Treatment of acute distal femur fractures

Risk Factors of Proximal Screw Breakage of Locking Plate (ZPLP®) after MIPO for Distal Femur Fractures -Analysis of Patients with Plate Removal after Bony Union

BACKGROUND

Locking a compression plate is a more favorable surgical technique than intramedullary nailing in the treatment of distal femur fractures. This study analyzed the risk factors of proximal screw breakage retrospectively, which was confirmed in the patients with plate removal after bony union.

METHODS

A total of 140 patients who were fixed by MIPO using ZPLP from 2009 to 2019 were identified. A total of 42 patients met the inclusion criteria and were included. The screw breakage group (12 patients) and the non-breakage group (30 patients) were compared.

RESULTS

Approximately 12 (28.6%) of 42 plate-removal patients showed proximal screw breakage. The breakage of proximal screws developed at the junction of the screw head and neck. The number of broken proximal screws averaged 1.4 (1~4). The breakage of the proximal screw even after the bony union is more frequent in older patients (p = 0.023), the dominant side (p = 0.025), the use of the cortical screw as the proximal uppermost screw (p = 0.039), and the higher plate-screw density (p = 0.048).

CONCLUSIONS

Advanced age, dominant side, use of the cortical screw as the uppermost screw, and higher plate-screw density were related to proximal screw breakage. When the plate is removed after bony union or delayed union is shown in these situations, the possibility of proximal screw breakage should be kept in mind.

Results of the surgical treatment of intra-articular fractures of the distal femur using a retrograde intramedullary technique

Background: Distal femoral fractures are a widely spread problem in traumatology, which can be caused by both a high-energy trauma and a low-energy trauma in senile patients with osteoporosis. The conservative treatment shows little promise. The surgical treatment of patients is still a challenge for orthopedic surgeons regarding both the technical aspect and a high risk of complications. There are several surgical methods with the use of plates and nails, but there is still no universal conception of the surgical treatment. Aim: comparative analysis of methods of intramedullary retrograde osteosynthesis and bone osteosynthesis in the treatment of fractures of the distal femur. Methods: In this study, we evaluated the treatment results of 46 patients who underwent osteosynthesis for intraarticular fractures of the distal femur using an intramedullary retrograde nail. The evaluation was carried out based on such parameters as the duration of the operation and the time from the moment of injury to the operation, the intraoperative blood loss and the function of the knee joint. On average, the operation time using a retrograde femoral nail was 45 minutes. Reducing the duration of the operation improved the functional results of the treatment. Reducing the operation time when installing a retrograde intramedullary nail was achieved with a relatively simple technique for installing this type of a fixator and the use of minimally invasive approaches. Results: On average, the operation time using a retrograde femoral nail was 45 minutes. Reducing the duration of the operation improved the functional results of treatment. Reducing the operation time when installing a retrograde intramedullary nail was due to a relatively simple technique for installing this type of fixator and the use of minimally invasive approaches. One year after the surgery, the following mean values were achieved: 78 (6485) points according to the KSS knee score, 85 (6889) points according to the KSS function score, 3.1 (1.34.2) cm for the severity of pain syndrome according to the VAS scale, 105 (88120) degrees for the flexion in the knee joint. However, a number of post-op complications were observed: deep vein thrombosis of lower extremities was found in 6 (13.1%) patients, formation of a false-joint was seen in 3 (6.5%) patients, 1st grade arthritis of the knee joint was detected in 36 patients (78.2%), 2nd grade arthritis was observed in 10 patients (21.8%). 3rd grade arthritis was not detected. 3.5 years after the operation, none of the patients needed a knee joint replacement. Conclusion: Retrograde intramedullary osteosynthesis in type C distal femoral fractures promotes early rehabilitation, a complete recovery of the knee joint function and healing of the fracture, and represents an effective method of treatment.

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.

Femoral condylar locking compression plates: a case series. The Rural District General Hospital Experience

Most studies regarding the use of locking condylar plates in distal femoral fractures have been carried out in tertiary centres. The aim of this case series was to examine outcomes for patients managed in a rural setting and to answer the question: ‘should we be shipping these patients out to a regional trauma centre?’ Recent insertions of condylar locking compression plates (LCPs) at a rural district general hospital were examined. (All used the Synthes LCP Condylar Plate 4.5/5.0 periarticular plating system). Their clinical records and radiology were reviewed to identify failure rates and facilitate discussion of such cases. Of 36 reviewed cases, 4 instances of failure were identified (11%), and their cases are discussed individually herein. This review not only affords the opportunity to discuss cases of failure and to speculate upon their potential causes, but also highlights reassuringly high quality of outcomes for these patients outside of larger teaching hospitals.

