Modern Implant Options for the Treatment of Distal Femur Fractures

Changing Epidemiology of Distal Femur Fractures: Increase in Geriatric Fractures and Rates of Distal Femur Replacement

INTRODUCTION

Distal femur fractures (DFFs) are associated with high complication and mortality rates in the elderly. Using the National Inpatient Sample and Medicare data, we describe trends in the incidence of DFFs by fixation type and associated healthcare costs.

METHODS

Annual population rates and volume of inpatient DFFs were estimated using Poisson regression with the US Census as a denominator. We used Current Procedural Terminology codes in Medicare patients to determine episode-of-care cost by treatment, classified as intramedullary nail, open reduction and internal fixation, and distal femur arthroplasty (DFR).

RESULTS

The annual incidence of DFFs in the United States is approximately 27.4 per 100,000. Admission for DFFs increased from 2002 to 2020, with the highest volume and rate in those aged 85 years and older. DFF incidence increased (1.95×) from 142 per 1 million (95% CI: 140 to 144) in 2006 to 281 per 1 million (95% CI: 278-284) in 2019. From 2012 to 2019, the percentage of DFFs treated by intramedullary nail increased from 6.8% to 8.4%, open reduction and internal fixation decreased from 89.9% to 76.6%, and DFR increased from 3.3% to 14.9%. DFR cost was significantly greater than other treatment choices across all years for initial inpatient admission costs and 90-day episode-of-care costs (all P < 0.0001).

CONCLUSION

DFF volume has increased in the past 20 years, predominantly in elderly patients. Greater than 4.5× increase was observed in the proportion of geriatric DFFs treated with DFR during this study period. The total cost of DFR treatment was consistently greater than other surgical treatments.

Quantitative-MRI analysis of the effects of retrograde nailing on vascularity of the distal femur: A cadaveric study

BACKGROUND

Distal femur fractures remain treatment challenges with a considerable postoperative non-union rate. Concern remains that surgery may compromise osseous vascularity. This study aimed to determine effects of retrograde femoral intramedullary nailing (RFIN) on distal femur vascularity, and the locations of the middle genicular artery terminal branches in relation to the standard RFIN entry point.

METHODS

Five lower limb cadaveric pairs were obtained (ten specimens). Experimental limbs were randomly assigned, and contralateral limbs served as controls. An 11 mm femoral nail was implanted in experimental specimens. Controls only underwent a medial parapatellar incision with capsulotomy. Quantitative pre- and post-contrast-MRI was performed to assess arterial contributions to distal femur regions. Osseous vascularity was further evaluated with contrast-CT imaging. Next, specimens were injected with latex medium, and dissection was performed to assess extraosseous vasculature.

RESULTS

No statistically significant differences were found with quantitative-MRI in experimental and control groups for the entire distal femur or individual regions. The experimental group demonstrated a small mean decrease of 1.4% in distal femur arterial contributions. CT and anatomic dissection confirmed maintenance of middle genicular artery terminal branches. On average, 3.3 (±1.3) terminal branches entered along the posterior intercondylar notch. A mean distance of 15.2 mm (±6.9 mm) was found between the posterior RFIN entry point and these terminal branches.

CONCLUSIONS

RFIN did not significantly alter arterial contributions to the distal femur or disrupt the middle genicular artery terminal branches. However, care must be taken to ensure nail entry point accuracy given proximity of the entry point to terminal branches.

Short-Term Morbidity and Mortality after Distal Femur Open Reduction Internal Fixation in the Geriatric Population

OBJECTIVE

Distal femur fractures remain a significant cause of morbidity and mortality for elderly patients. There is a lack of large population studies investigating short-term outcomes after distal femur c in elderly patients. The purpose of this study is to assess the incidence of and risk factors for various short-term outcomes after distal femur open reduction internal fixation (ORIF) in the geriatric population.

METHODS

The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database was used to identify all primary distal femur ORIF cases in patients 60+ years old between January 1, 2015 and December 31, 2020 using Current Procedural Terminology (CPT) codes 27511, 27513, and 27514. Demographic, medical, and surgical variables were extracted for all patients. Propensity score matching was used to match cases in the two age groups based on various demographic and medical comorbidity variables. Several 30-day outcome measures were compared between the 60-79-year-old and 80+-year-old groups both before and after matching. Subsequent multivariate logistic regression was used to identify independent risk factors for 30-day outcome measures in the matched cohort.

RESULTS

A total of 2913 patients were included in the final cohort: 1711 patients in the 60-79-year-old group and 1202 patients in the 80+-year-old group. Most patients were female (n = 2385; 81.9%). Prior to matching, the older group had a higher incidence of 30-day mortality (1.9% vs. 6.2%), readmission (3.7% vs. 9.7%, p = 0.024), and non-home discharge (74.3% vs. 89.5%, p < 0.001). Additionally, the older group had a higher rate of blood loss requiring transfusion (30.9% vs. 42.3%, p < 0.001) and medical complications (10.4% vs. 16.4%, p < 0.001), including myocardial infarction (0.7% vs. 2.7%, p < 0.001), pneumonia (2.7% vs. 4.6%, p = 0.008), and urinary tract infection (4.1% vs. 6.1%, p = 0.0188). After matching, the older group consistently had a higher incidence of mortality, non-home-discharge, blood loss requiring transfusion, and myocardial infarction. Various independent risk factors were identified for 30-day morbidity and mortality, including American Society of Anesthesiologists (ASA) classification, body mass index (BMI) status, operative duration, and certain medical comorbidities.

CONCLUSION

Geriatric patients undergoing distal femur ORIF are at significant risk for 30-day morbidity and mortality. After matching, octogenarians and older patients specifically are at increased risk for mortality, non-home discharge, and surgical complications compared to patients aged 60-79 years old. Multiple factors, such as BMI status, ASA classification, operative time, and certain medical comorbidities, are independently associated with poor 30-day outcomes.

Outcomes of operatively managed periprosthetic distal femur fractures compared to fractures in patients with native knees

Introduction

With the increasing incidence of total knee arthroplasty (TKA), there is an expected rise in rate of periprosthetic fractures in the coming years. It is unclear how the outcomes of patients with distal femur fractures (DFF) and a total knee arthroplasty compare to patients of the same age group with native knees (NK).

Materials and methods

A retrospective review was completed for distal femur fractures treated with surgical fixation from January 2019-March 2021. We excluded patients <50 years old, non-ambulatory patients, revision surgeries, and patients with less than 90 days of follow-up. A chart review was performed to collect age, gender, BMI, smoking status, American Society of Anesthesiology (ASA) classification, fracture type, fixation method, time to full weight bearing, and complications. Comparisons between the TKA vs native knee groups were performed using t-test, chi-square, and Fisher's exact test where appropriate.

Results

138 patients were included in our study with a mean age of 74 years. 69 DFF ipsilateral to a TKA were included in the study group and 71 DFF were included in the native knee group. Age, sex, BMI, smoking status, and ASA class were similar between the groups. All patients with periprosthetic femur fractures had 33A AO/OTA fracture classification. Patients with native knees were more likely to receive dual implant fixation, 15.5% compared to 4.3% (p = 0.02). Full weight bearing was achieved at 8.5 vs 8.6 weeks between the NK and TKA groups (p = 0.64). The complication rate was 16.9% in the NK group vs. 7.2% in the TKA group (p = 0.21).

Conclusion

Patients with periprosthetic femur fractures have similar time to weight bearing and complications rate with patients with distal femur fracture in native knees. We found a higher utilization rate of dual implant fixation in the native knee group.

Computer-aided design and 3D printing for a stable construction of segmental bone defect model in Beagles: a short term observation

OBJECTIVE

Segmental bone defect animal studies require stable fixation which is a continuous experimental challenge. Large animal models are comparable to the human bone, but with obvious drawbacks of housing and costs. Our study aims to utilize CAD and 3D printing in the construction of a stable and reproducible segmental bone defect animal mode.

