Clinical outcomes of distal femoral fractures in the geriatric population using locking plates with a minimally invasive approach

BACKGROUND

Fractures of the distal femur comprise 4% to 6% of all femoral fractures. Elderly patients are predisposed to low-energy fractures due to osteoporosis. Treatment of these fractures in the elderly group remains a challenge. Our hypothesis is that locking plates inserted with minimally invasive plate osteosynthesis (MIPO) techniques will produce better results compared to those inserted by open technique. The objective of this study is to evaluate the clinical outcomes of MIPO technique using locking plates in the elderly patients.

MATERIALS AND METHODS

A total of 24 elderly patients (mean age 73 years) with distal femur fractures treated using the MIPO technique (2007-2010) were reviewed retrospectively. Parameters analyzed included classification of fracture, time to fracture union, knee range of motion, functional knee score (Knee Society Score-Functional) at 6 months, and other significant complications. One patient was lost to follow-up.

RESULTS

In all, 88% of the fractures were extraarticular. The mean time to union was 13.48 (range: 8-28) weeks. Mean range of motion achieved at 6 months and beyond was 100° ranging from 0 to 30 (extension) to 90 to 140 (flexion). Functional knee scores at 6 months from fixation were satisfactory (mean score 88.8). There were no cases of implant failure, nonunion, and infection. In all, 6 (25%) patients developed deep vein thrombosis (DVT) in the early postoperative period, all of which were below the level of the knee joint.

CONCLUSION

Locking plates inserted using MIPO techniques in elderly patients with distal femur fractures appear to be promising based on clinical outcome measurements. However, there was a high incidence of DVT noted.

Incidence of surgical-site infection following open reduction and internal fixation of a distal femur fracture: An observational case-control study

Surgical-site infection (SSI) is a common complication in orthopedic surgery; however, SSI after surgically managed distal femur fractures was not well studied. The aim of this study was to investigate the incidence of SSI and identify some modifiable and nonmodifiable risk factors.The patients' electronic medical records (EMRs) were reviewed to identify those who sustained a distal femur fracture and treated by open reduction and internal fixation (ORIF) between March 2014 and February 2018. SSI was defined based on the Centers for Disease Control criteria and confirmed according to the descriptions in EMR. Univariate and multivariate logistic regression models were used to determine the independent risk factors associated with SSI.Totally, EMRs of 665 patients who underwent ORIF of distal femur fractures were reviewed and 24 SSIs were found, indicating the overall incidence of SSI was 3.6%. The rate of deep SSI was 1.2% and superficial SSI was 2.4%. Staphylococcus aureus was the most common causative pathogen, either alone (7/15, 46.7%) or as a mixed infection (3/15, 20%), followed by mixed bacterial (4/15, 26.7%) and S epidermidis (2/15, 13.3%) and others. Patients with SSI had approximately twice the length of hospital stay as those without SSIs (29.0 vs 16.0 days, P < .001). Open fracture, temporary use of external fixation, obesity, smoking, diabetes mellitus, and preoperative reduced albumin level were identified as independent risk factors associated with SSI, and current smoking and preoperative reduced albumin level were the true modifiable factors.Patients should be encouraged to cease smoking as early as possible and increase the good-quality protein intake to reduce or prevent the occurrence of SSI. An explanation of the nonmodifiable risk factors should be included when patients are counseled about their increased risk of SSI.

Mid term results of distal femoral fractures treated with a polyaxial locking plate: a multi-center study

Objective :

Locking plates have become a standard implant in the treatment of distal femoral fractures. Newer designs allow polyaxial screw placement as well as the ability to lock the lag screws.

Methods :

The consecutive multi-centre study cohort consists of all distal femoral fractures treated with the NCB® Distal Femur plate (Zimmer, Warsaw, USA) and a minimum follow-up of twelve months. Fracture classification according the AO/ OTA system and the trauma mechanism radiological evaluation and complications were documented. Clinical evaluation consisted of the Short Form SF12 questionnaire (SF12), the Hospital for Special Surgery Score (HSS) and clinical assessment of range of motion.

Results :

Twenty-five patients with twenty-six fractures were available for follow-up with a minimum required follow-up of twelve months. 81% of the fractures were intra-articular. 48% of the patients were multi-traumatised, 38% having open fractures. All except two went to union (92%) with the primary procedure. The HSS Score was 79 (32-99) and the SF 12 (physical and mental) 40 (19-57) and 54 (21-66) at follow-up. There were five patients requiring surgical revision (19%).

Conclusion :

These fractures are often combined with concomitant injuries. Using modern locked implants high union rates can be achieved with a good function and patient satisfaction when respecting biologic and biomechanical principles.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Therapeutic Level III.

