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Li X, Xu W, Yin Y, Zhang X, Xiong Z, Yang Y. A case of recurrent proximal femoral fracture after open reduction and internal fixation with bilateral locking plates for a Rorabeck type II periprosthetic fracture. Int J Surg Case Rep 2024; 123:110044. [PMID: 39178582 DOI: 10.1016/j.ijscr.2024.110044] [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: 05/23/2024] [Revised: 07/10/2024] [Accepted: 07/12/2024] [Indexed: 08/26/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Periprosthetic distal femur fractures (PDFFs) are rare complications that may occur during or after total knee arthroplasty (TKA). The incidence of PDFFs is increasing. Plate internal fixation has demonstrated positive results. However, there is limited research available on the recurrence of periimplant fractures following open reduction and internal fixation with bilateral locking plates. CASE PRESENTATION A 70-year-old female patient was diagnosed with a Rorabeck type II fracture. Based on the patient's physical condition and available surgical options, minimally invasive open reduction, bilateral plate fixation, and allograft artificial bone grafting were chosen. The postoperative recovery was successful. However, the patient experienced a fall 2 months after the surgery, resulting in a proximal femoral fracture. After considering the patient's condition and family preferences, conservative treatment was ultimately decided upon. CLINICAL DISCUSSION Minimally invasive bilateral Locking Compression Plate (LCP) as a surgical approach can effectively reduce surgical risks prior to the procedure. Careful selection of screws and the use of C-arm fluoroscopy during plate contouring and fixation are essential to prevent screw penetration through the contralateral cortex. Treatment outcomes were not impacted in patients with normal bone mass; however, in this particular case, the patient had severe osteoporosis, significantly increasing the risk of refracture. It is crucial to improve postoperative monitoring and raise awareness about safety among patients and their families. CONCLUSION The management of periprosthetic distal femur fractures (PDFFs) is influenced by the type of fracture and bone quality. Mechanical stability and stress dispersion of internal fixation are key factors to consider. In the perioperative setting, involving experienced clinicians is essential to reduce the risk of secondary injuries that may impact treatment outcomes, especially when choosing screws for fixation in patients with low bone density.
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Affiliation(s)
- Xiaobing Li
- Department of Joint Surgery, Yueyang People 's Hospital, Hunan Normal University, No.263 Baling East Road, Yueyang 414000, Hunan, China
| | - Wenhe Xu
- Department of Joint Surgery, Yueyang People 's Hospital, Hunan Normal University, No.263 Baling East Road, Yueyang 414000, Hunan, China.
| | - Yongqiang Yin
- Department of Joint Surgery, Yueyang People 's Hospital, Hunan Normal University, No.263 Baling East Road, Yueyang 414000, Hunan, China
| | - Xu Zhang
- Department of Joint Surgery, Yueyang People 's Hospital, Hunan Normal University, No.263 Baling East Road, Yueyang 414000, Hunan, China
| | - Zhizheng Xiong
- Department of Joint Surgery, Yueyang People 's Hospital, Hunan Normal University, No.263 Baling East Road, Yueyang 414000, Hunan, China
| | - Yuanqing Yang
- Department of Joint Surgery, Yueyang People 's Hospital, Hunan Normal University, No.263 Baling East Road, Yueyang 414000, Hunan, China
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Bostrom N, Paull TZ, Nguyen MP. Outcomes of operatively managed periprosthetic distal femur fractures compared to fractures in patients with native knees. J Orthop 2024; 53:114-117. [PMID: 38495580 PMCID: PMC10940881 DOI: 10.1016/j.jor.2024.02.039] [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: 11/30/2023] [Accepted: 02/24/2024] [Indexed: 03/19/2024] Open
Abstract
Introduction With the increasing incidence of total knee arthroplasty (TKA), there is an expected rise in rate of periprosthetic fractures in the coming years. It is unclear how the outcomes of patients with distal femur fractures (DFF) and a total knee arthroplasty compare to patients of the same age group with native knees (NK). Materials and methods A retrospective review was completed for distal femur fractures treated with surgical fixation from January 2019-March 2021. We excluded patients <50 years old, non-ambulatory patients, revision surgeries, and patients with less than 90 days of follow-up. A chart review was performed to collect age, gender, BMI, smoking status, American Society of Anesthesiology (ASA) classification, fracture type, fixation method, time to full weight bearing, and complications. Comparisons between the TKA vs native knee groups were performed using t-test, chi-square, and Fisher's exact test where appropriate. Results 138 patients were included in our study with a mean age of 74 years. 69 DFF ipsilateral to a TKA were included in the study group and 71 DFF were included in the native knee group. Age, sex, BMI, smoking status, and ASA class were similar between the groups. All patients with periprosthetic femur fractures had 33A AO/OTA fracture classification. Patients with native knees were more likely to receive dual implant fixation, 15.5% compared to 4.3% (p = 0.02). Full weight bearing was achieved at 8.5 vs 8.6 weeks between the NK and TKA groups (p = 0.64). The complication rate was 16.9% in the NK group vs. 7.2% in the TKA group (p = 0.21). Conclusion Patients with periprosthetic femur fractures have similar time to weight bearing and complications rate with patients with distal femur fracture in native knees. We found a higher utilization rate of dual implant fixation in the native knee group.
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Affiliation(s)
- Nicholas Bostrom
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN, 55455, USA
| | - Thomas Z. Paull
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN, 55455, USA
- Department of Orthopaedic Surgery, Regions Hospital, 640 Jackson Street, Mailstop 11503L, Saint Paul, MN, 55101, USA
| | - Mai P. Nguyen
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN, 55455, USA
- Department of Orthopaedic Surgery, Regions Hospital, 640 Jackson Street, Mailstop 11503L, Saint Paul, MN, 55101, USA
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Ozer MA, Keser S, Barıs D, Yazoglu O. A novel anatomical locked medial femoral condyle plate: a biomechanical study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2767-2772. [PMID: 38767681 DOI: 10.1007/s00590-024-03993-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/08/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Fixation with a distal lateral femoral plate is a standard approach in treating osteoporotic or comminuted supracondylar femur fractures. However, in clinical practice, this method may prove inadequate, necessitating the application of a plate on the medial side of the distal femur. The aim of this study is to perform a biomechanical evaluation of the newly manufactured anatomically locked plate applied to the distal medial femoral condyle. MATERIALS AND METHODS The plate underwent 2 biomechanical tests by simulating an AO/OTA 33A3 type supracondylar fracture model on synthetic femur bones. The samples were divided into three groups. Fracture fixations were carried out on the medial side using the distal femur medial anatomical locking plate (DFMALP) in group A samples, on the lateral side using the distal femur lateral anatomical locking plate in group B samples, and on both sides in group C samples. RESULTS In the axial compression test, stability was preserved 23% more in group C than in group B. During the cyclic axial compression test, total displacement was 21% less in group C than in group B. Group A was collapsed at early cycle degrees. CONCLUSION In our study, it was observed that the application of DFMALP in conjunction with the lateral plate in AO/OTA 33A3 fragmented supracondylar femur fractures significantly enhanced biomechanical fracture stability. LEVEL OF EVIDENCE This is a Level 2 prospective, randomized controlled study.
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Affiliation(s)
- M A Ozer
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Bulent Ecevit University, Zonguldak, Turkey.
| | - S Keser
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Bulent Ecevit University, Zonguldak, Turkey
| | - D Barıs
- Response Ortho, Istanbul, Turkey
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Babhulkar S, Trikha V, Babhulkar S, Gavaskar AS. Current Concepts in Management of Distal Femur Fractures. Injury 2024; 55 Suppl 2:111357. [PMID: 39098785 DOI: 10.1016/j.injury.2024.111357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 12/23/2023] [Accepted: 01/14/2024] [Indexed: 08/06/2024]
Abstract
Recent studies report the overall incidence of distal femur fractures as 8.7/100,000/year. This incidence is expected to rise with high energy motor vehicle collisions and elderly osteoporotic fractures in native and prosthetic knees keep increasing. These fractures are more common in males in the younger age spectrum while females predominate for elderly osteoporotic fractures. Surgical treatment is recommended for these fractures to maintain articular congruity, enable early joint motion and assisted ambulation. Over the last two decades, development of minimally invasive and quadriceps sparing surgical approaches, availability of angle stable implants have helped achieve predictable healing and early return to function in these patients. Currently, laterally positioned locked plate is the implant of choice across all fracture patterns. Retrograde with capital implantation of intramedullary nails with provision for multiplanar distal locking is preferred for extra-articular and partial articular fractures. Even with these advancements, nonunion after distal femur fracture fixation can be as high as 19%. Further recent research has helped us understand the biomechanical limitations and healing problems with lateral locked plate fixation and intramedullary nails. This has lead to development of more robust constructs such as nail-plate and double plate constructs aiming for improved construct strength and to minimise failures. Early results with these combination constructs have shown promise in high risk situations such as fractures with extensive metaphyseal fragmentation, osteoporosis and periprosthetic fractures. These constructs however, run the risk of being over stiff and can inhibit healing if not kept balanced. The ideal stiffness that is needed for fracture healing is not clearly known and current research in this domain has lead to the development of smart implants which are expected to evolve and may help improve clinical results in future.
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Affiliation(s)
- Sushrut Babhulkar
- Centre for Trauma & Joint Reconstruction Surgery, Sushrut Instt of Medical Sciences, Ramdaspeth, Nagpur, India.
| | - Vivek Trikha
- All India Institute of Medical Sciences, New Delhi, India, 110029
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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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Wähnert D, Miersbach M, Colcuc C, Brianza S, Vordemvenne T, Plecko M, Schwarz A. Promoting bone callus formation by taking advantage of the time-dependent fracture gap strain modulation. Front Surg 2024; 11:1376441. [PMID: 38756355 PMCID: PMC11096559 DOI: 10.3389/fsurg.2024.1376441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/23/2024] [Indexed: 05/18/2024] Open
Abstract
Delayed union and non-union of fractures continue to be a major problem in trauma and orthopedic surgery. These cases are challenging for the surgeon. In addition, these patients suffer from multiple surgeries, pain and disability. Furthermore, these cases are a major burden on healthcare systems. The scientific community widely agrees that the stability of fixation plays a crucial role in determining the outcome of osteosynthesis. The extent of stabilization affects factors like fracture gap strain and fluid flow, which, in turn, influence the regenerative processes positively or negatively. Nonetheless, a growing body of literature suggests that during the fracture healing process, there exists a critical time frame where intervention can stimulate the bone's return to its original form and function. This article provides a summary of existing evidence in the literature regarding the impact of different levels of fixation stability on the strain experienced by newly forming tissues. We will also discuss the timing and nature of this "window of opportunity" and explore how current knowledge is driving the development of new technologies with design enhancements rooted in mechanobiological principles.
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Affiliation(s)
- Dirk Wähnert
- Department of Trauma and Orthopedic Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL of Bielefeld University, Bielefeld, Germany
| | - Marco Miersbach
- Department of Trauma and Orthopedic Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL of Bielefeld University, Bielefeld, Germany
| | - Christian Colcuc
- Department of Trauma and Orthopedic Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL of Bielefeld University, Bielefeld, Germany
| | | | - Thomas Vordemvenne
- Department of Trauma and Orthopedic Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL of Bielefeld University, Bielefeld, Germany
| | - Michael Plecko
- Department of Orthopaedics and Traumatology, Trauma Hospital Graz (UKH), Graz, Austria
| | - Angelika Schwarz
- Department of Orthopaedics and Traumatology, Trauma Hospital Graz (UKH), Graz, Austria
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Yoon YC, Kim Y, Pesante BD, Chun YS, Lee SH, Sohn HS. Comparative study of retrograde intramedullary nailing versus locking extramedullary plating in complete articular fractures with metaphyseal comminution of the distal femur. Arch Orthop Trauma Surg 2024; 144:2109-2118. [PMID: 38466373 DOI: 10.1007/s00402-024-05265-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/27/2024] [Indexed: 03/13/2024]
Abstract
INTRODUCTION Fractures of the distal femur with metaphyseal comminution and complete intra-articular involvement (AO/OTA classifications 33C2 and 33C3) present challenges for reduction and fixation. However, an optimal fixation method remains unknown. This study aimed to compare the clinical and radiographic outcomes of locking extramedullary plating (LEP) and retrograde intramedullary nailing (RIN) for complete distal femoral intra-articular fractures with metaphyseal comminution. MATERIALS AND METHODS Between January 2016 and May 2022, 80 patients (45 men and 35 women; average age, 56.7 years) diagnosed with AO/OTA 33C2 and 33C3 were treated with either LEP or RIN and followed up for at least one year. Post-operative evaluations included radiographic assessments of bone union rate, timing, and alignment. Clinically, the knee joint range of motion (ROM), lower extremity functional scale (LEFS), and Kellgren and Lawrence (KL) grade were analyzed. The complications were also compared. RESULTS 36 underwent LEP and 44 underwent RIN. Bone union was observed in 69.4% and 63.6% of the patients in the LEP and RIN groups, respectively (p = 0.64). The average union time was 6.9 months for the LEP group and 6.6 months for the RIN group (p = 0.51). A tendency toward varus deformity was observed in the RIN group, although the difference was not statistically significant. No significant differences were observed in knee ROM, LEFS, or KL grade. Complications included non-union (33.8%; RIN, 11; LEP, 16), varus deformity (5%; RIN, 4; LEP, 0), infection (1.3%; RIN, 0; LEP, 1), heterotrophic ossification (1.3%; RIN, 0; LEP, 1), and wound dehiscence (2.5%; RIN, 2; LEP, 0). CONCLUSIONS The surgical fixation methods, RIN and LEP, for complete distal femoral intra-articular fractures with metaphyseal comminution showed similar clinical and radiological outcomes. However, regardless of the type of fixation device used, there was a reduced rate of bone union owing to high energy and a less favorable prognosis.
