Long-term functional outcomes after intra-articular distal femur fractures: ORIF versus retrograde intramedullary nailing

The fragility of statistical significance in distal femur fractures: systematic review of randomized controlled trials

PURPOSE

The purpose of this study was to apply both the fragility index (FI) and fragility quotient (FQ) to evaluate the degree of statistical fragility in the distal femur fracture (DFF) literature. We hypothesized that the dichotomous outcomes within the DFF literature are statistically fragile.

METHODS

Using preferred reporting items for systematic reviews and meta-analyses, we performed a PubMed search for distal femur fractures clinical trials from 2000 to 2022 reporting dichotomous outcomes. The FI of each outcome was calculated through the reversal of a single outcome event until significance was reversed. The FQ was calculated by dividing each fragility index by study sample size. The interquartile range (IQR) was also calculated for the FI and FQ.

RESULTS

Of the 4258 articles screened, 92 met the search criteria, with eleven RCTs included for analysis. Ninety eight outcome events with 25 significant (P < 0.05) outcomes and 73 nonsignificant (P > 0.05) outcomes were identified. The overall FI and FQ for all 98 outcomes were 5 (IQR 4-6) and 0.130 (IQR 0.087-0.174), respectively. Three studies (33.3%) reported loss to follow (LTF) greater than 5.

CONCLUSIONS

The randomized controlled trials in the peer-reviewed distal femur fracture literature may not be as robust as previously thought, as incorporating statistical analyses solely on a P value threshold is misleading. Standardized reporting of the P value, FI and FQ can help the clinician reliably draw conclusions based on the fragility of outcome measures.

Distal Femur Intraarticular Fracture in a Late Arthritic Knee Treated With Osteosynthesis and Computer Navigation Assisted Primary Total Knee Replacement: A Case Report

The incidence of osteoporosis and osteoarthritis is on the rise. What further complicates the scenario is a stress fracture in a weight-bearing joint such as a knee in the presence of arthritis, making the treatment challenging. Prolonged immobilization associated with osteosynthesis increases morbidity and mortality in elderly patients. Primary total knee arthroplasty (TKA) has been advocated as a treatment modality in patients with distal femoral fractures who already have painful arthritic knees. Most of these injuries get treated using a hinged prosthesis. However, there are concerns about the high rate of loosening and mechanical failure of this type of prosthesis. This report presents a distal femur intraarticular fracture nonunion in the late arthritic knee, which is a rare presentation as proximal tibia stress fractures are more common. This was treated with osteosynthesis, and computer navigation assisted primary total knee replacement using medial pivot knee in a 54-year-old male with a body mass index of 38. Based on clinical and radiographic evidence, primary total knee replacement and plate osteosynthesis are viable options for distal femur fractures with osteoarthritis using computer navigation. While limiting the number of procedures, it meets two prerequisites: early weight bearing, limiting decubitus-related complications, and early mobilization leading to patient autonomy.

The geriatric distal femur fracture: nail, plate or both?

Surgical fixation of distal femur fractures in geriatric patients is an evolving topic. Unlike hip fractures, treatment strategies for distal femur fractures are ill-defined and lack substantive high-quality evidence. With an increasing incidence and an association with significant morbidity and mortality, it is essential to understand existing treatment options and their supporting evidence. Current fixation methods include the use of either retrograde intramedullary nails, or plate and screw constructs. Due to the variability in fracture patterns, the unique anatomy of the distal femur, and the presence or absence or pre-existing implants, decision-making as to which method to use can be challenging. Recent literature has sought to describe the advantages and disadvantages of each, however, there is currently no consensus on a standard of care, and little randomized evidence is available that directly compares intramedullary nails with plating. Future randomized studies comparing intramedullary nails with plating constructs are necessary in order to develop a standard of care based on injury characteristics.

Retrograde intramedullary nailing of comminuted intra-articular distal femur fractures results in high union rate

PURPOSE

Retrograde intramedullary nailing of intra-articular distal femur fractures with metaphyseal and/or epiphyseal comminution is controversial and considered a contraindication to nailing. The purpose of this study was to report union rate, complications, and secondary procedures after open reduction and retrograde intramedullary nailing of comminuted, intra-articular, distal femur fractures.

MATERIALS AND METHODS

A retrospective review performed at an urban level one trauma center identified 16 patients AO/Orthopedic Trauma Association (OTA) 33-C2 and 33-C3 femur fractures treated with open reduction, lag screws, and retrograde intramedullary nail fixation. Radiographic union, complications, secondary operations were reviewed.

RESULTS

At the 3-month follow-up 12 (86%) of the 14 patients with radiographs had healed. At last follow-up, all 16 femur fractures achieved radiographic union after the index procedure. No patient required a revision procedure for delayed union or nonunion. Complications occurred in 6 (38%) patients, including failed distal interlocking screws (n = 2), knee arthrofibrosis (n = 3), superficial wound infection (n = 1), and wound dehiscence (n = 1). Three (19%) patients required secondary procedures, which included knee manipulation under anesthesia (n = 3), distal interlocking screw removal (n = 2), and closure of a wound dehiscence (n = 1).

CONCLUSIONS

Comminuted intra-articular distal femur fractures that can be successfully treated with retrograde IMN fixation will reliably go on to union with a complication rate that is favorable to that reported for plate fixation.

LEVEL OF EVIDENCE

Level IV, retrospective case-series.

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.

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.

Is the compressive nail method capable of accelerating bone union in patients with femoral distal diaphysis fracture?

