Comparison of the 95-degree angled blade plate and the locking condylar plate for the treatment of distal femoral fractures

A novel anatomical locked medial femoral condyle plate: a biomechanical study

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.

Far cortical locking constructs for fixation of distal femur fractures in an Asian population: A prospective observational study

BACKGROUND

The stiffness of locked plates suppresses healing process, prompting the introduction of far cortical locking to address this issue. This study aimed to demonstrate the clinical efficacy of far cortical locking constructs in treating distal femoral fractures in an Asian population.

METHODS

This multicenter prospective observational study was conducted at four university hospitals between February 2018 and February 2021. Demographic data, the presence of metaphyseal comminution, and surgical fixation details were recorded. Clinical outcomes, including single-leg standing, EQ-5D, and EQ-VAS scores, and radiologic outcomes, including the RUST score of each cortex, were evaluated and compared according to the presence of metaphyseal comminution.

RESULTS

There were 37 patients (14 men and 23 women) with a mean age of 67.3 ± 11.8 years. Twenty-two patients had metaphyseal comminution (59%), and 15 presented simple fractures in metaphyseal areas. Four patients (13%) could stand on one leg >10s at 6 weeks, and 24 patients (92%) at 1 year. EQ-5D increased from 0.022 ± 0.388 to 0.692 ± 0.347, and the mean EQ-VAS 51.1 ± 13.1 to 74.1 ± 24.1 between discharge (n = 37) and post-operative 1 year (n = 33), respectively. RUST score presented increment for time, from 6.2 ± 1.8 at 6 week to 11.6 ± 1.1 at 1 year. Radiological healing demonstrated rapid increase from week 6 (16/28, 43%) to month 3 (27/31, 87%), with no obvious increase was observed in 6 months (23/26, 89%) or 12 months (25/28, 89%). Simple metaphyseal fractures presented significantly higher RUST scores at 6 weeks and 3 months, but there was no difference in RUST scores at 6 months or 1 year according to metaphyseal comminution.

CONCLUSIONS

Plate constructs with far cortical locking screws provided safe and effective fixation for distal femoral fractures, with consistent radiological and clinical results, regardless of metaphyseal comminution.

Does Far Cortical Locking Improve Fracture Healing in Distal Femur Fractures: A Randomised, Controlled, Prospective Multicentre Study

(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.

Biomechanical design optimization of distal femur locked plates: A review

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.

Short-term outcomes of periprosthetic compared to native distal femur fractures, a national database study

BACKGROUND

Distal femur fractures (DFFx) are highly morbid injuries with a complication rate comparable to hip fractures. Rising rates of total knee arthroplasty (TKA) have led to increasing rates of periprosthetic DFFx (pDFFx). We sought to determine how pDFFx complication rates differed from native DFFx (nDFFx).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used to identify patients who sustained pDFFx or nDFFx between 2012 and 2018. Patients were further stratified by operative treatment: open reduction internal fixation (ORIF) or distal femur replacement (DFR). Multivariate logistic regression was used to compare 30-day complication rates between pDFFx versus nDFFx and, among pDFFx patients, ORIF versus DFR or revision TKA (rTKA).

RESULTS

563 patients with pDFFx and 2259 patients with nDFFx were identified between 2012 and 2018. pDFFx patients had significantly lower rates of ORIF than nDFFx patients (36.4 vs 95.4%, p < 0.001). On multivariate analysis, pDFFx were associated with a higher rate of surgical site complications (OR 2.48, p = 0.009) compared to nDFFx. There were no differences in mortality, reoperations, major complications, rate of blood transfusion, venous thromboembolism and disposition. In patients with pDFFx, patients undergoing DFR/rTKA were more likely to be discharged home versus a rehab facility, compared to those undergoing ORIF (OR 2.62, p < 0.001).

CONCLUSIONS

In this first large registry study comparing pDFFx and nDFFx, we find similar outcomes between these groups in the first 30 days after surgery. Patients with pDFFx did have higher rates of surgical site complications, including infection and dehiscence. In pDFFx patients, those undergoing DFR were more likely to return home post-operatively.

Interventions for treating fractures of the distal femur in adults

BACKGROUND

Fractures of the distal femur (the far end of the thigh bone just above the knee) are a considerable cause of morbidity. Various different surgical and non-surgical treatments have been used in the management of these injuries but the best treatment remains unknown.

OBJECTIVES

To evaluate the benefits and harms of interventions for treating fractures of the distal femur in adults.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was October 2021.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials in adults comparing interventions for treating fractures of the distal femur. Interventions included surgical implants (retrograde intramedullary nail (RIMN), fixed-angle devices, non-locking plate fixation, locking plate, internal fixation, distal femoral replacement, mono-axial plates, poly-axial plates and condylar buttress plates) and non-surgical management.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our critical outcomes were validated patient-reported outcome measures (PROMs), direct adverse events, participant-reported quality of life (QoL) and pain scores. Our other important outcomes were adverse events indirectly related to intervention, symptomatic non-union, malunion and resource use. We used GRADE to assess certainty of evidence for each outcome.

MAIN RESULTS

We included 14 studies with 753 participants: 13 studies compared different surgical interventions, and one study compared surgical with non-surgical management. Here, we report the effects for RIMN compared with locking plates. Three studies (221 participants) reported this comparison; it included the largest study population and these are the two most commonly used devices in contemporary orthopaedic trauma practice. Studies used three different tools to assess PROMs. We found very-low certainty evidence for lower Disability Rating Index scores after RIMN at short-term follow-up favouring RIMN (mean difference (MD) -21.90, 95% confidence interval (CI) -38.16 to -5.64; 1 study, 12 participants) and low-certainty evidence of little or no difference at long-term follow-up (standardised mean difference (SMD) -0.22, 95% CI -0.50 to 0.06; 2 studies, 198 participants). Re-expressing the SMD of the long-term follow-up data to Knee Society Score (KSS) used by one study found no clinical benefit of RIMN, based on a minimal clinically important difference of 9 points (MD 2.47, 95% CI -6.18 to 0.74). The effect on QoL was very uncertain at four months (MD 0.01, 95% CI -0.42 to 0.44; 1 study, 14 participants) and one year (MD 0.10, 95% CI -0.01 to 0.21; 1 study, 156 participants); this evidence was very low certainty. For direct adverse events, studies reported reoperation, loss of fixation, superficial and deep infection, haematoma formation and implant loosening. Effects for all events were imprecise with the possibility of benefit or harm for both treatments. We considered reoperation the most clinically relevant. There was very low-certainty evidence of little or no difference in reoperation between the two implants (risk ratio (RR) 1.48, 95% CI 0.55 to 4.00; 1 study, 104 participants). No studies reported pain.  For other important outcomes, we noted that people treated with RIMN may be more likely to have varus/valgus deformity (RR 2.18, 95% CI 1.09 to 4.37; 1 study, 33 participants; low-certainty evidence). However, we found no evidence of any important differences between treatments in terms of bony union, indirect adverse events, or resource use. Other comparisons of surgical interventions included in the review were: RIMN versus single fixed-angle device (3 studies, 175 participants); RIMN versus non-locking plate fixation (1 study, 18 participants); locking plate versus single fixed-angle device (2 studies, 130 participants); internal fixation versus distal femoral replacement (1 study, 23 participants); mono-axial plates versus poly-axial plates (2 studies, 67 participants); mono-axial plate versus condylar buttress plate (1 study, 78 participants). The certainty of the evidence for outcomes in these comparisons was low to very low, and most effect estimates were imprecise.

AUTHORS' CONCLUSIONS

This review highlights the major limitations of the available evidence concerning current treatment interventions for fractures of the distal femur. The currently available evidence is incomplete and insufficient to inform clinical practice. Priority should be given to randomised controlled trials comparing contemporary treatments for people with fractures of the distal femur. At a minimum, these should report validated patient-reported functional and quality-of-life outcomes at one and two years, with an agreed core outcome set. All trials should be reported in full using the CONSORT guidelines.

Axial and Rotational Malreduction (Golf Club Deformity) in Distal Femur Fractures

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 &lt; 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.

Fixed-angle plate fixation and autogenous iliac crest graft for repair of distal metaphyseal femoral nonunion

PURPOSE

To analyze clinical, radiographic and patient-reported outcomes of distal metaphyseal femoral nonunions treated with fixed-angle plates and screws.

METHODS

All patients presenting with a distal metaphyseal femoral fracture nonunion repaired with fixed-angle plating from one urban level 1 trauma center and an orthopedic specialty hospital were identified. Baseline demographic, injury information, and outcomes (healing rates, Short Musculoskeletal Function Assessment, range of motion, and post-operative pain levels) at 12 months following nonunion repair were collected. Outcomes were evaluated between patients fixed with a blade plate and with a locking plate.