METHODS

CAD-aided 3D printed surgical instruments were incorporated into the construction of the animal model through preoperative surgical emulation. 20 3D printed femurs were divided into either experimental group using 3D surgical instruments or control group. In Vitro surgical time and accuracy of fixation were analysed and compared between the two groups. A mature surgical plan using the surgical instruments was then utilized in the construction of 3 segmental bone defect Beagle models in vivo. The Beagles were postoperatively assessed through limb function and imaging at 1, 2 and 3 months postoperatively.

RESULTS

In vitro experiments showed a significant reduction in surgical time from 40.6 ± 14.1 (23-68 min) to 26 ± 4.6 (19-36 min) (n = 10, p < 0.05) and the accuracy of intramedullary fixation placement increased from 71.6 ± 23.6 (33.3-100) % to 98.3 ± 5.37 (83-100) %, (n = 30, p < 0.05) with the use of CAD and 3D printed instruments. All Beagles were load-bearing within 1 week, and postoperative radiographs showed no evidence of implant failure.

CONCLUSION

Incorporation of CAD and 3D printing significantly increases stability, while reducing the surgical time in the construction of the animal model, significantly affecting the success of the segmental bone defect model in Beagles.

Fixation or Revision for Periprosthetic Fractures: Epidemiology, New Trends, and Projections in the United States

BACKGROUND

Periprosthetic fractures can be devastating complications after total joint arthroplasty (TJA). The management of periprosthetic fractures is complex, spanning expertise in arthroplasty and trauma. The purpose of this study was to examine and project trends in the operative treatment of periprosthetic fractures in the United States.

METHODS

A large, public and private payer database was queried to capture all International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for periprosthetic femoral and tibial fractures. Statistical models were created to assess trends in treatment for periprosthetic fractures and to predict future surgical rates. An alpha value of 0.05 was used to assess significance. A Bonferroni correction was applied where applicable to account for multiple comparisons.

RESULTS

In this study, from 2016 to 2021, 121,298 patients underwent surgical treatment for periprosthetic fractures. There was a significant increase in the total number of periprosthetic fractures. The incidence of periprosthetic hip fractures rose by 38% and that for periprosthetic knee fractures rose by 73%. The number of periprosthetic fractures is predicted to rise 212% from 2016 to 2032. There was a relative increase in open reduction and internal fixation (ORIF) compared with revision arthroplasty for both periprosthetic hip fractures and periprosthetic knee fractures.

CONCLUSIONS

Periprosthetic fractures are anticipated to impose a substantial health-care burden in the coming decades. Periprosthetic knee fractures are predominantly treated with ORIF rather than revision total knee arthroplasty (TKA), whereas periprosthetic hip fractures are predominantly treated with revision total hip arthroplasty (THA) rather than ORIF. Both periprosthetic knee fractures and periprosthetic hip fractures demonstrated increasing trends in this study. The proportion of periprosthetic hip fractures treated with ORIF relative to revision THA has been increasing.

LEVEL OF EVIDENCE

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

Double plating is a suitable option for periprosthetic distal femur fracture compared to single plate fixation and distal femoral arthroplasty

Aims

The purpose of this study was to compare reoperation and revision rates of double plating (DP), single plating using a lateral locking plate (SP), or distal femoral arthroplasty (DFA) for the treatment of periprosthetic distal femur fractures (PDFFs).

Methods

All patients with PDFF primarily treated with DP, SP, or DFA between 2008 and 2022 at a university teaching hospital were included in this retrospective cohort study. The primary outcome was revision surgery for failure following DP, SP, or DFA. Secondary outcome measures included any reoperation, length of hospital stay, and mortality. All basic demographic and relevant implant and injury details were collected. Radiological analysis included fracture classification and evaluation of metaphyseal and medial comminution.

Results

A total of 111 PDFFs (111 patients, median age 82 years (interquartile range (IQR) 75 to 88), 86% female) with 32 (29%) Su classification 1, 37 (34%) Su 2, and 40 (37%) Su 3 fractures were included. The median follow-up was 2.5 years (IQR 1.2 to 5.0). DP, SP, and DFA were used in 15, 66, and 30 patients, respectively. Compared to SP, patients treated with DP were more likely to have metaphyseal comminution (47% vs 14%; p = 0.009), to be low fractures (47% vs 11%; p = 0.009), and to be anatomically reduced (100% vs 71%; p = 0.030). Patients selected for DFA displayed comparable amounts of medial/metaphyseal comminution as those who underwent DP. At a minimum follow-up of two years, revision surgery for failure was performed in 11 (9.9%) cases at a median of five months (IQR 2 to 9): 0 DP patients (0%), 9 SP (14%), and 2 DFA (6.7%) (p = 0.249).

Conclusion

Using a strategy of DP fixation in fractures, where the fracture was low but there was enough distal bone to accommodate locking screws, and where there is metaphyseal comminution, resulted in equivalent survival free from revision or reoperation compared to DFA and SP fixation.

Geriatric Distal Femur Fractures Treated with Arthroplasty Are Associated with Lower Mortality but Greater Costs Compared with Open Reduction and Internal Fixation at 30 Days

Distal femur fractures (DFFs) are common injuries with significant morbidity. Surgical options include open reduction and internal fixation (ORIF) with plates and/or intramedullary devices or a distal femur endoprosthesis (distal femur replacement [DFR]). A paucity of studies exist that compare the two modalities. The present study utilized a 1:2 propensity score match to compare 30-day outcomes of geriatric patients with DFFs who underwent an ORIF or DFR. The National Surgical Quality Improvement Program data from 2008 to 2019 were utilized to identify all patients who sustained a DFF and underwent either ORIF or DFR. This yielded 3,197 patients who underwent an ORIF versus 121 patients who underwent a DFR. A final sample of 363 patients (242 patients with ORIF vs. 121 with DFR) was obtained after a 1:2 propensity score match. Costs were obtained from the National Inpatient Sample database using multiple regression analysis and validated with a 7:3 train-test algorithm. Independent samples t-tests and chi-square analysis were conducted to assess cost and outcome differences, respectively. Patients who received a DFR had higher transfusion rates than ORIF (p = 0.021) and higher mean inpatient hospital costs (p = 0.001). Subgroup analysis for patients 80 years of age or older revealed higher 30-day unplanned readmission (0 vs. 18.2%; p < 0.001) and 30-day mortality (0 vs. 18.2%; p < 0.001) rates for patients undergoing ORIF compared with DFR. The total number of DFR cases needed to prevent one ORIF-related 30-day mortality for DFR for patients 80 years of age was 6 (95% confidence interval: 3.02-19.9). The mean hospital costs associated with preventing one case of death within 30 days from operation by undergoing DFR compared with ORIF was $176,021.39. Our results demonstrate higher rates of transfusion and increased inpatient costs among the DFR cohort compared with ORIF. However, we demonstrate lower rates of mortality for patients 80 years and older who underwent DFR versus ORIF. Future studies randomized controlled trials are necessary to validate the results of this study.

Which fixation produces the best outcome for distal femoral fractures? Meta-analysis and systematic review of retrograde nailing versus distal femoral plating in 2432 patients and 33 studies

PURPOSE

The distal femur comprises a wide intramedullary cavity and thin cortical bone. Firm internal fixation of comminuted fractures with displacement is challenging. Although many comparative studies have reported retrograde intramedullary nailing (RIN) and distal femoral plating (DFP) as the usual fixation methods for distal femoral fractures, no clear conclusion has been reached. Therefore, a meta-analysis and systematic review of the clinical and radiological results were conducted to determine the appropriate treatment method for distal femoral fractures.

METHODS

A systematic search of the PubMed, Embase, Scopus, and Cochrane Library databases from their inception to December 19, 2022, was performed using predefined criteria. Studies comparing the effects of RIN and DFP were considered. The analyzed outcome measures included duration of surgery, blood loss, time to union, delayed union, nonunion, malalignment, implant failure, infection, reoperation, limb length discrepancy, range of motion, persistent anterior knee pain, knee stiffness, and functional scores. Meta-analysis of pooled data was conducted using a random-effects model to determine the standard mean difference (SMD) or odds ratio (OR) with 95% confidence intervals (CIs).

RESULTS

Thirty-three studies with 2,432 patients were included. Compared to DFP, RIN was associated with a shorter time to fracture union (SMD, 1.83 months; 95% CI - 2.76 to - 0.90; P < 0.001) and a lower incidence of postoperative infection (OR 0.54; 95% CI 0.31-0.94; P = 0.03). Pooled analysis revealed no significant differences in other outcome measures between the two treatment modalities.