OBJECTIVES

This study was conducted to evaluate clinically and radiologically the patients for whom compressive and non-compressive intramedullary nails were applied and to analyse the compression effectiveness in adult femur distal diaphysis fractures.

HYPOTHESIS

The compressive locked nails shortened the union period in the distal diaphysis fractures, and it was found to be an effective method, as the pseudoarthrosis rate was lower.

MATERIAL AND METHODS

A retrospective study was conducted among 59 patients for whom the compressive and non-compressive IMNs were applied to treat femur distal diaphysis fractures. Thirty-one for whom the non-compressive IMN was applied were categorised as group I, and 28 for whom the compressive nail was applied were categorised as group II. Finite element analysis was performed using 1.5mm compression, and a mean stress value of 34.67Mpa.

RESULTS

The mean values of union period were calculated as 13.6±2.4 weeks (range: 11-20 months) and functional score was 79.2, respectively in group I, and they were evaluated as a good grade. In group II, the respective mean values of union period were 11.5±2.6 weeks (range: 10-17 months) and functional score was 86, and they were evaluated as excellent.

CONCLUSION

Radiological and functional scores were determined to be better with interlocking compressive nails and shortened the fracture union period in the follow-up in adult femur distal diaphysis fractures.

LEVEL OF EVIDENCE

III; retrospective cohort study.

Five-Year Risk of Conversion to Total Knee Arthroplasty After Operatively Treated Periarticular Knee Fractures in Patients Over 40 Years of Age

BACKGROUND

Periarticular knee fractures present a significant challenge to minimize post-traumatic osteoarthritis. The purpose of this study is to compare the rates of conversion to total knee arthroplasty (TKA) for different periarticular knee fractures, investigate the rate of knee injections as a more rapid assessment of knee symptoms, and identify risk factors that lead to conversion to TKA following periarticular fractures.

METHODS

A comprehensive retrospective review of the Humana administrative claims database was performed. A total of 2813 patients greater than 40 years of age with diagnosis code for tibial plateau fracture or distal femur fracture linked to a Current Procedural Terminology code of open reduction internal fixation between 2007 and 2011 were evaluated. The rates of TKA and knee injections within 5 years were compared. Cox proportional hazards model was used to evaluate risk factors for conversion.

RESULTS

Of 2813 periarticular fractures, the 5-year rate of conversion to TKA was 3.3%. The rate of conversion for tibial plateau fractures was significantly higher at 4.5% compared to 2.3% for distal femur fractures (P = .001). Tibial plateau fracture, obesity, and female gender were risk factors found to portend an increased risk of conversion to TKA with hazard ratios of 1.77, 1.69, and 1.88, respectively. The overall rate of knee injections was 12.8% with an average time to injection of 18.2 months after open reduction internal fixation.

CONCLUSION

The rate of conversion to TKA for periarticular knee fractures overall was 3.3%, while the rate of knee injections within 5 years of surgery was 12.8%, suggesting a not insignificant minority of patients require treatment for symptomatic knee pain.

LEVEL OF EVIDENCE

Therapeutic Level III.

Use of a Titanium Cage and Intramedullary Nails to Treat Distal Femoral Fracture Nonunion in a Patient with Renal Osteopathy: A Case Report

BACKGROUND Nonunion occurs to approximately 10% of people who suffer from distal femoral fracture, which can be induced by other diseases and medical interventions. CKD and subsequent renal osteopathy are regarded as risk factors for nonunion. Internal fixation is the most widely applied medical procedure to treat distal femoral fracture, the efficiency and stability of which are improved by emerging biological materials. Besides traditional screws and plate, titanium cages and intramedullary nails have been introduced lately to repair nonunion and large bone defects resulting from it, which is a huge challenge for orthopedic surgeons. To the best of our knowledge, this is the first report on a distal femoral fracture patient with renal osteopathy treated by internal fixation enhancement using a titanium cage and intramedullary nails. CASE REPORT We report the case of an 84-year-old Chinese woman with renal osteopathy who underwent 4 internal fixation operations to treat a distal femoral fracture. The first 3 surgeries used screws and a plate as internal fixation materials to treat the fracture and nonunion, but did not achieve satisfactory outcomes. In the final surgery, a titanium cage and intramedullary nail were used and the patient recovered soon. CONCLUSIONS Doctors should pay attention to patient's primary health conditions, especially renal disorders, before performing surgeries for distal femoral fracture. It is important to select the most appropriate materials and choose the most suitable surgical method in patients with poor health conditions.

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.

Posttraumatic Arthritis After Intra-Articular Distal Femur and Proximal Tibia Fractures

Posttraumatic arthritis (PTA) is a form of joint degeneration that occurs after physical trauma to a synovial joint. Development of PTA is multifactorial and results from mechanical damage at the time of trauma, a cell-mediated inflammatory response, and abnormal articulation due to persistent malalignment or joint instability. Although some risk factors may be unavoidable, preventing the development of PTA of the knee after intra-articular fracture (IAF) requires restoring anatomic articulation and alignment. Reconstruction with total knee arthroplasty is the treatment of choice for PTA and may be a useful primary treatment for IAF in some.

Modern Implant Options for the Treatment of Distal Femur Fractures

Distal femur fractures occur in a periarticular fracture pattern and disproportionately afflict an aging population. Although the goals of treatment have not changed, the emergence of new surgical techniques and devices has recently been developed and refined to treat this challenging fracture pattern. Treatment options include open reduction and internal fixation with periarticular locking plates, intramedullary nails, or distal femur replacement. Despite rapid adoption, these modern solutions display a concerning complication rate, specifically from nonunion and malunion. The indications for each of these treatment strategies are not well defined and are the subject of current debate. As with the use of any orthopaedic implant, the knowledge of the strengths and weaknesses of each construct is paramount to successful treatment of these fractures. Recently, as the understanding of the biomechanics of distal femur fracture healing has improved, the literature has demonstrated clinical and theoretical improvements in the outcomes after distal femur fracture repair.