RESULTS

Of these 31 patients, 27 (87.1%) healed after their index nonunion surgery, 2 (6.5%) healed after one reoperation, 1 (3.2%) healed after 2 reoperations, and 1 (3.2%) had a persistent nonunion but did not want further treatment. At one-year follow-up, the group demonstrated a significant improvement in functional recovery with a mean difference of 14.5 points (p = 0.007) when compared to status before fixed-angle fixation of the nonunion. There was also a significant change in patient-reported pain levels using the VAS scale with a mean difference of 2.0 points (p = 0.009). At one-year follow-up, 11 (39.3%) had full knee range of motion (0-130), 11 (39.3%) had flexion greater than 90 and less than 120°, and 6 (21.4%) had range of motion less than 90°.

CONCLUSION

Patients who undergo fixed angle plating and autogenous bone grafting for distal femoral metapyseal nonunions demonstrate improved functional outcomes and VAS pain score at one year follow up.

Local bone quality measure and construct failure prediction: a biomechanical study on distal femur fractures

INTRODUCTION

The aim of this investigation was to better understand the differences in local bone quality at the distal femur and their correlation with biomechanical construct failure, with the intention to identify regions of importance to optimize implant anchorage.

MATERIALS AND METHODS

Seven fresh-frozen female femurs underwent high-resolution peripheral quantitative computed tomography (HR-pQCT) to determine bone mineral density (BMD) within three different regions of interest (distal, intermedium, and proximal) at the distal femur. In addition, local bone quality was assessed by measuring the peak torque necessary to break out the trabecular bone along each separate hole of a locking compression plate (LCP) during its instrumentation. Finally, biomechanical testing was performed using cyclic axial loading until failure in an AO/OTA 33 A3 fracture model.

RESULTS

Local BMD was highest in the distal region. This was confirmed by the measurement of local bone quality using DensiProbe^™. The most distal holes represented locations with the highest breakaway torque resistance, with the holes on the posterior side of the plate indicating higher values than those on its anterior side. We demonstrated strong correlation between the cycles to failure and local bone strength (measured with DensiProbe^™) in the most distal posterior screw hole, having the highest peak torque.

CONCLUSION

The local bone quality at the distal femur indicates that in plated distal femur fractures the distal posterior screw holes seem to be the key ones and should be occupied. Measurement of the local bone strength with DensiProbe^™ is one possibility to determine the risk of construct failure, therefore, thresholds need to be defined.

Locking retrograde nail, non-locking retrograde nail and plate fixation in the treatment of distal third femoral shaft fractures: radiographic, bone densitometry and clinical outcomes

BACKGROUND

Distal third femoral shaft fractures are characterized by increasing incidence and complexity and are still considered a challenging problem (high morbidity and mortality). No consensus on best surgical option has been achieved. This study aims to investigate radiographic, mineral bone densitometry and clinical outcomes of locking retrograde intramedullary (LRN) nailing, non-locking retrograde intramedullary nailing and anatomical locking plate to surgically treat distal third femoral shaft fractures in young adults. Our hypothesis was that there is no significant statistical difference among the surgical options in terms of results (radiographic, bone densitometry and outcomes assessment).

METHODS

Retrospective study: 90 patients divided into three groups (group 1 LRN, group 2 NLRN, group 3 plating). Average age was respectively 42.67 (± 18.32), 44.27 (± 15.11) and 42.84 (± 18.32) years. Sex ratio F:M was respectively 2.75, 2.33 and 2.00. AO Classification, KOOS, NUSS and RUSH score, VAS, DEXA scans and plain radiographs were used. Evaluation endpoint: 12 months after surgery.

RESULTS

There were no statistical differences in terms of surgery time, transfusions, and wound healing. Results were similar with regard to average time of bone healing, RUSH scores, VAS, KOOS, regression between RUSH and VAS, average correlation clinical-radiographic results and patients outcomes.

CONCLUSIONS

Our results showed no statistical difference in the use of LNR, NLNR and plating for treatment of distal third femur shaft fractures in terms of radiographic, bone densitometry and clinical outcomes. Good subjective and objective results are provided by all three techniques. The choice among the studied techniques must be based on surgeons' experience, indications and subjective patients' aspects. The absence of relevant similar data in the published literature does not allow definitive validation (or rejection) of our hypothesis. A more powered study with a bigger cohort is needed for definitive validation.

New versus old: 95 degree angled blade plate versus distal femoral locking plate. A randomized clinical trial

INTRODUCTION

The purpose was to compare the locking condylar plate (LCP) with the 95° angled blade plate (ABP) for distal femoral fracture patterns amenable to either device. Our hypothesis was that LCP would outperform ABP with primary outcome of nonunion and secondary outcomes of reoperation and malunion.

METHODS

78 adult patients with 79 eligible fractures and mean age of 60 years were prospectively randomized to LCP (n = 45) or ABP (n = 34). Mean ISS was 16. 22% fractures were open. Patient-reported functional outcomes were assessed with the Musculoskeletal Function Assessment (MFA).

RESULTS

All patients were followed to union, and mean follow-up was 25 months. There were no differences in age, sex, fracture pattern, co-morbidities or mechanism for the two groups. Three patients had infections, one superficial after LCP and one deep infection each after ABP and LCP. Three patients developed nonunion after LCP versus none after ABP (p = 0.06). Nine patients healed with minor deformity after LCP versus 5 following ABP. One fracture had major deformity after ABP versus two after LCP. Eight patients had a secondary procedure following LCP versus two after ABP (p = 0.05).

CONCLUSIONS

The investigation failed to support newer technology being better. Evidence did not indicate the LCP was superior to the ABP. Trends for primary union and fewer secondary procedures suggest that ABP may have superior performance to LCP for fracture patterns which may be treated with either implant.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Removal of cement-augmented screws in distal femoral fractures and the effect of retained screws and cement on total knee arthroplasty: a biomechanical investigation

Background

Given the increasing number of osteoporotic fractures of the distal femur, screw augmentation with bone cement is an option to enhance implant anchorage. However, in implant removal or revision surgeries, the cement cannot be removed from the distal femur without an extended surgical procedure. Therefore, the aims of this study were to investigate (1) whether cement augmentation has any influence on screw removal and removal torque, and (2) whether the implantation of a femoral component of a knee arthroplasty and its initial interface stability are affected by the remaining screws/cement.

Material and methods

Eight pairs of fresh-frozen human female cadaveric distal femurs (mean age, 86 years) with a simulated AO/OTA 33 A3 fracture were randomized in paired fashion to two groups and fixed with a distal femoral locking plate using cannulated perforated locking screws. Screw augmentation with bone cement was performed in one of the groups, while the other group received no screw augmentation. Following biomechanical testing until failure (results published separately), the screws were removed and the removal torque was measured. A femoral component of a knee arthroplasty was then implanted, and pull-out tests were performed after cement curing. Interference from broken screws/cement was assessed, and the maximum pull-out force was measured.

Results

The mean screw removal torque was not significantly different between the augmented (4.9 Nm, SD 0.9) and nonaugmented (4.6 Nm, SD 1.3, p = 0.65) screw groups. However, there were significantly more broken screws in in the augmented screw group (17 versus 9; p < 0.001). There was no significant difference in the pull-out force of the femoral component between the augmented (2625 N, SD 603) and nonaugmented (2653 N, SD 542, p = 0.94) screw groups.

Conclusion

The screw removal torque during implant removal surgery does not significantly differ between augmented and nonaugmented screws. In the augmented screw group, significantly more screws failed. To overcome this, the use of solid screws in holes B, C, and G can be considered. Additionally, it is possible to implant a femoral component for knee arthroplasty that retains the initial anchorage and does not suffer from interference with broken screws and/or residual cement.

Level of Evidence

5

Incidence of nonunion after surgery of distal femoral fractures using contemporary fixation device: a meta-analysis

PURPOSE

Nonunion is the most frequent cause of reoperation and is associated with high morbidity after distal femur fracture (DFF). We examined the rates of nonunion requiring reoperation after fixation for DFF using a locking compression plate (LCP) or retrograde intramedullary nail (RIMN).

METHODS

We included four studies comparing LCP and RIMN and 38 single-cohort studies reporting LCP or RIMN. In total, 2156 femurs were included and 166 non-unions were detected. We conducted a pair-wise meta-analysis (with a fixed-effects model) on the four comparative studies and a proportional meta-analysis on the 38 articles to estimate the nonunion rate. We performed sensitivity analysis by comparing studies using LCP with less invasive surgical systems (LISS) with those that used RIMN.

