1
|
Kale S, Dhar S, Chaudhari P, Mehta N, Das S, Modi R. Integrated Nail and Plate Fixation with Allograft in the Management of Osteoporotic Intra-articular Distal Femur Fracture - A Case Report. J Orthop Case Rep 2024; 14:93-97. [PMID: 39035394 PMCID: PMC11258720 DOI: 10.13107/jocr.2024.v14.i07.4588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/02/2024] [Indexed: 07/23/2024] Open
Abstract
Introduction Securing stable internal fixation for fractures in osteoporotic intra-articular distal femur proves to be a demanding task due to thin cortices, a wide medullary canal, diminished bone stock, and fracture comminution. No singular therapeutic approach has successfully tackled all facets of this injury. Consequently, we now introduce a pioneering fixation method in our report, aiming to offer a holistic solution to the intricate challenges associated with this scenario. Case Report A 60-year-old female presented with an intra-articular distal femur fracture, and underwent a combination fixation of distal femur plate and intramedullary interlocking nailing. The patient was rehabilitated with active knee range of motion on post-operative day 7 and has now attained full knee range of motion. Conclusion The utilization of anatomical plates with locking mechanisms, in tandem with intramedullary interlocking nailing, holds promise for the secure stabilization and fixation of osteoporotic distal femur fractures, potentially leading to an expedited recovery process.
Collapse
Affiliation(s)
- Sachin Kale
- Department of Orthopaedics, Dr. DY Patil Medical College and Hospital, Mumbai, Maharashtra, India
| | - Sanjay Dhar
- Department of Orthopaedics, Dr. DY Patil Medical College and Hospital, Mumbai, Maharashtra, India
| | - Prasad Chaudhari
- Department of Orthopaedics, Dr. DY Patil Medical College and Hospital, Mumbai, Maharashtra, India
| | - Nrupam Mehta
- Department of Orthopaedics, Dr. DY Patil Medical College and Hospital, Mumbai, Maharashtra, India
| | - Sonali Das
- Department of Orthopaedics, Dr. DY Patil Medical College and Hospital, Mumbai, Maharashtra, India
| | - Ravi Modi
- Department of Orthopaedics, Dr. DY Patil Medical College and Hospital, Mumbai, Maharashtra, India
| |
Collapse
|
2
|
Ozer MA, Keser S, Barıs D, Yazoglu O. A novel anatomical locked medial femoral condyle plate: a biomechanical study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2767-2772. [PMID: 38767681 DOI: 10.1007/s00590-024-03993-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/08/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Fixation with a distal lateral femoral plate is a standard approach in treating osteoporotic or comminuted supracondylar femur fractures. However, in clinical practice, this method may prove inadequate, necessitating the application of a plate on the medial side of the distal femur. The aim of this study is to perform a biomechanical evaluation of the newly manufactured anatomically locked plate applied to the distal medial femoral condyle. MATERIALS AND METHODS The plate underwent 2 biomechanical tests by simulating an AO/OTA 33A3 type supracondylar fracture model on synthetic femur bones. The samples were divided into three groups. Fracture fixations were carried out on the medial side using the distal femur medial anatomical locking plate (DFMALP) in group A samples, on the lateral side using the distal femur lateral anatomical locking plate in group B samples, and on both sides in group C samples. RESULTS In the axial compression test, stability was preserved 23% more in group C than in group B. During the cyclic axial compression test, total displacement was 21% less in group C than in group B. Group A was collapsed at early cycle degrees. CONCLUSION In our study, it was observed that the application of DFMALP in conjunction with the lateral plate in AO/OTA 33A3 fragmented supracondylar femur fractures significantly enhanced biomechanical fracture stability. LEVEL OF EVIDENCE This is a Level 2 prospective, randomized controlled study.