CONCLUSION

In distal femoral fractures, RIN had a shorter bone union time and was more resistant to infection than DFP. However, there were no significant differences in the other clinical parameters. Therefore, the characteristics, strengths, and weaknesses of RIN and DFP should be carefully identified, and appropriate treatment should be provided based on the patient's medical condition and fracture pattern.

Comparative study of retrograde intramedullary nailing versus locking extramedullary plating in complete articular fractures with metaphyseal comminution of the distal femur

INTRODUCTION

Fractures of the distal femur with metaphyseal comminution and complete intra-articular involvement (AO/OTA classifications 33C2 and 33C3) present challenges for reduction and fixation. However, an optimal fixation method remains unknown. This study aimed to compare the clinical and radiographic outcomes of locking extramedullary plating (LEP) and retrograde intramedullary nailing (RIN) for complete distal femoral intra-articular fractures with metaphyseal comminution.

MATERIALS AND METHODS

Between January 2016 and May 2022, 80 patients (45 men and 35 women; average age, 56.7 years) diagnosed with AO/OTA 33C2 and 33C3 were treated with either LEP or RIN and followed up for at least one year. Post-operative evaluations included radiographic assessments of bone union rate, timing, and alignment. Clinically, the knee joint range of motion (ROM), lower extremity functional scale (LEFS), and Kellgren and Lawrence (KL) grade were analyzed. The complications were also compared.

RESULTS

36 underwent LEP and 44 underwent RIN. Bone union was observed in 69.4% and 63.6% of the patients in the LEP and RIN groups, respectively (p = 0.64). The average union time was 6.9 months for the LEP group and 6.6 months for the RIN group (p = 0.51). A tendency toward varus deformity was observed in the RIN group, although the difference was not statistically significant. No significant differences were observed in knee ROM, LEFS, or KL grade. Complications included non-union (33.8%; RIN, 11; LEP, 16), varus deformity (5%; RIN, 4; LEP, 0), infection (1.3%; RIN, 0; LEP, 1), heterotrophic ossification (1.3%; RIN, 0; LEP, 1), and wound dehiscence (2.5%; RIN, 2; LEP, 0).

CONCLUSIONS

The surgical fixation methods, RIN and LEP, for complete distal femoral intra-articular fractures with metaphyseal comminution showed similar clinical and radiological outcomes. However, regardless of the type of fixation device used, there was a reduced rate of bone union owing to high energy and a less favorable prognosis.

Titanium versus stainless steel alloy bridge plates for distal femur fractures: Does callus form earlier with titanium?

INTRODUCTION

Distal femur fractures account for 3-6% of all femur fractures. Internal fixation of most distal femur fractures with an anatomic lateral locking plate should permit some motion at the metaphyseal portion of the fracture when secondary bone healing is planned by the operating surgeon. While several studies have been performed evaluating union rates for distal femur fractures with stainless steel and titanium plates, the timing of callus formation between stainless steel and titanium implants used as bridge plates for distal femur fractures (AO/OTA 33-A and -C) has been investigated to a lesser extent. We hypothesize that callus will be visualized earlier with post-operative radiographs with titanium versus stainless steel bridge plates.

METHODS

We retrospectively reviewed a consecutive cohort of patients over 18 years of age with acute AO/OTA 33-A and 33-C fracture patterns treated with an isolated stainless steel or titanium lateral bridge plate within 4 weeks of injury by a single fellowship-trained orthopedic trauma surgeon from 2011 to 2020 at one academic Level 1 trauma center. An independent, fellowship-trained orthopedic trauma attending surgeon reviewed anterior-posterior (AP) and lateral radiographs from every available post-operative clinic visit and graded them using the Modified Radiographic Score for Tibia (mRUST).

RESULTS

Twenty-five subjects were included in the study with 10 with stainless steel and 15 with titanium plates. There were no significant differences in demographics between both groups, including age, sex, BMI, injury classification, open versus closed, mechanism, and laterality. Statistically significant increased mRUST scores, indicating increased callus formation, were seen on 12-week radiographs (8.4 vs. 11.9, p = 0.02) when titanium bridge plates were used. There were no statistically significant differences in mRUST scores at 6 or 24-weeks, but scores in the titanium group were higher in at every timepoint.

DISCUSSION

In conclusion, we observed greater callus formation at 12 weeks after internal fixation of 33-A and 33-C distal femur fractures treated with titanium locked lateral distal femoral bridge plates compared to stainless steel plates. Our data suggest that titanium metallurgy may have quicker callus formation compared to stainless steel if an isolated, lateral locked bridge plate is chosen for distal femur fracture fixation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cortical bone thickness on preoperative CT scans as predictor of bone quality in distal femur fractures: a retrospective study in Caucasians

AIM

Distal femur fractures (DFF) are rare, but associated with high complication rates and mortality, particularly in patients with osteoporosis. To improve preoperative assessment, we analyzed if cortical bone thickness on CT and AP radiographs is associated with clinical parameters of bone quality.

METHODS

Retrospective single-center study of adult patients presenting at a level-one trauma center, with a DFF between 2011 and 2020. Clinical parameters for bone quality, such as age, sex, body mass index (BMI), energy impact level of trauma, and known history of osteoporosis, were assessed. Mean cortical bone thickness (CBTavg) on AP radiograph was determined using a previously published method. Cortical thickness on CT scan was measured at 8 and 14 cm proximal to the articular surface of the lateral condyle.

RESULTS

71 patients (46 females) between 20 and 100 years were included in the study. Cortical thickness determined by CT correlated significantly with CBTavg measurements on AP radiograph (Spearman r = 0.62 to 0.80; p < 0.001). Cortical thickness was inversely correlated with age (Spearman r = - 0.341 to - 0.466; p < 0.001) and significantly associated with trauma impact level and history of osteoporosis (p =  < 0.001). The CT-based values showed a stronger correlation with the clinical parameters than those determined by AP X-ray.

CONCLUSION

Our results showed that cortical thickness of the distal femur correlates with clinical parameters of bone quality and is therefore an excellent tool for assessing what surgical care should be provided. Interestingly, our findings indicate that cortical thickness on CT is more strongly correlated with clinical data than AP radiograph measurements.

Weight-bearing Restrictions after Distal Femur Fractures - Review of Current Literature

The incidence of distal femur fractures increases in the geriatric patient. The primary treatment goal in these fractures is early mobilisation to prevent secondary injuries associated with immobility. In light of the increasing spectrum of therapeutic options for postoperative fracture treatment, including double plating, nail-plate combination and distal femur replacement as postoperative treatments, weight-bearing recommendations are becoming increasingly important. The aim of this study was thus to analyse the weight-bearing recommendations and associated therapy results within the literature of the past 9 years and compare the recommendations to our own approach.

Weight-bearing Guidelines for Common Geriatric Upper and Lower Extremity Fractures

PURPOSE OF REVIEW

The purpose of this review paper is to summarize current weight-bearing guidelines for common geriatric fractures, around weight-bearing joints, of the upper and lower extremities.

RECENT FINDINGS

There is an increasing amount of literature investigating the safety and efficacy of early weight-bearing in geriatric fractures, particularly of the lower extremity. Many recent studies, although limited, suggest that early weight-bearing may be safe for geriatric distal femur and ankle fractures. Given the limited data pertaining to early weight-bearing in geriatric fractures, it is difficult to establish concrete weight-bearing guidelines in this population. However, in the literature available, early weight-bearing appears to be safe and effective across most injuries. The degree and time to weight-bearing vary significantly based on fracture type and treatment method. Future studies investigating postoperative weight-bearing protocols should focus on the growing geriatric population and identify methods to address specific barriers to early weight-bearing in these patients such as cognitive impairment, dependence on caregivers, and variations in post-acute disposition.

Nail Plate Combination Fixation Versus Lateral Locked Plating for Distal Femur Fractures: A Multicenter Experience

OBJECTIVES

To (1) report on clinical, radiographic, and functional outcomes after nail-plate fixation (NPF) of distal femur fractures and (2) compare outcomes after NPF with a propensity matched cohort of fractures treated with single precontoured lateral locking plates.