RESULTS

The pairwise meta-analysis showed a similar nonunion rate between the groups [odds ratio: 1.02; 95% confidence interval (CI) 0.94-1.11, p = 0.633]. According to proportional meta-analysis, the pooled prevalence of nonunion was 5% (95% CI 4-7) totally, 6% (95% CI 4-8) in the LCP group, and 4% (95% CI 2-6) in the RIMN group (heterogeneity: p = 0.105). According to the sensitivity analysis, there was no difference in the union rate. The pooled prevalence of nonunion from sensitivity analysis was 4 % (95% CI, 3-5); it was 4% (95% CI, 3-6) in LCP with LISS and was 4% (95% CI, 2-6) in RIMN group (heterogeneity: p = 0.941).

CONCLUSION

Approximately 5% of patients who underwent LCP or RIMN fixation developed nonunion. Therefore, LCP and RIMN are effective DFF techniques and mastering one of them is essential.

Early fixation failure of locked plating in complex distal femoral fractures: Root causes analysis

BACKGROUND/PURPOSE

Orthopaedic Trauma Association (OTA) C-type distal femoral fractures can be very challenging to treat effectively. While locked plating is widely used in the complex distal femoral fracture, failure of locked plate fixation is not uncommon. First, we tried to determine the risk factor related to early failure of multiplanar OTA C-type fracture in the distal femur after fixation with lateral locked plate. Second, we tried to provide a strategy for surgeons to prevent pitfalls of early failure in the complex distal femoral fractures treated with lateral locked plating.

METHODS

We retrospectively reviewed 44 adults with OTA C-type fractures of the distal femur treated with locked plate fixation between 2010 and 2016 at Tri-Service General Hospital. Average length of follow-up was 27.6 months (range, 12-54 months). Univariate and multivariate logistic regression were used to determine the association of variables on early failure of fixation. A p-value < 0.05 in univariate and multivariate analyses were considered significant.

RESULTS

There were six patients experiencing early failure, and the early failure rate was 13.6%. The risk factors associated with early failure of complex distal femoral fracture identified by univariate analysis included sagittal oblique fracture pattern, longer working length and post-operative sagittal malalignment (odds ratio [OR] and 95% confidence intervals [CI]: 90.00 (6.85-1183.33), 0.55 (0.31-0.98) and 8.63 (1.077-69.075) respectively). The multivariate analysis showed only sagittal oblique fracture pattern was associated with early failure [OR: 52.348 (3.06-895.23)].

CONCLUSION

Sagittal oblique fracture was more likely to result in early postoperative failure. Early recognition of the fracture pattern should be considered to avoid catastrophic results.

Radiographic, Bone Densitometry and Clinic Outcomes Assessments in Femoral Shaft Fractures Fixed by Plating or Locking Retrograde Nail

Introduction:

Distal femoral shaft fractures are characterized by increasing incidence and complexity and are still considered a challenging problem (high morbidity and mortality). No consensus on best surgical option has been achieved.

Aim:

This study aims is to investigate radiographic, mineral bone densitometry and clinical outcomes of locking retrograde intramedullary (LRN) nailing and anatomical locking plate to surgically treat distal femoral shaft fractures in young adults based on the hypothesis that there is no statistical difference among the two surgical options in terms of results (radiographic, bone densitometry and outcomes assessment).

Methods:

Retrospective study: 30 patients divided into 2 groups (Group 1 LRN, Group 2 Nailing). Average age was 42.67±18.32 for Group 1 and 42.84 ±18.32 for Group 2 (range of age 18-65 for both groups). Gender Ratio (male: female) was 2.75 (11:4) for both Group 1 and 2. AO Classification, NUSS and RUSH score, VAS, Dexa scans, plain radiographs were used. Evaluation endpoint: 12 months after surgery (mean follow up 16.24).

Results:

No statistical difference in terms of surgery time, transfusions, wound healing. Similar results with regard to average time of bone healing, RUSH scores, VAS, regression between RUSH and VAS, average correlation clinical-radiographic results and patients outcomes. Only one patient of each group had reduction of mineral bone densitometry values.

Conclusion:

No statistical difference about the use of LNR or Nailing for treatment of distal femur shaft fractures in terms of radiographic, bone densitometry and outcomes has been found accordingly to our results. Good subjective and objective results are provided by both techniques. The choice among the two techniques must be based on surgeons’ experience, indications and subjective patients’ aspects. The absence of relevant similar data in the published literature does not allow definitive validation (or rejection) of our hypothesis. A more powered study with bigger cohort is needed for definitive validation.

Dual Plating of the Distal Femur: Indications and Surgical Techniques

Dual-plating of the distal femur is required in some cases to achieve stable fixation. The indications of a medial plate in addition to the lateral plate are medial supracondylar bone loss, low trans-condylar bicondylar fractures, medial Hoffa fracture, peri-prosthetic distal femur fractures, non-union after failed fixation with single lateral plate, poor bone quality and comminuted distal femur fractures (AO type C3). We recommend orthogonal plate configuration with locked plates by a single incision or dual incision approach as per surgeon choice.

Supplementation of Lateral Locked Plating for Distal Femur Fractures: A Biomechanical Study

OBJECTIVES

To investigate the biomechanical properties of a lateral locked plate alone or in combination with a supplemental medial plate or an intramedullary nail (IMN).

METHODS

Intra-articular distal femur fractures with metaphyseal comminution (OTA/AO 33-C) were simulated with a standardized model in 28 synthetic femora and divided into 4 groups. Group I was instrumented with a 4.5-mm lateral locked distal femoral plate alone, group II with a lateral locked plate plus a low-profile precontoured 3.5-mm medial distal tibial plate, group III with a lateral locked plate plus a medial 3.5-mm reconstruction plate, and group IV with a lateral locked plate plus a retrograde IMN. Specimens were then axially loaded and cycled to failure or runout. Outcomes of interest were baseline stiffness, survivability, and cycles to failure.

RESULTS

Groups III and IV have a significantly higher baseline stiffness (P < 0.001) when compared with groups I and II. Furthermore, groups III and IV had a higher max load to failure (P < 0.01) when compared with groups I and II. The survivability in groups III and IV was 71% and 100%, respectively, while no specimens in group I or II survived maximum loading. There was no significant difference between group III and IV regarding stiffness, survivability, and cycles to failure.

CONCLUSION

When considering fixation for intra-articular distal femur fractures with metaphyseal comminution (OTA/AO 33-C), we found that supplementation of a lateral locked plate with a medial plate or an IMN to be biomechanically superior to lateral locked plating alone regarding stiffness, survivability, and cycles to failure. A low-profile precontoured plate did not add significantly to the construct stiffness in this study.

Risk Factors for Tibial Plafond Nonunion: Medial Column Fixation May Reduce Nonunion Rates

OBJECTIVES

To identify the incidence and risk factors for development of tibial plafond nonunion.

DESIGN

Retrospective comparative study.

SETTING

Two Level 1 academic trauma centers.

PATIENTS/PARTICIPANTS

Seven hundred forty tibial plafond fractures (OTA/AO 43B3 and 43C) treated January 2006 to December 2015.

INTERVENTION

Open reduction and internal fixation.

MAIN OUTCOME MEASUREMENT

Nonunion.

RESULTS

Five hundred eighteen patients with a mean age of 43 years (range, 18-81 years) and mean follow-up of 27 months (range, 12-115 months) were involved. Seventy-two patients (72/518, 14%) were identified as having a nonunion. Surgical approach was not associated with nonunion in univariate analysis. Multiple regression model 1 identified OTA/AO 43C [odds ratio (OR) = 4.43; 95% confidence interval (CI), 1.01-19.41; P = 0.048], tobacco use (OR = 2.02; 95% CI, 1.10-3.71; P = 0.024), both minimal and substantial bone loss (P = 0.006 and P < 0.001, respectively), and open fracture (OR = 1.96; 95% CI, 1.10-3.48; P = 0.022) as risk factors for tibial plafond nonunion. Model 2 identified locking plate (OR = 1.97; 95% CI, 1.13-3.40; P = 0.016) and failure to treat the medial column (vs. screw P = 0.047, or plate P = 0.038) as risk factors.

CONCLUSIONS

The tibial plafond nonunion rate was 14%. Bone loss, open fracture, failure to treat the medial column, locking plates, and tobacco use were all significant risk factors for developing tibial plafond nonunion. Equally important, surgical approach was not significantly associated with plafond nonunion.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Narrow locking compression plate vs long philos plate for minimally invasive plate osteosynthesis of spiral humerus shaft fractures

Background

Our hypothesis was that minimally invasive plate osteosynthesis (MIPO) using long philos plate (LPP) would show better clinical and radiological outcomes and less complications than narrow locking compression plate (NLCP) for spiral humerus shaft fractures with or without metaphyseal fracture extension.