Collapse
Affiliation(s)
- M A Ozer
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Bulent Ecevit University, Zonguldak, Turkey.
| | - S Keser
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Bulent Ecevit University, Zonguldak, Turkey
| | - D Barıs
- Response Ortho, Istanbul, Turkey
| | | |
Collapse
|
3
|
Yoon YC, Kim Y, Pesante BD, Chun YS, Lee SH, Sohn HS. Comparative study of retrograde intramedullary nailing versus locking extramedullary plating in complete articular fractures with metaphyseal comminution of the distal femur. Arch Orthop Trauma Surg 2024; 144:2109-2118. [PMID: 38466373 DOI: 10.1007/s00402-024-05265-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/27/2024] [Indexed: 03/13/2024]
Abstract
INTRODUCTION Fractures of the distal femur with metaphyseal comminution and complete intra-articular involvement (AO/OTA classifications 33C2 and 33C3) present challenges for reduction and fixation. However, an optimal fixation method remains unknown. This study aimed to compare the clinical and radiographic outcomes of locking extramedullary plating (LEP) and retrograde intramedullary nailing (RIN) for complete distal femoral intra-articular fractures with metaphyseal comminution. MATERIALS AND METHODS Between January 2016 and May 2022, 80 patients (45 men and 35 women; average age, 56.7 years) diagnosed with AO/OTA 33C2 and 33C3 were treated with either LEP or RIN and followed up for at least one year. Post-operative evaluations included radiographic assessments of bone union rate, timing, and alignment. Clinically, the knee joint range of motion (ROM), lower extremity functional scale (LEFS), and Kellgren and Lawrence (KL) grade were analyzed. The complications were also compared. RESULTS 36 underwent LEP and 44 underwent RIN. Bone union was observed in 69.4% and 63.6% of the patients in the LEP and RIN groups, respectively (p = 0.64). The average union time was 6.9 months for the LEP group and 6.6 months for the RIN group (p = 0.51). A tendency toward varus deformity was observed in the RIN group, although the difference was not statistically significant. No significant differences were observed in knee ROM, LEFS, or KL grade. Complications included non-union (33.8%; RIN, 11; LEP, 16), varus deformity (5%; RIN, 4; LEP, 0), infection (1.3%; RIN, 0; LEP, 1), heterotrophic ossification (1.3%; RIN, 0; LEP, 1), and wound dehiscence (2.5%; RIN, 2; LEP, 0). CONCLUSIONS The surgical fixation methods, RIN and LEP, for complete distal femoral intra-articular fractures with metaphyseal comminution showed similar clinical and radiological outcomes. However, regardless of the type of fixation device used, there was a reduced rate of bone union owing to high energy and a less favorable prognosis.
Collapse
Affiliation(s)
- Yong-Cheol Yoon
- Orthopedic Trauma Division, Trauma Center, Gachon University College of Medicine, Namdong-gu, Incheon, Republic of Korea
| | - Youngwoo Kim
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Gyeonggi-do, Republic of Korea
| | - Benjamin D Pesante
- Department of Orthopedics, Denver Health Medical Center, Denver, CO, USA
| | - You Seung Chun
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Gyeonggi-do, Republic of Korea
| | - Sang Ho Lee
- Department of Orthopedic Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
| | - Hoon-Sang Sohn
- Department of Orthopedic Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea.
| |
Collapse
|
4
|
Dong W, Lisitano LSJ, Marchand LS, Reider LM, Haller JM. Weight-bearing Guidelines for Common Geriatric Upper and Lower Extremity Fractures. Curr Osteoporos Rep 2023; 21:698-709. [PMID: 37973761 DOI: 10.1007/s11914-023-00834-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 11/19/2023]
Abstract
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.
Collapse
Affiliation(s)
- Willie Dong
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Leonard S J Lisitano
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Lucas S Marchand
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Lisa M Reider
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Justin M Haller
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
| |
Collapse
|
5
|
Nester M, Borrelli J. Distal femur fractures management and evolution in the last century. INTERNATIONAL ORTHOPAEDICS 2023:10.1007/s00264-023-05782-1. [PMID: 37079125 DOI: 10.1007/s00264-023-05782-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 03/13/2023] [Indexed: 04/21/2023]
Abstract
PURPOSE The purpose of this historical review is to illustrate the progression and evolution of treatment for distal femur fractures. METHODS Scientific literature was searched for descriptions of treatment for distal femur fractures to provide an in-depth overview of the topic, with emphasis on the evolution of surgical constructs used to treat these fractures. RESULTS Prior to the 1950s, distal femur fractures were treated nonoperatively, resulting in considerable morbidity, limb deformity, and limited function. As principles of surgical intervention for fractures emerged in the 1950s, surgeons developed conventional straight plates to better stabilize distal femur fractures. Angle blade plates and dynamic condylar screws emerged out of this scaffolding to prevent post-treatment varus collapse. Meanwhile, intramedullary nails, and later, in the 1990s, locking screws, were introduced to minimize soft tissue disruption. Treatment failure led to the development of locking compression plates with the advantage of accommodating either locking or nonlocking screws. Despite this advancement, the rare but significant incidence of nonunion has not been eliminated, leading to the recognition of the biomechanical environment as important for prevention and the development of active plating techniques. CONCLUSION Emphasis for the surgical treatment of distal femur fractures has incrementally progressed over time, with initial focus on complete stabilization of the fracture while the biological environment surrounding the fracture was ignored. Techniques slowly evolved to minimize soft tissue disruption, allow more ease of implant placement at the fracture site, and attend to the systemic health of the patient, while simultaneously ensuring appropriate fracture fixation. Through this dynamic process, the desired results of complete fracture healing and maximization of functional outcomes have emerged.