Medium term results of total knee arthroplasty as a primary treatment for knee fractures

Introduction: Successful treatment of knee comminuted periarticular fractures associated with osteoporosis and pre-existing arthritis is a challenging task.

Methods: This is a prospective study on 27 patients who had comminuted intra and periarticular knee fractures and pre-existing arthritis. Fractures were classified according to Muller's AO classification. Primary knee arthroplasty was performed ± internal fixation following 4 weeks of splinting. A stem was added to the tibial tray and Legacy Constrained Condylar Knee (LCCK) or Rotating Hinge (RH) prosthesis were used depending on the level of ligament damage and bone defects. The Knee Society Score (KSS) and radiological evaluation were performed at 3, 6 and 12 months then annually thereafter.

Results: The average age of this group of patients was 63 years (range 59–74). Sixteen knees received primary femoral component and Posterior Stabilized insert, while 8 had LCCK. RH implants were chosen in 2 and distal femoral replacement was necessary in one knee. Twenty five patients were available for the final review at an average 6 years in whom the KSS was 80 (range 75–89) points. All patients achieved full knee extension and average knee flexion of 110° (range 90–135°). One knee needed re-admission for early Debridement Antibiotic Irrigation and Retention (DAIR) but none of the knees was revised or awaiting revision.

Conclusion: Knee arthroplasty achieves highly successful outcome when performed as a primary treatment for comminuted intra and periarticular knee fractures in elderly patients. Survival of implants and functional range of movement at midterm are excellent.

Clinical effect of locking compression plate via posterolateral approach in the treatment of distal femoral fractures: a new approach

BACKGROUND

Distal femur fractures are difficult to manage, and the selection of implant approach for internal fixation remains controversial. This study explores the clinical outcome of treating distal femoral fractures with a locking compression plate using a posteriolateral novel approach.

METHODS

Twenty patients with distal femoral fractures were included in our study, and all patients underwent fixation of the fracture using a locking compression plate through a posterolateral approach. The postoperative fracture healing time, complications, and functional recovery were observed and recorded. The joint function was categorized according to the Kolmert functional criteria.

RESULTS

All patients were followed up for an average of 12 months, and all incisions healed by first intention. Among the all patients, 19 patients achieved fracture healing 3 to 4 months after surgery. The remaining 1 patient with distal femoral C3 comminuted fracture achieved partial fracture healing 15 months after surgery, and bone grafting was needed. All knees can reach the state of straightening, and the postoperative excellent rate was 90%. Among them, 8 patients had maximal flexion of more than 120°, 10 patients had flexion between 90° and 120°, and 2 other patients had flexion of 70° and 40°.

CONCLUSIONS

Fixation of the fracture using a locking compression plate through a posterolateral approach seemed to be an acceptable surgical option for treatment of distal femoral fractures.

[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.

Complex knee injury scenario in tertiary level care in North India: An epidemiological study

Floating knee injury has been considered as one of the severe orthopedic injury, and is often associated with major systemic trauma involving other organs.

OBJECTIVE

To identify the incidence of floating knee injury, severity of injury and associated orthopaedic and non-orthopaedic injury.

METHODS

Epidemiologic study conducted from 1 Jan 2014 to 31 Dec 2014.

RESULTS

A total of 136 cases with floating knee injury were registered. Modified Fraser classification showed 58 patients had type 1, 74 had type 2 and 4 had type 3 floating knees. 119(87.5%) patients had open fractures and Gustilo-Anderson type IIIA(29.4%) being the commonest. No Mortality was found. 16 (11.76%) of floating knees had to undergo amputation of afflicted limb.

CONCLUSION

Statics of such data would be helpful in planning and preparing ourselves as healthcare professionals to prevent high mortality and morbidity/disability in floating knee injury.

STUDY DESIGN

Retrospective Epidemiological.

LEVEL OF EVIDENCE

Level 4 (Case Study).

‘Modern’ distal femoral locking plates allow safe, early weight-bearing with a high rate of union and low rate of failure

Aims

Fractures of the distal femur can be challenging to manage and are on the increase in the elderly osteoporotic population. Management with casting or bracing can unacceptably limit a patient’s ability to bear weight, but historically, operative fixation has been associated with a high rate of re-operation. In this study, we describe the outcomes of fixation using modern implants within a strategy of early return to function.

Patients and Methods

All patients treated at our centre with lateral distal femoral locking plates (LDFLP) between 2009 and 2014 were identified. Fracture classification and operative information including weight-bearing status, rates of union, re-operation, failure of implants and mortality rate, were recorded.

Results

A total of 127 fractures were identified in 122 patients. The mean age was 72.8 years (16 to 101) and 92 of the patients (75%) were female. A consultant performed the operation in 85 of the cases, (67%) with the remainder performed under direct consultant supervision. In total 107 patients (84%) were allowed to bear full weight immediately. The rate of clinical and radiological union was 81/85 (95%) and only four fractures of 127 (3%) fractures required re-operation for failure of surgery. The 30-day, three- and 12-month mortality rates were 6 (5%), 17 (15%) and 25 (22%), respectively.