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Affiliation(s)
- Yong-Cheol Yoon
- Orthopedic Trauma Division, Trauma Center, Gachon University College of Medicine, Namdong-gu, Incheon, Republic of Korea
| | - Youngwoo Kim
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Gyeonggi-do, Republic of Korea
| | - Benjamin D Pesante
- Department of Orthopedics, Denver Health Medical Center, Denver, CO, USA
| | - You Seung Chun
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Gyeonggi-do, Republic of Korea
| | - Sang Ho Lee
- Department of Orthopedic Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
| | - Hoon-Sang Sohn
- Department of Orthopedic Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea.
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Honda S, Fujibayashi S, Shimizu T, Yamaguchi S, Okuzu Y, Takaoka Y, Masuda S, Takemoto M, Kawai T, Otsuki B, Goto K, Matsuda S. Strontium-loaded 3D intramedullary nail titanium implant for critical-sized femoral defect in rabbits. J Biomed Mater Res B Appl Biomater 2024; 112:e35393. [PMID: 38385959 DOI: 10.1002/jbm.b.35393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 02/01/2024] [Accepted: 02/08/2024] [Indexed: 02/23/2024]
Abstract
The treatment of critical-sized bone defects has long been a major problem for surgeons. In this study, an intramedullary nail shaped three-dimensional (3D)-printed porous titanium implant that is capable of releasing strontium ions was developed through a simple and cost-effective surface modification technique. The feasibility of this implant as a stand-alone solution was evaluated using a rabbit's segmental diaphyseal as a defect model. The strontium-loaded implant exhibited a favorable environment for cell adhesion, and mechanical properties that were commensurate with those of a rabbit's cortical bone. Radiographic, biomechanical, and histological analyses revealed a significantly higher amount of bone ingrowth and superior bone-bonding strength in the strontium-loaded implant when compared to an untreated porous titanium implant. Furthermore, one-year histological observations revealed that the strontium-loaded implant preserved the native-like diaphyseal bone structure without failure. These findings suggest that strontium-releasing 3D-printed titanium implants have the clinical potential to induce the early and efficient repair of critical-sized, load-bearing bone defects.
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Affiliation(s)
- Shintaro Honda
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shunsuke Fujibayashi
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takayoshi Shimizu
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Seiji Yamaguchi
- Department of Biomedical Sciences, College of Life and Health Sciences, Chubu University, Aichi, Japan
| | - Yaichiro Okuzu
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yusuke Takaoka
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Soichiro Masuda
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Mitsuru Takemoto
- Department of Orthopaedic Surgery, Kyoto City Hospital, Kyoto, Japan
| | - Toshiyuki Kawai
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Bungo Otsuki
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koji Goto
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Nauth A, Haller J, Augat P, Anderson DD, McKee MD, Shearer D, Jenkinson R, Pape HC. Distal femur fractures: basic science and international perspectives. OTA Int 2024; 7:e320. [PMID: 38487402 PMCID: PMC10936154 DOI: 10.1097/oi9.0000000000000320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/21/2023] [Accepted: 12/26/2023] [Indexed: 03/17/2024]
Abstract
Distal femur fractures are challenging injuries to manage, and complication rates remain high. This article summarizes the international and basic science perspectives regarding distal femoral fractures that were presented at the 2022 Orthopaedic Trauma Association Annual Meeting. We review a number of critical concepts that can be considered to optimize the treatment of these difficult fractures. These include biomechanical considerations for distal femur fixation constructs, emerging treatments to prevent post-traumatic arthritis, both systemic and local biologic treatments to optimize nonunion management, the relative advantages and disadvantages of plate versus nail versus dual-implant constructs, and finally important factors which determine outcomes. A robust understanding of these principles can significantly improve success rates and minimize complications in the treatment of these challenging injuries.
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Affiliation(s)
- Aaron Nauth
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Peter Augat
- Paracelsus Medical University in Salzburg, Austria and Institute of Biomechanics at Trauma Centre Murnau, Salzburg, Germany
| | - Donald D. Anderson
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - Michael D. McKee
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ
| | - David Shearer
- Department of Orthopaedic Surgery, University of California, San Francisco, CA
| | - Richard Jenkinson
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Huppke CM, Fahlbusch H, Frosch KH, Krause M, von Rehlingen-Prinz F. Cortical bone thickness on preoperative CT scans as predictor of bone quality in distal femur fractures: a retrospective study in Caucasians. Arch Orthop Trauma Surg 2024; 144:731-740. [PMID: 38049535 PMCID: PMC10822795 DOI: 10.1007/s00402-023-05131-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/07/2023] [Indexed: 12/06/2023]
Abstract
AIM Distal femur fractures (DFF) are rare, but associated with high complication rates and mortality, particularly in patients with osteoporosis. To improve preoperative assessment, we analyzed if cortical bone thickness on CT and AP radiographs is associated with clinical parameters of bone quality. METHODS Retrospective single-center study of adult patients presenting at a level-one trauma center, with a DFF between 2011 and 2020. Clinical parameters for bone quality, such as age, sex, body mass index (BMI), energy impact level of trauma, and known history of osteoporosis, were assessed. Mean cortical bone thickness (CBTavg) on AP radiograph was determined using a previously published method. Cortical thickness on CT scan was measured at 8 and 14 cm proximal to the articular surface of the lateral condyle. RESULTS 71 patients (46 females) between 20 and 100 years were included in the study. Cortical thickness determined by CT correlated significantly with CBTavg measurements on AP radiograph (Spearman r = 0.62 to 0.80; p < 0.001). Cortical thickness was inversely correlated with age (Spearman r = - 0.341 to - 0.466; p < 0.001) and significantly associated with trauma impact level and history of osteoporosis (p = < 0.001). The CT-based values showed a stronger correlation with the clinical parameters than those determined by AP X-ray. CONCLUSION Our results showed that cortical thickness of the distal femur correlates with clinical parameters of bone quality and is therefore an excellent tool for assessing what surgical care should be provided. Interestingly, our findings indicate that cortical thickness on CT is more strongly correlated with clinical data than AP radiograph measurements.
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Affiliation(s)
- Calvin M Huppke
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Hendrik Fahlbusch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany.
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - Fidelius von Rehlingen-Prinz
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
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11
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Erbulut DU, Green N, Grant C, Tetsworth K. Plate fixation optimization for distal femoral fractures with segmental bone loss: Defining the preferred screw distribution using finite element analysis. Injury 2024; 55:111079. [PMID: 37863754 DOI: 10.1016/j.injury.2023.111079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/26/2023] [Accepted: 09/26/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVES Distal femur fractures can exhibit extensive comminution, and open fractures may result in bone loss. These injuries are under high mechanical demands when stabilized with a lateral locked plate (LLP), and are at risk of non-union or implant failure. This study investigates the optimal LLP screw configuration for distal femur fractures with a large metadiaphyseal gap of 5 cm. METHODS A finite element (FE) model, validated against experimentally measured strains and displacement, evaluated pull-out forces and stress concentration on typical implants under clinical conditions corresponding with the 10 % point during the stance phase of the gait cycle. RESULTS Maximum stress was up to 83 % less when the ratio (Cp) between the proximal screw-distribution-length and the distance of the first screw to the fracture was less than 0.2; maximum pull-out force was 99 % less when this ratio was higher than 0.4. CONCLUSIONS Screw configuration based on either normal or osteopenic bone quality plays an important role in determining the risk of construct failure for a major (50 mm) distal femoral metadiaphyseal segmental defect. This study provides valuable information when planning definitive fixation for distal femur fractures with extensive comminution or segmental bone defects, to mitigate the risk of implant failure and subsequent nonunion.
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Affiliation(s)
- Deniz U Erbulut
- Herston Biofabrication Institute, Metro North Hospital and Health Service, Brisbane, QLD, 4029, Australia; Department of Orthopaedic Surgery, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; School of Mechanical and Mining engineering, University of Queensland, Saint Lucia, QLD, Australia.
| | - Nicholas Green
- Herston Biofabrication Institute, Metro North Hospital and Health Service, Brisbane, QLD, 4029, Australia; Department of Orthopaedic Surgery, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Caroline Grant
- Faculty of Engineering, Queensland University of Technology, Brisbane, QLD, Australia
| | - Kevin Tetsworth
- Herston Biofabrication Institute, Metro North Hospital and Health Service, Brisbane, QLD, 4029, Australia; Department of Orthopaedic Surgery, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Orthopaedic Research Centre of Australia, Brisbane, QLD, Australia; Limb Reconstruction Unit, Macquarie University Hospital, Sydney, NSW, Australia
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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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Lee HS, Lewis DP, Balogh ZJ. Supplementary medial plating in revision surgery for distal femoral fractures: A surgical technique with clinical outcomes. Injury 2024; 55:111272. [PMID: 38134491 DOI: 10.1016/j.injury.2023.111272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 11/09/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023]
Abstract
INTRODUCTION Distal femur fractures (DFF) are common, especially in the elderly and high energy trauma patients. Lateral locked osteosynthesis constructs have been widely used, however non-union and implant failures are not uncommon. Recent literature advocates for the liberal use of supplemental medial plating to augment lateral locked constructs. However, there is a lack of proprietary medial plate options, with some authors supporting the use of repurposing expensive anatomic pre-contoured plates. The aim of this study was to investigate the feasibility of an effective, readily available medial implant option. METHODS A retrospective analysis from January 2014 to August 2023 was performed on DFF requiring revision open reduction internal fixation (rORIF) with supplemental medial plating with a Large Fragment Locking Compression Plate (LCP) T-Plate via a medial sub-vastus approach. The T-plate was contoured and placed superior to the medial condyle. A combination of 4.5 mm cortical, 5 mm locking and/or 6.5 mm cancellous screws were used, with oblique screw trajectories towards the distal lateral cortex of the lateral condyle. The primary outcome was union rate. RESULTS This technique was utilised on fifteen patients. The mean age was 55±15 (range 23-81); 73 % of cases were male and the median follow-up was 61 weeks (IQR 49-87). The two most common fracture patterns were AO/OTA 33-C3 (n = 5) and 33-A3 (n = 4), and three patients had open fractures. The union rate was 93 % (14/15), with a median time to union of 29 weeks (IQR 18-49). There were two complications: a deep infection requiring two debridements and locally eluding antibiotic insertion, and a prominent screw requiring removal; both patients achieved union. The median range of motion was 0° (IQR 0-5) of extension and 100° (IQR 90-120) of flexion. CONCLUSION Supplemental medial plating of DFF with a Large Fragment LCP T-Plate is a feasible, safe, and economical option for rORIF. Further validation on a larger scale is warranted, along with considerations to developing a specific implant in line with these principles.
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Affiliation(s)
- Hai S Lee
- Department of Traumatology, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW, Australia
| | - Daniel P Lewis
- Department of Traumatology, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW, Australia; Discipline of Surgery, School of Public Medicine and Health, University of Newcastle, Newcastle, NSW, Australia
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW, Australia; Discipline of Surgery, School of Public Medicine and Health, University of Newcastle, Newcastle, NSW, Australia.
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14
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Gilli A, Ghirardelli S, Pozzi P, Touloupakis G, Messori M, Theodorakis E, Antonini G. Do working length and proximal screw density influence the velocity of callus formation in distal tibia fractures treated with a medial bridge plate? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:523-528. [PMID: 37644334 PMCID: PMC10771589 DOI: 10.1007/s00590-023-03697-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/17/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Aim of our study was to evaluate the influence of working length and screw density on callus formation in distal tibial fractures fixed with a medial bridge plate. MATERIALS AND METHODS 42 distal tibia fractures treated with a bridge plate were analyzed. Minimum follow-up was 12 months. mRUST score (modified Radiographic Union Scale for Tibial fractures) was used to assess callus formation. Working length and screw density were measured from post-operative radiographs. RESULTS 39 (92.9%) fractures healed uneventfully. 32 (76.19%) patients showed signs of early callus formation 3 months post-surgery. In these patients a lower screw density was used compared to patients who didn't show early callus (33.4 vs. 26.6; p = 0.04). No differences was noticed in working length. CONCLUSION Bridge plate osteosynthesis is a good treatment option in distal tibia fractures. In our series increasing the working length was not associated with a faster callus formation in distal tibia fractures. Conversely, a lower screw density proximally to the fracture site was associated to a faster callus growth.