Immediate Full Weight-Bearing Versus Partial Weight-Bearing After Plate Fixation of Distal Femur Fractures in Elderly Patients. A Randomized Controlled Trial

Introduction

After surgery for distal femur fractures in elderly patients, weight-bearing is commonly restricted. Immediate non-restrictive weight-bearing might have beneficial effects. There are no randomized studies on the topic. The purpose of this study was to compare the functional outcome between immediate full weight-bearing (FWB) as tolerated and partial weight-bearing (PWB) during the first 8 weeks following plate fixation of distal femur fractures in elderly patients.

Methods

Patients aged 65 years or older with distal femur fractures of AO/OTA types 33 A2, A3, B1, B2, C1, and C2 were included. Exclusion criteria were impaired cognitive function, concomitant injuries, or inability to follow the postoperative regimen. Internal fixation was achieved with an anatomical lateral distal femur plate applied as a strictly bridge-plating construct. The primary outcome measure was the function index of the short musculoskeletal functional assessment (SMFA) after 52 weeks from injury.

Results

Thirty-two patients were randomized to FWB (n = 11) or PWB (n = 21). After 16 and 52 weeks, there were no differences in the mean SMFA function index between FWB and PWB (36 vs 43, P = .42 and 52 vs 40, P = .18, respectively) nor in the mean EuroQol 5-dimension index or range of motion (ROM). Overall, the SMFA function index was higher at 52 weeks compared with before injury (44 vs 30, P = .001) as was the mean bothersome index (37 vs 21, P = .011). There was no clear difference in the occurrence of adverse events between the treatment groups.

Conclusions

There were no differences in functional outcome, adverse events, or ROM between immediate FWB and PWB following plate fixation for a distal femur fracture in elderly patients. A distal femur fracture has a negative effect on the functional status of elderly patients that persists at least up to 1 year following injury.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Mortality Following Distal Femur Fractures Versus Proximal Femur Fractures in Elderly Population: The Impact of Best Practice Tariff

Background and objectives

The mortality after hip, proximal femur, fractures in elderly patients has steadily declined in the last decade in the United Kingdom as a result of implementing of multiple protocols focusing on prompt multidisciplinary pre- and post-operative optimization and reducing time to surgery. The pinnacle of these protocols is the development of the best practice tariff as an incentive program for hospitals that meet set criteria by the National Health Service (NHS) England in managing these injuries. Until the time of writing this paper, there was no parallel program for the management of fractures involving distal femur in the elderly. The aim of this study is to evaluate the outcomes of distal femur fractures in elderly patients against proximal femur fractures regarding post-injury mortality, the prevalence of surgical treatment and time delay till surgery.

Methods

A retrospective study of all patients above the age of 60 admitted to Queens Hospital Burton between 2010 and 2014 with fractures involving distal end of the femur. Patient data were assessed for demographic criteria, co-morbidities as per Charleston Comorbidities Index, type of management, time-lapse before surgery and 30-day, six-month and one-year mortality. Results were compared to an age-matched control group of patients with proximal femur fractures randomly selected during the same time window.

Results

The main demographic criteria such as age, gender, and Charleston Comorbidities Index were similar in both groups. There were more patients treated non-operatively in the distal femur group than in the proximal femur group (15% vs 4%). Time to surgery was statistically significantly longer in distal femur group compared to the proximal femur (49.130 hours vs 34.075 hours, P = 0.041). The mortality in distal femur group was higher at all times (9.68% at 30 days, 20.32% at six months and 34.41% at one year) when compared to that in the proximal femur group (6.99% at 30 days, 14.52% at six months, 21.51% at one year).

Conclusion

The distal femoral fractures showed higher mortality at 30 days, six months and one year compared to the proximal femur group. This could be partly influenced by the implementation of best practice tariff in the proximal femur fracture group reflected in less time to surgery, pre- and post-operative multidisciplinary approach and more frequent operative management.

Distal Femoral Replacement for Periprosthetic Fractures After TKA: Australian Orthopaedic Association National Joint Replacement Registry Review

BACKGROUND

Distal femoral replacement (DFR) is a potential treatment option following periprosthetic fracture (PPF) of a total knee arthroplasty (TKA). However, there is limited literature regarding implant survivorship and complication rates. The aim of this study was to examine patient demographics and trends in usage, implant survivorship and modes of failure, and patient mortality following DFR for PPF captured by a national joint replacement registry.

METHODS

A retrospective registry review was performed using data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). In total, 306 DFR were performed for PPF of a known primary TKA. Eighty-five percent of patients were female, and the mean age was 76.4 years. Kaplan-Meier estimates of implant and patient survivorship were performed.