Conclusion

Our study suggests an exponential increase in the incidence of a fracture of the distal femur with age, analogous to the population suffering from a proximal femoral fracture. Allowing immediate unrestricted weight-bearing after LDFLP fixation in these elderly patients was not associated with failure of fixation. There was a high rate of union and low rate of re-operation. Cite this article: Bone Joint J 2017;99-B:951–7.

Minimally invasive internal fixation of distal femur fractures

Fractures of the distal femur remain a daunting challenge. Since 1970, operative treatment has been recommended. Unfortunately, it is fraught with complications, and techniques have been developed to limit incidence of non-union, infection and stiffness. A soft-tissue friendly approach is the key point, with minimally invasive surgery as the ultimate goal: its biological and anatomical advantages have been demonstrated, but clinical studies have been less convincing, being based on historical series. At present, retrograde nailing and minimally invasive percutaneous plate osteosynthesis (ideally by locking plate) are the two main techniques. Unfortunately, reports tend to compare implants rather than operative techniques, hindering solid conclusions. Lastly, the delineation of "distal femur fracture" is quite variable, sometimes situated well above the AO epiphyseal square. Meta-analyses find almost no difference between the two implants in minimally invasive procedures. The main advantage of the plate is its versatility, whereas nailing can be impossible in case of certain hip or knee prostheses, compound articular fracture or medullary canal obstruction by fixation material (nail, stem, screw, etc.). The role of arthroscopy is limited. Only a few case reports describe its use in reduction of epiphyseal fracture. In the last analysis, the surgeon's experience is more relevant to outcome than any particular implant.

Distal Femoral Replacement for Acute Distal Femoral Fractures in Elderly Patients

OBJECTIVES

To evaluate outcomes and complications using cemented modular distal femoral replacement in elderly patients with distal femoral fractures.

DESIGN

Retrospective chart review, case series.

SETTING

A Level 1 and Level 2 trauma center, both tertiary referral hospitals.

PATIENTS/PARTICIPANTS

Eighteen patients older than 60 years (average age 77 years) who had cemented distal femoral replacement for distal femoral fractures (comminuted, intraarticular, osteoporotic, arthritic) between 2005 and 2013. Patients with previous knee surgery were excluded.

INTERVENTION

Cemented modular distal femoral replacement.

MAIN OUTCOME MEASURES

Implant status, complications, Knee Society Score, Musculoskeletal Tumor Society score, and Western Ontario and McMaster Osteoarthritis Index.

RESULTS

All patients were extremely or very satisfied with their outcomes. For patients with functional outcome data, Knee Society Score averaged 85.7 with a functional score of 35, Musculoskeletal Tumor Society score averaged 19.2, and Western Ontario and McMaster Osteoarthritis Index score averaged 23.1 at an average follow-up of 2.3 years. Range of motion was 1-99 degrees. Implant-related complications occurred in 2 patients (11%); one required revision to total femoral replacement because of periprosthetic fracture and the other had a deep infection that required exchange of the components. No patient had aseptic loosening or patellar maltracking. There were no perioperative deaths or late amputations.

CONCLUSIONS

Cemented modular distal femoral replacement is a viable treatment option in elderly patients that permits immediate full weight-bearing, with most patients returning to preoperative functional status.

LEVEL OF EVIDENCE

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

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.

Management principles of osteoporotic fractures

Osteoporotic fractures are difficult to manage. They pose a number of difficulties to the surgeon arising from the underlying poor bone stock compromising the intention to achieve optimum fixation. Moreover, the frail elderly patients present with a variety of medical co-morbidities increasing the risk of developing perioperative complications. Despite these recognized challenges, there are currently a number of improving technologies and strategies at the surgeon's disposal to provide more confidence with fracture fixation and maximize the chance of success.

Management of Distal Femur Fractures in Adults: An Overview of Options

Surgical treatment of periarticular and intra-articular fractures of the distal femur pose a significant challenge to the orthopedic surgeon. The primary goal of surgical treatment remains: restoration of the articular surface to the femoral shaft, while maintaining enough stability and alignment to enable early range of motion and rehabilitation. With appropriate surgical planning, these injuries can be managed with a variety of methods and techniques, while taking into account patients' functional goals, fracture characteristics, health comorbidities, bone quality, and risk of malunion and nonunion.

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.

Management of distal femur fractures with modern plates and nails: state of the art

Fractures of the distal femur, even those with articular extension, are well suited to surgical fixation with modern precontoured anatomic plates and nails. Numerous adjuvant techniques are available to the treating surgeon to obtain and maintain reduction while preserving fracture biology. Yet despite their proven track record and benefits over older implants, technical errors are common and must be overcome with proper preoperative planning and intraoperative attention to detail. This review summarizes the current state of the art regarding distal femur fractures, with an emphasis on relevant modern plate and nail surgical techniques, tempered by our current understanding of implant biomechanics, fracture healing, and long-term outcomes.

Distal femoral fractures: The need to review the standard of care

BACKGROUND

Hip fracture care has evolved, largely due to standardisation of practice, measurement of outcomes and the introduction of the Best Practice Tariff, leading to the sustained improvements documented by the National Hip Fracture Database (NHFD). The treatment of distal femoral fractures in this population has not had the same emphasis. This study defines the epidemiology, current practice and outcomes of distal femoral fractures in four English centres.

PATIENTS AND METHODS

105 patients aged 50 years or greater with a distal femoral fracture, presenting to four UK major trauma centres between October 2010 and September 2011 were identified. Data was collected using an adapted NHFD data collection tool via retrospective case note and radiograph review. Local ethics approval was obtained.