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Affiliation(s)
- Antonio Gilli
- Department of Orthopedic and Traumatology, San Carlo Borromeo Hospital, Milan, Italy.
- University of Milan, Milan, Italy.
| | - Stefano Ghirardelli
- Women's College Hospital, Orthopaedic Sports Medicine, University of Toronto, Toronto, Canada
| | - Pierrenzo Pozzi
- Department of Orthopedic and Traumatology, San Carlo Borromeo Hospital, Milan, Italy
| | - Georgios Touloupakis
- Department of Orthopedic and Traumatology, San Carlo Borromeo Hospital, Milan, Italy
| | - Matteo Messori
- Department of Orthopedic and Traumatology, San Carlo Borromeo Hospital, Milan, Italy
| | - Emmanouil Theodorakis
- Department of Orthopedic and Traumatology, San Carlo Borromeo Hospital, Milan, Italy
| | - Guido Antonini
- Department of Orthopedic and Traumatology, San Carlo Borromeo Hospital, Milan, Italy
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15
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Andring NA, Kaupp SM, Henry KA, Helmig KC, Babcock S, Halvorson JJ, Pilson HT, Carroll EA. Dual Plate Fixation of Periprosthetic Distal Femur Fractures. J Orthop Trauma 2024; 38:36-41. [PMID: 37684010 DOI: 10.1097/bot.0000000000002695] [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: 09/05/2023] [Indexed: 09/10/2023]
Abstract
OBJECTIVES Dual implants for distal femur periprosthetic fractures is a growing area of interest for these challenging fractures with dual plating (DP) emerging as a viable construct for these injuries. In the current study, an experience with DP constructs is described. METHODS DESIGN Retrospective case series with comparison group. SETTING Level 1 academic trauma center. PATIENT SELECTION CRITERIA Adults >50 years old sustaining comminuted OTA/AO 33-A2 or 33-A3 DFPF treated with either DP or a single distal femur locking plating (DFLP). Patients with simple 33-A1 fractures were excluded. Prior to 2018, patients underwent DFLP after which the treatment of choice became DP. OUTCOME MEASURES AND COMPARISONS Reoperation rate, alignment, and complications. RESULTS 34 patients treated with DFLP and 38 with DP met inclusion and follow up criteria. Average follow up was 18.2 ± 13.8 months in the DFLP group and 19.8 ± 16.1 months in the DP group ( P = 0.339). The average patient age in the DFLP group was 74.8 ± 7.3 years compared to 75.9 ± 11.3 years in the DP group. There were no statistical differences in demographics, fracture morphology, loss of reduction, or reoperation for any cause ( P >.05). DP patients were more likely to be weight bearing in the twelve-week postoperative period ( P <0.001) and return to their baseline ambulatory status ( P = 0.004) compared to DFLP patients. CONCLUSIONS Dual plating of distal femoral periprosthetic fractures maintained coronal alignment with a low reoperation rate even with immediate weight bearing and these patients regained baseline level of ambulation more reliably as compared to patients treated with a single distal femoral locking plate. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Pereira S, Bidolegui F, Garabano G, Pesciallo CA, Giordano V, Pires RE, Mariolani JR, Belangero WD. Does the type of medial plate fixation matter for supplemental fixation of distal femur fractures manage with a lateral pre-contoured locked plate? A Biomechanical study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:605-612. [PMID: 37661241 DOI: 10.1007/s00590-023-03685-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/13/2023] [Indexed: 09/05/2023]
Abstract
INTRODUCTION Fixation of distal femur fractures with a lateral pre-contoured locking plate provides stable fixation and is the standard treatment in most cases, allowing early range of motion with a high rate of union. However, in situations, the stability achieved with the lateral plate alone may be insufficient, predisposing to fixation failure. The objective of the study was to compare, in synthetic bone models, the biomechanical behaviour of the fixation with a distal femur lateral pre-contoured locking plate solely and associated with a 3.5 mm proximal humeral locking plate applied upside down or a 4.5 mm helical locking compression plate on the medial side. MATERIAL AND METHODS A total of 15 solid synthetic left femur samples were used. A metaphysical defect at the level of the medial cortex was simulated. The samples were randomly distributed into three groups equally. All groups received a 4.5/5.0 mm single lateral 9-hole distal femur lateral pre-contoured locking plate. Group 1 had no supplementary plate. Group 2 received a supplementary 6-hole 3.5 mm proximal humeral locking plate and Group 3 received a supplementary 4.5/5.0 mm helical 14-hole narrow locking compression plate. RESULTS Both supplementary plate types used in groups 2 and 3 contributed to increase the apparent stiffness of the construct, but pairwise comparison showed statically significant difference only between group 1 and 3. No significant difference was observed between groups 2 and 3. CONCLUSION Both supplementary plates might be considered for improving the fixation in distal femur fracture in selected cases.
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Affiliation(s)
- Sebastián Pereira
- Servicio de Ortopedia y Traumatologia, Sanatorio San Lucas, Belgrano 369, B1642, San Isidro, Buenos Aires, Argentina.
- Servicio de Ortopedia y Traumatologia, Hospital Sirio-Libanes, Campana 4658, C1419, Buenos Aires, Argentina.
| | - Fernando Bidolegui
- Servicio de Ortopedia y Traumatologia, Hospital Sirio-Libanes, Campana 4658, C1419, Buenos Aires, Argentina
- Servicio de Ortopedia y Traumatologia, Sanatorio Otamendi Miroli, Azcuénaga 870, C1115, Buenos Aires, Argentina
| | - Germán Garabano
- Servicio de Ortopedia y Traumatologia, Hospital Británico de Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
| | - Cesar Angel Pesciallo
- Servicio de Ortopedia y Traumatologia, Hospital Británico de Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
| | - Vincenzo Giordano
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Robinson Estevez Pires
- Departamento do Aparelho Locomotor, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - José Ricardo Mariolani
- Biomaterials Laboratory in Orthopedics (LABIMO), Faculty of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - William Dias Belangero
- Biomaterials Laboratory in Orthopedics (LABIMO), Faculty of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
- Department of Orthopedics, Faculty of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
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England T, Khan H, Moniz S, Mitchell D, Kuster MS. Does Far Cortical Locking Improve Fracture Healing in Distal Femur Fractures: A Randomised, Controlled, Prospective Multicentre Study. J Clin Med 2023; 12:7554. [PMID: 38137622 PMCID: PMC10743881 DOI: 10.3390/jcm12247554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/16/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
(1) Background: Bone healing is influenced by various mechanical factors, such as stability, interfragmentary motion, strain rate, and direction of loading. Far cortical locking (FCL) is a novel screw design that promotes bone healing through controlled fracture motion. (2) Methods: This study compared the outcome of distal femur fractures treated with FCL or SL (standard locking) screws and an NCB plate in a randomised controlled prospective multicentre trial. The radiographic union scale (RUST) and healing time was used to quantify bone healing on follow-up imaging. (3) Results: The study included 21 patients with distal femur fractures, 7 treated with SL and 14 treated with FCL screws. The mean working length for patients with SL screws was 6.1, whereas for FCL screws, it was 3.9. The mean RUST score at 6 months post fracture was 8.0 for patients with SL plates and 7.3 for patients with FCL plates (p value > 0.05). The mean healing time was 6.5 months for patients with SL plates and 9.9 months for patients with FCL plates (p value < 0.05). (4) Conclusions: Fractures fixed with SL plates had longer working lengths and faster healing times when compared to FCL constructs, suggesting that an adequate working length is important for fracture healing regardless of screw choice.
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Affiliation(s)
- Thomas England
- Department of Orthopaedics, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia;
| | - Humza Khan
- Department of Orthopaedics, Royal Perth Hospital, Perth, WA 6000, Australia; (H.K.); (S.M.)
| | - Sheldon Moniz
- Department of Orthopaedics, Royal Perth Hospital, Perth, WA 6000, Australia; (H.K.); (S.M.)
| | - David Mitchell
- Department of Orthopaedics, Ballarat Base Hospital, Ballarat, VIC 3350, Australia;
| | - Markus S. Kuster
- Department of Orthopaedics, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia;
- Department of Orthopaedics, Royal Perth Hospital, Perth, WA 6000, Australia; (H.K.); (S.M.)
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Moosabeiki V, de Winter N, Cruz Saldivar M, Leeflang MA, Witbreuk MMEH, Lagerburg V, Mirzaali MJ, Zadpoor AA. 3D printed patient-specific fixation plates for the treatment of slipped capital femoral epiphysis: Topology optimization vs. conventional design. J Mech Behav Biomed Mater 2023; 148:106173. [PMID: 37866280 DOI: 10.1016/j.jmbbm.2023.106173] [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] [Received: 07/03/2023] [Revised: 10/05/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023]
Abstract
Orthopedic plates are commonly used after osteotomies for temporary fixation of bones. Patient-specific plates have recently emerged as a promising fixation device. However, it is unclear how various strategies used for the design of such plates perform in comparison with each other. Here, we compare the biomechanical performance of 3D printed patient-specific bone plates designed using conventional computer-aided design (CAD) techniques with those designed with the help of topology optimization (TO) algorithms, focusing on cases involving slipped capital femoral epiphysis (SCFE). We established a biomechanical testing protocol to experimentally assess the performance of the designed plates while measuring the full-field strain using digital image correlation. We also created an experimentally validated finite element model to analyze the performance of the plates under physiologically relevant loading conditions. The results indicated that the TO construct exhibited higher ultimate load and biomechanical performance as compared to the CAD construct, suggesting that TO is a viable approach for the design of such patient-specific bone plates. The TO plate also distributed stress more evenly over the screws, likely resulting in more durable constructs and improved anatomical conformity while reducing the risk of screw and plate failure during cyclic loading. Although differences existed between finite element analysis and experimental testing, this study demonstrated that finite element modelling can be used as a reliable method for evaluating and optimizing plates for SCFE patients. In addition to enhancing the mechanical performance of patient-specific fixation plates, the utilization of TO in plate design may also improve the surgical outcome and decrease the recovery time by reducing the plate and incision sizes.
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Affiliation(s)
- V Moosabeiki
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime, and Materials Engineering, Delft University of Technology (TU Delft), Mekelweg 2, 2628, CD, Delft, the Netherlands.
| | - N de Winter
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime, and Materials Engineering, Delft University of Technology (TU Delft), Mekelweg 2, 2628, CD, Delft, the Netherlands; Medical Physics, OLVG, Oosterpark 9, 1091, AC, Amsterdam, the Netherlands
| | - M Cruz Saldivar
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime, and Materials Engineering, Delft University of Technology (TU Delft), Mekelweg 2, 2628, CD, Delft, the Netherlands
| | - M A Leeflang
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime, and Materials Engineering, Delft University of Technology (TU Delft), Mekelweg 2, 2628, CD, Delft, the Netherlands
| | - M M E H Witbreuk
- Department of Orthopaedic Surgery, OLVG, Oosterpark 9, 1091, AC, Amsterdam, the Netherlands
| | - V Lagerburg
- Medical Physics, OLVG, Oosterpark 9, 1091, AC, Amsterdam, the Netherlands
| | - M J Mirzaali
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime, and Materials Engineering, Delft University of Technology (TU Delft), Mekelweg 2, 2628, CD, Delft, the Netherlands
| | - A A Zadpoor
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime, and Materials Engineering, Delft University of Technology (TU Delft), Mekelweg 2, 2628, CD, Delft, the Netherlands; Department of Orthopedic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, the Netherlands
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Galante C, Djemetio MDT, Fratus A, Cattaneo S, Ronchi S, Domenicucci M, Milano G, Casiraghi A. Management of distal femoral fractures with metaphyseal and articular comminution (AO/OTA 33C) using nail and plate fixation: a technical note and case series of 14 patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3519-3529. [PMID: 37204623 DOI: 10.1007/s00590-023-03577-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/05/2023] [Indexed: 05/20/2023]
Abstract
PURPOSE To describe the surgical technique and the outcome of a case series of comminuted intra-articular distal femur fractures (AO/OTA 33C) treated with a nail-plate combination (NPC) implant. METHODS We retrospectively analyzed a case series of 14 patients with comminuted intra-articular distal femur fractures (DFF) treated with an intramedullary retrograde nail in combination with a lateral low-contact condylar locking plate, in a period between June 2020 and January 2023 at a Level 1 trauma center. Baseline demographic and clinical data were recorded. Time to bone healing, function using Schatzker Lambert Score, and complications were documented. RESULTS Fourteen patients, 8 males and 6 females, with a total of 15 NPC implants, were included in this study. Eight out of 14 patients had open fractures, all with a Gustilo Anderson type IIIA exposure. The mean age was 48.5 ± 18.05 years. The median follow-up was 392 days, with only one patient lost to follow-up. 11 out of 15 implants achieved complete radiographic consolidation during follow-up, at a mean of 5.40 ± 1.07 months. At the 12-month follow-up, all patients could fully bear weight painlessly or with mild pain. Schatzker Lambert Score was excellent for 4 patients, good for 2 patients, fair for 5 patients, and failure for 2 patients. The main postoperative complications were rigidity (3 cases), limb shortening (2 cases), and septic non-union (1 case). CONCLUSION This study suggests that the nail-plate combination (NPC) may provide a more effective surgical technique for addressing the challenges associated with comminuted intra-articular distal femur fractures (AO/OTA 33C). LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Claudio Galante
- Department of Bone and Joint Surgery, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy.