DESIGN

Multicenter retrospective cohort study.

SETTING

Ten Level 1 trauma centers.

PATIENTS/PARTICIPANTS

Patients with OTA/AO 33A or 33C fractures.

INTERVENTION

Fixation with (1) retrograde intramedullary nail combined with lateral locking plate (n = 33) or (2) single precontoured lateral locking plate alone (n = 867).

MAIN OUTCOME MEASUREMENTS

The main outcomes of interest were all-cause unplanned reoperation and presence of varus collapse at final follow-up.

RESULTS

One nail-plate patient underwent unplanned reoperation excluding infection and 2 underwent reoperation for infection at an average of 57 weeks after surgery. No nail-plate patients required unplanned reoperation to promote union and none exhibited varus collapse. More than 90% were ambulatory with no or minimal pain at final follow-up. In comparison, 7 of the 30 matched lateral locked plating patients underwent all-cause unplanned reoperation excluding infection (23% vs. 3%, P = 0.023), and an additional 3 lateral locked plating patients were found to have varus collapse on final radiographs (10% vs. 0%, P = 0.069).

CONCLUSIONS

Despite a high proportion of high-energy, open, and comminuted fractures, no NPF patients underwent unplanned reoperation to promote union or demonstrated varus collapse. Propensity score matched analysis revealed significantly lower rates of nonunion for NPF compared with lateral locked plating alone. Larger studies are needed to identify which distal femur fracture patients would most benefit from NPF.

LEVEL OF EVIDENCE

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

Biodegradable Implants for Internal Fixation of Fractures and Accelerated Bone Regeneration

Bone fractures have always been a burden to patients due to their common occurrence and severe complications. Traditionally, operative treatments have been widely used in the clinic for implanting, despite the fact that they can only achieve bone fixation with limited stability and pose no effect on promoting tissue growth. In addition, the nondegradable implants usually need a secondary surgery for implant removal, otherwise they may block the regeneration of bones resulting in bone nonunion. To overcome the low degradability of implants and avoid multiple surgeries, tissue engineers have investigated various biodegradable materials for bone regeneration, whereas the significance of stability of long-term bone fixation tends to be neglected during this process. Combining the traditional orthopedic implantation surgeries and emerging tissue engineering, we believe that both bone fixation and bone regeneration are indispensable factors for a successful bone repair. Herein, we define such a novel idea as bone regenerative fixation (BRF), which should be the main future development trend of biodegradable materials.

Biomechanical design optimization of distal femur locked plates: A review

Clinical findings, manufacturer instructions, and surgeon's preferences often dictate the implantation of distal femur locked plates (DFLPs), but healing problems and implant failures still persist. Also, most biomechanical researchers compare a particular DFLP configuration to implants like plates and nails. However, this begs the question: Is this specific DFLP configuration biomechanically optimal to encourage early callus formation, reduce bone and implant failure, and minimize bone "stress shielding"? Consequently, it is crucial to optimize, or characterize, the biomechanical performance (stiffness, strength, fracture micro-motion, bone stress, plate stress) of DFLPs influenced by plate variables (geometry, position, material) and screw variables (distribution, size, number, angle, material). Thus, this article reviews 20 years of biomechanical design optimization studies on DFLPs. As such, Google Scholar and PubMed websites were searched for articles in English published since 2000 using the terms "distal femur plates" or "supracondylar femur plates" plus "biomechanics/biomechanical" and "locked/locking," followed by searching article reference lists. Key numerical outcomes and common trends were identified, such as: (a) plate cross-sectional area moment of inertia can be enlarged to lower plate stress at the fracture; (b) plate material has a larger influence on plate stress than plate thickness, buttress screws, and inserts for empty plate holes; (c) screw distribution has a major influence on fracture micro-motion, etc. Recommendations for future work and clinical implications are then provided, such as: (a) simultaneously optimizing fracture micro-motion for early healing, reducing bone and implant stresses to prevent re-injury, lowering "stress shielding" to avoid bone resorption, and ensuring adequate fatigue life; (b) examining alternate non-metallic materials for plates and screws; (c) assessing the influence of condylar screw number, distribution, and angulation, etc. This information can benefit biomedical engineers in designing or evaluating DFLPs, as well as orthopedic surgeons in choosing the best DFLPs for their patients.

Using a Traction Table for Fracture Reduction during Minimally Invasive Plate Osteosynthesis (MIPO) of Distal Femoral Fractures Provides Anatomical Alignment

INTRODUCTION

Fracture reduction and fixation of distal femur fractures are technically demanding. Postoperative malalignment is still commonly reported after minimally invasive plate osteosynthesis (MIPO). We evaluated the postoperative alignment after MIPO using a traction table with a dedicated femoral support.

METHODS

The study included 32 patients aged 65 years or older with distal femur fractures of all AO/OTA types 32 (c) and 33 (except 33 B3 and C3) and peri-implant fractures with stable implants. Internal fixation was achieved with MIPO using a bridge-plating construct. Bilateral computed tomography (CT) scans of the entire femur were performed postoperatively, and measurements of the uninjured contralateral side defined anatomical alignment. Due to incomplete CT scans or excessively distorted femoral anatomy, seven patients were excluded from analyses.

RESULTS

Fracture reduction and fixation on the traction table provided excellent postoperative alignment. Only one of the 25 patients had a rotational malalignment of more than 15° (18°).

CONCLUSIONS

The surgical setup for MIPO of distal femur fractures on a traction table with a dedicated femoral support facilitated reduction and fixation, resulting in a low rate of postoperative malalignment, despite a high rate of peri-implant fractures, and could be recommended for surgical treatment of distal femur fractures.

Risk Factors for Nonunion of Distal Femur Fractures

OBJECTIVES

To determine patient, fracture, and construct related risk factors associated with nonunion of distal femur fractures.

DESIGN

Retrospective cohort study.

SETTING

Academic Level I trauma center.

PARTICIPANTS

Patients 18 years and older presenting with OTA/AO 33A and 33C distal femur fractures from 2004 to 2020. A minimum follow-up of 6 months was required for inclusion. OTA/AO 33B and periprosthetic fractures were excluded, 438 patients met inclusion criteria for the study.

MAIN OUTCOMES

The primary outcome of the study was fracture nonunion defined as a return to the OR for management of inadequate bony healing. Patient demographics, comorbidities, injury characteristics, fixation type, and construct variables were assessed for association with distal femur fracture nonunion. Secondary outcomes include conversion to total knee arthroplasty, surgical site infection, and other reoperation.

RESULTS

The overall nonunion rate was 13.8% (61/438). The nonunion group was compared directly with the fracture union group for statistical analysis. There were no differences in age, sex, mechanism of injury, Injury Severity Score, and time to surgery between the groups. Lateral locked plating characteristics including length of plate, plate metallurgy, screw density, and working length were not significantly different between groups. Increased body mass index [odds ratio (OR), 1.05], chronic anemia (OR, 5.4), open fracture (OR, 3.74), and segmental bone loss (OR, 2.99) were independently associated with nonunion. Conversion to total knee arthroplasty (TKA) ( P = 0.005) and surgical site infection ( P < 0001) were significantly more common in the nonunion group.

CONCLUSION

Segmental bone loss, open fractures, chronic anemia, and increasing body mass index are significant risk factors in the occurrence of distal femoral nonunion. Lateral locked plating characteristics did not seem to affect nonunion rates. Further investigation into the prevention of nonunion should focus on fracture fixation constructs and infection prevention.