RESULTS

Mean age was 77 years (range 50-99), with 86% female. 95% of injuries were sustained from a low energy mechanism, and 72% were classified as either 33-A1 or 33-C1. The mean Parker mobility score and Barthel Independence Index were 5.37 (0-9) and 75.5 (0-100) respectively. Operative management was performed in 84%, and 86% had their surgery within 36 h. Three quarters were fixed with a peri-articuar locking plate. There was no consensus on post operative rehabilitation, but no excess of complications in the centres where weight bearing as tolerated was the standard. 45% were seen by an orthogeriatrician during their admission. Mean length of stay was 29 days. Mortality at 30 days, 6 months, and 1 year was 7%, 16% and 18% respectively.

DISCUSSION

This study demonstrates that the distal femoral and hip fracture populations are similar, and highlights the current disparity in their management. The metrics and standards of care currently applied to hip fractures should be applied to the treatment of distal femoral fractures. Optimal operative treatment and rehabilitation remains unclear, and is in need of further research.

Clinical instability of the knee and functional differences following tibial plateau fractures versus distal femoral fractures

BACKGROUND

Fractures of the knee account for about 6% of all trauma admissions. While its management is mostly focused on fracture treatment, it is not the only factor that defines the final outcome.

OBJECTIVES

This study aimed to study objective and subjective outcomes after proximal tibial versus distal femoral fractures in terms of knee instability and health-related quality of life.

PATIENTS AND METHODS

This retrospective, cross-sectional, cohort study was carried out on 80 patients with either isolated proximal tibial (n = 42) or distal femoral (n = 38) fractures, who underwent open reduction and internal fixation. All the fractures were classified based on the Schatzker and AO classification for tibial plateau and distal femoral fractures, respectively. The patients were followed and examined by an orthopedic knee surgeon for clinical assessment of knee instability. In their last follow-up visit, these patients completed a Lysholm knee score and the short-form (SF) 36 health survey.

RESULTS

Among the 42 tibial plateau fractures, 25% were classified as Schatzker type 2. Of the 38 distal femoral fractures, we did not find any type B1 or B3 fractures. The overall prevalence of anterior and posterior instability was 42% and 20%, respectively. Medial Collateral Ligament (MCL) and Lateral Collateral Ligament (LCL) injuries were detected clinically in 50% and 28%, respectively. The incidence rates of ligament injuries in tibial plateau fractures were as follows: Anterior Collateral Ligament (ACL) 26%, Posterior Collateral Ligament (PCL) 7%, MCL 24%, and LCL 14%. Medial collateral ligament injury was the most common in the Schatzker type 2 (50% of the injuries). Distal femoral fractures were associated with ACL injury in 16%, PCL in 13%, MCL in 26% and LCL in 14%. However, final knee range of motion (ROM) and function (Lysholm score) were not associated with fracture location. No statistically significant difference was observed between the two groups, except for the valgus stress test at 30°knee flexion, which was more positive in tibial fractures. All eight domains of SF-36 score in the distal femoral and proximal tibial fractures were significantly different from the normal values; however, there were no statistically significant differences between femoral and tibial fracture scores.

CONCLUSIONS

Although ROM is acceptable in knee joint fractures, instability is common. However, it seems that knee function and quality of life are not associated with the location of the fracture.

Do elderly patients fare worse following operative treatment of distal femur fractures using modern techniques?

BACKGROUND

The purpose of this study was to compare the functional outcomes and quality of life of older and younger patients with similarly treated distal femur fractures.

METHODS

We conducted an assessment of 57 patients who sustained distal femur fractures (Orthopaedic Trauma Association Type 33B, C) and underwent surgical treatment at our academic medical center. Patients were divided into 2 groups for analysis: an elderly cohort of patients aged 65 or older and a comparison cohort of patients younger than age of 65. A retrospective review of demographics, preoperative ambulatory status, radiographic data, and physical examination data was collected from the medical records. Follow-up functional data were collected via telephone at a mean of 2.5 years (range 6 months-8 years) using a Short Musculoskeletal Functional Assessment (SMFA). All patients underwent standard operative treatment of either nail or plate fixation.

RESULTS

There was no statistical difference in gender, fracture type, surgical technique, surgeon, or institution where the surgery was performed. The percentage of patients with healed fractures at 6-months follow-up was not significantly different between the cohorts. The elderly cohort had slightly worse knee range of motion at 3, 6, and 12 months postoperatively but there was not a statistically significant difference between the groups. The SMFA Daily Activity, Functional, and Bother indices were significantly worse in the older cohort (P < .01, P = .01, P = .02, respectively). However, there was no significant difference in the SMFA Emotional or Mobility indices.

CONCLUSION

Despite lower quality of life and functional scores, this study suggests that relatively good clinical outcomes can be achieved with surgical fixation of distal femoral fractures in the elderly patients. Age should not be used as a determinate in deciding against operative treatment of distal femur fractures in the elderly patients.

Distal femur fractures. Surgical techniques and a review of the literature

Fractures of the distal femur are rare and severe. The estimated frequency is 0.4% with an epidemiology that varies: there is a classic bimodal distribution, with a frequency peak for men in their 30s and a peak for elderly women; however, at present it is found predominantly in women and in the elderly with more than 50% of patients who are over 65. The most common mechanism is an indirect trauma on a bent knee, and more rarely direct trauma by crushing. The anatomy of the distal femur explains the three major types of fracture. Because of the anatomy of the distal femur, only surgical treatment is indicated to stabilize the fracture. A non-surgical treatment is a rare option. The aim of this report was to provide an update on the existing surgical solutions for the management of these fractures and describe details of the surgical technique applicable to these injuries. Recent radiological, clinical and biomechanical data published in the literature are reported to compare different surgical options.