| | - Mac D Tedah Djemetio
- Orthopaedics and Traumatology, Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Abramo Fratus
- Orthopaedics and Traumatology, Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Stefano Cattaneo
- Department of Bone and Joint Surgery, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Silvia Ronchi
- Department of Bone and Joint Surgery, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Marco Domenicucci
- 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
- Orthopaedics and Traumatology, Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Alessandro Casiraghi
- Department of Bone and Joint Surgery, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
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Pastor T, Zderic I, Souleiman F, Drenchev L, Skulev HK, Berk T, Gueorguiev B, Knobe M. Medial helical versus straight lateral plating of distal femoral fractures-a biomechanical comparative study. Clin Biomech (Bristol, Avon) 2023; 110:106119. [PMID: 37832469 DOI: 10.1016/j.clinbiomech.2023.106119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Distal femoral fractures are commonly treated with lateral straight plates. However, the lateral approach may not always be desirable, and 180°-helical plates may be an alternative. AIM To investigate the biomechanical competence of 180°-helical plating versus standard straight lateral plating of unstable fractures at the distal femur. METHODS Twelve left artificial femora were instrumented with a 15-hole Locking Compression Plate-Distal Femur, using either 180°-helical plates (group 1) or conventional straight lateral plates (group 2). An unstable distal femoral fracture AO/OTA 33-A3.3 was simulated. All specimens were biomechanically tested under quasi-static and progressively increasing combined cyclic axial and torsional loading in internal rotation until failure. FINDINGS Initial axial stiffness (N/mm) was significantly higher in group 1 (185.6 ± 50.1) compared to group 2 (56.0 ± 14.4), p < 0.001. Group 1 demonstrated significantly higher initial interfragmentary flexion (°) and significantly lower initial varus/valgus deformation (°) under 500 N static axial compression versus group 2 (2.76 ± 1.02 versus 0.87 ± 0.77 and 4.08 ± 1.49 versus 6.60 ± 0.47), p ≤ 0.005. Shear displacement (mm) under 6 Nm static torsion was significantly higher in group 1 versus group 2 in both internal (1.23 ± 0.28 versus 0.40 ± 0.42) and external (1.21 ± 0.40 versus 0.57 ± 0.33) rotation, p ≤ 0.013. Cycles to failure and failure load (N) (clinical/catastrophic) were significantly higher in group 1 (12,484 ± 2116/13,752 ± 1518 and 1748.4 ± 211.6/1875.2 ± 151.8) compared to group 2 (7853 ± 1262/9727 ± 836 and 1285.3 ± 126.2/1472.7 ± 83.6), p ≤ 0.001. INTERPRETATION Although 180°-helical plating using a pre-contoured standard straight lateral plate was associated with higher shear and flexion movements, it demonstrated improved initial axial stability and resistance against varus/valgus deformation compared to straight lateral plating. Moreover, the helical plates were associated with significantly higher endurance to failure. From a biomechanical perspective, 180°-helical plating may be considered as a valuable alternative to standard straight lateral plating of unstable distal femoral fractures.
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Affiliation(s)
- Torsten Pastor
- AO Research Institute Davos, Davos, Switzerland; Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
| | - Firas Souleiman
- AO Research Institute Davos, Davos, Switzerland; Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Ludmil Drenchev
- Bulgarian Academy of Sciences, Institute of Metal Science "Acad. A. Balevski", Sofia, Bulgaria
| | - Hristo Kostov Skulev
- Bulgarian Academy of Sciences, Institute of Metal Science "Acad. A. Balevski", Sofia, Bulgaria
| | - Till Berk
- AO Research Institute Davos, Davos, Switzerland; Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | | | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland; Medical Faculty, RWTH Aachen University Hospital, Aachen, Germany
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21
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Roytman GR, Beitler B, LaMonica J, Spero M, Toy K, Ramji AF, Yoo B, Leslie MP, Baumgaertner M, Tommasini SM, Wiznia DH. An analytical model of lateral condylar plate working length. Clin Biomech (Bristol, Avon) 2023; 110:106129. [PMID: 37871506 PMCID: PMC10848195 DOI: 10.1016/j.clinbiomech.2023.106129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/10/2023] [Accepted: 10/17/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND The locking plate is a common device to treat distal femur fractures. Healing is affected by construct stiffness, thus many surgeon-controlled variables such as working length have been examined for their effects on strain at the fracture. No convenient analytical model which aids surgeons in determining working length has yet been described. We propose an analytical model and compare it to finite element analysis and cadaveric biomechanical testing. METHODS First, an analytical model based on a cantilever beam equation was derived. Next, a finite element model was developed based on a CT scan of a "fresh-frozen" cadaveric femur. Third, biomechanical testing in single-leg stance loading was performed on the cadaver. In all methods, strain at the fracture was recorded. An ANCOVA test was conducted to compare the strains. FINDINGS In all models, as the working length increased so did strain. For strain at the fracture, the shortest working length (35 mm) had a strain of 8% in the analytical model, 9% in the finite element model, and 7% for the cadaver. The longest working length (140 mm) demonstrated strain of 15% in the analytical model, and the finite element and biomechanical tests both demonstrated strain of 14%. INTERPRETATION The strain predicted by the analytical model was consistent with the strain observed in both the finite element and biomechanical models. As demonstrated in existing literature, increasing the working length increases strain at the fracture site. Additional work is required to refine and establish validity and reliability of the analytical model.
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Affiliation(s)
- Gregory R Roytman
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA; Biomedical Engineering, Yale University School of Engineering & Applied Science, 17 Hillhouse Avenue, New Haven, CT 06520, USA.
| | - Brian Beitler
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA
| | - Julia LaMonica
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA
| | - Matthew Spero
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA
| | - Kendal Toy
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA
| | - Alim F Ramji
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA
| | - Brad Yoo
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA
| | - Michael P Leslie
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA
| | - Michael Baumgaertner
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA
| | - Steven M Tommasini
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA; Biomedical Engineering, Yale University School of Engineering & Applied Science, 17 Hillhouse Avenue, New Haven, CT 06520, USA
| | - Daniel H Wiznia
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA; Mechanical Engineering & Materials Science, Yale University School of Engineering & Applied Science, 17 Hillhouse Avenue, New Haven, CT 06520, USA
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22
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Koguchi M, Mori Y, Kamimura M, Ito K, Tanaka H, Kurishima H, Koyama T, Mori N, Masahashi N, Aizawa T. Low Young's Modulus TiNbSn Alloy Locking Plates Accelerate Osteosynthesis in Rabbit Tibiae. TOHOKU J EXP MED 2023; 261:199-209. [PMID: 37704419 DOI: 10.1620/tjem.2023.j075] [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] [Indexed: 09/15/2023]
Abstract
A new beta TiNbSn alloy with a low Young's modulus of approximately 40 GPa has been developed to resolve the stress shielding by Young's modulus divergence. In this study, the efficacy of TiNbSn alloy locking plates on bone repair is compared to that of commercially pure titanium (CP-Ti). The TiNbSn alloy and CP-Ti, which have Young's moduli of 49.1 GPa and 107 GPa, respectively, were compared. Male Japanese white rabbits were anesthetized, and osteotomy and osteosynthesis with locking plates were performed on the right tibia. The bone repair was assessed using micro-computed tomography (CT), histomorphometry, immunohistochemistry, and mechanical testing. Micro-CT, histomorphometry, immunohistochemistry, and mechanical testing were performed four weeks after osteotomy. Six weeks after surgery, micro-CT and mechanical testing were performed. Micro-CT analysis at four weeks after surgery showed that the intramedullary fracture callus in the TiNbSn alloy group had more bone volume and numerous bridging structures compared to the CP-Ti group (CP-Ti vs. TiNbSn alloy, 34.3 ± 13.1 mm3 vs. 61.3 ± 19.6 mm3, p = 0.02; mean ± standard deviation). At four weeks post-osteotomy, the healed tibia showed significantly higher strength in the TiNbSn alloy group compared with CP-Ti (CP-Ti vs. TiNbSn alloy, 81.3 ± 31.2 N vs. 133.7 ± 46.6 N, p = 0.04). TiNbSn alloy locking plates had a more positive impact on bone formation and bone strength restoration than the CP-Ti locking plates during the early phase of bone healing.
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Affiliation(s)
- Masashi Koguchi
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine
| | - Yu Mori
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine
| | - Masayuki Kamimura
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine
| | - Kentaro Ito
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine
| | - Hidetatsu Tanaka
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine
| | - Hiroaki Kurishima
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine
| | - Tomoki Koyama
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine
| | - Naoko Mori
- Department of Radiology, Akita University Graduate School of Medicine
| | | | - Toshimi Aizawa
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine
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23
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Liu J, Huang Z, Qi Y, Long Y, Zhang Y, Liu N, Zuo G, Wang W. Biomechanical analysis of bridge combined fixation system as a novel treatment for the fixation of type A3 distal femoral fractures. Front Surg 2023; 10:1264904. [PMID: 38033528 PMCID: PMC10687203 DOI: 10.3389/fsurg.2023.1264904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/25/2023] [Indexed: 12/02/2023] Open
Abstract
Background To compare the biomechanical parameters of AO/OTA type A3 distal femoral fractures fixed bilaterally with a bridge combined fixation system (BCFS) and lateral locking compression plate + locking reconstruction plate (LCP + LRP). Methods Twelve A3 distal femoral fracture models with medial cortical defects of the distal femur were created using synthetic femoral Sawbones. BCFS and LCP + LRP were used for bilateral fixation, with six in each group. Axial compression and torsion tests were performed on the two groups of fracture models to determine their stiffness during axial compression and the Torsional stiffness during torsion tests. Axial compression failure tests were performed to collect the vertical loads of the ultimate failure tests. Results In the test conducted on the fixed type A3 distal femoral fracture models, the axial stiffness in the BCFS group (group A) (1,072.61 ± 113.5 N/mm) was not significantly different from that in the LCP + LRP group (group B) (1,184.13 ± 110.24 N/mm) (t = 1.726, P = 0.115), the Torsional stiffness in group A (3.73 ± 0.12 N.m/deg) was higher than that in group B (3.37 ± 0.04 N.m/deg) (t = 6.825, P < 0.001),and the ultimate failure test of type A3 fracture model showed that the vertical load to destroy group A fixation (5,290.45 ± 109.63 N) was higher than that for group B (3,978.43 ± 17.1 N) (t = 23.28, P < 0.05). Notably, intertrochanteric fractures occurred in groups A and B. Conclusions In the fixation of type A3 distal femoral fractures, the anti-axial compression of the BCFS group was similar to that of the LCP + LRP group, but the anti-torsion was better.