LEVEL OF EVIDENCE

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

Treatment of distal femur fractures with retrograde intramedullary nailing utilizing a tibial nail

Abstract Aim Retrograde intramedullary nailing for the treatment of femur fractures is a sound option due to its advantages including ease of implant placement and better control of the distal segment, especially in distal femur fractures. Unfortunately, retrograde femoral nails are not available in most developing countries or rural areas. The primary aim of the study is to investigate the outcomes of an alternative treatment of distal femur fracture with retrograde intramedullary nailing using a tibial nail. Material and Method Patients who had distal femur fractures and underwent retrograde intramedullary nailing with a tibial nail between January 2020 – March 2022 are retrospectively evaluated. Patients who were treated other than a tibial nail, aged below 18, had follow-up less than 6 months, multiple fractures, and open fractures were excluded. Patients’ demographics, time to union, and complications were recorded. Functional outcomes included visual analogue pain score (VAS), Lysholm score, Tegner activity scale, Knee Society Score (KSS), and Short Form-36 (SF36) on the latest follow-up. Results A total of 15 patients (11 male, 4 female) met the inclusion criteria and included in the study. The mean age of the patients was 42.9 ± 17.3 (range, 18 to 72) months. The mean follow-up period was 10.1 ± 5.2 (range, 6 to 18). There was no reduction loss and implant failure during follow-ups. One patient had nonunion. No intraoperative fracture occurred. Persistent knee pain was seen in a patient due to an intraarticular screw and removed arthroscopically. In the latest follow-up, the mean VAS was 0.73 ± 0.70 (range, 0 to2), the mean Tegner score was 5.0 ± 1.5 (range, 3 to 7), the mean Lysholm score was 90.9 ± 9.9(range, 64 to 100), the mean KSS was 86.6 ± 8.6 (range, 70 to 97), and the mean SF-36 score was 96.5 ± 4.7 (range, 87 to 100). Conclusion The results of this study suggest that a tibial nail with retrograde intramedullary nailing has good functional outcomes in the treatment of distal femur fractures. The tibial nail should be considered as an alternative treatment option where distal femoral nails are not available.

Open Reduction Internal Fixation Versus Distal Femoral Replacement (DFR) for Treatment of OTA/AO 33C Fractures in the Elderly: A Review of Functional Outcomes and Cost Analysis

OBJECTIVES

To determine the economic cost associated with the treatment of OTA/AO 33C fractures in patients older than 65 years of age using open reduction internal fixation (ORIF) or DFR and to assess the perioperative outcomes of elderly patients treated surgically following OTA/AO 33C fractures.

DESIGN

Retrospective cohort over a 10-year period.

SETTING

A single level-1 trauma center.

PARTICIPANTS AND INTERVENTION

Thirty-nine patients 65 or older with OTA/AO 33C fractures who underwent treatment with ORIF (n = 27) or DFR (n = 12) were included.

MAIN OUTCOME MEASUREMENTS

Direct cost associated with surgical treatment along with LOS, functional outcomes, patient-reported outcomes, and all-cause reoperation.

RESULTS

Index procedure costs were as follows: DFR: $ 61,259 vs. ORIF: $44,490 (P = 0.056). Five (20%) ORIF patients required revision versus one (8%) in the DFR group. Total cost when including reoperation resulted in DFR being $14,805 more costly, which was not significant. Hospital LOS was similar between groups; however, convalescent LOS was longer in ORIF patients (43.2 vs. 23.1 days, P = 0.02).

CONCLUSION

This study demonstrates that there is no significant difference in overall cost between ORIF and DFR when all costs are considered. A larger portion of DFR patients were able to mobilize postoperatively, with subacute length of stay being longer in ORIF patients. A multicenter trial is warranted to determine optimal treatment for this complex problem.

LEVEL OF EVIDENCE

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

Analysis of 101 Mechanical Failures in Distal Femur Fractures Treated with 3 Generations of Precontoured Locking Plates

OBJECTIVES

To evaluate mechanical treatment failure in a large patient cohort sustaining a distal femur fracture treated with a distal femoral locking plate (DFLP).

DESIGN

This retrospective case-control series evaluated mechanical treatment failures of DFLPs.

SETTING

The study was conducted at 8 Level I trauma centers from 2010 to 2017.

PATIENTS AND PARTICIPANTS

One hundred one patients sustaining OTA/AO 33-A and C distal femur fractures were treated with DFLPs that experienced mechanical failure.

INTERVENTION

The intervention included the treatment of a distal femur fracture with a DFLP, affected by mechanical failure (implant failure by loosening or breakage).

MAIN OUTCOME MEASURE

The main outcome measures included injury and DFLP details; modes and timing of failure were studied.

RESULTS

One hundred forty-six nonunions were found overall (13.4%) including 101 mechanical failures (9.3%). Failures occurred in different manners, locations, and times depending on the DFLPs. For example, 33 of 101 stainless steel (SS) plates (33%) failed by bending or breaking in the working length, whereas no Ti plates failed here ( P < 0.05). Eleven of 12 failures with titanium-Less Invasive Stabilization System (92%) occurred by lost shaft fixation, mostly by the loosening of unicortical screws (91%). Sixteen of 44 variable -angled-LCP failures (36%) occurred at the distal plate-screw junction, whereas only 5 of 61 other DFLPs (8%) failed this way ( P < 0.05). Distal failures occurred on average at 23.7 weeks compared with others that occurred at 38.4 weeks ( P < 0.05). Variable -angled-LCP distal screw-plate junction failures occurred earlier (mean 21.4 weeks).

CONCLUSION

Nonunion and mechanical failure occurred in 14% and 9% of patients, respectively, in this large series of distal femur fracture treated with a DFLP. The mode, location, presence of a prosthesis, and timing of failure varied depending on the characteristics of DFLP. This information should be used to optimize implant usage and design to prolong the period of stable fixation before potential implant failures occur in patients with a prolonged time to union.

LEVEL OF EVIDENCE

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

Outcomes of dual plating for unstable distal femoral fractures: a subgroup comparison between periprosthetic and non-periprosthetic fractures

PURPOSE

This study aimed to evaluate the outcomes of dual plating for unstable distal femoral fractures via a subgroup analysis between periprosthetic and non-periprosthetic fractures.

METHODS

This retrospective cohort study analyzed the outcomes of dual plating for unstable distal femoral fractures among 49 consecutive patients (43 women and 6 men) enrolled from July 2008 to August 2020. The patients were divided into periprosthetic (group P, n = 29) and non-periprosthetic (group N, n = 20) groups. The radiographic outcomes included the mechanical lateral distal femoral angle (mLDFA) and union rate based on the computed tomography findings. The clinical parameters included the knee range of motion and knee society score (KSS).

RESULTS

The mean patient age was 71.1 years, and the average follow-up period was 37 months (range, 12-138 months). Union was achieved in 47 patients (96%). The average final mLDFA was 90.5° in group P and 88.3° in group N. The average final knee range of motion was 130° in group P and 107° in group N. The average final KSS was 73.8 in group P and 87.1 in group N.

CONCLUSION

Dual plating for distal femoral fractures yielded an excellent union rate and limb alignment with a low complication rate.

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.

Investigation of distal femur microarchitecture and factors influencing its deterioration: An ex vivo high-resolution peripheral quantitative computed tomography study

While fractures of the distal femur are often considered as fragility fractures, detailed knowledge of the bone microarchitecture at this skeletal site is largely unavailable. Initial evaluation of a patient cohort with distal femur fractures showed a markedly increased occurrence in elderly women. The purpose of this study was to determine the extent to which demographic characteristics of distal femur fractures are reflected by general age- and sex-specific variations in local microarchitectural parameters. Fifty cadaveric femora were collected from 25 subjects (12 females, 13 males, age 25-97 years). A volume of interest within 3 cm proximal to the condyles was analyzed using high-resolution peripheral quantitative computed tomography (HR-pQCT), which revealed impaired trabecular and cortical bone microarchitecture in women compared to men as well as in osteoporotic compared to normal or osteopenic subjects, as classified by dual-energy X-ray absorptiometry (DXA) T-score. Linear regression analyzes showed negative associations between age and HR-pQCT parameters in women (e.g., cortical thickness -14 µm/year, 95% CI: -21 to -7 µm/year), but not in men (e.g., cortical thickness 1 µm/year, 95% CI: -12 to 14 µm/year). HR-pQCT parameters showed strong positive associations with areal bone mineral density (aBMD) determined by DXA at the hip in both sexes. Taken together, our findings suggest that female sex, advanced age, and low aBMD represent major risk factors for impaired microarchitecture at the distal femur. Both the diagnostic value of DXA for predicting distal femur fractures and the efficacy of bone-specific agents on fracture risk reduction should be investigated in the future.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Does distance from joint line influence complications after distal femur fractures in native and periprosthetic knees?