Retrograde nailing versus locked plating of extra-articular distal femoral fractures: comparison of 36 cases

OBJECTIVE

The purpose of this study was to retrospectively evaluate the use of locked plating (LP) and retrograde nailing (RN) for treating extra-articular distal femoral fractures.

MATERIALS AND METHODS

From January 2004 to March 2009, 36 patients with extra-articular distal femoral fractures were surgically treated at our Trauma Center. The patients were divided into two groups according to the treatment method, with 19 patients being treated by LP (LP group) and 17 patients via RN (RN group).

RESULTS

The demographics of age (p = 0.460) and gender (p = 0.481) in both LP and RN groups were similar. No differences were found with respect to postoperative malreduction, deep infection, hardware failure, operating time, knee pain, HSS score and range of knee movement. The mean intraoperative blood loss was significantly higher in the RN group (298 ± 65.2 ml, range 200-410) than in the LP group (200 ± 48.9 ml, range 130-300) (p < 0.01). However, a higher rate of union disturbance was observed in the LP group (36.8%) compared to the RN group (5.9%) (p = 0.044).

CONCLUSIONS

The overall union disturbance rate in the LP group was higher than in the RN group. However, further analysis revealed that clinical outcome may largely depend on surgical technique rather than on the choice of implant. Therefore, correct rules (the same for every procedure) should be strictly adhered to, especially in the application of LP.

Designing a biomechanics investigation: choosing the right model

Physical testing is commonly performed to answer important biomechanical questions in the treatment of patients with fractures and other orthopaedic conditions. However, a variety of mistakes that are made in performing such investigations can severely limit their impact. The goal of this article is to discuss important aspects of study design to consider when planning for biomechanical investigations so that the studies can provide maximal benefit to the field. The best mechanical investigations begin with a good research question, one that comes out of patient care experience, is clearly defined, and can be stated concisely. The first practical issue to be considered is often choosing the type of physical specimens to be tested to address the research question. A related issue involves determining how many specimens will be needed to answer the posed mechanical question. Cadavers are generally still the closest to the actual clinical situation, but they are limited by interspecimen variability, which often requires a matched pair design that can address only one question. Simulated bone specimens limit variability and can replicate normal and osteoporotic bone. In planning the physical testing, the critical mechanical variables involved in answering the research question must be identified and due consideration given to deciding how best to measure them. Another important issue that arises relates to whether or not single static loadings will suffice in the testing (eg, to study construct stiffness) or whether cyclic dynamic testing is necessary (eg, to study late failure likely attributable to fatigue). To summarize, experimental design should be carefully planned before initiating mechanical testing. Sample size calculations should be performed to ensure adequate power and that clinically relevant differences can be detected. This pregame analysis can save significant time and cost and greatly increase the likelihood that the results will advance knowledge.

Retrograde nailing and compression bolts in the treatment of type C distal femoral fractures

INTRODUCTION

This is a prospective study that verifies the usefulness of retrograde intramedullary nailing (IMN) combined with 'independent' compression bolts in the management of type C (AO/OTA classification) fractures of the distal femur.

PATIENTS AND METHODS

Within a period of 4 years, 17 patients (mean age of 54 years) with intra-articular fractures of the distal femur (type C according to AO/OTA classification) were treated with retrograde IMN and compression condylar bolts. The patients followed an early mobilisation and weight-bearing protocol.

RESULTS

All fractures healed in a mean time of 14.78 weeks with no incidences of malunion, nonunion or infections. No secondary failure of fixation occurred. Partial weight bearing was initiated in average 6.35 weeks postoperatively whilst full weight bearing in 14.6 weeks. The patients regained full extension and 117.22° of mean flexion of the knee joint while the mean New Oxford knee score was 42.05.

CONCLUSIONS

In the treatment of type C fractures of the distal femur, the combination of retrograde nailing and 'independent' compression condylar bolt (inserted prior to the nailing) provided a strong fixation that facilitated uncomplicated outcomes and uneventful early mobilisation.

Retrograde femoral nailing in elderly patients: outcome and functional results

Functional outcome after retrograde femoral intramedullary nailing was investigated in 35 patients older than 60 years (mean, 86 years) with 36 fractures, comprising 15 (41.7%) shaft and 21 (58.3%) distal fractures; overall, 7 (19.4%) periprosthetic fractures occured. Twenty-two (62.9%) of 35 patients were evaluated at a mean 16.5-month follow-up with the Lyshom-Gillquist score and the SF-8 questionaire. Primary union rate was 97.8%, with no significant differences in duration of surgery, bone healing, mobilization, and weight bearing among different fracture types; periprosthetic fractures revealed a significantly delayed mobilization (P=.03). Complications occured significantly more often among distal femoral fractures (P=.009), including all revision surgeries. The most frequently encountered complication was loosening of distal locking bolts (n=3). Lysholm score results were mainly influenced by age-related entities and revealed fair results in all fractures (mean in the femoral shaft fracture group, 78.1 vs mean in the distal femoral fracture group, 74.9; P=.69), except in the periprosthetic subgroup, which had good results (mean, 84.8; P=.23). This group also had increased physical parameters according to SF-8 score (P=.026). No correlation existed between SF-8 physical parameters and patient age or surgery delay, whereas a negative correlation existed between patient age and SF-8 mental parameters (P=.012). Retrograde femoral intramedullary nailing is commonly used in elderly patients due to reliable bone healing, minimal soft tissue damage, and immediate full weight bearing. It also offers a valid alternative to antegrade nailing in femoral shaft fractures.