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.

The Epidemiology of Adult Distal Femoral Shaft Fractures in a Central London Major Trauma Centre Over Five Years

Background:

Distal femoral fractures account for 3-6% of adult femoral fractures and 0.4% of all fractures and are associated with significant morbidity and mortality rates. As countries develop inter-hospital trauma networks and adapt healthcare policy for an aging population there is growing importance for research within this field.

Methods:

Hospital coding and registry records at the central London Major Trauma Center identified 219 patients with distal femoral shaft fractures that occurred between December 2010 and January 2016. CT-Scans were reviewed resulting in exclusion of 73 inappropriately coded, 10 pediatric and 12 periprosthetic cases. Demographics, mechanism of injury, AO/OTA fracture classification and management were analyzed for the remaining 124 patients with 125 fractures. Mann Whitney U and Chi Squared tests were used during analyses.

Results:

The cases show bimodal distribution with younger patients being male (median age 65.6) compared to female (median age 71). Injury caused through high-energy mechanisms were more common in men (70.5%) whilst women sustained injuries mainly from low-energy mechanisms (82.7%) (p<0.0001). Majority of fractures were 33-A (52.0%) followed by 33-B (30.4%) and 33-C (17.6%). Ninety-two (73.6%) underwent operative management. The most common operation was locking plates (64.1%) followed by intramedullary nailing (19.6%).

Interpretation:

The epidemiology of a rare fracture pattern with variable degrees of complexity is described. A significant correlation between biological sex and mechanism of injury was identified. The fixation technique favored was multidirectional locking plates. Technical requirements for fixation and low prevalence of 33-C fractures warrant consideration of locating treatment at centers with high caseloads and experience.

Double plating of intra-articular multifragmentary C3-type distal femoral fractures through the anterior approach

INTRODUCTION

In this prospective case series, we report a mean of 12-month follow-up of the utilization of a dual plating of distal femoral fractures. Our technique included a lateral distal femoral locked plate with a low-contact-locked medial plate and bone graft through an extended medial parapatellar anterior approach for the fixation of C3-type distal femoral fractures.

PATIENTS AND METHODS

Sixteen patients (11 males and 5 females) presented with supracondylar femoral fracture type C3, according to Müller long-bone classification system and its revision OA/OTA classification. These were treated using dual plating through extended anterior approach and bone grafting. Our outcomes included clinical and radiological outcomes. Secondary outcomes included postoperative complications.

RESULTS

The mean time of complete radiological union in the studied population was 6.0 ± 3.5 months with a range of 3-14 months. We have not observed postoperative varus or valgus deformity in our cohort. The majority (68.75%) of the studied patients showed significant improvement in range of motion (90°-120°) during follow-up. Eleven out of sixteen patients (68.75%) had well-to-excellent functional outcome. Poor outcome was reported in only two patients (12.50%).

CONCLUSIONS

Dual plating fixation using anterior approach for type C3 distal femoral fractures is an efficient method of management. It has several advantages such as precise exposure, easy manipulation, anatomical reduction and stable fixation. However, operative indications and instructions should be strictly followed. The surgical technique must be rigorous, and the biomechanical qualities of these implants must be understood to prevent the development of major complications.

Distal Femur Locking Plate: The Answer to All Distal Femoral Fractures

INTRODUCTION

Good results have been published by researchers with distal femur nail, dynamic condylar screw and even addition of a medial plate to a distal femur locking plate for treating distal femur fractures. By this study, we explore the capability of a distal femur locking plate to counter distal femur fractures of extra- articular, partial or intra- articular nature. Positive results have been published by various groups from all over the world.

AIM

To study the functional and radiological outcome of distal femoral fractures in skeletally mature patients treated by open reduction and internal fixation with distal femur locking plate.

MATERIALS AND METHODS

This was a prospective study conducted from January 2012 to March 2014 at the Government Medical College and Hospital (GMCH) with a 2 year follow-up. Twenty five skeletally mature patients with post-traumatic distal femur fractures were included. Patients with open grade 3B and 3C distal femur fractures, according to the Gustilo- Anderson classification and pathological distal femur fractures were excluded from the study. Patients with any fracture other than the distal femur in the ipsilateral limb were excluded from the study. Follow-up at 3 months, 6 months, 1 year and 2 years was carried out and evaluation was done according to the Neer scoring system. The statistical data analysis was carried out using SPSS version 20 (IBM, Chicago, USA). The p-value <0.05 was considered significant.