Collapse
Affiliation(s)
- Matthew Nester
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Joseph Borrelli
- Department of Orthopedic and Sports Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
| |
Collapse
|
6
|
Nail plate combination in fractures of the distal femur in the elderly: A new paradigm for optimum fixation and early mobilization? Injury 2023; 54:288-291. [PMID: 36400628 DOI: 10.1016/j.injury.2022.11.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Distal femoral fractures in elderly or osteoporotic patients constitute a challenging injury, especially in the settings of fracture comminution or periprosthetic fractures. A recent trend in the treatment of these difficult injuries is the double fixation with a nail and a plate, a strategy that comes with advantages including faster weight-bearing and lower risk for non-union. Although biomechanical studies have demonstrated the superiority of nail-plate constructs, there is a paucity in the literature regarding the indications and results of treatment. A review of the literature to date was carried out to identify which group of patients would benefit the most from this type of reconstruction and to evaluate the clinical outcomes.
Collapse
|
7
|
Laubach LK, Sharma V, Krumme JW, Larkin K, Satpathy J. Novel classification system for periprosthetic distal femoral fractures: a consideration for comminution. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-022-03468-9. [PMID: 36635567 DOI: 10.1007/s00590-022-03468-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/20/2022] [Indexed: 01/13/2023]
Abstract
PURPOSE Comminution is an aspect of periprosthetic distal femoral fractures (PDFFs) that can influence postoperative outcomes and treatment selection, but is not included in current classification systems. We propose a new classification system for PDFFs based on comminution and cortical reads. This study aims to prove its reliability and efficacy to predict fracture severity and guide treatment. METHODS A retrospective chart review of patients treated with single or dual locking plates for PDFFs was performed. Two fellowship-trained orthopedic joint reconstruction specialists used available imaging to classify each PDFF as either type 1 (minimal or no comminution allowing for reconstruction of medial and lateral cortices), type 2 (comminution reasonably allowing for reconstruction of either medial or lateral cortex), and type 3 (extensive comminution not allowing reasonable reconstruction of medial or lateral cortex). Each PDFF was then analyzed for radiographic outcomes including lateral distal femoral angle (LDFA) and the posterior distal femoral angle (PDFA). RESULTS Interobserver reliability assessed by Cohen's Kappa statistic was 0.707, and average intraobserver reliability was 0.843, showing substantial reliability. Type 3 PDFFs had greater varus deformity than type 1 (p = 0.0457) or 2 (0.0198). CONCLUSION The proposed classification system accounts for comminution, demonstrates strong interobserver and intraobserver reliability, and can be used to guide treatment in regard to single versus dual plating. LEVEL OF EVIDENCE Retrospective comparative study, Level IV.
Collapse
Affiliation(s)
- Logan K Laubach
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, PO Box 980153, Richmond, VA, 23298, USA
| | - Viraj Sharma
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, PO Box 980153, Richmond, VA, 23298, USA
| | - John W Krumme
- KC Orthopedic Alliance, UMKC, 3651 College Blvd, Leawood, KS, 66211, USA
| | - Kevin Larkin
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, PO Box 980153, Richmond, VA, 23298, USA
| | - Jibanananda Satpathy
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, PO Box 980153, Richmond, VA, 23298, USA.