Methods

From January 2009 to May 2016, we retrospectively studied 35 patients who underwent MIPO for spiral humerus shaft fractures with or without metaphyseal fracture extension (AO classification 12 A, B, C except A3). Eighteen patients underwent MIPO with a 4.5 mm NLCP (group I) in the early period of this study, while 17 patients underwent MIPO with LPP (group II) in the later period. Range of motion (ROM), pre- and post-operative anteroposterior (AP) and lateral angulation of the fracture, operation time, amount of bleeding, and functional outcomes including American Shoulder and Elbow Surgeons score, University of California at Los Angeles score, and Simple Shoulder Test score were analyzed at the final follow up.

Results

All patients had complete bony union and achieved satisfactory functional outcomes except 2 patients. In LPP group, better outcomes in postoperative fracture angulation on X-ray and operation time (p < 0.05) were shown. But, two revision surgery with NLCP and bone graft was performed owing to 2 metal failures.

Conclusions

In spiral humeral shaft fractures, LPP group showed better fracture reduction on X-ray and shorter operation time except metal failure owing to weak fixation. Even though MIPO technique using LPP is easier and more accurate reduction method, rigid fixation should be considered.

The utility of the angled blade plate in hip fracture nonunion treatment: A report of three cases and review of the literature

Objectives:

We report the radiographic and clinical outcome of patients treated with an angled blade plate (ABP) for hip fracture nonunion. We also provide a review of the literature on joint preserving treatment approaches to hip fracture nonunions.

Design:

Retrospective, case series.

Setting:

Tertiary academic hospital.

Patients/Participants:

Three.

Intervention:

We treated three patients with varied hip fracture nonunions using a joint preserving approach with an ABP.

Main outcome measurements:

Radiographic union and clinical outcome.

Results:

All three patients achieved radiographic union, and were ambulating without pain at final follow-up.

Conclusions:

The treatment approach to hip fracture nonunions is either restorative (joint preserving) or reconstructive (joint replacing). The primary restorative approach to nonunions around the hip consists of revision open reduction and internal fixation with or without bone grafting. Though a variety of implants and treatment techniques have demonstrated excellent success in this setting, revision open reduction and internal fixation with an ABP remains an efficacious implant selection in hip nonunion surgery.

Clinical outcomes in periarticular knee fractures with flexible fixation using far cortical locking screws in locking plate: a prospective study

PURPOSE

Periarticular fractures around the knee joint are treated traditionally by locking plates which provide excellent stability but suppress callus formation. Far cortical locking (FCL) screws allow axial motion and enhance uniform callus formation. Our study aims to evaluate the outcomes of FCL screws in traditional locking plate in periarticular fractures of the knee.

METHODS

Thirty patients with periarticular fractures of the knee joint were operated with locking plate using FCL screws. All patients were evaluated clinically and radiographically using X-rays at 6, 12, 24 weeks, 1 year and with CT scan at 12-weeks follow-up.

RESULTS

The average time for complete union was 20 weeks in tibial fractures and 24 weeks in femur fractures. Average time to full weight bearing ambulation was 4.8 ± 0.93 weeks. One patient had delayed union in which union was complete after 9 months.

CONCLUSION

This study shows that FCL screws in locking plates allow uniform callus formation and fracture union with minimal complication rates.

Far Cortical Locking Fixation of Distal Femur Fractures is Dominated by Shear at Clinically Relevant Bridge Spans

OBJECTIVES

Far cortical locking (FCL) constructs have been shown to increase axial interfragmentary displacement while limiting shear and have been specifically recommended in the treatment of distal femur fractures. However, there is no available data regarding their mechanical behavior within the range of bridge spans typically used for comminuted distal femur fractures. This biomechanical study of distal femur locked plate fixation assessed 4 methods of diaphyseal fixation for associated axial and shear displacement at bridge spans typically used in clinical practice.

METHODS

Distal femur locking plates were used to bridge simulated fractures in femur surrogates with 4 different methods of diaphyseal fixation (bicortical locking, bicortical nonlocking, near cortical locking, and FCL). Axial and shear displacement were assessed at 5 different bridge spans for each fixation method.

RESULTS

Diaphyseal fixation type was associated with the amount of shear (P = 0.04), but not the amount of axial displacement (P = 0.39). Specifically, FCL constructs demonstrated greater shear than bicortical locking (median 4.57 vs. 2.94 mm, P = 0.02) and bicortical nonlocking (median 4.57 vs. 3.41 mm, P = 0.02) constructs.

CONCLUSIONS

Unexpectedly, FCL constructs demonstrated greater shear than bicortical locking and nonlocking constructs and similar axial displacement for all fixation methods. Bridge span had a dominant effect on displacement that interacted negatively with more flexible FCL diaphyseal fixation. Potentially interactive construct features are best studied in concert. Given the complexity of these relationships, computational modeling will likely play an integral role in future mechanotransduction research.

The Use of Fibular Allograft in Complex Periarticular Fractures Around the Knee

Although the use of fibular strut allografts in proximal humerus fractures has gained popularity, their use in other types of fractures is less well described. Fibular allografts have recently been used in the repair of complex periarticular fractures of the proximal tibia and distal femur. Fibular allografts can be inserted in a variety of manners to achieve goals specific to each individual fracture pattern. In the proximal tibia, insertion through a fracture line or cortical window facilitates joint surface elevation, prevents subsidence and enhances overall construct stability. In distal femoral fractures, including complex periarticular fractures, insertion through the fracture or cortical window permits indirect reduction of the medial cortex and provides necessary medial column support. An additional option in distal femur fractures includes fibula insertion as an intramedullary nail, allowing enhanced fixation in short distal fracture segments. In all cases, the use of a fibular allograft augments poor bone stock and provides improved screw purchase and construct stability when combined with conventional plating methods. Here we present a series of cases at our institution illustrating an array of novel techniques utilizing endosteal fibular allografts in the fixation of complex periarticular fractures about the knee.

Distal femur: dynamization of plating

With advances in osteosynthesis technology providing improved stability of fixation and better outcomes, surgical treatment has become the standard of care for distal femur fractures. Pre-contoured distal femoral locking plates are the most commonly used implants for fixation. However, healing problems such as delayed union, failure of fixation, and /or nonunion are not uncommon. The fixation construct being "too stiff" is a commonly quoted reason when nonunion/failure of fixation occurs on distal femur fractures fixed with a plate. A flexible fixation construct allowing controlled axial micromotion could help stimulate the bone healing. In order to achieve this goal, plating construct stiffness can be modified by several methods.

[Current status and progress of clinical research on distal femoral fractures]

Objective

To investigate current status and latest progress of clinical research on distal femoral fractures.

Methods

The related literature was extensively reviewed to summarize the trend of the researches and their clinical application in the treatment of distal femoral fractures.

Results

Distal femoral fractures are likely to occur in young people who suffer from high-energy damage and the elderly with osteoporosis, which is always comminuted and unstable fractures, and often involved in the articular surface and combined with serious soft tissue injury. Therefore, the treatment faces many challenges. External fixation is now used as a temporary means of controlling injury. The vast majority of patients are feasible to internal fixation, including plates system and intramedullary nail system. Different internal fixator also has its own characteristics, such as double plates can strengthen the medial support of the femur, less invasive stabilization system protects the blood supply of fractures, distal cortial locking plate is theoretically more fit for the requirements of bone healing, retrograde intramedullary nail can resist varus and valgus.

Conclusion

The treatment of distal femoral fractures should be based on the type of fracture and the characteristics of internal fixators.

Open Supracondylar-Intercondylar Fractures of the Femur Treatment With Taylor Spatial Frame

OBJECTIVES

To evaluate the Taylor spatial frame (TSF) for primary and definitive fixation of open supracondylar-intracondylar femoral (SIF) fractures.

DESIGN

Retrospective.

SETTING

Level I trauma center.

PATIENTS

Subset of 20 SIF open fractures treated with TSF extracted from a consecutive series of 80 SIF fractures treated between 2007 and 2013.

INTERVENTION

Eighteen (90%) fractures underwent definitive fixation with the TSF; 2 were treated primarily within 24 hours of injury. Mean time interval between primary treatment and secondary TSF was 5 days.

MAIN OUTCOME MEASUREMENTS

Clinical and radiological.

RESULTS

Complete union was obtained in 17 (85%) fractures without additional surgery at an average of 33 weeks. Three nonunions and 1 malunion occurred. No deep infection occurred. Results based on Association for the Study and Application of the Method of Ilizarov criteria: 37% excellent, and 63% good for bone outcomes; 5% excellent, 58% good, and 37% fair for functional outcomes. Neer knee scores were 21% excellent, 68% good, and 11% fair. The mechanical lateral distal femoral angle and anatomic posterior distal femoral angle values were within normal range in 80% and 90% of patients, respectively. Abnormal mechanical axis deviation was observed in 4 (20%) cases (2 had associated tibia fractures).