RESULTS

Following all principles of fracture reduction, union was achieved in all patients with mean time to radiological union being 19 weeks. The mean Range of Motion (ROM) was 109 degrees with 20 patients having a Neer score graded as excellent to satisfactory. Our study had nine cases which required additional surgeries. Out of these, all nine cases required bone grafting, three also required antibiotic cement bead insertion initially. Three patients developed complications in the form of infection (two cases) and mal-union (one case) during the course of our study, but were completely treated by the end of the study.

CONCLUSION

Positive results can be obtained by distal femur locking plate alone as it is the main implant of choice for distal femur fractures of all varieties. Best outcome is expected if fracture fixation is done following all the basic principles of fracture fixation and taking benefit of the mechanical properties of a locking plate.

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.

Tibial fracture treated by minimally invasive plating using a novel low-cost, high-technique system

PURPOSE

The less invasive stabilization system (LISS) can effectively treat tibial fractures. However, the LISS is technically demanding, has a long learning curve, and presents a heavy economic burden to patients. The U-grooved locking compression plate (U-LCP), characterized by a U-groove at each end, is designed to treat tibial fractures. This paper reports the outcomes of tibial fractures treated using the U-LCP compared with the LISS.

METHODS

Seventy-eight patients with unilateral tibial fractures treated with either the U-LCP (group I) or LISS (group II) were enrolled. In group I, a U-LCP was inserted subcutaneously with two Kirschner wires embedded into the U-grooves to temporarily secure the plate. A second identical plate was placed over the first to guide screw insertion. In group II, the LISS was used to fix the tibial fractures. Patient age, sex, fracture type, severity of soft tissue injury, operative time, fluoroscopic time, complications, and functional recovery of affected limbs were recorded.

RESULTS

The two groups were comparable in age, sex, fracture type, and severity of soft tissue injury (p > 0.05). The average operation and fluoroscopic times in group I were significantly less than those in group II (p < 0.05). At follow-up, all fractures healed. There were no significant differences between both groups in time to bony union, wound complication rate, or functional recovery of injured limbs (p > 0.05).

CONCLUSIONS

The U-LCP can yield good outcomes in the treatment of proximal tibial fractures, with less radiation exposure, a shorter operation time, and a sustainable price compared with the LISS.

Biomechanical measurements of axial crush injury to the distal condyles of human and synthetic femurs

Few studies have evaluated the ‘bulk’ mechanical properties of human longbones and even fewer have compared human tissue to the synthetic longbones increasingly being used by researchers. Distal femur fractures, for example, comprise about 6% of all femur fractures, but the mechanical properties of the distal condyles of intact human and synthetic femurs have not been well quantified in the literature. To this end, the distal portions of a series of 16 human fresh-frozen femurs and six synthetic femurs were prepared identically for mechanical testing. Using a flat metal plate, an axial ‘crush’ force was applied in-line with the long axis of the femurs. The two femur groups were statistically compared and values correlated to age, size, and bone quality. Results yielded the following: crush stiffness (human, 1545 ± 728 N/mm; synthetic, 3063 ± 1243 N/mm; p = 0.002); crush strength (human, 10.3 ± 3.1 kN; synthetic, 12.9 ± 1.7 kN; p = 0.074); crush displacement (human, 6.1 ± 1.8 mm; synthetic, 2.8 ± 0.3 mm; p = 0.000); and crush energy (human, 34.8 ± 15.9 J; synthetic, 18.1 ± 5.7 J; p = 0.023). For the human femurs, there were poor correlations between mechanical properties versus age, size, and bone quality (R2 ≤ 0.18), with the exception of crush strength versus bone mineral density (R2 = 0.33) and T-score (R2 = 0.25). Human femurs failed mostly by condyle ‘roll back’ buckling (15 of 16 cases) and/or unicondylar or bicondylar fracture (7 of 16 cases), while synthetic femurs all failed by wedging apart of the condyles resulting in either fully or partially displaced condylar fractures (6 of 6 cases). These findings have practical implications on the use of a flat plate load applicator to reproduce real-life clinical failure modes of human femurs and the appropriate use of synthetic femurs. To the authors’ knowledge, this is the first study to have done such an assessment on human and synthetic femurs.