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Affiliation(s)
- Jianke Liu
- Shandong First Medical University & Shandong Academy Medical Sciences, Jinan, China
| | - Zhaozhao Huang
- Tianjin Walkman Biomaterial Co., Ltd. Newton Laboratory, Tianjin, China
| | - Yubin Qi
- Department of Orthopaedics, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Yuntao Long
- Shandong First Medical University & Shandong Academy Medical Sciences, Jinan, China
| | - Yanhui Zhang
- Department of Orthopaedics, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Na Liu
- Tianjin Walkman Biomaterial Co., Ltd. Newton Laboratory, Tianjin, China
| | - Guilai Zuo
- Department of Orthopaedics, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Wen Wang
- Department of Orthopaedics, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
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24
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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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25
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Crutcher WL, Magnusson EA, Griffith KM, Alford CA, Nielsen ED, Elkins JM, Lujan TJ, Kleweno CP, Lack WD. Bridge Plate Fixation of Distal Femur Fractures: Defining Deficient Radiographic Callus Formation and Its Associations. J Orthop Trauma 2023; 37:475-479. [PMID: 37127901 DOI: 10.1097/bot.0000000000002629] [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: 04/24/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE To determine whether deficient early callus formation can be defined objectively based on the association with an eventual nonunion and specific patient, injury, and treatment factors. METHODS Final healing outcomes were documented for 160 distal femur fractures treated with locked bridge plate fixation. Radiographic callus was measured on postoperative radiographs until union or nonunion had been declared by the treating surgeon. Deficient callus was defined at 6 and 12 weeks based on associations with eventual nonunion through receiver-operator characteristic analysis. A previously described computational model estimated fracture site motion based on the construct used. Univariable and multivariable analyses then examined the association of patient, injury, and treatment factors with deficient callus formation. RESULTS There were 26 nonunions. The medial callus area at 6 weeks <24.8 mm 2 was associated with nonunion (12 of 39, 30.8%) versus (12 of 109, 11.0%), P = 0.010. This association strengthened at 12 weeks with medial callus area <44.2 mm 2 more closely associated with nonunion (13 of 28, 46.4%) versus (11 of 120, 9.2%), P <0.001. Multivariable logistic regression analysis found limited initial longitudinal motion (OR 2.713 (1.12-6.60), P = 0.028)) and Charlson Comorbidity Index (1.362 (1.11-1.67), P = 0.003) were independently associated with deficient callus at 12 weeks. Open fracture, mechanism of injury, smoking, diabetes, plate material, bridge span, and shear were not significantly associated with deficient callus. CONCLUSION Deficient callus at 6 and 12 weeks is associated with eventual nonunion, and such assessments may aid future research into distal femur fracture healing. Deficient callus formation was independently associated with limited initial longitudinal fracture site motion derived through computational modeling of the surgical construct but not more routinely discussed parameters such as plate material and bridge span. Given this, improved methods of in vivo assessment of fracture site motion are necessary to further our ability to optimize the mechanical environment for healing. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- William L Crutcher
- University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, WA
| | | | | | - Cory A Alford
- University of Washington School of Medicine, Seattle, WA
| | - Ena D Nielsen
- University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, WA
| | - Jacob M Elkins
- University of Iowa Hospitals and Clinics, Department of Orthopaedics and Rehabilitation, Iowa City, IA; and
| | - Trevor J Lujan
- Boise State University, Department of Mechanical and Biomedical Engineering, Boise, ID
| | - Conor P Kleweno
- University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, WA
| | - William D Lack
- University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, WA
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26
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Sainio H, Rämö L, Reito A, Silvasti-Lundell M, Lindahl J. Prediction of fracture nonunion leading to secondary surgery in patients with distal femur fractures. Bone Jt Open 2023; 4:584-593. [PMID: 37580052 PMCID: PMC10425244 DOI: 10.1302/2633-1462.48.bjo-2023-0077.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
Aims Several previously identified patient-, injury-, and treatment-related factors are associated with the development of nonunion in distal femur fractures. However, the predictive value of these factors is not well defined. We aimed to assess the predictive ability of previously identified risk factors in the development of nonunion leading to secondary surgery in distal femur fractures. Methods We conducted a retrospective cohort study of adult patients with traumatic distal femur fracture treated with lateral locking plate between 2009 and 2018. The patients who underwent secondary surgery due to fracture healing problem or plate failure were considered having nonunion. Background knowledge of risk factors of distal femur fracture nonunion based on previous literature was used to form an initial set of variables. A logistic regression model was used with previously identified patient- and injury-related variables (age, sex, BMI, diabetes, smoking, periprosthetic fracture, open fracture, trauma energy, fracture zone length, fracture comminution, medial side comminution) in the first analysis and with treatment-related variables (different surgeon-controlled factors, e.g. plate length, screw placement, and proximal fixation) in the second analysis to predict the nonunion leading to secondary surgery in distal femur fractures. Results We were able to include 299 fractures in 291 patients. Altogether, 31/299 fractures (10%) developed nonunion. In the first analysis, pseudo-R2 was 0.27 and area under the receiver operating characteristic curve (AUC) was 0.81. BMI was the most important variable in the prediction. In the second analysis, pseudo-R2 was 0.06 and AUC was 0.67. Plate length was the most important variable in the prediction. Conclusion The model including patient- and injury-related factors had moderate fit and predictive ability in the prediction of distal femur fracture nonunion leading to secondary surgery. BMI was the most important variable in prediction of nonunion. Surgeon-controlled factors had a minor role in prediction of nonunion.
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Affiliation(s)
- Heini Sainio
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Lasse Rämö
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Aleksi Reito
- Centre for Musculoskeletal Diseases, Tampere University Hospital and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Marja Silvasti-Lundell
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jan Lindahl
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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27
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Lotzien S, Baron D, Rosteius T, Cibura C, Ull C, Schildhauer TA, Geßmann J. Medial augmentation plating of aseptic distal femoral nonunions. BMC Musculoskelet Disord 2023; 24:554. [PMID: 37407946 DOI: 10.1186/s12891-023-06675-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 06/27/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Distal femur nonunions are well-recognized contributors to persistent functional disability, with limited data regarding their treatment options. In the current study, we asked whether additional medial augmentation plating is a feasible treatment option for patients with aseptic distal femoral nonunion and intact lateral implants. METHODS We conducted a single-center, retrospective study including 20 patients treated for aseptic distal femoral nonunion between 2002 and 2017. The treatment procedure included a medial approach to the distal femur, debridement of the nonunion site, bone grafting and medial augmentation plating utilizing a large-fragment titanium plate. Outcome measures were bone-related and functional results, measured by the Hospital for Special Surgery Knee Rating Scale (HSS) and the German Short Musculoskeletal Function Assessment questionnaire (SMFA-D). RESULTS Eighteen of 20 nonunions showed osseous healing at 8.16 ± 5.23 (range: 3-21) months after augmentation plating. Regarding functional results, the mean HSS score was 74.17 ± 11.12 (range: 57-87). The mean SMFA-D functional index was 47.38 ± 16.78 (range 25.74-71.32) at the last follow-up. Index procedure-associated complications included two cases of persistent nonunion and one case of infection. CONCLUSIONS According to the assessed outcome measures, augmentation plating is a feasible treatment option, with a high proportion of patients achieving bony union and good functional outcomes and a few patients experiencing complications.
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Affiliation(s)
- Sebastian Lotzien
- Department of General and Trauma Surgery, Ruhr University Bochum, Bürkle-de-La-Camp-Platz 1, 44789, Bochum, Germany.
| | - Darius Baron
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle- de- La- Camp Platz 1, 44789, Bochum, Germany
| | - Thomas Rosteius
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle- de- La- Camp Platz 1, 44789, Bochum, Germany
| | - Charlotte Cibura
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle- de- La- Camp Platz 1, 44789, Bochum, Germany
| | - Christopher Ull
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle- de- La- Camp Platz 1, 44789, Bochum, Germany
| | - Thomas Armin Schildhauer
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle- de- La- Camp Platz 1, 44789, Bochum, Germany
| | - Jan Geßmann
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle- de- La- Camp Platz 1, 44789, Bochum, Germany
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28
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Zdero R, Gide K, Brzozowski P, Schemitsch EH, Bagheri ZS. Biomechanical design optimization of distal femur locked plates: A review. Proc Inst Mech Eng H 2023; 237:791-805. [PMID: 37366552 DOI: 10.1177/09544119231181487] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
Clinical findings, manufacturer instructions, and surgeon's preferences often dictate the implantation of distal femur locked plates (DFLPs), but healing problems and implant failures still persist. Also, most biomechanical researchers compare a particular DFLP configuration to implants like plates and nails. However, this begs the question: Is this specific DFLP configuration biomechanically optimal to encourage early callus formation, reduce bone and implant failure, and minimize bone "stress shielding"? Consequently, it is crucial to optimize, or characterize, the biomechanical performance (stiffness, strength, fracture micro-motion, bone stress, plate stress) of DFLPs influenced by plate variables (geometry, position, material) and screw variables (distribution, size, number, angle, material). Thus, this article reviews 20 years of biomechanical design optimization studies on DFLPs. As such, Google Scholar and PubMed websites were searched for articles in English published since 2000 using the terms "distal femur plates" or "supracondylar femur plates" plus "biomechanics/biomechanical" and "locked/locking," followed by searching article reference lists. Key numerical outcomes and common trends were identified, such as: (a) plate cross-sectional area moment of inertia can be enlarged to lower plate stress at the fracture; (b) plate material has a larger influence on plate stress than plate thickness, buttress screws, and inserts for empty plate holes; (c) screw distribution has a major influence on fracture micro-motion, etc. Recommendations for future work and clinical implications are then provided, such as: (a) simultaneously optimizing fracture micro-motion for early healing, reducing bone and implant stresses to prevent re-injury, lowering "stress shielding" to avoid bone resorption, and ensuring adequate fatigue life; (b) examining alternate non-metallic materials for plates and screws; (c) assessing the influence of condylar screw number, distribution, and angulation, etc. This information can benefit biomedical engineers in designing or evaluating DFLPs, as well as orthopedic surgeons in choosing the best DFLPs for their patients.
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Affiliation(s)
- Radovan Zdero
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada
| | - Kunal Gide
- Department of Mechanical Engineering, George Mason University, Fairfax, VA, USA
| | - Pawel Brzozowski
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada
| | - Emil H Schemitsch
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada
- Division of Orthopaedic Surgery, Western University, London, ON, Canada
| | - Z Shaghayegh Bagheri
- Department of Mechanical Engineering, George Mason University, Fairfax, VA, USA
- Kite Research Institute, Toronto Rehab Institute, University Health Network, Toronto, ON, Canada
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29
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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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Haase DR, Haase LR, Moon TJ, Dallman J, Vance D, Benedick A, Ochenjele G, Napora JK, Wise BT. Perioperative allogenic blood transfusions are associated with increased fracture related infection rates, but not nonunion in operatively treated distal femur fractures. Injury 2023:S0020-1383(23)00383-2. [PMID: 37188588 DOI: 10.1016/j.injury.2023.04.041] [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: 12/03/2022] [Revised: 04/11/2023] [Accepted: 04/23/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Distal femur fractures are common injuries that remain difficult for orthopedic surgeons to treat. High complication rates, including nonunion rates as high as 24% and infection rates of 8%, can lead to increased morbidity for these patients. Allogenic blood transfusions have previously been identified as risk factors for infection in total joint arthroplasty and spinal fusion surgeries. No studies have explored the relationship between blood transfusions and fracture related infection (FRI) or nonunion in distal femur fractures. METHODS 418 patients with operatively treated distal femur fractures at two level I trauma centers were retrospectively reviewed. Patient demographics were collected including age, gender, BMI, medical comorbidities, and smoking. Injury and treatment information was also collected including open fracture, polytrauma status, implant, perioperative transfusions, FRI, and nonunion. Patients with less than three months of follow up were excluded. RESULTS 366 patients were included in final analysis. One hundred thirty-nine (38%) patients received a perioperative blood transfusion. Forty-seven (13%) nonunions and 30 (8%) FRI were identified. Allogenic blood transfusion was not associated with nonunion (13% vs 12%, P = 0.87), but was associated with FRI (15% vs 4%, P<0.001). Binary logistic regression analysis identified a dose dependent relationship between number of perioperative blood transfusions and FRI: total transfusion ≥2 U PRBC RR= 3.47(1.29, 8.10, P = 0.02), ≥3 RR= 6.99 (3.01, 12.40, P<0.001), and ≥4 RR= 8.94 (4.03, 14.42, P<0.001). DISCUSSION In patients undergoing operative treatment of distal femur fractures, perioperative blood transfusions are associated with increased risk of fracture related infection, but not the development of a nonunion. This risk association increases in a dose-dependent relationship with increasing total blood transfusions received.
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Gendya AGMK, El-Zaher EZH, Zakaria ZM, Awad MES, Metwaly RGEA. Double Plating Fixation vs Distal Femoral Replacement in the Management of Distal Femoral Fractures in Geriatric Patients. Arthroplast Today 2023; 20:101113. [PMID: 36949829 PMCID: PMC10025122 DOI: 10.1016/j.artd.2023.101113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 11/24/2022] [Accepted: 01/24/2023] [Indexed: 03/24/2023] Open
Abstract
Background Distal femur fractures are considered challenging to manage, particularly in geriatric patients. Double plating (DP) is a technique that helps with earlier rehabilitation and return to preinjury level of activity. Distal femoral replacement (DFR) is an alternative technique in the management of these fractures that may help to solve problems like associated knee osteoarthritis, osteoporosis, and severely comminuted condyles. The current study compares the functional and radiological outcomes of DFR and DP in the management of these fractures among geriatric patients. Methods This randomized, comparative, interventional study was performed at a university hospital. A total of 30 patients who underwent DFR or DP after distal femur fractures (AO/OTA 33 A3, 33 C) were analyzed. The primary outcome was Knee Society Score (KSS), whereas secondary outcomes included postoperative complications rate, knee range of motion, reoperation rate, and operative time. Results No significant difference was observed between DFR and DP except for the knee component of the KSS at a 12-month interval (P = .03) and knee range of motion at a 12-month interval (P = .001), both of which were in favor of DP. No significant difference in postoperative complications (P = .06), reoperation rate (P = 1.00), or operative time (P = .06) was noted. Conclusions DFR and DP had comparable functional (KSS) and radiological outcomes with no significant difference in postoperative complications, reoperation rate, or operative time.