BACKGROUND

Distal femur fractures are projected to increase in incidence secondary to an aging population and growing utilization of total knee arthroplasty. Surgical management is the standard of care, but optimal treatment for far distal fractures is still unclear. Our study investigates if there are distal femur fractures too distal to be treated with lateral locked plating in periprosthetic fractures.

METHODS

One hundred and ten consecutive patients treated with locked plating for distal femur fractures around a total knee replacement were identified using CPT codes. Fractures were classified by length of the distal fracture segment and Su classification. Complications studied were nonunion, malunion, infection, further fracture related surgery, readmission within 90 days, and mortality within 1 year of surgery. Sixty six fractures met inclusion criteria of 180 days of follow-up or sustaining a complication prior to180 days.

RESULTS

The size of the distal fracture segment and Su classification did not correlate with increased complication rate in periprosthetic distal femur fractures.

CONCLUSIONS

There was no difference between complications following lateral locked plating of distal femur fractures based on the size of the distal fracture segment in periprosthetic fractures. Lateral locked plating is an effective treatment modality for these fractures regardless of how distal the fracture extends.

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.

Practical approach to the native distal femur fractures in the elderly: A rapid review over the recent trends

Significant work has been done in recent years on treatment strategies for distal femur fractures. Inclusive reviews on periprosthetic fractures of distal femur have been carried out recently, but there is a lack of such reviews on the subject of native distal femur fractures in the recent literature. In this narrative review, we are set out to address the latest updates on geriatric non-periprosthetic distal femur fractures, and perform a rapid review over different treatment options, arriving at a summarized proposed treatment algorithm.

[Distal femoral fractures]

CLINICAL ISSUE

Fractures of the distal femur represent rare but serious injuries with a high 1‑year mortality. An increasingly older patient population requires adapted treatment concepts.

STANDARD TREATMENT PROCEDURE

Surgical treatment using angular stable plating and retrograde nailing is the standard procedure. Conservative treatment is only indicated in cases of low demands and high perioperative risks of the patient.

TREATMENT INNOVATIONS

Primary double plate osteosynthesis and primary implantation of a distal femoral replacement represent new treatment procedures and show promising initial results in the collective of geriatric patients.

DIAGNOSTIC WORK-UP

Conventional radiographs in 2 planes and computed tomography with multiplanar and 3D reconstructions should be performed to enable an adequate assessment of the indications and treatment planning.

PERFORMANCE

Nonunion rates of plate and nail osteosyntheses range from 4% to 10%. No significant differences in long-term results can be observed. The results regarding double plate osteosynthesis and distal femoral replacement so far do not show any disadvantages compared to the existing procedures but there is still insufficient data for general recommendations.

ASSESSMENT

Complex fractures with extensive reconstructive procedures and treatment by distal femoral replacement should be performed in specialized centers.

PRACTICAL RECOMMENDATIONS

The gold standard is still surgical treatment by means of minimally invasive angular stable plate or retrograde nail osteosynthesis. Complex fracture forms require individual treatment planning considering all currently available treatment options.

Distal femur complex fractures in elderly patients treated with megaprosthesis: Results in a case series of 11 patients

BACKGROUND

Surgical treatment of complex fractures of the distal femur in the elderly is controversial. Osteoporosis and pre-existent osteoarthritis are common comorbidities in the elderly which add to the need for early walking and rapid restoration of function and also pose significant obstacles to achievement of satisfactory results with standard fixation techniques. Recently, several authors have suggested that primary arthroplasty could be a viable alternative option to standard fixation techniques in selected patients with complex distal femur fractures.

AIM

To present our experience with 11 cases of distal femur fractures treated with knee arthroplasty and large femoral resection in a population of patients over the age of 85.

METHODS

Data from 11 consecutive patients (10 females, 1 male) presenting with acute intra-articular supracondylar or intercondylar distal femur fractures and with pre-existent primary osteoarthritis who were treated with primary knee arthroplasty were recorded. We collected standard demographic data, comorbidities and patient reported outcomes including Visual Analogical Scale (VAS), Oxford Knee Score (OKS) and Barthel's Index. Post-operative joint range of motion (ROM) and standard radiographic data were also collected.

RESULTS

At a mean follow-up of 23.2 mo, all of the implants were well-positioned and osteointegrated. Furthermore, all the patients were alive and walking either independently or with walking aids. There was a marked improvement in pain (VAS 4.5 postop vs 1.9 at the last follow-up), OKS score (29.5 postop vs 36.81 at the last follow-up), ROM (96.2° postop vs 102° at the last follow-up) and restoration of pre-injury ambulatory status (average Barthel Index 77.3). The radiographic evaluations showed good restoration of the articular geometry. No deaths and no complications were recorded.

CONCLUSION

In conclusion, we believe that knee megaprosthesis in the case of complex fractures of the distal femur is a valid surgical choice. This is particularly true in elderly patients with severe osteoporosis and pre-existing osteoarthritis. It is important to note that this surgery should be performed by surgeons with proven experience in prosthetic hip and knee surgery and that a scrupulous selection of the cases is completed.

Environmental, Microbiological, and Immunological Features of Bacterial Biofilms Associated with Implanted Medical Devices

The spread of biofilms on medical implants represents one of the principal triggers of persistent and chronic infections in clinical settings, and it has been the subject of many studies in the past few years, with most of them focused on prosthetic joint infections. We review here recent works on biofilm formation and microbial colonization on a large variety of indwelling devices, ranging from heart valves and pacemakers to urological and breast implants and from biliary stents and endoscopic tubes to contact lenses and neurosurgical implants. We focus on bacterial abundance and distribution across different devices and body sites and on the role of environmental features, such as the presence of fluid flow and properties of the implant surface, as well as on the interplay between bacterial colonization and the response of the human immune system.

The value of megaprostheses in non-oncological fractures in elderly patients: A short-term results

INTRODUCTION

The management of both hip and distal femur fractures as well as periprosthetic fractures can be challenging for orthopaedic surgeons. The use of megaprosthetic implants could provide substantial advantages in elderly population affected by complex fractures. The aim of the study was to evaluate the effectiveness of megaprosthetic implants for treating hip and distal femur fractures as well as periprosthetic fractures in elderly.

MATERIAL AND METHODS

From January 1st 2015 to December 31st 2019, patients treated for proximal or distal femoral fractures with severe bone loss or failure of previous surgery were retrospectively reviewed. Patients were divided into two group based on diagnosis: proximal femur fractures (group A) and distal femur fractures (group B). Subsequently, patients underwent hip (group A) or knee (group B) megaprosthesis. Self-assessed questionnaires were administered to all patients pre and postoperatively. Primary outcome was the Activity Daily Living. Secondary outcomes were: Instrumental Activity Daily Living, Short Form-12, Oxford knee or hip score, complications. Charlson score, Harris classification for hip or Anderson Orthopaedic Research Institute score and complication were recorded. All patients underwent a radiological follow up to rule out implant loosening and mobilization. Pre and postoperative functional score comparisons in each group were undertaken. Significance was set p ≤ 0.05.

RESULTS

Twelve patients were finally included in the study. There were 6 male and 6 females, the mean age was 72,9 years old (± 7,4); the mean BMI was 29,8 points (± 4.5). The mean follow-up was 2.9 years (± 1.4). No differences could be found between pre and postoperative evaluation in each group. No aseptic loosening, dislocation, mobilization or radiolucency were recorded during the follow-up. In group A, two surgical site infections (2/6 patients) and one pneumonia (1/6 patients) were recorded. In group B, two surgical site infections occurred (2/6 patients). All patients were treated by antimicrobial oral therapy with complete regression.

CONCLUSION

The use of hip and knee megaprosthetic implants in traumatology is a safe and viable option in elderly patients.

Application of Finite Element Analysis Combined With Virtual Computer in Preoperative Planning of Distal Femoral Fracture

Background

Distal femoral fractures are increasing with an aging population. The computer-assisted preoperative planning has great potential, but there are no preoperative plans to determine appropriate fixation methods for distal femoral fractures on an individual basis. The aims of this study are: (1) to describe the technique of finite element analysis combined with computer-assisted preoperative planning to determine a fixation method for distal femoral fractures and (2) to evaluate the intra-operative realization of this technology and the clinical outcomes based on it for distal femoral fractures.