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

OBJECTIVES

In the distal femur, locked plating is efficacious when coronal fractures preclude the use of a conventional fixed-angle device. However, minimal comparative data exist for supracondylar fracture patterns, which could be treated with other devices. The purpose of this study was to compare the 95-degree angled blade plate (ABP) versus the Locking Condylar Plate (LCP) by assessing complications and secondary procedures in fractures amenable to treatment with either implant.

DESIGN

Retrospective review.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Seventy patients with 71 distal femoral fractures (OTA 33-A, 33-C1, 33-C2) amenable to either ABP or LCP with a mean age of 59.5 years (range, 20-92 years) were included. Seventeen fractures (24%) occurred adjacent to a previous knee arthroplasty (10 ABP and 7 LCP). The 2 groups were similar with respect to age, fracture pattern, and the presence of open fracture. Most injuries were the result of high-energy trauma, and 21% were open fractures.

INTERVENTION

Thirty-two fractures (45%) were treated with an ABP, and 39 (55%) were treated with the LCP.

MAIN OUTCOME MEASURES

Complications, including infection, nonunion, and malunion, and secondary operations were determined.

RESULTS

After a mean of 26-month follow-up, 4 patients (6.0%) were treated for infections. Malunions occurred in 11% of LCP patients and in 1 ABP patient (3.4%, P = 0.14). All patients with malunions were older than 55 years. Seven patients (11%) were treated for nonunions. Six of the nonunions occurred after LCP (16% vs. 3.4%, P = 0.11) Complications were more frequent in LCP patients (35%) versus ABP patients (10%, P = 0.001). Complications were not related to fracture pattern, periprosthetic fracture, or open fracture. Mean age of patients with complications was 64 years (vs. 53 years, P = 0.01), and they were more likely to have lower energy mechanisms (P = 0.017). Overall, 18 patients (27%) underwent secondary procedures, including treatment of infection, nonunion, malunion, or prominent implant removal. Secondary procedures were more common after LCP (43%) versus ABP (6.9%, P = 0.0008) patients. Painful prominent implants were removed from 7 LCP patients (18%) and no ABP patients (P = 0.01).

CONCLUSIONS

Distal femur fractures are often associated with prolonged healing and rehabilitation times, which increase substantially when complications occur. Internal fixation of these fractures may be performed successfully with ABP or LCP. In our review of fractures that could be treated with either implant, patients treated with locking plates had more complications and nonunions, requiring more secondary procedures to treat complications and to remove prominent implants. Furthermore, locking plates are substantially more expensive than conventional fixed-angle devices. Future investigation is needed in the form of a large randomized prospective study to clearly define clinical differences, functional outcomes, and costs of care.

LEVEL OF EVIDENCE

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

Modified retrograde-locked nailing for aseptic femoral supracondylar nonunion with severe osteoporosis in elderly patients

BACKGROUND

Femoral supracondylar nonunions in elderly patients are uncommon. To date, there is no convincing technique for managing this condition. When the nonunion is associated with severe osteoporosis, treatment becomes even more complicated. We developed a modified retrograde-locked nailing technique to treat this complex lesion.

METHODS

Twenty-four aseptic femoral supracondylar nonunions with severe osteopenia in 24 elderly patients (aged ≥65 years) were treated. A retrograde femoral-locked nail was inserted in the dynamic mode. Next, the medial ½ to 2/3 marrow cavity in the nonunion site was filled with bone cement, and the lateral 1/3 to ½ marrow cavity received a cancellous bone graft with or without a bone graft substitute. A cylindrical brace was applied for 3 weeks postoperation. Early ambulation with a walker or wheelchair was encouraged.

RESULTS

Twenty patients were followed up for an average period of 2.5 years (range, 1.1-4.5 years), and 18 nonunions healed. The union rate was 90.0% with an average union period of 4.9 months (range, 4-7 months). No deep infection or malunion was found. The two patients with persistent nonunions were advised to use a walker whenever necessary. The satisfactory rate for knee function improved from 0% preoperatively to 80.0% at the latest follow-up.

CONCLUSIONS

The described technique may concomitantly provide sufficient stability and initiate osteogenic potential, thus facilitating bone union. This technique is simple with a low complication rate and thus should be considered as a useful alternative for treating this complex lesion.

Early results of retrograde expandable nail fixation of 29 distal femoral fractures

The authors retrospectively reviewed 27 consecutive patients with 29 fractures of the distal femur treated with the new retrograde expandable nail. One 10-mm diameter nail that expands to 16 mm was used with the possibility of locking in the condylar area only. Retrieved data included single versus multiple injuries, fracture type, operation time, reaming or nonreaming, hospitalization and healing times, and intra- and postoperative complications. The overall average operation time was 96 (range 40-320) minutes, but only 65 (range 40-120) minutes for isolated fractures. The overall mean hospitalization time was 16 (range 3-40) days, but only 7 (range 4-10) days for isolated fractures. Follow-up continued until fracture healing or for a minimum of 1 year (average 14 months, range 12-24 months). The average clinical union time was 83 (range 43-179) days, and the mean radiographic healing was 87 (range 43-179) days. One patient developed a nonunion that required exchange of the nail to the same device. Another patient underwent hardware removal during a procedure for a torn meniscus. These preliminary results demonstrate satisfactory healing and alignment for the treatment of distal femoral shaft fractures by means of this new device without jeopardizing the knee joint by nail protrusion.