| |
Collapse
|
8
|
Poelmann J, Kloen P. Modified use of the proximal humeral internal locking system (PHILOS) plate for distal femoral nonunions. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:425-433. [PMID: 35061100 PMCID: PMC9930358 DOI: 10.1007/s00590-022-03203-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/29/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Nonunion is a common complication after a distal femoral fracture (DFF). Standard treatment consists of revision plating and/or bone grafting. Single lateral plating for a distal femoral nonunion can be insufficient in case of a persistent medial gap and compromised bone stock. Alternatively, dual plating can be used to treat a distal femoral nonunion, but to date there is no Gold standard. The aim of our study was to report our results after use of a minimally invasively placed proximal humeral internal locking system (Philos) plate as a medial buttress in the treatment of a distal femoral nonunion. METHODS Fifteen adult patients with a distal femoral nonunion were prospectively entered in a trauma database and retrospectively assessed. All patients underwent a similar operation, which included removal of failed hardware, nonunion debridement, fixation with a lateral plate, and a medial Philos plate combined with bone grafting. Data collected included union rate, time to union, complications and functional outcome. RESULTS In twelve out of fifteen patients (80%), the fracture united after our index operation. Median time to union was 4.8 months (range 1.6-15). Three patients (20%) needed additional bone grafting surgery. One patient underwent a Judet quadricepsplasty. CONCLUSION This study suggests that the Philos plate is a safe and effective adjunct as a medial buttress plate for distal femoral nonunions.
Collapse
Affiliation(s)
- Josje Poelmann
- Department of Orthopedic Surgery, Amsterdam University Medical Center, Meiberdreef 9, Amsterdam, 1105AZ, The Netherlands.
| | - Peter Kloen
- grid.509540.d0000 0004 6880 3010Department of Orthopedic Surgery, Amsterdam University Medical Center, Meiberdreef 9, Amsterdam, 1105AZ The Netherlands
| |
Collapse
|
9
|
Oransky M, Galante C, Cattaneo S, Milano G, Motta M, Biancardi E, Grava G, Johnson EE, Casiraghi A. Endosteal plating for the treatment of malunions and nonunions of distal femur fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03458-x. [PMID: 36539626 DOI: 10.1007/s00590-022-03458-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 12/12/2022] [Indexed: 06/17/2023]
Abstract
PURPOSE To describe the surgical technique and the outcome of a case series of nonunion and malunion of distal femur fractures treated with an endosteal medial plate combined with a lateral locking plate and with autogenous bone grafting. METHODS We retrospectively analyzed a series of patients with malunion or nonunion of the distal femur treated with a medial endosteal plate in combination with a lateral locking plate, in a period between January 2011 and December 2019, Database from chart review was obtained including all the clinical relevant available baseline data (demographics, type of fracture, mechanism of injury, time from injury to surgery, number of previous surgical procedures, type of bone graft, and type of lateral plate). Time to bone healing, limb alignment at follow-up and complications were documented. RESULTS Ten patients were included into the study: 7 male and 3 female with mean age of 48.3 years (range 21-67). The mechanism of trauma was in 8 cases a road traffic accident and in 2 cases a fall from height. According to AO/OTA classification 5 fractures were 33 A3, 3 were 33 C1, 1 was 33 C2 and 1 was 33 C3. The average follow up was 13.5 months. In all cases but one bony union was achieved. Bone healing was observed in average 3.3 months after surgery. No intraoperative or postoperative complications were reported. CONCLUSION A medial endosteal plate is a useful augmentation for lateral plate fixation in nonunion or malunion following distal femur fractures, particularly in cases of medial bone loss, severe comminution, or poor bone quality. LEVEL OF EVIDENCE Level IV (retrospective case series).
Collapse
Affiliation(s)
- Michel Oransky
- Department of Bone and Joint Surgery, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Claudio Galante
- Department of Bone and Joint Surgery, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Stefano Cattaneo
- Department of Bone and Joint Surgery, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Giuseppe Milano
- Department of Bone and Joint Surgery, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Viale Europa 11, 25123, Brescia, BS, Italy
| | - Marcello Motta
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Viale Europa 11, 25123, Brescia, BS, Italy.
| | - Elena Biancardi
- Department of Bone and Joint Surgery, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Giuseppe Grava
- Department of Bone and Joint Surgery, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Eric E Johnson
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA Center for the Health Sciences, Los Angeles, CA, 90095-6902, USA
| | - Alessandro Casiraghi
- Department of Bone and Joint Surgery, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| |
Collapse
|
10
|
Barzen S, Buschbeck S, Hoffmann R. [Distal femoral fractures]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 125:507-517. [PMID: 35725933 DOI: 10.1007/s00113-022-01197-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 06/15/2023]
Abstract
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.