Materials and Methods

Between January 2017 and January 2020, 31 patients with distal femoral fractures treated by open reduction and internal fixation were included and randomly divided into two groups based on preoperative planning methods: conventional group (n = 15) and computer-assisted group (n = 16). Firstly, how to determine the most appropriate plate and screw length and placement in the preoperative planning of distal femoral fractures was described. The time taken for preoperative planning for different fracture types in the computer-assisted group was then analyzed. Finally, intraoperative and postoperative parameters were compared between the conventional and computer-assisted groups, assessing operative time, intraoperative blood loss, number of intraoperative fluoroscopies, days of hospital stay, Visual Analog Scale for Pain Score (VAS), and Knee Society Score (KSS).

Results

Mean total planning time for 33-A, 33-B, and 33-C fractures in computer-assisted group were 194.8 ± 6.49, 163.71 ± 9.22, and 237 ± 5.33 min, respectively. Compared with the conventional group, the patients in the computer-assisted group had less blood loss, fewer fluoroscopic images, and shorter operation time (p < 0.05). However, there was no significant difference in the hospitalization days, KSS score and VAS score between the two groups (p > 0.05).

Conclusions

The results of this study show that finite element combined with computer-assisted preoperative planning can effectively help surgeons to make accurate and clinically relevant preoperative planning for distal femoral fractures, especially in the selection of appropriate plate length and screw positioning.

Cost-effectiveness of fixation versus arthroplasty for geriatric distal femur fractures

INTRODUCTION

Geriatric distal femur fractures are challenging to treat. The high mortality rate associated with a loss of mobility in this population has led some authors to compare distal femur fractures to femoral neck fractures with respect to the importance of rapidly regaining mobility in the geriatric population. Acute distal femur replacement has been advocated by some as a preferred treatment over internal fixation because arthroplasty may facilitate a more rapid return to a patient's baseline mobility level. The purpose of this study was to systematically review the literature on the costs and outcomes of fixation and arthroplasty in the geriatric distal femur fracture population and to employ decision modeling techniques to generate evidence-based treatment recommendations.

METHODS

A systematic literature review of clinical studies published since 2000 was conducted to synthesize the available data on outcomes, reoperation rates, and mortality rates after fixation or arthroplasty for distal femur fractures in patients with an average age greater than 70 years. A Markov decision analysis model was created. Costs, health state utilities, reoperation rates, and mortality rates were derived from the systematic literature review and publicly available data. The model was analyzed via probabilistic statistical analysis as well as sensitivity analyses with a willingness-to-pay threshold set at $100,000 per QALY and a 5-year time horizon.

RESULTS

From a US societal perspective, fixation was associated with a greater quality of life benefit (2.44 QALYs vs. 2.34 QALYs) and lower cost ($25,556 vs. $65,536) compared with distal femur replacement for geriatric distal femur fractures. Probabilistic analysis demonstrated that 82 in 100 model outcomes favored fixation over arthroplasty and 18 in 100 model outcomes favored distal femur replacement. Sensitivity analyses demonstrated that this result was robust to small deviations in the cost and functional outcome variables in the model.

CONCLUSION

Compared to distal femur replacement, ORIF is likely to be a more cost-effective treatment for distal femur fractures in the geriatric patient population, though this recommendation is tempered by the relatively low quality of evidence available on the comparative functional outcomes of these treatments.

[Current status and progress of locking plate in the treatment of distal femoral comminuted fracture]

OBJECTIVE

To review the current status and progress of locking plate for the treatment of distal femoral comminuted fractures.

METHODS

The related literature was extensively reviewed to summarize the current status and progress in the treatment of distal femoral comminuted fracture with locking plate from four aspects: the current treatment situation, the shortcomings of locking plate and countermeasures, the progress of locking technology, locking plate and digital orthopedic technology.

RESULTS

Treatment of distal femoral comminuted fractures is challenging. Locking plates, the most commonly used fixation for distal femoral comminuted fractures, still face a high rate of treatment failure. Double plates can improve the mechanical stability of comminuted fractures, but specific quantitative criteria are still lacking for when to choose double plates for fixation. The far cortial locking screw has shown good application value in improving the micro-movement and promoting the growth of callus. The biphasic plating is a development of the traditional locking plate, but needs further clinical examination. As an auxiliary means, digital orthopedic technology shows a good application prospect.

CONCLUSION

The inherent defect of locking plate is a factor that affects the prognosis of distal femoral comminuted fracture. The optimization of locking technology combined with digital orthopedic technology is expected to reduce the failure rate of treatment of distal femoral comminuted fracture.

Retrograde Intramedullary Nail for Distal Femur Fracture, Through a Total Knee Arthroplasty

Distal femur fractures are common in the elderly population. The risk of sustaining a distal femur fracture is increased with the presence of total knee arthroplasty components. Fixation with a retrograde intramedullary nail is a viable option for treatment of these injuries. This case-based video demonstrates the preoperative planning, techniques, and potential technical pitfalls to performing a retrograde intramedullary nail through a total knee arthroplasty in patients with a distal femur fracture.

Ballistic Supracondylar Distal Femur Fractures Have Lower Rates of Intra-articular Extension Than Blunt Distal Femur Fractures

OBJECTIVES

To compare the relative frequencies of intra-articular extension of supracondylar distal femur fractures in blunt versus ballistic trauma and the diagnostic accuracy of conventional radiography in identifying intra-articular extension in these fractures.

DESIGN

A retrospective review.

SETTING

Urban academic trauma center.

STUDY GROUP

Thirty-eight patients were included for analysis, with 19 blunt and 19 ballistic mechanism distal femur fractures.

INTERVENTION

Fleiss' kappa score was calculated in determining interobserver reliability of the OTA/AO classification. Radiographic specificity and sensitivity were compared using Fischer exact testing. Quantitative data were compared using 2-tailed t-testing for continuous variables and chi-square tests for proportions.

MAIN OUTCOME MEASUREMENTS

Rate of intra-articular extension of ballistic versus blunt supracondylar femur fractures.

RESULTS

Seventeen of 19 patients (89.5%) with blunt trauma had intra-articular involvement compared with 5 of 19 patients (26.3%) with ballistic trauma (P = 0.001). For blunt fractures, preoperative radiographs were 94% sensitive for the detection of intra-articular extension compared with 100% sensitive for ballistic fractures (P = 1.000). We identified one case, in the blunt cohort, where the operative plan changed from intramedullary nail to open reduction and internal fixation as a result of the additional coronal plane fracture pattern identified on CT. There were no such occurrences in the ballistic cohort.

CONCLUSIONS

The rate of intra-articular extension for ballistic supracondylar femur fractures is lower than blunt distal femur fracture. There were low rates of missed intra-articular fractures and changes in operative plans after reviewing CT imaging for both blunt and ballistic distal femur fractures.

LEVEL OF EVIDENCE

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

Hybrid locked medial plating in dual plate fixation optimizes the healing of comminuted distal femur fractures: A retrospective cohort study

OBJECTIVES

Dual plate fixation has been reported to be effective in the treatment of comminuted distal femur fractures (DFFs). However, optimized use of the medial plate and screws is less studied. This study aimed to evaluate the effect of a hybrid configuration of the medial plate in dual plate fixation of comminuted DFFs in promoting fracture healing.

MATERIALS AND METHODS

We retrospectively analyzed 62 patients with comminuted DFFs (AO/OTA 33-A3/33-C2/33-C3) from January 2015 to March 2020, who were either fixed with lateral locked plating augmented with hybrid locked medial plating (LP-HLMP, n = 32) or lateral locked plating (LLP, n = 30) alone. Specifically, compression screws were applied in the middle of the medial plate and flanked by locking ones at both ends. Baseline characteristics, radiological and clinical outcomes were reviewed and analyzed. Multivariate logistic regression analysis was used to identify predictive factors for early fracture healing, and risk factors for delayed union/nonunion.

