic Porcn knockout mice had normal musculoskeletal development, with normal bone quantity and quality on micro-CT scans of the vertebrae. They also had normal gross skeletal dimensions and normal bone strength. Hematopoietic Wnt depletion in the healing fracture resulted in fewer osteoclasts in the fracture callus, with a resultant delay in callus remodeling. All calluses eventually progressed to full maturation. Hematopoietic Wnts, while not essential, modulate osteoclast numbers during fracture healing. These osteoclasts participate in callus maturation and remodeling. This demonstrates the importance of diverse Wnt sources in bone repair.
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Affiliation(s)
- Kenon Chua
- Programme in Cancer and Stem Cell Biology, Duke-NUS Medical School, Singapore, Singapore
- Department of Orthopedic Surgery, Singapore General Hospital, Singapore, Singapore
- Programme in Musculoskeletal Sciences Academic Clinical Program, SingHealth/Duke-NUS, Singapore, Singapore
| | - Victor K. Lee
- Department of Pathology, National University of Singapore, Singapore, Singapore
| | - Cheri Chan
- Programme in Musculoskeletal Sciences Academic Clinical Program, SingHealth/Duke-NUS, Singapore, Singapore
| | - Andy Yew
- Department of Orthopedic Surgery, Singapore General Hospital, Singapore, Singapore
| | - Eric Yeo
- Department of Pathology, National University of Singapore, Singapore, Singapore
| | - David M. Virshup
- Programme in Cancer and Stem Cell Biology, Duke-NUS Medical School, Singapore, Singapore
- Department of Pediatrics, Duke University, Durham, NC, United States
- *Correspondence: David M. Virshup,
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22
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Wright DJ, DeSanto DJ, McGarry MH, Lee TQ, Scolaro JA. Supplemental Fixation of Supracondylar Distal Femur Fractures: A Biomechanical Comparison of Dual-Plate and Plate-Nail Constructs. J Orthop Trauma 2020; 34:434-440. [PMID: 32032183 DOI: 10.1097/bot.0000000000001749] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This biomechanical study compares the effectiveness of dual-plate (DP) and plate-nail (PN) constructs for fixation of supracondylar distal femur fractures in synthetic and cadaveric specimens. METHODS Twenty-four synthetic osteoporotic femurs were used to compare 4 constructs in an extra-articular, supracondylar fracture gap model (OTA/AO type 33-A3). Constructs included: (1) distal lateral femoral locking plate (DLFLP), (2) retrograde intramedullary nail (rIMN), (3) DLFLP + medial locking compression plate (DP construct), and (4) DLFLP + rIMN (PN construct). DP and PN constructs were then directly compared using 7 matched pairs of cadaveric femurs. Specimens underwent cyclic loading in torsion and compression. Biomechanical effectiveness was measured by quantifying the load-dependent stiffness of each construct. RESULTS In synthetic osteoporotic femurs, the DP construct had the greatest torsional stiffness (1.76 ± 0.33 Nm/deg) followed by the rIMN (1.67 ± 0.14 Nm/deg), PN construct (1.44 ± 0.17 Nm/deg), and DLFLP (0.68 ± 0.10 Nm/deg) (P < 0.01). The DP construct also had the greatest axial stiffness (507.9 ± 83.1 N/mm) followed by the PN construct (371.4 ± 41.9 N/mm), DLFLP (255.0 ± 45.3 N/mm), and rIMN (109.2 ± 47.6 N/mm) (P < 0.05). In cadaveric specimens, the DP construct was nearly twice as stiff as the PN construct in torsion (8.41 ± 0.58 Nm/deg vs. 4.24 ± 0.41 Nm/deg, P < 0.001), and over one-and-a-half times stiffer in compression (2148.1 ± 820.4 vs. 1387.7 ± 467.9 N/mm, P = 0.02). CONCLUSIONS DP constructs provided stiffer fixation than PN constructs in this biomechanical study of extra-articular distal femur fractures. In the clinical setting, fracture morphology, desired healing mode, surgical approach, and implant cost should be considered when implementing these fixation strategies.