Collapse
Affiliation(s)
- S Barzen
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Unfallchirurgie und orthopädische Chirurgie, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland.
| | - S Buschbeck
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Unfallchirurgie und orthopädische Chirurgie, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - R Hoffmann
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Unfallchirurgie und orthopädische Chirurgie, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| |
Collapse
|
11
|
Sharma V, Laubach LK, Krumme JW, Satpathy J. Comminuted periprosthetic distal femoral fractures have greater postoperative extension malalignment. Knee 2022; 36:65-71. [PMID: 35526350 DOI: 10.1016/j.knee.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/19/2022] [Accepted: 04/18/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Comminution is a significant aspect of periprosthetic distal femoral fracture characterization and may influence post-surgical outcomes. Existing classification systems that guide treatment decisions do not take into account comminution and current literature is unclear on which surgical approach is optimal. We hypothesize that fractures with comminution will have poorer quality post-reduction alignment, especially with a lateral approach. MATERIALS AND METHODS 37 study patients were identified with billing codes designating a distal femoral periprosthetic fracture. A retrospective chart review was performed to categorize fractures by absence or presence of comminution and medial parapatellar versus lateral surgical approach. These patients underwent an imaging evaluation for the primary outcome of reduction quality including the anatomic lateral distal femoral angle (LDFA) and the posterior distal femoral angle (PDFA). Differences in radiographic outcomes were analyzed with Wilcoxon/Kruskal-Wallis tests, and analysis by approach was through Fisher's exact test. RESULTS Patients with comminuted fractures had significantly greater extension of the fragment (PDFA = 95.4° vs 90.0°, p = 0.018) and similar coronal alignment (LDFA = 85.3° vs 86.3°, p = 0.83) of the knee compared to non-comminuted fractures after surgical reduction. This difference was more prominent amongst those treated with a lateral approach (PDFA = 96.1° vs 89.4°, p = 0.032) than with a medial approach (PDFA = 93.7° vs 91.5°, p = 0.41) (Table 1). DISCUSSION Current classification systems and treatment guidelines for periprosthetic distal femoral fractures do not adequately address several issues that may influence treatment outcomes, especially comminution. Comminuted fractures had greater post-reduction extension malalignment, falling outside the recommended PDFA range of 87-90°, especially with a lateral approach. Consideration should be given to surgical approach and techniques to reduce excessive extension when treating comminuted periprosthetic distal femoral fractures.
Collapse
Affiliation(s)
- Viraj Sharma
- VCU Health Department of Orthopaedic Surgery, PO Box 980153, Richmond, VA 23298, United States.
| | - Logan K Laubach
- VCU Health Department of Orthopaedic Surgery, PO Box 980153, Richmond, VA 23298, United States.
| | - John W Krumme
- KC Orthopedic Alliance, UMKC, 3651 College Blvd, Leawood, KS 66211, United States.
| | - Jibanananda Satpathy
- VCU Health Department of Orthopaedic Surgery, PO Box 980153, Richmond, VA 23298, United States.
| |
Collapse
|
12
|
Tripathy SK, Mishra NP, Varghese P, Panigrahi S, Purudappa PP, Goel A, Sen RK. Dual-Plating in Distal Femur Fracture: A Systematic Review and Limited Meta-analysis. Indian J Orthop 2022; 56:183-207. [PMID: 35140850 PMCID: PMC8789962 DOI: 10.1007/s43465-021-00489-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/13/2021] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Although lateral locking plate has shown promising results in distal femur fracture, there are high rates of varus collapse and implant failure in comminuted metaphyseal and articular fractures. This systematic review evaluates the functional outcomes and complications of dual plating in the distal femur fracture. MATERIALS AND METHODS Manual and electronic search of databases (PubMed, Medline Embase and Cochrane Central Register of Controlled Trials) was performed to retrieve studies on dual plate fixation in the distal femur fracture. Of the retrieved 925 articles, 12 were included after screening. RESULTS There were one randomized-controlled, four prospective and seven retrospective studies. A total of 287 patients with 292 knees were evaluated (dual plating 213, single plating 76, lost to follow-up 3). The nonunion and delayed union rates following dual plate fixations were up to 12.5% and 33.3%, respectively. The mean healing time ranged from 11 weeks to 18 months. Good to excellent outcome was observed in 55-75% patients. There was no difference between the single plate and dual plate fixation with regards to the functional outcomes (VAS score, Neer Score and Kolmert's standard) and complications. Pooled analysis of the studies revealed a longer surgical duration (MD - 16.84, 95% CI - 25.34, - 8.35, p = 0.0001) and faster healing (MD 5.43, 95% CI 2.60, 8.26, p = 0.0002) in the double plate fixation group, but there was no difference in nonunion rate (9.2% vs. 0%, OR 4.95, p = 0.13) and blood loss (MD - 9.86, 95% CI - 44.97, 25.26, p = 0.58). CONCLUSION Dual plating leads to a satisfactory union in the comminuted metaphyseal and articular fractures of the distal femur. There is no difference between the single plate and dual plate with regards to nonunion rate, blood loss, functional outcomes and complications. However, dual fixation leads to faster fracture healing at the cost of a longer surgical duration.