RESULTS

Demographics including age, gender, smoking, diabetes, and injury mechanism were comparable between the two groups. Reduction quality was better in the LP-HLMP group (p < 0.001). Although the LP-HLMP group experienced longer duration of surgery (125 min vs. 100 min, p < 0.001), sign of healing at 3 months was more obvious in this group (75%, 24/32 vs. 30%, 9/30; p < 0.001). The LP-HLMP group also presented with higher union rate (93.8%, 30/32 vs. 56.7%, 17/30; p = 0.001) and lower reoperation rate (0%, 0/32 vs. 13.3%, 4/30; p = 0.049). Kolment score showed no statistical significance between the two groups. Multivariate analysis revealed that younger age (< 60 years) (OR 5.99, 95%CI 1.16 - 31.03; p = 0.001) and LP-HLMP fixation (OR 45.90, 95% CI 4.78 - 440.56; p = 0.001) predict early healing; while smoking (OR 17.80, 95% CI 2.41 - 131.49; p = 0.01) and fracture translation (OR 3.49, 95% CI 1.46 - 8.32; p = 0.01) were identified as risk factors for delayed union/nonunion.

CONCLUSION

Hybrid locked medial plating in this study favors the healing of comminuted DFFs and reduces reoperation. Additionally, smoking and suboptimal reduction (translation) predict delayed union/nonunion.

C3 geriatric distal femoral fracture - ORIF or replace with a distal femoral replacement (DFR)

HISTORY

A 83yo female tripped on a rug at home. She fell onto her left knee. She had immediate left knee pain. She had never hurt her left knee before.

PAST MEDICAL HISTORY

She takes medication for her blood pressure and has no allergies. She has had prior successful bilateral total hip arthroplasties 5 years ago. Her BMI is in the normal range. She has had no problems with her bilateral total hip arthroplasties.

SOCIAL HISTORY

She lives alone, but her daughter is close by to help her with activities like heavy cleaning. This woman is still driving and doing her own shopping and uses no walking aids. She is a retired secretary.

PHYSICAL EXAM

Distal function is good in the leg. She has no other injuries. Her neck and head are uninjured.

XRAY AND CT

There is a C3 left sided comminuted distal femoral fracture. The bilateral total hip arthroplasties are in good position and appear normal (Fig. 1).

Intra-articular Fracture Pattern in Intercondylar Distal Femur Fractures: An Analysis of Frequency and Major Fracture Fragments

INTRODUCTION

The treatment of intercondylar distal femur fractures requires anatomic reduction of intra-articular fragments and absolute fixation. Preoperative planning is necessary to understand fracture morphology. All fracture lines need to be recognized as the primary implant may not capture all articular fragments, mainly when coronal plane fractures are present. Oftentimes, independent interfragmentary compression screws are necessary. No recent studies have visually mapped out the distal femur articular fracture fragments necessary for absolute fixation. The objectives of this study are to determine the frequency of coronal plane fractures in intercondylar distal femur fractures and describe the pattern of intra-articular fracture fragments.

MATERIALS AND METHODS

The hospital's trauma registry was queried for distal femur ORIF CPT codes logged in the past four years. A retrospective chart review was performed using the EMR and CT scans. Demographics and mechanisms of injury were analyzed. Fracture fragments were surveyed and drawn out by hand on a template for easy organization. Patients' fractures were categorized into the following groups: fractures with no intra-articular coronal plane fractures, those with medial coronal fractures, those with lateral coronal fractures, or those with both medial and lateral coronal fractures. Major fracture fragments were identified.

RESULTS

A total of 55 patients were included. 26 patients (47%) were found to have no intra-articular coronal plane fractures; 6 patients (11%) were found to have medial coronal plane fractures; 15 patients (27%) were found to have lateral coronal plane fractures, and 8 patients (15%) had medial and lateral coronal plane fractures. Collectively, intra-articular coronal plane fractures were identified in 29 patients (53%) with intercondylar distal femur fractures. Four major fracture fragments along with intercondylar and condylar comminution sites were identified.

DISCUSSION

Distal femur intra-articular coronal plane fractures can yield large anterior and posterior condylar fracture fragments of either the medial condyle, lateral condyle, or both condyles. Coronal plane fracture fragments must be identified to obtain absolute fixation. Our study found a higher coronal plane fracture line frequency (52.7%) than prior commonly cited studies. Surgeons must be on the lookout for anterior fracture fragments, posterior fracture fragments, and articular comminution when treating intercondylar femur fractures.

Application of a double reverse traction repositor in the retrograde intramedullary nailing of distal femur fractures

Objective

The purpose of this prospective study was to introduce the application of a double reverse traction repositor (DRTR) in the retrograde intramedullary nailing (RE-IMN) of AO/OTA 33A distal femur fractures.

Patients and methods

A total of 27 patients with AO/OTA type 33A distal femur fractures who were admitted from January 2015 to May 2017 to a level I trauma center of a tertiary university hospital were enrolled in this prospective study. A DRTR was used to facilitate RE-IMN for the reduction of distal femur fractures in all patients. The demographic and fracture characteristics, surgical data, postoperative complications, and prognostic indicators of 24 patients were recorded.

Results

The DRTR helped achieve and maintain the reduction of all distal femur fractures in the present study. All surgeries were conducted by closed reduction, and excellent alignment was observed in the postoperative X-ray images. In the present study, 18 males and 6 females were included, and the average age of all patients was 51.3 years (range, 24–68 years). The mean operation time, intraoperative blood loss, intraoperative fluoroscopy time, and length of postoperative hospital stay were 137 min (range from 80 to 210 min), 320 ml (range from 200 to 600 ml), 28 (from 24 to 33), and 9 days (from 5 to 14 days), respectively. Eleven patients were found to have postoperative deep venous thrombosis before discharge. No cases of wound infection were observed. No cases of nonunion or malunion were observed. The average follow-up duration was 21 months (18–30 months). The average HHS, LKFS, and VAS scores at the 1-year follow-up were 89.9 (86–97), 79.1 (75–87), and 2.1 (from 0 to 5). No complications associated with DRTR were found.

Conclusions

A DRTR can be successfully applied in the treatment of distal femur fractures with RE-IMN, and it can not only help achieve or maintain the reduction of distal femur fractures with closed methods but also promote fixation with RE-IMN.

Acute Distal Femoral Replacement for Fractures About the Knee in the Elderly

Distal femoral replacement (DFR) is a reasonable treatment option when used for select indications. In the setting of comminuted intra-articular distal femoral fractures, distal femoral arthroplasty should be considered in low-demand patients with poor bone quality. This article summarizes the existing literature plus the authors' personal experience with DFR use for distal femoral fractures of the native knee.

Total knee arthroplasty with distal femoral replacement is associated with an important complication rate. A case series

BACKGROUND

With the aging population and an increasing number of total knee arthroplasties (TKAs) performed yearly worldwide, revision surgeries for many causes (septic or aseptic loosening, periprosthetic femoral fractures (PDFF), non-unions, malunions) are more frequent and challenging. Distal femoral replacement (DFR) is sometimes the only option to restore knee function and quality of life. DFR in non-oncologic patient is still a rare indication and few reports are published on this topic, with a non-consistent variety of functional results, complication rates and survivorship.

METHODS

We present a retrospective series of patients who underwent a DFR for a non-oncologic indication between 2010 and 2017. Nineteen patients were available for a full evaluation (clinical and radiological) with a mean follow-up of 48.3 months (range 15-99). Goniometry was performed at the six-week postoperative visit. Complications were reported. Osteolysis and/or signs of aseptic loosening were described using the Knee Society Radiographic Evaluation. Survivorship was calculated for aseptic loosening, infection, and revision for any cause.

RESULTS

The mean Knee Society Score was good for the pain score (42.2, range 10-50) and fair for the function score (60.6, range 0-100). Four deep infections (21.1%) were successfully treated with mobile parts exchange and debridement. Three patients presented femoral osteolysis ≥5 years after the DFR. Survivorship for aseptic loosening was 100% at four years, 81.8% after five years and 53.3% after eight years.

CONCLUSIONS

TKA with DFR is a valuable option for patients with a severe bone loss and poor bone quality in the distal femur. DFR restores an acceptable quality of life but is related to an important complication rate.