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Affiliation(s)
- Amr Gamaleldin Mahmoud Khalil Gendya
- Corresponding author. Department of Orthopaedic surgery, Ain Shams University, 143 Golf District, El-Sherouk City, Cairo, Egypt 62451. Tel.: (002)01147219920.
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Chen SR, Shaikh H, Turvey BR, Moloney GB. Technical Trick: Supplemental Medial Column Screw Fixation of Distal Femur Fractures Treated With a Laterally Based Locked Plate. J Orthop Trauma 2023; 37:e175-e180. [PMID: 36001898 DOI: 10.1097/bot.0000000000002475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 02/02/2023]
Abstract
SUMMARY Given known failure rates after lateral plating of distal femur fractures, there is an increasing interest in augmenting fixation to improve outcomes. The addition of medial plates or intramedullary nails have been described with promising results, decreasing nonunion and varus collapse rates. However, the use of dual implants increases implant costs, adds surgical complexity, and requires a second surgical approach that may increase morbidity. A supplemental, percutaneously placed, medial column screw may provide a less invasive means of improving stability and achieving fracture union compared with lateral plating alone.
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Affiliation(s)
- Stephen R Chen
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA
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Kursad Bayraktar M, Akdaş Tekin E. Headless cannulated screw and external fixator in the treatment of type C distal femur fractures: Effect of early mobilization on clinical outcomes. Acta Orthop Belg 2023; 89:122-127. [PMID: 37294995 DOI: 10.52628/89.1.11119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Distal femur fractures occur due to high-energy trauma in young patients and with low-energy traumas in osteoporotic elderly patients. Implants selected for use in the treatment of distal femur fracture should provide stable fixation and allow early mobilization especially at elder patients. We aimed to investigate the effects of the headless cannulated screw and external fixator combination on the early mobilization of the patients and postoperative complications. Twenty-one patients with Type C distal femur fracture were included in the study.The fracture lines were temporarily fixed with K wires. After the fracture reduction with headless cannulated screws a tubular external fixator with carbon fiber rods was applied to bridge the knee joint. The external fixators were removed at the 6th week follow-up, and the patients were forced to perform knee flexion as much as they could tolerate. The 6th month KSS scores of the patients were 44.3 (34-60) and the 18th month KSS scores were 77.5 (60-88).Preoperative VAS score was 8(7-10) and postoperative VAS score was 4(3-6).Knee flexion of the patients at 6th months was 95.9 (80-110 degrees) and at 6th months knee flexion was 114.5 (100-125 degrees). Superficial pin site infection was observed at 4 patients and regressed with antibiotic therapy. Combination of cannulated screws with an external fixator for joint restoration in type C distal femur fractures allows early mobilization and reduces postoperative morbidity.
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Outcome Evaluation of Distal Femoral Fractures Following Surgical Management: A Retrospective Cohort Study. J Pers Med 2023; 13:jpm13020350. [PMID: 36836584 PMCID: PMC9960625 DOI: 10.3390/jpm13020350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/07/2023] [Accepted: 02/16/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Distal femur fractures are challenging in surgical management as the outcome is crucial for restoring the biomechanical stability and longitudinal axis of the leg and function of the knee joint. METHODS A retrospective review of all distal femoral fractures treated in a level I trauma center over a decade was performed. The radiographs were reviewed for fracture entity, osseous healing, implant failure, mechanical axis, and degenerative joint changes. Clinical outcome was reviewed regarding postoperative complications and postoperative range of motion of the knee joint. RESULTS 130 patients who were managed with screw fixation (n = 35), plating systems (n = 92) or intramedullary nailing systems (n = 3) remained for evaluation. Mean follow up was 26 months. Clinical outcome was significantly better for flexion degrees following screw fixation (p = 0.009). Delayed fracture union (p = 0.002) or non-union (p = 0.006) rates were significantly higher in plate osteosynthesis. Mild pathologic deformity for varus and valgus collapse was found following plate osteosynthesis. CONCLUSIONS Screw fixation shows fewer postoperative complications than plate fixation and is favored for extra and partial intraarticular distal femur fractures. Plating constructs remain the superior fixation method in complex distal femur fractures but are associated with higher rates of non-union and leg axis deviation.
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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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Locked Lateral Plating Versus Retrograde Nailing for Distal Femur Fractures: A Multicenter Randomized Trial. J Orthop Trauma 2023; 37:70-76. [PMID: 36026544 DOI: 10.1097/bot.0000000000002482] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The 2 main forms of treatment for distal femur fractures are locked lateral plating and retrograde nailing. The goal of this trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN Multicenter randomized controlled trial. SETTING Twenty academic trauma centers. PATIENTS/PARTICIPANTS One hundred sixty patients with distal femur fractures were enrolled. One hundred twenty-six patients were followed 12 months. Patients were randomized to plating in 62 cases and intramedullary nailing in 64 cases. INTERVENTION Lateral locked plating or retrograde intramedullary nailing. MAIN OUTCOME MEASUREMENTS Functional scoring including Short Musculoskeletal Functional Assessment, bother index, EQ Health, and EQ Index. Secondary measures included alignment, operative time, range of motion, union rate, walking ability, ability to manage stairs, and number and type of adverse events. RESULTS Functional testing showed no difference between the groups. Both groups were still significantly affected by their fracture 12 months after injury. There was more coronal plane valgus in the plating group, which approached statistical significance. Range of motion, walking ability, and ability to manage stairs were similar between the groups. Rate and type of adverse events were not statistically different between the groups. CONCLUSIONS Both lateral locked plating and retrograde intramedullary nailing are reasonable surgical options for these fractures. Patients continue to improve over the course of the year after injury but remain impaired 1 year postoperatively. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Rosell-Pradas J, Redondo-Trasobares B, Sarasa-Roca M, Albareda-Albareda J, Puértolas-Broto S, Herrera-Rodríguez A, Gracia-Villa L. Influence of plate size and screw distribution on the biomechanical behaviour of osteosynthesis by means of lateral plates in femoral fractures. Injury 2023; 54:395-404. [PMID: 36528423 DOI: 10.1016/j.injury.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Abstract
Distal femoral fractures are fractures associated with high rates of morbidity and mortality, affecting to three different groups of individuals: younger people suffering high-energy trauma, elderly people with fragile bones and people with periprosthetic fractures around previous total knee arthroplasty. They have been classically treated with conventional plates and intramedullary nails and more recently with locked plates that have increased their indications to more types of fractures. The main objective of the present work is the biomechanical study, by means of finite element simulation, of the stability achieved in the osteosynthesis of femoral fractures in zones 4 and 5 of Wiss, by using locked plates with different plate lengths and different screw configurations, and analysing the effect of screw proximity to the fracture site. A three dimensional (3D) finite element model of the femur from 55-year-old male donor was developed, and then a stability analysis was performed for the fixation provided by Osteosynthesis System LOQTEC® Lateral Distal Femur Plate in two different fracture zones corresponding to the zones 4 and 5 according to the Wiss fracture classification. The study was focused on the immediately post-operative stage, without any biological healing process. The obtained results show that more stable osteosyntheses were obtained by using shorter plates. In the cases of longer plates, it results more convenient disposing screws in a way that the upper ones are closer to fracture site. The obtained results can support surgeons to understand the biomechanics of fracture stability, and then to guide them towards the more appropriate osteosynthesis depending on the fracture type and location.
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Affiliation(s)
- J Rosell-Pradas
- Department of Mechanical Engineering, University of Zaragoza, Zaragoza, Spain
| | - B Redondo-Trasobares
- Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital, Zaragoza, Spain; Aragón Health Research Institute, Zaragoza, Spain
| | - M Sarasa-Roca
- Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital, Zaragoza, Spain; Aragón Health Research Institute, Zaragoza, Spain
| | - J Albareda-Albareda
- Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital, Zaragoza, Spain; Aragón Health Research Institute, Zaragoza, Spain; Department of Surgery, University of Zaragoza, Zaragoza, Spain.
| | - S Puértolas-Broto
- Department of Mechanical Engineering, University of Zaragoza, Zaragoza, Spain; Aragón Institute for Engineering Research, Zaragoza, Spain
| | | | - L Gracia-Villa
- Department of Mechanical Engineering, University of Zaragoza, Zaragoza, Spain; Aragón Institute for Engineering Research, Zaragoza, Spain
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Guo Z, Liu H, Luo D, Cai T, Zhang J, Wu J. Application of Cortical Bone Plate Allografts Combined with Less Invasive Stabilization System (LISS) Plates in Fixation of Comminuted Distal Femur Fractures. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020207. [PMID: 36837409 PMCID: PMC9961610 DOI: 10.3390/medicina59020207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/22/2023]
Abstract
Background and Objectives: At present, the management of comminuted distal femur fractures remains challenging for orthopedic surgeons. The aim of this study is to report a surgical treatment for comminuted distal femur fractures using supplementary medial cortical bone plate allografts in conjunction with the lateral less invasive stabilization system (LISS) plates. Materials and Methods: From January 2009 to January 2014, the records of thirty-three patients who underwent supplementary medial cortical bone plate allografts combined with lateral LISS plates fixation were reviewed. Clinical and radiographic data were collected during regular postoperative follow-up visits. Functional outcomes were determined according to the special surgery knee rating scale (HSS) used at the hospital. Results: Thirty patients were followed for 13 to 73 months after surgery, with an average follow-up time of 31.3 months. The mean time to bone union was 5.4 months (range of 3-12 months) and the mean range of knee flexion was 105.6° (range of 80-130°). Of the remaining patients, 10 had a score of "Excellent", while 10 had a score of "Good". Three patients had superficial or deep infections, one patient had nonunion that required bone grafting, and one patient had post-traumatic knee arthritis. Conclusions: Based on these promising results, we propose that supplementary medial cortical bone plate allografts combined with lateral LISS plate fixation may be a good treatment option for comminuted distal femur fractures. This treatment choice not only resulted in markedly improved stability on the medial side of the femur, but also satisfactory outcomes for distal femoral fractures.
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Affiliation(s)
| | | | | | | | | | - Jin Wu
- Correspondence: ; Tel.: +86-0596-2931538
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Medial and lateral dual plating of native distal femur fractures: a systematic literature review. OTA Int 2023; 6:e227. [PMID: 36760659 PMCID: PMC9904193 DOI: 10.1097/oi9.0000000000000227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 10/02/2022] [Indexed: 01/18/2023]
Abstract
Introduction Lateral locked plating (LLP) development has improved outcomes for distal femur fractures. However, there is still a modest rate of nonunion in fractures treated with LLP alone, with higher nonunion risk in high-energy fractures, intra-articular involvement, poor bone quality, severe comminution, or bone loss. Several recent studies have demonstrated both the safety and the biomechanical advantage of dual medial and lateral plating (DP). The purpose of this study was to evaluate the clinical outcomes of DP for native distal femoral fractures by performing a systematic review of the literature. Methods Studies reporting clinical outcomes for DP of native distal femur fractures were identified and systematically reviewed. Publications without full-text manuscripts, those solely involving periprosthetic fractures, or fractures other than distal femur fractures were excluded. Fracture type, mean follow-up, open versus closed fracture, number of bone grafting procedures, nonunion, reoperation rates, and complication data were collected. Methodologic study quality was assessed using the Coleman methodology score. Results The initial electronic review and reverse inclusion protocol identified 1484 publications. After removal of duplicates and abstract review to exclude studies that did not discuss clinical treatment of femur fractures with dual plating, 101 potential manuscripts were identified and manually reviewed. After final review, 12 studies were included in this study. There were 199 fractures with average follow-up time of 13.72 months. Unplanned reoperations and nonunion occurred in 19 (8.5%) and 9 (4.5%) cases, respectively. The most frequently reported complications were superficial infection (n = 6, 3%) and deep infection (n = 5, 2.5%) postoperatively. Other complications included delayed union (n = 6, 3%) not requiring additional surgical treatment and knee stiffness in four patients (2%) necessitating manipulation under anesthesia or lysis of adhesions. The average Coleman score was 50.5 (range 13.5-72), suggesting that included studies were of moderate-to-poor quality. Conclusions Clinical research interest in DP of distal femoral fractures has markedly increased in the past few decades. The current data suggest that DP of native distal femoral fractures is associated with favorable nonunion and reoperation rates compared with previously published rates associated with LLP alone. In the current review, DP of distal femoral fractures was associated with acceptable rates of complications and generally good functional outcomes. More high-quality, directly comparable research is necessary to validate the conclusions of this review.