Collapse
Affiliation(s)
- Sujit Kumar Tripathy
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019 India
| | - Narayan Prasad Mishra
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019 India
| | - Paulson Varghese
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019 India
| | - Sibasish Panigrahi
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019 India
| | | | - Akshay Goel
- Joan C Edwards School of Medicine, Marshall University, Huntington, WV USA
| | | |
Collapse
|
13
|
Ghirardelli S, Touloupakis G, Theodorakis E, Antonini G, Violante B, Indelli PF. A modified anterolateral swashbuckler approach for distal femoral fractures: description and outcomes. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022005. [PMID: 35315401 PMCID: PMC8972876 DOI: 10.23750/abm.v93i1.12091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 08/26/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND The treatment of distal femur fractures represents a challenging task. General and local factors, including bone quality, articular surface involvement, fracture comminution, associated soft tissue injuries and ultimately fixation system, all play a role in the final clinical outcome. Current surgical approaches often undermine patellar vascularization and integrity of the extensor apparatus, not guaranteeing sufficient visualization of the medial condyle. This technical note presents the efficacy and safety a new surgical technique to address distal femoral fractures. METHODS The original "swashbuckler" surgical approach was modified in order to obtain a better visualization of the lateral and medial femoral condyles without affecting the knee extensor mechanism and the anastomotic arterial supply of the patella. This modified surgical approach was utilized in a consecutive series of patients presenting with an AO Foundation/Orthopaedic Trauma Association (AO/OTA) 33 distal femur or periprosthetic fracture of the knee. The final outcome was recorded according to a functional evaluation scoring system. RESULTS Twelve patients (2 males and 10 females) with a mean age of 67,8 years were included in this series. The same, modified "swashbuckler" surgical approach was applied in all cases. Multiple internal fixation techniques, including a single lateral plate, a combination of a lateral and medial plate, a single lateral plate associated with lag screws, were used to obtain a satisfactory stabilization of the fracture site. All patients were reviewed at a minimum one-year follow up (median 15 months): all patients regained their level of activities of daily living. No major intraoperative or postoperative complications were recorded. CONCLUSIONS The modified swashbuckler approach allows anatomical reduction and appropriate fixation without sacrificing the blood supply to the patella and ensures rapid weight bearing resumption thanks to an intact extensor mechanism.