CONCLUSIONS

Primary and definitive fixation with the TSF are effective. Advantages include continuity of device until union, reduced risk of infection, early mobilization, restoration of primary defect caused by bone loss, easy and accurate application, convertibility and versatility, and improved union rate and range of motion for SIF open fractures.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison of 4 Methods for Dynamization of Locking Plates: Differences in the Amount and Type of Fracture Motion

BACKGROUND

Decreasing the stiffness of locked plating constructs can promote natural fracture healing by controlled dynamization of the fracture. This biomechanical study compared the effect of 4 different stiffness reduction methods on interfragmentary motion by measuring axial motion and shear motion at the fracture site.

METHODS

Distal femur locking plates were applied to bridge a metadiaphyseal fracture in femur surrogates. A locked construct with a short-bridge span served as the nondynamized control group (LOCKED). Four different methods for stiffness reduction were evaluated: replacing diaphyseal locking screws with nonlocked screws (NONLOCKED); bridge dynamization (BRIDGE) with 2 empty screw holes proximal to the fracture; screw dynamization with far cortical locking (FCL) screws; and plate dynamization with active locking plates (ACTIVE). Construct stiffness, axial motion, and shear motion at the fracture site were measured to characterize each dynamization methods.

RESULTS

Compared with LOCKED control constructs, NONLOCKED constructs had a similar stiffness (P = 0.08), axial motion (P = 0.07), and shear motion (P = 0.97). BRIDGE constructs reduced stiffness by 45% compared with LOCKED constructs (P < 0.001), but interfragmentary motion was dominated by shear. Compared with LOCKED constructs, FCL and ACTIVE constructs reduced stiffness by 62% (P < 0.001) and 75% (P < 0.001), respectively, and significantly increased axial motion, but not shear motion.

CONCLUSIONS

In a surrogate model of a distal femur fracture, replacing locked with nonlocked diaphyseal screws does not significantly decrease construct stiffness and does not enhance interfragmentary motion. A longer bridge span primarily increases shear motion, not axial motion. The use of FCL screws or active plating delivers axial dynamization without introducing shear motion.

Implant Material, Type of Fixation at the Shaft, and Position of Plate Modify Biomechanics of Distal Femur Plate Osteosynthesis

OBJECTIVES

To investigate whether (1) the type of fixation at the shaft (hybrid vs. locking), (2) the position of the plate (offset vs. contact) and (3) the implant material has a significant effect on (a) construct stiffness and (b) fatigue life in a distal femur extraarticular comminuted fracture model using the same design of distal femur periarticular locking plate.

METHODS

An extraarticular severely comminuted distal femoral fracture pattern (OTA/AO 33-A3) was simulated using artificial bone substitutes. Ten-hole distal lateral femur locking plates were used for fixation per the recommended surgical technique. At the distal metaphyseal fragment, all possible locking screws were placed. For the proximal diaphyseal fragment, different types of screws were used to create 4 different fixation constructs: (1) stainless steel hybrid (SSH), (2) stainless steel locked (SSL), (3) titanium locked (TiL), and (4) stainless steel locked with 5-mm offset at the diaphysis (SSLO). Six specimens of each construct configuration were tested. First, each specimen was nondestructively loaded axially to determine the stiffness. Then, each specimen was cyclically loaded with increasing load levels until failure.

RESULTS

Construct Stiffness: The fixation construct with a stainless steel plate and hybrid fixation (SSH) had the highest stiffness followed by the construct with a stainless steel plate and locking screws (SSL) and were not statistically different from each other. Offset placement (SSLO) and using a titanium implant (TiL) significantly reduced construct stiffness. Fatigue Failure: The stainless steel with hybrid fixation group (SSH) withstood the most number of cycles to failure and higher loads, followed by the stainless steel plate and locking screw group (SSL), stainless steel plate with locking screws and offset group (SSLO), and the titanium plate and locking screws group (TiL) consecutively. Offset placement (SSLO) as well as using a titanium implant (TiL) reduced cycles to failure.

CONCLUSIONS

Using the same plate design, the study showed that implant material, screw type, and position of the plate affect the construct stiffness and fatigue life of the fixation construct. With this knowledge, the surgeon can decide the optimal construct based on a given fracture pattern, bone strength, and reduction quality.

Treatment of Distal Femur Nonunion Following Initial Fixation with a Lateral Locking Plate

OBJECTIVE

To report and evaluate the outcomes of patients undergoing definitive treatment for distal femur nonunion after initial treatment with a locking plate.

METHODS

Fourteen patients who had undergone definitive treatment at an academic Level 1 trauma center from May 2007 to December 2013 for distal femur nonunion were identified from a fracture database. Thirteen of them were female; the average age was 65 years (range, 50-84 years). Ten patients had sustained their injuries in falls at ground level, and four in motor vehicle accidents. Twelve patients were obese (body mass index ≥30), 10 had diabetes, none were current smokers, and one had an open fracture classified as type IIIa according to the Gustilo-Anderson classification system for open fractures. The fractures were classified according to the AO classification system for distal femur fractures; there were three type 33-A1, six 33-A2, two 33-A3 and three 33-C3 fractures. Methods of definitive treatment involved open reduction and internal fixation (ORIF) revision, medial plating, bone grafting and the use of other biologic materials.

RESULTS

Eight of the 14 patients (57%) achieved union during follow-up. Definitive treatment for nonunion involved ORIF revision in 11 cases. Three patients who did not undergo ORIF revision were treated with iliac crest stem cell autografts, bone graft substitutes or recombinant human-bone morphogenetic protein-2 (rh-BMP-2). Other treatments included rh-BMP-2 (12 cases), iliac crest bone autograft (five), iliac crest stem cell autograft (two), crushed cancellous bone allograft (three), CaSO 4 and tricalcium phosphate bone graft substitute (two) and demineralized bone matrix (one). The average time from definitive treatment to union was 19 weeks (range, 12-51 weeks). Two of the 11 cases who underwent ORIF revision had medial plates added to improve biomechanical stability and prevent varus collapse. This was also performed in one patient with a grade III open type 33-C3 fracture and one with a closed 33-A2 fracture. Five study patients had comminuted fractures. Two had type 33-A3 and three type 33-C3 fractures. Both patients with 33-A3 fractures and 2 two with 33-C3 fractures had persistent nonunion at the end of follow-up.

CONCLUSIONS

Definitive treatment of distal femur nonunion after initial treatment with a locking plate had a low rate of success in this study, suggesting that this procedure is ineffective as a definitive treatment for distal femur nonunion.

Open Reduction vs Distal Femoral Replacement Arthroplasty for Comminuted Distal Femur Fractures in the Patients 70 Years and Older

BACKGROUND

The ideal management of distal femur fractures in the elderly is unclear. Acute arthroplasty has the theoretical advantage of earlier mobilization. We examined the outcomes of patients 70 years and older who underwent open reduction internal fixation (ORIF) vs distal femoral replacement (DFR) for comminuted, intra-articular distal femur fractures.

METHODS

A retrospective review of patients with AO/OTA classification 33C distal femur fractures treated with either ORIF or DFR was performed. Outcomes including all-cause reoperation, length of stay, fracture union, postoperative complications, use of ambulatory device and living situation at 1 year, and mortality were evaluated.

RESULTS

The study cohort included 38 patients: 10 underwent DFR and 28 ORIF. Mean patient age for both cohorts was 82 years. No difference in comorbidities or mechanism of injury was found between groups. The incidence of reoperation was 11% in the ORIF group and 10% in the DFR group. In the ORIF group, the average time to fracture union was 24 weeks, with a nonunion incidence of 18%. Twenty-three percent of ORIF group were wheelchair dependent vs none in the DFR cohort, although not statistically significant. Differences between the groups with respect to all-cause reoperation, living situation or need for ambulatory device at 1 year, and 1-year mortality did not reach statistical significance.

CONCLUSION

Nearly 1 in 5 patients older than 70 years developed a nonunion after ORIF of an intra-articular distal femur fracture. At 1-year follow-up, all patients in DFR group were ambulatory while 1 in 4 in the ORIF group were wheelchair bound.

The use of interfragmentary positional screw in minimally invasive plate osteosynthesis for simple distal femur fractures in elderly patients: A retrospective, single-centre pilot study

INTRODUCTION

Minimally invasive plate osteosynthesis (MIPO) using locking plates has been used in distal femur fractures, but various problems, such as nonunion, malalignment, and implant failure, have been reported. Simple fractures sometimes have poorer outcomes than complex fractures. We studied elderly patients with simple fracture patterns who underwent open reduction followed by placement of a single positional screw to hold the reduced interfragmentary gap, and compared these cases with patients who underwent surgery using conventional MIPO techniques.

PATIENTS AND METHODS

A retrospective analysis was conducted on 80 cases of patients with distal femur fractures and simple fracture patterns (33-A1, A2, and C1). The mean age was 74 (60-90) years, and the mean follow-up period was 14 (12-25) months. Group A included 40 patients who underwent conventional MIPO technique while Group B included 40 patients who had surgery using positional screws. Interfragmentary gaps in Group B were reduced using percutaneous reduction clamps, and cortical screws were inserted to sustain the reduction. Then, locking plates were inserted using conventional MIPO techniques.