Mortality after distal femur fractures in elderly patients

BACKGROUND

Hip fractures in the elderly are associated with high 1-year mortality rates, but whether patients with other lower extremity fractures are exposed to a similar mortality risk is not clear.

QUESTIONS/PURPOSES

We evaluated the mortality of elderly patients after distal femur fractures; determined predictors for mortality; analyzed the effect of surgical delay; and compared survivorship of elderly patients with distal femur fractures with subjects in a matched hip fracture group.

PATIENTS AND METHODS

We included 92 consecutive patients older than 60 years with low-energy supracondylar femur fractures treated between 1999 and 2009. Patient, fracture, and treatment characteristics were extracted from operative records, charts, and radiographs. Data regarding mortality were obtained from the Social Security Death Index.

RESULTS

Age-adjusted Charlson Comorbidity Index and a previous TKA were independent predictors for decreased survival. Congestive heart failure, dementia, renal disease, and history of malignant tumor led to shorter survival times. Patients who underwent surgery more than 4 days versus 48 hours after admission had greater 6-month and 1-year mortality risks. No differences in mortality were found comparing patients with native distal femur fractures with patients in a hip fracture control group.

CONCLUSIONS

Periprosthetic fractures and fractures in patients with dementia, heart failure, advanced renal disease, and metastasis lead to reduced survival. The age-adjusted Charlson Comorbidity Index may serve as a useful tool to predict survival after distal femur fractures. Surgical delay greater than 4 days increases the 6-month and 1-year mortality risks. Mortality after native fractures of the distal femur in the geriatric population is high and similar to mortality after hip fractures.

LEVEL OF EVIDENCE

Level II, prognostic study. See the guidelines online for a complete description of evidence.

Femoral corrective osteotomy for malunited supracondylar femoral fracture after TKA in a patient with rheumatoid arthritis

This article presents a case of femoral corrective osteotomy for malunited supracondylar femoral fracture after total knee arthroplasty (TKA) in a patient with rheumatoid arthritis. The patient underwent 1-stage bilateral TKA and 2-stage bilateral total hip arthroplasty 17 years prior at our institution. Her fall 10 years before led to a supracondylar femoral fracture that was treated nonoperatively for 3 months and led to malunion. Complaints of mild right knee pain and remarkable varus deformity were observed. On examination, the right knee was not swollen and tender. Range of motion (ROM) of the right knee was 0° to 130°. The patient needed crutches to ambulate. Knee score and function scores, according to the Knee Society clinical rating system, were 65 and 25 points, respectively. Radiographs after malunion showed remarkable varus knee and the femorotibial angle was 197°. At the time of surgery, the components were stable and bone union was completed. Valgus corrective osteotomy of the femur was performed using a retrograde intramedullary nail, with satisfactory results at 10-year follow-up. The patient is able to walk without a cane and has 0° to 130° ROM. Knee and function scores were 88 and 80 points, respectively. Radiographs showed complete bone union and the femorotibial angle was 179° with no loosening of the prostheses. Femoral corrective osteotomy is recommended for malunited supracondylar femoral fracture after TKA.

Distal femoral fractures: current concepts

The diversity of surgical options for the management of distal femoral fractures reflects the challenges inherent in these injuries. These fractures are frequently comminuted and intra-articular, and they often involve osteoporotic bone, which makes it difficult to reduce and hold them while maintaining joint function and overall limb alignment. Surgery has become the standard of care for displaced fractures and for patients who must obtain rapid return of knee function. The goal of surgical management is to promote early knee motion while restoring the articular surface, maintaining limb length and alignment, and preserving the soft-tissue envelope with a durable fixation that allows functional recovery during bone healing. A variety of surgical exposures, techniques, and implants has been developed to meet these objectives, including intramedullary nailing, screw fixation, and periarticular locked plating, possibly augmented with bone fillers. Recognition of the indications and applications of the principles of modern implants and techniques is fundamental in achieving optimal outcomes.

How comparable is so-called standard fracture fixation with an identical implant? A prospective experience with the antegrade femoral nail in South Africa and Europe

BACKGROUND

The utilisation and consequences of standardised operative procedures may importantly differ between different healthcare systems. This is the first investigation comparing the treatment and outcome of femoral shaft fractures stabilised with an identical implant between trauma centres in 2 continents (Europe, EU and South Africa, SA).

METHODS

Following standardised introduction of the technique, the prospective, observational multicentre study enrolled 175 patients who underwent intramedullary fracture fixation using the antegrade femoral nail (AFN) for femoral shaft fractures. Eleven EU hospitals recruited 86 patients and 1 SA centre 89 patients in the study period. Comparison of epidemiologic data, operative characteristics as well as subjective (e.g., pain, SF-36) and objective (e.g., X-ray, range of motion [ROM]) 3-month and 1-year outcomes were performed (p<0.05).

RESULTS

Compared to EU centres, several significant differences were observed in SA: (1) on average, patients operated on were younger, had less concomitant diseases and had more severe open fractures; (2) operative stabilisation was more often undertaken by young, unsupervised residents, with shorter operating and intraoperative fluoroscopy times; (3) mean hospital stay was shorter, with less recorded complications, but a higher loss to follow-up rate. Non- or malunion rates and subjective outcomes were similar for both groups, with the physical component of the SF-36 at the 1-year follow-up not fully restoring to baseline values.

CONCLUSIONS

Our investigation demonstrates the importance of several major differences between 2 different regions of the world in the treatment of femoral shaft fractures, despite involving only high level trauma centres and using an identical implant. The intercontinental comparison of results from clinical studies should be interpreted very carefully considering the heterogeneity of populations and clinical settings.