Collapse
Affiliation(s)
- Stefano Ghirardelli
- Department of Orthopedics and Traumatology, Bressanone/Brixen Hospital, Bressanone, Italy, These authors contributed equally to this work
| | - Georgios Touloupakis
- Department of Orthopedics and Traumatology, San Carlo Borromeo Hospital, Milan, Italy, These authors contributed equally to this work
| | - Emmanouil Theodorakis
- Department of Orthopedics and Traumatology, San Carlo Borromeo Hospital, Milan, Italy
| | - Guido Antonini
- Department of Orthopedics and Traumatology, San Carlo Borromeo Hospital, Milan, Italy
| | - Bruno Violante
- Department of Orthopedic Surgery, IRCCS Sant’Ambrogio, Milan, Italy
| | - Pier Francesco Indelli
- Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine and the Palo Alto Veterans Affairs Health Care System (PAVAHCS), Palo Alto, USA
| |
Collapse
|
14
|
Starčević N, Karačić A. Infected Nonunion of the Distal Femur in the Elderly with Bone Loss: Case Report and Treatment Options. Case Rep Orthop 2021; 2021:3530297. [PMID: 34580614 PMCID: PMC8464431 DOI: 10.1155/2021/3530297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/06/2021] [Indexed: 11/17/2022] Open
Abstract
The management of infected nonunion associated with bone loss in long bones is both a time-consuming and challenging procedure for the orthopedic and trauma surgeon. In this paper, we present the case of a 75-year-old woman with infected nonunion of the distal femur associated with bone loss after plate osteosynthesis for a distal femur fracture. The patient was referred for nonunion of the distal femur after plate fixation (nonlocking "classic" plate) and was treated with a locking compression plate (LCP) and autologous cancellous bone transplant. During the follow-up, the patient was ambulatory without pain; however, the nonunion failed to heal, therefore, the induced membrane technique (Masquelet procedure) was performed in two stages, tissue samples were taken and revealed a bacterial infection (S. epidermidis), and antibiotic treatment was started. Due to infection, fracture healing was slowed, but did commence. Unfortunately, the LC plate failed before union occurred, the nonunion was treated with a femoral nail and blocking (Poller) screws, and the bony defect was filled with Ca-P cement. The patient was operated one last time for cement dislocation when not only the dislocated cement was removed but also the femoral nail dynamized. After one year after treatment completion, the fracture healed, and leg length discrepancy was 1.5 cm shorter on the left side. The patient experienced significant pain relief and can walk with the help of crutches. Our paper demonstrates the application of different techniques in fracture surgery as they are required can result in fracture healing even in very adverse circumstances.
Collapse
Affiliation(s)
- Neven Starčević
- Traumatology Department, University Hospital Sveti Duh, Sveti Duh, 64 Zagreb, Croatia
| | - Andrija Karačić
- Department of General Surgery, University Hospital Sveti Duh, Sveti Duh, 64 Zagreb, Croatia
| |
Collapse
|
15
|
Siddiqui YS, Mohd J, Abbas M, Gupta K, Khan MJ, Istiyak M. Technical difficulties and mechanical failure of distal femoral locking compression plate (DFLCP) in management of unstable distal femoral fractures. INTERNATIONAL JOURNAL OF BURNS AND TRAUMA 2021; 11:9-19. [PMID: 33824780 PMCID: PMC8012867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/18/2020] [Indexed: 06/12/2023]
Abstract
Objective of the paper is to portray the technical difficulties and mechanical failure of Distal Femoral Locking Compression Plate in the management of unstable distal femoral fractures. The primary outcome measure was defined as revision surgery due to implant failure with subsequent non-union. Secondary outcome measures were mal-union, delayed union, peri-implant fracture and infection. Functional outcome were evaluated using Schatzker & Lambert criteria. Thirty nine patients were available for final follow up. The rate of revision surgery as primary outcome measure was 7.69%. Mal-union was seen in 5.1%, delayed union in 7.69%, superficial infection in 10.25% and deep infection in 5.1% patients. All except three fractures united following index surgery. Functional outcome as per the Schatzker & Lambert Criteria was excellent in 20.5%, good in 48.7%, fair in 18% and failure in 12.8%. In sight of the findings of our study along with existing literature we propose for creating a fixation construct that is conducive for fracture healing by following principles of locking compression plating and augmenting stability by medial column reconstruction.
Collapse
|
16
|
Yuan Y, Luo B, Hao Q, Yuan J, Qu GB, Hao PD, Zeng ZJ, Yang JF, Xu ZJ. Clinical outcomes of revision with retrograde intermedullary nailing for failed plating of distal femoral fractures: a retrospective study. INTERNATIONAL ORTHOPAEDICS 2020; 44:2437-2442. [PMID: 32654056 DOI: 10.1007/s00264-020-04621-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/12/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess the feasibility and effectiveness of retrograde intramedullary nail (RIN) revision surgeries for locking compression plate (LCP) failure in distal femoral fractures. METHODS This retrospective study included 13 patients who suffered from metalwork failures after they initially underwent open reduction and LCP fixation. In patients who eventually underwent RIN revision from January 2014 to December 2016, range of motion (ROM) and Hospital for Special Surgery (HSS) scores obtained before surgery and at the final follow-up time were analysed. RESULTS The average operative time was 155 minutes (range, 120-210 minutes), and the average blood loss volume was 650 ml (range, 200-1350 ml). There were two cases of complications (15.38%): one was calf muscle vein thrombosis, and the other was a superficial infection. No deep tissue infection or deep vein thrombosis was observed post-operatively. The average follow-up time was 16 months (range, 12-24 months). All fractures healed in a mean of 6.5 months (range, 4-12 months), and one patient underwent an additional bone graft surgery that did not involve a bone graft during the RIN revision operation (this eventually healed at 12 months post-operatively). The mean ROM before the operation was 86.92 ± 12.34°. At the final follow-up, the mean ROM was 112.69 ± 9.27°. There was a significant difference between pre-operative and post-operative ROM (P < 0.01). The mean HSS score improved significantly from 38.85 ± 9.62 points pre-operatively to 79.62 ± 5.42 points post-operatively. There was a significant difference between pre-operative and post-operative HSS scores (P < 0.01). CONCLUSIONS RIN revision surgery achieved excellent clinical results in patients with LCP failure.