RESULTS

Bony union was achieved in all 80 cases, mean initial callus formation was observed in 11 weeks (8-13 weeks), and radiological union was observed in 27 weeks (15-54 weeks). Time to initial callus formation was not different, but radiologic union was achieved in 30 weeks (18-54 weeks) for Group A and 25 weeks (15-41 weeks) for Group B (p=0.006). No differences were seen in clinical function at 1year (p=0.580). Five cases of malalignment occurred in Group A (p=0.021). The rate of union during the 1-year period was significantly higher in group B than in group A (p=0.002).

CONCLUSIONS

In a distal femur fracture with a simple fracture pattern, using positional screws to sustain the reduced interfragmentary gap may achieve a more rapid union by reducing fracture gap. Though functional differences were not seen in follow-ups, patients can be expected to return to their normal lives earlier as union is achieved in a shorter time. Performing MIPO using positional screws to sustain the reduced interfragmentary gap after fracture reduction will be helpful in the treatment of simple femoral fracture.

Periprosthetic Distal Femur Fracture after Total Knee Arthroplasty: A Systematic Review

This study was designed to itemize and analyze the classification of fracture types and their corresponding outcomes in an attempt to provide a better understanding of the current treatment methods. Two PubMed searches were performed using the words "periprosthetic distal femur fracture" and "periprosthetic supracondylar femur fracture" in studies that were published in the previous 10 years (2004-2014). Data from 41 articlesthat met the general inclusion criteria, were collected and categorized into fracture type and treatment method groupings. Healing outcome and complications were the two parameters used to analyze the data. Treatment techniques were grouped in the following categories: locking plate, non-locking plate, intramedullary nail/rod, screw, blade plate, cerclage wires, allograft, external fixation, revision arthroplasty, non-operative, and other. Classification systems by Lewis and Rorabeck, the Association for Osteosynthesis/Orthopedic Trauma Association (AO/OTA), Su et al., Neer et al., Kim et al., Backstein et al., and the Société Française de Chirurgie Orthopédique et Traumatologique were reported. In total 448 fractures were identified, of which Rorabeck type II was the most common fracture studied. The two most successful treatment options for periprosthetic distal femur fractures were locking plate (87%) and intramedullary nail/rod (84%). The most frequent complications associated with periprosthetic distal femur fractures included non/mal/delayed union and the need for revision. Locking plates used to treat Rorabeck type II fractures had a complication rate of 35% and those treated with intramedullary nailing had a higher complication rate of 53%. In conclusion, the most frequent type of periprosthetic distal femur fracture after total knee arthroplasty was Rorabeck type II. The most common treatments for these types of fractures are locked plating and intramedullary nailing, with similar healing rates of 87% and 84%, respectively. However, the complication rate for locked plating was lower than for intramedullary nailing.

Comminuted supracondylar femoral fractures: a biomechanical analysis comparing the stability of medial versus lateral plating in axial loading

The aim of this study was to compare the biomechanical properties of medial and lateral plating of a medially comminuted supracondylar femoral fracture. A supracondylar femoral fracture model comparing two fixation methods was tested cyclically in axial loading. One-centimetre supracondylar gap osteotomies were created in six synthetic femurs approximately 6 cm proximal to the knee joint. There were two constructs investigated: group 1 and group 2 were stabilized with an 8-hole LC-DCP, medially and laterally, respectively. Both construct groups were axially loaded. Global displacement (total length), wedge displacement, bending moment and strain were measured. Medial plating showed a significantly decreased displacement, bending moment and strain at the fracture site in axial loading. Medial plating of a comminuted supracondylar femur fracture is more stable than lateral plating.

Mechanical Construct Characteristics Predisposing to Non-union After Locked Lateral Plating of Distal Femur Fractures

OBJECTIVES

To identify discrete construct characteristics related to overall construct rigidity that may be independent predictors of nonunion after lateral locked plate (LLP) fixation of distal femur fractures.

DESIGN

Retrospective case-control study.

SETTING

Three level-1 urban trauma centers.

PATIENTS/PARTICIPANTS

Two hundred and seventy-one supracondylar femoral fractures treated with LLP at 3 affiliated level 1 urban trauma centers between August 2004 and December 2010.

METHODS

Nonunion was defined as a secondary procedure for poor healing. Construct variables included: (1) combined plate design and material variable, (2) Plate length, (3) # screws proximal to fracture, (4) total screw density (TSD), (5) proximal screw density (PSD), (6) presence of a screw crossing the main fracture, and (7) rigidity score multivariable analysis was performed using logistic regression to identify independent risk factors for nonunion.

INTERVENTION

LLP fixation.

MAIN OUTCOME MEASURE

Nonunion.

RESULTS

Nonunion rate was 13.3% (n = 36). There was a significant association between plate design/material and nonunion with 41% of stainless constructs and 10% of titanium constructs resulting in a nonunion (P < 0.001). Rigidity scores reached significance (P = 0.001) with constructs resulting in a nonunion having higher scores. No significant univariate differences with respect to number of proximal screws, plate length, total screw density, or proximal screw density were observed between healed fractures and those with nonunion. Results of the multivariate analysis confirmed that the primary significant independent predictor of nonunion was plate design/material (odds ratio, 6.8; 95% CI, 2.9-16.1; P < 0.001).

CONCLUSIONS

When treating distal femur fractures with LLP, combined plate design and material variable has a highly significant influence on the risk of nonunion independent of any other construct variable.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

LCP Versus LISS in the Treatment of Open and Closed Distal Femur Fractures: Does it Make a Difference?

OBJECTIVES

We compared the postoperative complication rates between the less invasive stabilization system (LISS) plating and locking compression plate for open and closed distal femoral fracture fixation for superiority.

DESIGN

Retrospective Review.

SETTING

Multicenter.

PARTICIPANTS

Patients identified through a hospital database who were treated for supracondylar femur fractures using LISS or LCP techniques between January 2005 and July 2010.

INTERVENTION

Medical history, patient demographics, injury characteristics, presence of polytrauma, and surgical characteristics were collected for each patient.

MAIN OUTCOME MEASUREMENTS

χ and logistic regression analysis was performed to compare postoperative infection and nonunion/reoperation regarding both plating techniques.

RESULTS

Of 339 distal femoral fractures, 185 (54.6%) were repaired with a LISS plate and 154 (45.4%) were repaired with a LCP. Multivariate analysis revealed only open fractures to be a risk factor for nonunion (Odds ratio 2.42, P = 0.01) and infection (Odds ratio 3.47, P = 0.02), regardless of device used. No difference was seen between either plate type in infection, plate failure, or nonunion.

CONCLUSIONS

Postoperative infection and nonunion rates are comparable between LISS and LCP for both open and closed distal femoral fracture fixation. As no difference was detected between plates, either may be used to treat distal femur fractures. Nonunion rate was higher than expected based on previous reports.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Locking plate fixation of distal femoral fractures is a challenging technique: a retrospective review

Distal femoral fractures have typically a bimodal occurrence: in young people due to a high-energy trauma and in older people related to a low-energy trauma. These fractures are associated to a very high morbidity and mortality in elderly. Distal femoral fractures might be treated with plates, intramedullary nails, external fixations, and prosthesis. However, difficulties in fracture healing and the rate of complications are important clinical issues. The purpose of this retrospective review was to present our experience in treatment of distal femoral fracture in a sample of older people in order to evaluate the technical pitfalls and strategies used to face up the fractures unsuccessfully treated with locking plates. We included people aged more than 65 years, with a diagnosis of distal femoral fracture, treated with locking plates. We considered 'unsuccessfully treated' the cases with healing problems or hardware failures. Of the 12 patients (9 females and 3 males; mean aged 68.75 ± 3.31 years) included, we observed 3 'unsuccessfully cases', 2 due to nonunions and 1 due to an early hardware failure, all treated using a condylar blade plate with a bone graft. One patient obtained a complete fracture healing after 1 year and in the other cases there was a nonunion. We observed as most common technical pitfalls: inadequate plate lengthening, fracture bridging, and number of locking screws. The use of locking plates is an emerging technique to treat these fractures but it seems more challenging than expected. In literature there is a lack of evidences about the surgical management of distal femoral fractures that is still an important challenge for the orthopaedic surgeon that has to be able to use all the fixation devices available.