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Affiliation(s)
- David J Wright
- University of California, Irvine, Department of Orthopaedic Surgery, Orange, CA; and
| | - Donald J DeSanto
- University of California, Irvine, Department of Orthopaedic Surgery, Orange, CA; and
| | - Michelle H McGarry
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA
| | - John A Scolaro
- University of California, Irvine, Department of Orthopaedic Surgery, Orange, CA; and
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23
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Scolaro JA, Mark BJ. Monofocal Compression-Distraction Osteosynthesis in a Distal Femoral Nonunion Using a Magnetic Medullary Nail: A Case Report. JBJS Case Connect 2020; 10:e2000124. [PMID: 32910579 DOI: 10.2106/jbjs.cc.20.00124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
CASE A 65-year-old woman presented with a malaligned, shortened supracondylar distal femoral nonunion. An acute medial closing wedge osteotomy was performed through the nonunion and compressed with a retrograde magnetically controlled intramedullary nail. Osteogenesis with sequential compression and then distraction was performed at the osteotomy site using the nail to successfully restore limb length and alignment. CONCLUSION A magnetically controlled nail can be used to perform monofocal sequential compression-distraction osteosynthesis through a nonunion after an alignment correcting osteotomy.
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Affiliation(s)
- John A Scolaro
- 1Department of Orthopaedic Surgery, University of California, Irvine, Irvine, California
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24
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Rollick NC, Gadinsky NE, Klinger CE, Kubik JF, Dyke JP, Helfet DL, Wellman DS. The effects of dual plating on the vascularity of the distal femur. Bone Joint J 2020; 102-B:530-538. [PMID: 32228080 DOI: 10.1302/0301-620x.102b4.bjj-2019-1776] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Natalie C Rollick
- Orthopaedic Trauma Service, Hospital for Special Surgery, Weill Cornell Medical College, NY Presbyterian Hospital, New York, New York, USA
| | - Naomi E Gadinsky
- Orthopaedic Trauma Service, Hospital for Special Surgery, Weill Cornell Medical College, NY Presbyterian Hospital, New York, New York, USA
| | - Craig E Klinger
- Orthopaedic Trauma Service, Hospital for Special Surgery, Weill Cornell Medical College, NY Presbyterian Hospital, New York, New York, USA
| | - Jeremy F Kubik
- Orthopaedic Trauma Service, Hospital for Special Surgery, Weill Cornell Medical College, NY Presbyterian Hospital, New York, New York, USA
| | - Jonathan P Dyke
- Citigroup Biomedical Imaging Center and Weill Medical College of Cornell University, New York, New York, USA
| | - David L Helfet
- Orthopaedic Trauma Service, Hospital for Special Surgery, Weill Cornell Medical College, NY Presbyterian Hospital, New York, New York, USA
| | - David S Wellman
- Westchester Medical Center, New York Medical College, Valhalla, New York, USA
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Abstract
Despite advances in technology such as locked plating, osteoporotic bone and bone defects remain challenging complications for orthopaedic surgeons. The concept of augmented fixation is useful in these settings. Augmented fixation can be described as improving construct strength and stability by enhancing the surrounding environment. By understanding and using the techniques of alternative fixation strategies, endosteal or medullary support, structural grafting, or the use of bone graft substitutes in combination with standard or integrated fixation, surgeons can improve the chances of success when treating difficult fractures. The purpose of this article is to introduce the reader to the concept of augmented fixation, review strategies for its application, and review applicable published results.
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Abstract
OBJECTIVES To determine the failure rate of the DePuy-Synthes variable angle locking compression curved condylar plate (VA-LCP) and quantify failure modes. DESIGN Retrospective review. SETTING Level I Trauma Center. PATIENTS/PARTICIPANTS One hundred thirteen patients with 118 OTA/AO classification 33A and 33C distal femoral fractures were included in the study. INTERVENTION Internal fixation using only the DePuy-Synthes VA-LCP plate. MAIN OUTCOME MEASUREMENTS Primary outcomes included mechanical failure rate of the DePuy-Synthes VA-LCP plate in open and closed fractures. Secondary outcomes included overall failure rate of treatment, risk factors for mechanical failure, and the specific location of failure: loss of fixation in the proximal segment, implant failure over the working length, or failure of locking screw fixation distally. RESULTS There were 11 total failures (9.3%) in 118 fractures. Failure rates for the closed and open fracture groups were 5.4% and 15.9%, respectively. Twenty patients (16.9%) required reoperation to promote union. Open fractures (P = 0.00475), the presence of medial metaphyseal comminution (P = 0.037), the length of the zone of comminution (P = 0.037), and plate length (P = 0.0096) were significantly higher in those with implant failure. Most failures (63.6%) were in the working length of the implant. CONCLUSIONS The use of the Synthes VA-LCP is a viable option in distal femoral fractures and has an acceptable failure rate and reoperation to promote union rate. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Rajasekaran RB, Jayaramaraju D, Palanisami DR, Agraharam D, Perumal R, Kamal A, Rajasekaran S. 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. Arch Orthop Trauma Surg 2019; 139:1057-1068. [PMID: 30895463 DOI: 10.1007/s00402-019-03172-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Indexed: 02/09/2023]
Abstract
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.