Collapse
Affiliation(s)
- Yi Yuan
- Department of Orthopaedics, Traditional Chinese Medicine Hospital, Southwest Medical University, 182# Chunhui Road, Luzhou, 646000, Sichuan, People's Republic of China
| | - Bing Luo
- Department of Orthopaedics, Traditional Chinese Medicine Hospital, Southwest Medical University, 182# Chunhui Road, Luzhou, 646000, Sichuan, People's Republic of China
| | - Qi Hao
- Department of Orthopaedics, Traditional Chinese Medicine Hospital, Southwest Medical University, 182# Chunhui Road, Luzhou, 646000, Sichuan, People's Republic of China
| | - Jun Yuan
- Department of Orthopaedics, Traditional Chinese Medicine Hospital, Southwest Medical University, 182# Chunhui Road, Luzhou, 646000, Sichuan, People's Republic of China
| | - Gang-Bo Qu
- Department of Orthopaedics, Traditional Chinese Medicine Hospital, Southwest Medical University, 182# Chunhui Road, Luzhou, 646000, Sichuan, People's Republic of China
| | - Pan-Deng Hao
- Department of Orthopaedics, Traditional Chinese Medicine Hospital, Southwest Medical University, 182# Chunhui Road, Luzhou, 646000, Sichuan, People's Republic of China
| | - Zhi-Jiang Zeng
- Department of Orthopaedics, Traditional Chinese Medicine Hospital, Southwest Medical University, 182# Chunhui Road, Luzhou, 646000, Sichuan, People's Republic of China
| | - Jia-Fu Yang
- Department of Orthopaedics, Traditional Chinese Medicine Hospital, Southwest Medical University, 182# Chunhui Road, Luzhou, 646000, Sichuan, People's Republic of China.
| | - Zu-Jian Xu
- Department of Orthopaedics, Traditional Chinese Medicine Hospital, Southwest Medical University, 182# Chunhui Road, Luzhou, 646000, Sichuan, People's Republic of China.
| |
Collapse
|
17
|
Pogliacomi F, Artoni C, Calderazzi F, Leigheb M, Primiceri P, Pedrazzini A, Ceccarelli F, Vaienti E. Distal femur nonunion treated with retrograde intramedullary nailing and RIA: a case report. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:259-266. [PMID: 32555107 PMCID: PMC7944819 DOI: 10.23750/abm.v91i4-s.9656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Indexed: 11/23/2022]
Abstract
The current treatment of distal femur fractures includes locking plating and retrograde intramedullary nailing. These fractures are difficult to manage also for experienced surgeons, with results not always satisfactory. Reported nonunion rates now range from 0 to 34%. Factors associated with nonunion include comorbidities, such as obesity and diabetes, as well as the presence of open fractures, medial bone defects and comminuted fractures. This case report summarizes all of these assumptions and it concerns a 58 years old patient who underwent to 6 surgical procedures before to arrive to bone healing. (www.actabiomedica.it)
Collapse
Affiliation(s)
- Francesco Pogliacomi
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | - Carlotta Artoni
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | - Filippo Calderazzi
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | - Massimiliano Leigheb
- Orthopaedics and Traumatology Unit, "Maggiore della Carità" Hospital, Università del Piemonte Orientale (UPO), Corso Mazzini 18, 28100 Novara (Italy).
| | - Paolo Primiceri
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | | | - Francesco Ceccarelli
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | - Enrico Vaienti
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| |
Collapse
|