Risk factors for long bone fracture non-union: a stratification approach based on the level of the existing scientific evidence

Non-union continues to be the most devastating complication after fracture fixation. Its treatment can be prolonged and often unpredictable. The burden to the patient, surgeon and health care system can be immense. Strategies to prevent it and or identify early its development are desirable in order to improve the clinical course of the affected patients and their outcomes. We undertook a systematic review of the literature in order to identify the most common and important risk factors based on the hierarchy of level of evidence. Accordingly, a stratification scale was formed which highlighted 10 risk factors including; an open method of fracture reduction, open fracture, presence of post-surgical fracture gap, smoking, infection, wedge or comminuted types of fracture, high degree of initial fracture displacement, lack of adequate mechanical stability provided by the implant used, fracture location in the poor zone of vascularity of the affected bone, and the presence of the fracture in the tibia. Clinicians should take in to account these findings when managing patients with long bone fractures, particularly the femur and tibia in order to minimise the risk of non-union.

Biomechanical Concepts for Fracture Fixation

Application of the correct fixation construct is critical for fracture healing and long-term stability; however, it is a complex issue with numerous significant factors. This review describes a number of common fracture types and evaluates their currently available fracture fixation constructs. In the setting of complex elbow instability, stable fixation or radial head replacement with an appropriately sized implant in conjunction with ligamentous repair is required to restore stability. For unstable sacral fractures with vertical or multiplanar instabilities, "standard" iliosacral screw fixation is not sufficient. Periprosthetic femur fractures, in particular Vancouver B1 fractures, have increased stability when using 90/90 fixation versus a single locking plate. Far cortical locking combines the concept of dynamization with locked plating to achieve superior healing of a distal femur fracture. Finally, there is no ideal construct for syndesmotic fracture stabilization; however, these fractures should be fixed using a device that allows for sufficient motion in the syndesmosis. In general, orthopaedic surgeons should select a fracture fixation construct that restores stability and promotes healing at the fracture site, while reducing the potential for fixation failure.

Interventions for treating fractures of the distal femur in adults

BACKGROUND

Fractures of the distal femur (the part of the thigh bone nearest the knee) are a considerable cause of morbidity. Various different surgical and non-surgical treatments have been used in the management of these injuries but the best treatment remains controversial.

OBJECTIVES

To assess the effects (benefits and harms) of interventions for treating fractures of the distal femur in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (9 September 2014); the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2014, Issue 8); MEDLINE (1946 to August week 4 2014); EMBASE (1980 to 2014 week 36); World Health Organization (WHO) International Clinical Trials Registry Platform (January 2015); conference proceedings and reference lists without language restrictions.

SELECTION CRITERIA

Randomised and quasi-randomised controlled clinical trials comparing interventions for treating fractures of the distal femur in adults. Our primary outcomes were patient-reported outcome measures (PROMs) of knee function and adverse events, including re-operations.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies and performed data extraction and risk of bias assessment. We assessed treatment effects using risk ratios (RR) or mean differences (MD) and, where appropriate, we pooled data using a fixed-effect model.

MAIN RESULTS

We included seven studies that involved a total of 444 adults with distal femur fractures. Each of the included studies was small and assessed to be at substantial risk of bias, with four studies being quasi-randomised and none of the studies using blinding in outcome assessment. All studies provided an incomplete picture of outcome. Based on GRADE criteria, we assessed the quality of the evidence as very low for all reported outcomes, which means we are very uncertain of the reliability of these results.One study compared surgical (dynamic condylar screw (DCS) fixation) and non-surgical (skeletal traction) treatment in 42 older adults (mean age 79 years) with displaced fractures of the distal femur. This study, which did not report on PROMs, provided very low quality evidence of little between-group differences in adverse events such as death (2/20 surgical versus 1/20 non-surgical), re-operation or repeat procedures (1/20 versus 3/20) and other adverse effects including delayed union. However, while none of the findings were statistically significant, there were more complications such as pressure sores (0/20 versus 4/20) associated with prolonged immobilisation in the non-surgical group, who stayed on average one month longer in hospital.The other six studies compared different surgical interventions. Three studies, including 159 participants, compared retrograde intramedullary nail (RIMN) fixation versus DCS or blade-plate fixation (fixed-angle devices). None of these studies reported PROMS relating to function. None of the results for the reported adverse events showed a difference between the two implants. Thus, although there was very low quality evidence of a higher risk of re-operation in the RIMN group, the 95% confidence interval (CI) also included the possibility of a higher risk of re-operation for the fixed-angle device (9/83 RIMN versus 4/96 fixed-angle device; 3 studies: RR 1.85, 95% CI 0.62 to 5.57). There was no clinically important difference between the two groups found in quality of life assessed using the 36-item Short Form in one study (23 fractures).One study (18 participants) provided very low quality evidence of there being little difference in adverse events between RIMN and non-locking plate fixation. One study (53 participants) provided very low quality evidence of a higher risk of re-operation after locking plate fixation compared with a single fixed-angle device (6/28 locking plate versus 1/25 fixed-angle device; RR 5.36, 95% CI 0.69 to 41.50); however, the 95% CI also included the possibility of a higher risk of re-operation for the fixed-angle device. Neither of these trials reported on PROMs.The largest included study, which reported outcomes in 126 participants at one-year follow-up, compared RIMN versus locking plate fixation; both implants are commonly used in current practice. None of the between-group differences in the reported outcomes were statistically significant; thus the CIs crossed the line of no effect. There was very low quality evidence of better patient-reported musculoskeletal function in the RIMN group based on Short Musculoskeletal Function Assessment (0 to 100: best function) scores (e.g. dysfunction index: MD -5.90 favouring RIMN, 95% CI -15.13 to 3.33) as well as quality of life using the EuroQoL-5D Index (0 to 1: best quality of life) (MD 0.10 favouring RIMN, 95% CI -0.01 to 0.21). The CIs for both results included a clinically important effect favouring RIMN but also a clinically insignificant effect in favour of locking plate fixation.

AUTHORS' CONCLUSIONS

This review highlights the major limitations of the available evidence concerning current treatment interventions for fractures of the distal femur. The currently available evidence is incomplete and insufficient to inform current clinical practice. Priority should be given to a definitive, pragmatic, multicentre randomised controlled clinical trial comparing contemporary treatments such as locked plates and intramedullary nails. At minimum, these should report validated patient-reported functional and quality-of-life outcomes at one and two years. All trials should be reported in full using the CONSORT guidelines.

Dynamic locking plates provide symmetric axial dynamization to stimulate fracture healing

Axial dynamization of an osteosynthesis construct can promote fracture healing. This biomechanical study evaluated a novel dynamic locking plate that derives symmetric axial dynamization by elastic suspension of locking holes within the plate. Standard locked and dynamic plating constructs were tested in a diaphyseal bridge-plating model of the femoral diaphysis to determine the amount and symmetry of interfragmentary motion under axial loading, and to assess construct stiffness under axial loading, torsion, and bending. Subsequently, constructs were loaded until failure to determine construct strength and failure modes. Finally, strength tests were repeated in osteoporotic bone surrogates. One body-weight axial loading of standard locked constructs produced asymmetric interfragmentary motion that was over three times smaller at the near cortex (0.1 ± 0.01 mm) than at the far cortex (0.32 ± 0.02 mm). Compared to standard locked constructs, dynamic plating constructs enhanced motion by 0.32 mm at the near cortex and by 0.33 mm at the far cortex and yielded a 77% lower axial stiffness (p < 0.001). Dynamic plating constructs were at least as strong as standard locked constructs under all test conditions. In conclusion, dynamic locking plates symmetrically enhance interfragmentary motion, deliver controlled axial dynamization, and are at least comparable in strength to standard locked constructs. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 33:1218-1225, 2015.

Extremity War Injuries IX: Reducing Disability Within the Military

Extremity War Injury Symposium IX focused on reducing disability within the military, centering on cartilage defects, amputations, and spinal cord injury. Many areas of upper and lower extremity trauma and disability were discussed, including segmental nerve injuries, upper extremity allotransplantation, and the importance of patient-reported functional outcomes compared with the traditionally reported measures. Strategic planning addressed progression toward clinical solutions by setting clear objectives and goals and outlining pathways to address the "translation gap" that often prevents bridging of basic science to clinical application.

Retrograde locked intramedullary nailing for aseptic supracondylar femoral nonunion following failed locked plating

PURPOSE

To review the outcome of retrograde locked nailing for aseptic supracondylar femoral nonunions following failed locked plating.

METHODS

Records of 20 men and 4 women aged 20 to 57 (mean, 39) years who underwent retrograde locked intramedullary nailing for aseptic supracondylar femoral nonunion following failed locked plating were reviewed. There were 20 closed and 4 open Gustilo type II or IIIA fractures secondary to motor vehicle accidents (n=21) or falls (n=3). Patients had undergone one to 3 operations. The mean time from injury to the present revision surgery was 1.3 years. No patient had a flexion contracture. The locked plate was removed and replaced with a retrograde dynamic locked nail (with or without buttress plate augmentation) followed by bone grafting.