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Affiliation(s)
- Raja Bhaskara Rajasekaran
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India.
| | - Dheenadhayalan Jayaramaraju
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
| | - Dhanasekara Raja Palanisami
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
| | - Devendra Agraharam
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
| | - Ramesh Perumal
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
| | - Arun Kamal
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
| | - Shanmuganathan Rajasekaran
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
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DeKeyser GJ, Kellam PJ, Haller JM. Locked Plating and Advanced Augmentation Techniques in Osteoporotic Fractures. Orthop Clin North Am 2019; 50:159-169. [PMID: 30850075 DOI: 10.1016/j.ocl.2018.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
"The incidence of osteoporotic fracture is increasing with the aging US population. Because osteoporosis leads to a decrease in bone mineral density with a decrease in both trabecular and cortical bones, osteoporotic fracture presents fixation challenges with standard plate and screw constructs. Locked plating has been developed to create a fixed-angle plate-screw construct that is more resistant to failure in osteoporotic bone. Endosteal replacement, additional plates, and cement augmentation have all been demonstrated to further supplement osteoporotic fracture fixation. Technologies on the horizon to treat osteoporotic fracture include SMV screws, hydroxyapatite-coated implants, and far cortical locking screws."
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Affiliation(s)
- Graham J DeKeyser
- University of Utah, Department of Orthopaedics, Orthopaedic Center, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Patrick J Kellam
- University of Utah, Department of Orthopaedics, Orthopaedic Center, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Justin M Haller
- University of Utah, Department of Orthopaedics, Orthopaedic Center, 590 Wakara Way, Salt Lake City, UT 84108, USA.
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29
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Stable Fixation and Immediate Weight-Bearing After Combined Retrograde Intramedullary Nailing and Open Reduction Internal Fixation of Noncomminuted Distal Interprosthetic Femur Fractures. J Orthop Trauma 2018. [PMID: 29521874 DOI: 10.1097/bot.0000000000001154] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
With an aging population, treatment of interprosthetic femur fractures continues to pose a challenge to the orthopaedic surgeon. Retrograde intramedullary nailing combined with open reduction internal fixation using a tissue-preserving plating technique was used in our series of 9 patients with noncomminuted, distal femur fractures. No interfragmentary screws, cables, cerclage wires, or supplemental bone grafts of any type were used. Each patient initiated weight-bearing as tolerated after operative intervention. Every fracture healed at an average of 20 weeks (range 18-24 weeks). Use of a lateral locking plate combined with a retrograde intramedullary nailing enables immediate postoperative weight-bearing and stable fixation for patients with interprosthetic femur fractures.
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30
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Abstract
The management of fractures with segmental bone loss or abundant comminution on the far cortex is often complicated by deformity or frank hardware failure. Using plate constructs that rely on off-axis loading may not be sufficient to support the limb until healing occurs. There are a number of techniques to mitigate this problem, notably the use of intramedullary nails and bicolumnar plating of the fracture. These techniques are not always possible and do come with the biologic cost of additional surgery. In this article, the authors present a technique along with 2 case examples of using plates in an intraosseous location that was described by Dr Mast in his classic orthopaedic text. By placing these plates in the intramedullary space and then interdigitating fixation from the standard cortical plate, a rigid "I-beam" of fixation can be created to mitigate the eccentric loading placed on extraosseous plates. This technique is especially useful in situations in which intramedullary nails are precluded (comminuted intraarticular and some periprosthetic fractures).
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31
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Abstract
BACKGROUND Morbid obesity and segmental fracture/bone loss are challenging problems in the treatment of fractures and nonunions of the distal femur. The use of an intramedullary rod as an endosteal substitute for a deficient medial cortex along with a lateral locked plate is 1-tool to combat these problems. This article describes the technique used and its results at a single Level 1 trauma center. METHODS Retrospective chart and radiographic review of all patients treated for acute fractures and nonunions of the distal femur using endosteal substitution with an intramedullary nail and a lateral locked plate. Fixation construct was determined at the surgeon's discretion and was strongly influenced by bone loss and patient body habitus. RESULTS Seven of 8 acute fractures and 8 of 8 nonunions healed without an unplanned reoperation. There were no cases of secondary displacement after fixation, and only 1 unplanned reoperation in the study group. CONCLUSION Endosteal substitution with an intramedullary rod and the use of a lateral locked plate provides the stability needed to allow bone healing under prolonged or supraphysiologic loads seen in morbid obesity or segmental bone loss. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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