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Jitprapaikulsarn S, Chantarapanich N, Gromprasit A, Mahaisavariya C, Sukha K, Chiawchan S. Dual plating for fixation failure of the distal femur: Finite element analysis and a clinical series. Med Eng Phys 2023; 111:103926. [PMID: 36792233 DOI: 10.1016/j.medengphy.2022.103926] [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: 09/06/2022] [Revised: 10/21/2022] [Accepted: 11/15/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND The optimal technique for managing distal femur fixation failure remains inconclusive. The author studied the efficacy of a combined proximal humerus locking compression plate (LCP-PH) and 3.5 mm reconstruction plate (LCP-RP) by finite element (FE) analysis and retrospectively described the clinical outcomes of the present technique in such difficult circumstances. METHODS Biomechanical study setting included FE models of the distal femur with remaining holes from previous distal femur LCP (LCP-DF) fixation stabilized with three different constructs i.e., LCP-DF alone, LCP-DF-and-LCP-RP, as well as LCP-PH-and-LCP-RP. All settings were analyzed by using FE under physiological loads. Regarding the clinical series, the outcomes of 8 LCP-DF fixation failures operated on by the present technique were retrospectively reviewed. RESULTS High Implant stress of 911.2 MPa and elastic strain at fracture site of 200.8 µɛ were found when stabilized with LCP-DF. The constructs of LCP-DF-and-LCP-RP, and LCP-PH-and-LCP-RP presented lower implant stress compared to LCP-DF, 511.5, and 617.5 MPa, respectively. The elastic strain of both dual plating constructs was also 4-5 times lower than LCP-DF and differed from each other by approximately 10 µɛ. Regarding the clinical series, bony consolidation was achieved in all cases with a mean duration of 28.5 weeks (range 24-36). An average ROM of the affected knee was 115° (range 105-140). Regarding the KSS, 1 was determined to be excellent and 7 to be good. CONCLUSION By the biomechanical analysis and the clinical results, the construct of LCP-PH-and-LCP-RP could be an effective technique for revision surgery of LCP-DF fixation failure.
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Affiliation(s)
| | - Nattapon Chantarapanich
- Department of Mechanical Engineering, Faculty of Engineering at Sriracha, Kasetsart University, Sriracha, Chonburi, Thailand.
| | - Arthit Gromprasit
- Department of Orthopedics, Buddhachinaraj Hospital, Phitsanulok, Thailand
| | - Chantas Mahaisavariya
- Department of Orthopedic Surgery, Golden Jubilee Medical Center, Faculty of Medicine Siriraj Hospital, Mahidol University, 888 Salaya, Phutthamonthon District, Nakhon Pathom 73170, Thailand
| | - Kritsada Sukha
- Department of Orthopedics, Buddhachinaraj Hospital, Phitsanulok, Thailand
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Birlie T, Biresaw B, Yadeta E, Getachew T, Debella A, Eyeberu A. Knee Pain After Retrograde Intramedullary Nailing with Surgical Implant Generation Network of Femur Shaft Fractures at Public Hospitals in Bahir Dar City, Ethiopia: Analysis of 6-Months Follow-Up Results. Orthop Res Rev 2023; 15:59-68. [PMID: 37077943 PMCID: PMC10106822 DOI: 10.2147/orr.s406176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/06/2023] [Indexed: 04/21/2023] Open
Abstract
Background The incidence of femur fractures in young and elderly people has increased, particularly in countries with limited resources like Ethiopia. Intra-medullary nailing (IM) has been an effective and cost-effective method of treating long bone shaft fractures, but it can lead to complications such as knee pain. Purpose This study aimed to evaluate knee pain and its associated factors following retrograde intramedullary nailing for femur fractures. Patients and Methods The study followed 110 patients diagnosed with femur fractures and treated with retrograde SIGN Standard Nail or Fin Nail from January 2020 to December 2022 at two hospitals in Ethiopia. The patients were followed up for at least 6 months, and data were collected from medical charts, patient interviews, and phone calls to patients who did not attend the follow-up appointment. Binary logistic regression analysis was used to identify factors associated with knee pain. Results The study showed that 40 patients reported knee pain at 6-months follow-up, making a prevalence of 36.4%. Factors significantly associated with knee pain were a time of injury to nailing (AOR=4.23, 95% CI: 1.28-13.92), use of a screw to the medial cortex (AOR=9.30, 95% CI: 2.90-12.74), and fracture site (AOR= 2.67, 95% CI: 14.01-7.03). Specifically, the longer the time from injury to nailing, the higher the risk of knee pain. The use of a longer screw to the medial cortex and a fracture site were also positively associated with knee pain. Conclusion This study concludes that although retrograde intramedullary nail fixation is an effective method for femur fractures, it often results in knee pain. Approximately 4 of 10 patients suffered from knee pain in this study. Avoiding delayed surgical management and minimizing the use of prominent metalwork may reduce knee pain.
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Affiliation(s)
- Tsegalem Birlie
- School of Medicine, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Biniam Biresaw
- School of Medicine, College of Health and Medical Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Elias Yadeta
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- Correspondence: Elias Yadeta, School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, P.O. Box: 138, Dire Dawa, Ethiopia, Tel +251924899107, Email
| | - Tamirat Getachew
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Adera Debella
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Addis Eyeberu
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
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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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Su WC, Yu TC, Peng CH, Liu KL, Wu WT, Chen IH, Wang JH, Yeh KT. Use of an Intramedullary Allogenic Fibular Strut Bone and Lateral Locking Plate for Distal Femoral Fracture with Supracondylar Comminution in Patients over 50 Years of Age. Medicina (B Aires) 2022; 59:medicina59010009. [PMID: 36676633 PMCID: PMC9866707 DOI: 10.3390/medicina59010009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/16/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022] Open
Abstract
Background and Objectives: Distal femoral fracture is a severe injury that makes surgery challenging, particularly comminuted fractures in the supracondylar region. This study aimed to evaluate the outcomes of distal femoral fracture treated with the application of an intramedullary fibular allogenic bone strut in open reduction and internal fixation (ORIF) with precontoured locking plates in patients over 50 years of age. Materials and Methods: The study retrospectively enrolled 202 patients over 50 years of age with traumatic comminuted distal femoral fracture (AO/OTA 33-A3, 33-C2 and 33-C3) treated with ORIF with a locking plate from January 2016 to December 2019. The two groups were divided into patients who received an intramedullary allogenic bone strut and those who did not. Patients were followed for at least 1 year, with their function scores and radiographic data recorded. Results: A total of 124 patients were recruited, comprising 60 men and 64 women with an average age of 62.4 ± 8.5 years. The 36 patients who had received an intramedullary allogenic fibular bone strut reported lower postoperative pain scores at 1 month and lower postoperative Knee Society Scores (KSS) at 3 months than the control group. The application of an intramedullary allogenic fibular bone strut appeared to be significantly correlated with better 3-month postoperative KSS. Conclusions: The ORIF of distal femoral comminuted fracture with an intramedullary allogenic fibular bone strut can reduce pain and improve knee function in the early stages of postoperative rehabilitation and may reduce the time to union in patients over 50 years of age.
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Affiliation(s)
- Wen-Chin Su
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970473, Taiwan
| | - Tzai-Chiu Yu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970473, Taiwan
- School of Medicine, Tzu Chi University, Hualien 970374, Taiwan
| | - Cheng-Huan Peng
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970473, Taiwan
- School of Medicine, Tzu Chi University, Hualien 970374, Taiwan
| | - Kuan-Lin Liu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970473, Taiwan
- School of Medicine, Tzu Chi University, Hualien 970374, Taiwan
| | - Wen-Tien Wu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970473, Taiwan
- School of Medicine, Tzu Chi University, Hualien 970374, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien 970374, Taiwan
| | - Ing-Ho Chen
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970473, Taiwan
- School of Medicine, Tzu Chi University, Hualien 970374, Taiwan
| | - Jen-Hung Wang
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970473, Taiwan
| | - Kuang-Ting Yeh
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970473, Taiwan
- School of Medicine, Tzu Chi University, Hualien 970374, Taiwan
- Graduate Institute of Clinical Pharmacy, Tzu Chi University, Hualien 970374, Taiwan
- Correspondence:
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Wang Y, Zou Q, Wang Z, Wang W, Shen H, Lu H. Micromotion-based balanced drilling technology to increase near cortical strain. BMC Surg 2022; 22:387. [DOI: 10.1186/s12893-022-01816-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 10/11/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objective
A micromotion-based balanced drilling system was designed based on a locking plate (LP) and far cortical locking (FCL) concept to maintain the balance of micromotions of the cortex on both sides of a fracture region. The system was tested by axial compression test.
Methods
The fracture gap was set to 2 cm, and locking screws with a diameter of 5 mm and a locking plate were used to fix it. The diameters of the two sections of the stepping drill were 3.5 mm and 5.0 mm, respectively. One of the matching drilling sleeves was a standard sleeve (eccentricity, 0 mm) and the other was an eccentric sleeve (proximal eccentricity, 1 mm). A model of the fixed locking plate (AO/ASIF 33-A3) for distal femoral fractures with a gap of 2 cm was established based on data from 42 artificial femurs (SAWBONE). According to the shape of the screw holes on the cortex, the fixed fracture models were divided into a control group (standard screw hole group X126, six cases) and an experimental group (elliptical screw hole group N, 36 cases). The experimental group was further divided into six subgroups with six cases in each (N126, N136, N1256, N1356, N12356, N123456), based on the number and distribution of the screws on the proximal fracture segment. The control, N126, and N136 groups were subjected to an axial load of 500 N, and the other groups were subjected to an axial load of 1000 N. The displacements of the kinetic head, far cortex, and near cortex were measured. The integral structural stiffness of the model and the near cortical strain were calculated. The data of each group were analyzed by using a paired t-test.
Results
When the far cortical strains were 2%, 5%, and 10%, the near cortical strains in group N126 were 0.96%, 2.35%, and 4.62%, respectively, significantly higher than those in the control group (X126) (p < 0.05). For a different distribution of the screws, when the far cortical strains were 2%, 5%, and 10%, the near cortical strains in group N126 were significantly higher than those in group N136 (p < 0.05). However, there was no significant difference between the near cortical strains in the two groups with four screws (p > 0.05). For different numbers of screws, the near cortical strains in the three-screw groups were significantly higher than those in the four-screw groups (p < 0.05), and there was no significant difference in near cortical strains among the four-, five-, and six-screw groups (p > 0.05).
Conclusion
The proposed drill and matching sleeves enabled a conventional locking compression plate to be transformed into an internal fixation system to improve the balanced motion of the near and far cortices. Thus, strain on a fracture site could be controlled by adjusting the diameter of the drill and the eccentricity of the sleeve.
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Biomechanical and anatomical considerations for dual plating of distal femur fractures: a systematic literature review. Arch Orthop Trauma Surg 2022; 142:2597-2609. [PMID: 34097123 DOI: 10.1007/s00402-021-03988-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/28/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Distal femur fractures are challenging injuries historically associated with high rates of nonunion and varus collapse with operative management. As a result, clinical and research interest in dual plating (DP) of distal femur fractures has seen a dramatic increase in recent years. The purpose of this study was to systematically review the literature regarding vascular anatomy and biomechanics of distal femur fractures treated with DP constructs. MATERIALS AND METHODS A systematic literature review of two medical databases (PubMed & Scopus) was performed to identify peer-reviewed studies on the anatomy and biomechanics regarding DP of distal femur fractures. A total of 1,001 papers were evaluated and 14 papers met inclusion criteria (6 anatomy and 8 biomechanics). Methodological quality scores were used to assess quality and potential bias in the included studies. RESULTS In the biomechanical studies, DP constructs demonstrated greater axial and rotational stiffness, as well as less displacement and fewer incidences of failure compared to all other constructs. Vascular studies showed that the femoral artery crosses the mid-shaft femur approximately 16.0-18.8 cm proximal to the adductor tubercle and it is located on average 16.6-31.1 mm from the femoral shaft at this location, suggesting that medial plate application can be achieved safely in the distal femur. The methodological quality of the included studies was good for biomechanical studies (Traa score 79.1; range 53-92.5) and excellent for anatomical studies (QUACs score 81.9; range 69.0-88.5). CONCLUSIONS Existing biomechanics literature suggests that DP constructs are mechanically stronger than other constructs commonly used in the treatment of distal femur fractures. Furthermore, medial distal femoral anatomy allows for safe application of DP constructs, even in a minimally invasive fashion. Dual plating should be considered for patients with distal femur fractures that have risk factors for instability, varus collapse, or nonunion.