RESULTS

17 men and 4 women were followed up for a mean of 3.4 years. The rest were lost to follow-up. The 21 patients achieved bone union after a mean of 4.3 months. The mean maximal knee flexion improved from 97.1º to 107.6º (p=0.03). Knee function was excellent in one, good in 15, and fair in 5 knees. The fair outcome was due to extension contracture, varus knee deformity, or knee pain. There were 3 malunions with varus deformity of 7º, 8º, and 9º each. No patient had deep infection causing a nonunion. All 21 patients could walk without aids.

CONCLUSION

Retrograde locked intramedullary nailing for aseptic supracondylar femoral nonunions following failed locked plating achieved a high union rate.

Varization open-wedge osteotomy of the distal femur: comparison between locking plate and angle blade plate constructs

PURPOSE

Biomechanical properties of locking plate and angle blade plate constructs in opening-wedge distal femur osteotomy were compared, with special attention to the impact of opposite cortex breakage and buttressing.

METHODS

Forty-eight synthetic femora underwent a lateral opening-wedge distal femur osteotomy, which was fixed either with a locking plate or with an angle blade plate. Two main groups were constituted based on the integrity of the opposite medial cortex-intact medial cortex and fractured medial cortex (FMC). Axial compression and torsion tests were performed comparing stiffness of all bone-implant constructs. In the group FMC, a special subgroup has been tested taking into consideration the effect of placing an additional 6.5-mm cancellous screw buttressing the medial cortex. Statistical level of significance was fixed in 0.05 using a confidence interval of 95 %.

RESULTS

Intact medial cortex significantly increased the stiffness for both implants tested in this study. In the FMC group, angle blade plate constructs reached higher stiffness mean values for both torsion and axial compression. The insertion of a buttressing screw on the medial cortex increased the stiffness of all tested bone-plate constructs. This additional screw favoured mostly locking plate constructs implementing their stiffness to torsion to mean values comparable to those reached by angle blade plate constructs.

CONCLUSIONS

Angle blade plate constructs reached higher stiffness mean values than locking plates for both axial compression and torsion loads. The addition of a buttressing screw on the opposite cortex increased the stability of all bone-implant constructs to levels similar to those showed with an intact medial cortex. The present study findings support the clinical use of angle blade plates, alone or associated with a medial buttressing screw, as an alternative fixation method for supracondylar open-wedge osteotomies of the femur.

Periarticular Fractures of the Knee in Polytrauma Patients

Periarticular fractures around the knee are a challenge for the orthopaedic surgeon. When these fractures are presented in the context of a multiple trauma patient, they are even more difficult to manage because the treatment approach depends not only on the fracture itself, but also on the patient's general condition. These fractures, caused by high-energy trauma, present complex fracture patterns with severe comminution and major loss of articular congruity, and are often associated with vascular and nerve complications, particularly in the proximal tibia, due to its anatomical features with poor myocutaneous coverage. They are almost always accompanied by soft tissue injury. The management of polytrauma patients requires a multidisciplinary team and accurate systemic stabilization of the patient before undertaking orthopaedic treatment. These fractures are usually addressed sequentially, either according to the general condition of the patient or to the local characteristics of the lesions. In recent decades, various fixation methods have been proposed, but there is still no consensus as to the ideal method for stabilizing these fractures. In this paper, we describe the general characteristics of these fractures, the stabilization methods traditionally used and those that have been developed in recent years, and discuss the treatment sequences proposed as most suitable for the management of these injuries.

Mega prosthetic distal femoral arthroplasty for non-tumour indications: does the indication affect the functional outcome and survivorship?

PURPOSE

To report the functional outcome, implant survival, and patient mortality after mega prosthetic distal femoral arthroplasty according to the surgical indication.

METHODS

A prospective database was compiled for 45 consecutive patients undergoing distal femoral arthroplasty, of which 26 had fractures of the distal femur (group 1) and 19 underwent revision of a total knee arthroplasty (group 2). There were 17 males and 28 females with a median age of 74.5 years. Short form (SF)-12 scores were recorded pre-operatively (before the fracture or revision) and 1 year post-operatively, at which point a Toronto Extremity Salvage Score (TESS) was also obtained. Length of hospital stay and return to place of domicile was obtained from the hospital database. Mortality status was obtained from the General Register Office for Scotland. No patient was lost to follow-up.

RESULTS

The 1-year physical (52.4) and mental (63.4) components of the SF-12 score and the TESS (70.5 %) did not significantly differ between the groups (n.s.). The fracture group, however, had a longer length of stay (8 vs. 19 days, p = 0.001) and were also less likely to return to their original domicile (odds ratio 9.5, p = 0.02). The overall implant survival rate was 85 % at 5 years, which was worse for the fracture group (80 vs. 90 %, n.s.). The 5-year mortality rate for the revision group was 17 %, whereas the fracture group demonstrated a greater mortality rate of 43 % (n.s.).

CONCLUSION

The functional outcome, revision rate, and mortality of patients undergoing distal femoral arthroplasty for non-tumour reasons are not influenced by indication, but patients undergoing surgery for fractures of the distal femur have a longer length of stay and are less likely to return home. Distal femoral arthroplasty should be considered as a management option for non-tumour salvage procedures of the distal femur.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.

Locked plating for internal fixation of the adult distal femur: influence of the type of construct and hardware on the clinical and radiological outcomes

INTRODUCTION

Distal femoral fractures are rare and serious. Along with traditional internal fixation, new, dedicated hardware have appeared (distal nails, locked plating). We report the results of a multicenter prospective study of these fractures treated with locked plating.

HYPOTHESIS

The short-term results are satisfactory and related to the type of construct and the hardware used, with better results for elastic assemblies and titanium implants.

MATERIALS AND METHODS

From June 2011 to May 2012, 92 patients, mean age 64 years, were included in 12 centres. The fractures were classified as follows: 44 type A, 7 type B, and 41 type C according to the AO classification. Thirteen fractures were open. The plates were uniaxial. The assemblies were elastic in 52 cases, rigid in 26, and unconventional in 14.

RESULTS

Seventy-six patients underwent a radiological follow-up at 6 months and 66 patients had a clinical result evaluated at 1 year. The mean range of motion was 100° and the mean IKS score was 122. The bone union rate was 87% within 12 weeks. Seven valgus, two varus, ten flexion deformities, and three recurvatum greater than 5° were observed (19.5%). Revisions involved two cases with loss of fixation, five cases of infection, and one case of arthrofibrosis (requiring arthroscopic arthrolysis). Secondary bone grafting was carried out in seven cases (four successfully). No influence of the type of assembly or the hardware used was demonstrated.

DISCUSSION

The results remain modest, underscoring the severity of these fractures. Neither the type of construct nor the hardware used influenced the radiological and clinical outcomes. The hypothesis was not confirmed.

LEVEL OF EVIDENCE

Level IV prospective, non-comparative study.

Blade-plate fixation for distal femoral fractures: a case-control study

BACKGROUND

The blade-plate is the earliest of the contemporary internal fixation devices introduced for distal femoral fractures. The recent development of dedicated, fixation devices has considerably limited its use. The objective of this study was to evaluate outcomes after blade-plate fixation and after fixation using other devices.

HYPOTHESIS

Outcomes after blade-plate fixation are similar to those after condylar screw-plate, distal femoral nail, or locking condylar plate fixation.

MATERIAL AND METHODS

We reviewed outcomes after 62 patients managed with blade-plate fixation and included in a multicentre retrospective study (n=57) or a multicentre prospective study (n=5) and we compared them to outcomes after fixation using condylar screw-plates (n=82), distal femoral nail (n=219), or locking condylar plates (n=301). The four groups were comparable for age, gender distribution, occupational status, prevalence of skin wounds, patient-related factors, type of accident, and type of fracture. The evaluation relied on the clinical International Knee Society (IKS) score and on radiographs.

RESULTS

No significant differences existed across the four groups for operative time, blood transfusion use, complications, need for bone grafting, non-union rate, or IKS score values. The early surgical revision rate for removal of the fixation material was 4% with the blade-plate and 16% with the other three fixation devices (P=0.02). Post-operative fracture deformity was similar in the four groups with, however, a higher proportion of residual malalignment in the screw-fixation group. The final anatomic axis was 3.3±1.4° with the blade-plate versus 2.3±3.7° with the other three fixation devices. The blade-plate group had few patients with axial malalignment, and the degree of malalignment was limited to 3° of varus and 10° of valgus at the most, compared to 10° and 18° respectively, with the other three fixation devices.

CONCLUSION

Despite the now extremely limited use and teaching of blade-plate fixation, as well as the undeniable technical challenges raised by the implantation of this device, the blade-plate is a simple, strong, and inexpensive fixation method. It remains reliable for the fixation of distal femoral fractures. The disfavour into which the blade-plate is currently falling is not warranted.

LEVEL OF EVIDENCE

III, case-control study.