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Ledet EH, Caparaso SM, Stout M, Cole KP, Liddle B, Cady NC, Archdeacon MT. Smart fracture plate for quantifying fracture healing: Preliminary efficacy in a biomechanical model. J Orthop Res 2022; 40:2414-2420. [PMID: 34989023 DOI: 10.1002/jor.25254] [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: 03/08/2021] [Revised: 10/31/2021] [Accepted: 12/19/2021] [Indexed: 02/04/2023]
Abstract
The diagnosis of fracture nonunion following plate osteosynthesis is subjective and frequently ambiguous. Initially following osteosynthesis, loads applied to the bone are primarily transmitted through the plate. However, as callus stiffness increases, the callus is able to bear load proportional to its stiffness while forces through the plate decrease. The purpose of this study was to use a "smart" fracture plate to distinguish between phases of fracture healing by measuring forces transmitted through the plate. A wireless force sensor and small adapter were placed on the outside of a distal femoral locking plate. The adapter converts the slight bending of the plate under axial load into a transverse force which is measurable by the sensor. An osteotomy was created and then plated in the distal femur of biomechanical Sawbones. Specimens were loaded to simulate single-leg stance first with the osteotomy defect empty (acute healing), then sequentially filled with silicone (early callus) and then polymethyl methacrylate (hard callus). There was a strong correlation between applied axial load and force measured by the "smart" plate. Data demonstrate statistically significant differences between each phase of healing with as little as 150 N of axial load applied to the femur. Forces measured in the plate were significantly different between acute (100%), early callus (66.4%), and hard callus (29.5%). This study demonstrates the potential of a "smart" fracture plate to distinguish between phases of healing. These objective data may enable early diagnosis of nonunion and enhance outcomes for patients.
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Affiliation(s)
- Eric H Ledet
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute & Research and Development Service, Stratton VA Medical Center, Albany, New York, USA
| | - Sydney M Caparaso
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Madelyn Stout
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Keegan P Cole
- Division of Orthopaedic Surgery, Albany Medical College, Albany, New York, USA
| | - Benjamin Liddle
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Nathaniel C Cady
- Department of Nanobio Science, State University of New York Polytechnic Institute, Utica, New York, USA
| | - Michael T Archdeacon
- Department of Orthopaedic Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
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Axial and Rotational Malreduction (Golf Club Deformity) in Distal Femur Fractures. J Orthop Trauma 2022; 36:515-518. [PMID: 35436242 DOI: 10.1097/bot.0000000000002373] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To describe malreduction of supracondylar distal femur fractures stabilized with lateral femoral locking plates and determine whether a mismatch in axial lateral distal femur anatomy and lateral distal femoral plate design contributes to supracondylar distal femoral fracture malreduction. MATERIALS AND METHODS OTA/AO 33A were simulated in 7 cadaver femurs and fixed with a lateral distal locking femoral plate placed flush to the lateral femoral condyle (group 1). In group 2, the anterior flange of the plate was externally rotated 10 degrees in relation to the lateral condyle. A motion capture system measured translation and rotation of the articular segment as shaft screws were applied, reducing plate to femoral diaphysis. Articular segment movement was compared between groups using paired Student t test, P < 0.05. A large database of 3D scans of 800 femurs was used to define the relationship of the lateral femoral condyle to the lateral cortical surface of the human femur. RESULTS Malreduction was observed with anatomic plate application results from medial translation (17 mm) and external rotation (12.2 degrees) (group 1). Modifying plate geometry to match lateral femur anatomy (group 2) improved medial translation by 46% and external rotation by 80%. An analysis of the shape of the 800 distal femurs showed that the average posterior anterior inclination is 16.5 degrees. CONCLUSIONS Anatomic application of distal femoral plates results in significant malreduction. Modifying the plate design to accommodate 10 degrees slope of lateral distal femur results in partial correction of deformity. Future studies should investigate other means of correcting the malalignment, especially considering the 16.5-degree posterior anterior inclination of the condyle.
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Ito K, Mori Y, Kamimura M, Koguchi M, Kurishima H, Koyama T, Mori N, Masahashi N, Hanada S, Itoi E, Aizawa T. β-type TiNbSn Alloy Plates With Low Young Modulus Accelerates Osteosynthesis in Rabbit Tibiae. Clin Orthop Relat Res 2022; 480:1817-1832. [PMID: 35543573 PMCID: PMC9384929 DOI: 10.1097/corr.0000000000002240] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 04/19/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ti6Al4V alloy, which is commonly used for biomedical applications, has a Young modulus (110 GPa) that is higher than that of human cortical bone (11 to 20 GPa). Using an implant with a material with a low Young modulus that enhances load sharing by the bone even more than those made of Ti6Al4V could be beneficial for bone healing and further reduce the potential for stress shielding. A new β-type TiNbSn alloy has a low Young modulus of approximately 40 to 49 GPa. However, whether the new titanium alloy with a lower Young modulus is advantageous in terms of fracture healing has not been assessed, and a small-animal model seems a reasonable first step in its assessment. QUESTIONS/PURPOSES To assess the impact of a TiNbSn alloy plate with a lower Young modulus compared with a Ti6Al4V alloy plate on fracture healing, we evaluated: (1) bony bridging and callus volume, (2) new bone formation and remaining cartilage tissue, (3) osteoblast activity in the callus, and (4) mechanical strength and stiffness of the callus in bending. METHODS Fracture plates manufactured from TiNbSn and Ti6Al4V alloys, which have Young moduli of 49 GPa and 110 GPa, respectively, were compared. The main reason for using rabbits was the high reliability of the three-point bending mechanical test of the rabbit tibia. Forty-two male Japanese white rabbits weighing 2.8 to 3.4 kg were anesthetized. A 5-cm skin incision was made on the medial side in the mid-diaphysis of the right tibia. Eight-hole plates were used, which were 42 mm long, 5 mm wide, and 1.2 mm thick. Plate fixation was performed using three proximal and three distal screws. After the plate was installed, an osteotomy was performed using a 1-mm-wide wire saw to create a standardized tibial transverse osteotomy model with a 1-mm gap. Bone healing was quantitatively assessed by two nonblinded observers using micro-CT (bony bridging and callus volume), histomorphometry (new bone formation and remaining cartilage tissue), immunohistochemistry (osteoblast activity), and mechanical testing (mechanical strength and stiffness in bending). Measurements on nondemineralized specimens were descriptive statistics due to their small number. Four weeks after osteotomy and fixation, 30 rabbits were euthanized to undergo micro-CT and subsequent mechanical testing (n = 12), histomorphometry and immunohistochemistry with demineralized specimens (n = 12), and histomorphometry with a nondemineralized specimen (n = 6). Eight weeks postoperatively, 12 rabbits were euthanized for micro-CT and subsequent mechanical testing. RESULTS Intramedullary fracture calluses treated with TiNbSn alloy plates had larger bone volumes and more numerous bridging structures than those treated with Ti6Al4V alloy plates at 4 weeks after osteotomy (Ti6Al4V alloy versus TiNbSn alloy: 30 ± 7 mm 3 versus 52 ± 14 mm 3 , mean difference 22 [95% CI 9 to 37]; p = 0.005; ICC 0.98 [95% CI 0.95 to 0.99]). Histologic assessments demonstrated there was greater new bone formation (total callus: Ti6Al4V versus TiNbSn: 16 ± 4 mm 2 versus 24 ± 7 mm 2 , mean difference 8 [95% CI 1 to 16]; p = 0.04; ICC 0.98 [95% CI 0.93 to 0.99]; intramedullary callus: Ti6Al4V versus TiNbSn: 6 ± 4 mm 2 versus 13 ± 5 mm 2 , mean difference 7 [95% CI 1 to 13]; p = 0.02; ICC 0.98 [95% CI 0.95 to 0.99]) and a higher number of osteocalcin-positive cells (Ti6Al4V alloy versus TiNbSn alloy: 1397 ± 197 cells/mm 2 versus 2044 ± 183 cells/mm 2 , mean difference 647 [95% CI 402 to 892]; p < 0.001; ICC 0.98 [95% CI 0.95 to 0.99]) in the TiNbSn alloy group than in the Ti6Al4V alloy group. At 4 weeks after osteotomy, both bone strength and stiffness of the healed bone in the TiNbSn alloy group were higher than those in the Ti6Al4V alloy group (maximum load: Ti6Al4V alloy versus TiNbSn alloy: 83 ± 30 N versus 127 ± 26 N; mean difference 44 [95% CI 8 to 80]; p = 0.02; stiffness: Ti6Al4V alloy versus TiNbSn alloy: 92 ± 43 N/mm versus 165 ± 63 N/mm; mean difference 73 [95% CI 4 to 143]; p = 0.047). Eight weeks after osteotomy, no between-group differences were observed in the strength and stiffness of the healed bone. CONCLUSION The results of this study indicate that TiNbSn alloy plate with a lower Young modulus resulted in improved bone formation and stiffer callus during the early phase (4 weeks after surgery) but not the later phase (8 weeks after surgery) of bone healing. CLINICAL RELEVANCE An overly stiff plate may impair callus formation and bone healing. The TiNbSn alloy plate with a low Young modulus improves the early formation of new bone and stiff callus at the osteotomy site compared with the Ti6Al4V alloy plate in the healing process, which may promote bone repair. TiNbSn alloy may be a promising biomaterial for fracture treatment devices. Further research to address concerns about the strength of TiNbSn alloy plates, such as fatigue life and plate fracture, will be necessary for clinical applications, including mechanical tests to verify fatigue life and validation in larger animals with greater body weight.
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Affiliation(s)
- Kentaro Ito
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yu Mori
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masayuki Kamimura
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masashi Koguchi
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroaki Kurishima
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomoki Koyama
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Naoko Mori
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Naoya Masahashi
- Institute for Material Research, Tohoku University, Sendai, Japan
| | - Shuji Hanada
- Institute for Material Research, Tohoku University, Sendai, Japan
| | - Eiji Itoi
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshimi Aizawa
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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Jang JH, Rhee SJ, Jun SB, Choi YY. Scattering and clustering the proximal screw construct in unilateral locking plate osteosynthesis of distal femoral fractures. Arch Orthop Trauma Surg 2022; 142:2193-2203. [PMID: 34018021 DOI: 10.1007/s00402-021-03912-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/12/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The importance of fixation construct in locking compression plate (LCP) is not well enlightened until recently. The aim of this study was to investigate radiological and clinical outcomes of scattering and clustering of the proximal screw fixation construct in unilateral LCP treatment of the distal femoral fractures. MATERIALS AND METHODS Patients who were treated for distal femoral fractures using unilateral LCP between January 2014 and December 2019 in our institute were included in this retrospective study. They were divided into groups 1 (35 cases, scattered proximal screw fixation) and 2 (35 cases, clustered proximal screw fixation). Mean follow-up period was 23.6 months for group 1 and 21.3 months for group 2. Medical history, patient demographics, injury characteristics, and surgical characteristics were reviewed and analyzed. Radiological findings including time to callus formation, bridging callus formation, union, and symmetry of the union were assessed and compared between the groups. Clinical outcomes included total blood loss during the operation, postoperative range of motion, and number of revision surgery. RESULTS The time for callus formation (5.8 weeks in group 1 vs. 4.1 weeks in group 2, p = 0.009) and bridging callus formation (12.5 weeks in group 1 vs. 10.7 weeks in group 2, p = 0.009) was significantly earlier in group 2. Despite similar union rates between groups, the mean time for radiological union was longer in group 2 (10.7 vs 7.4 months, p = 0.001). Though statistically insignificant, more asymmetric union was observed in group 2 (17 vs 11 cases). CONCLUSIONS Despite a delay in initial callus and bridging callus formation, scattering the proximal screws was better in achieving earlier and more balanced radiographic union than the clustered fixation. We recommend to avoid bridging more than five holes in the whole plate fixation construct to lessen the asymmetric callus formation and to prevent eventual plate breakage.
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Affiliation(s)
- Jae Hoon Jang
- Department of Orthopedic Surgery, Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan, 602-739, Korea
| | - Seung Joon Rhee
- Department of Orthopedic Surgery, Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan, 602-739, Korea.
| | - Se Bin Jun
- Department of Orthopedic Surgery, Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan, 602-739, Korea
| | - Yoon Young Choi
- Department of Diagnostic Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Mukhopadhaya J, Ranjan R, Sinha AK, Bhadani JS. The Management of Aseptic Non-unions of Distal Femur Fractures with Anatomical Lateral Locking Plates. Strategies Trauma Limb Reconstr 2022; 17:137-143. [PMID: 36756289 PMCID: PMC9886028 DOI: 10.5005/jp-journals-10080-1564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/17/2022] [Indexed: 01/02/2023] Open
Abstract
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.
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Affiliation(s)
- John Mukhopadhaya
- Department of Orthopaedics, Paras HMRI Hospital, Patna, Bihar, India
| | - Rajeev Ranjan
- Department of Orthopaedics, Paras HMRI Hospital, Patna, Bihar, India
| | - Amit Kumar Sinha
- Department of Orthopaedics, Paras HMRI Hospital, Patna, Bihar, India
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