RESULTS

The number of DFR performed for PPF has doubled over the past five years. The cumulative percent second revision rate at six years was 12%. The most common indications for revision were infection (37%) and aseptic loosening (33%). Patient survivorship after DFR was 97% and 83% at five and ten years, respectively.

CONCLUSION

A national registry review has identified the increasing prevalence of DFR for PPF after primary TKA and demonstrated implant survivorship of 88% at midterm follow-up. Surgeons may consider DFR as an acceptable and durable treatment option.

LEVEL OF EVIDENCE

Level III - Case Series.

Nottingham Hip Fracture Score: Does It Predict Mortality in Distal Femoral Fracture Patients?

Background

Patients with distal femur fractures are associated with mortality rates comparable to neck of femur fractures. Identifying high-risk patients is crucial in terms of orthogeriatric input, pre-operative medical optimisation and risk stratification for anaesthetics. The Nottingham Hip Fracture Score (NHFS) is a validated predictor of 30-day mortality in neck of femur fracture patients. In this study, we aim to investigate and evaluate the suitability of the NHFS in predicting 30-day as well as one-year mortality of patients who have sustained distal femur fractures.

Methods

Patients admitted to a level 1 major trauma centre with distal femur fractures were retrospectively reviewed between June 2012 and October 2017. NHFSs were recorded using parameters immediately pre-operatively.

Results

Ninety-one patients were included for analysis with a mean follow-up of 32 months. The mean age was 69, 56 (61%) patients were female, 10 (11%) were open fractures and 32 (35%) were peri-prosthetic fractures with 85% of patients being surgically managed. Forty-one patients were found to have an NHFS >4. Overall mortality at 30 days was 7.7% and at 1 year was 21%. Patients with an NHFS of ≤4 had a lower mortality rate at 30 days of 6% compared with those with >4 at 9.8% (p=0.422). On Kaplan-Meier plotting and log-rank test, patients with an NHFS of >4 were associated with a higher mortality rate at 1 year at 36.6% compared to patients with an NHFS of ≤4 at 8% (p=0.001).

Conclusion

NHFS is a promising tool not only in neck of femur fractures but also distal femur fractures in risk-stratifying patients for pre-operative optimisation as well as a predictor of mortality. 

Management of Non-union Distal Femur Fractures With Augmentation Nail Plate Construct

Background and objective A non-union distal femur fracture is a challenging fracture to treat. Common treatment modalities for non-union distal femur fractures include dual plating, intramedullary nails, ilizarov, and hybrid fixators. Despite the availability of a wide armamentarium of constructs, the clinical and functional outcome of these modalities is often complicated by significant morbidity, joint stiffness, and delayed union. The augmentation of the intramedullary nail with a locking plate results in a robust architecture, improving the likelihood of union. The use of this nail plate construct improves biomechanical stability and restores limb alignment, which enables early rehabilitation and weight bearing and lowers the likelihood of fixation failure. Methodology A prospective study was conducted at the Government Institute of Medical Science, Greater Noida, from January 2021 to January 2022 on 10 patients with non-union of the distal femur. All the patients were operated on with nail plate construct. The minimum follow-up period was 12 months. Results A total of 10 patients with a mean age of 55 years were included. Six were earlier treated with an intramedullary nail and four with extramedullary implants. All patients were managed with implant removal and fixation with nail plate construct and bone grafting. The average duration of the union was 10.3 months. The International Knee Documentation Committee (IKDC) score improved from 30.6 preoperatively to 67.3 postoperatively. Only one patient developed a superficial infection, which was managed by wound debridement and targeted antibiotic therapy. Conclusion In our experience, this relatively novel technique of combining nail plate constructs offers encouraging outcomes in the management of non-union of distal femur fractures, especially in elderly and osteopenic patients.

Associations between Early Surgery and Postoperative Outcomes in Elderly Patients with Distal Femur Fracture: A Retrospective Cohort Study

Previous literature has provided conflicting results regarding the associations between early surgery and postoperative outcomes in elderly patients with distal femur fractures. Using data from the Japanese Diagnosis Procedure Combination inpatient database from April 2014 to March 2019, we identified elderly patients who underwent surgery for distal femur fracture within two days of hospital admission (early surgery group) or at three or more days after hospital admission (delayed surgery group). Of 9678 eligible patients, 1384 (14.3%) were assigned to the early surgery group. One-to-one propensity score matched analyses showed no significant difference in 30-day mortality between the early and delayed groups (0.5% versus 0.5%; risk difference, 0.0%; 95% confidence interval, −0.7% to 0.7%). Patients in the early surgery group had significantly lower proportions of the composite outcome (death or postoperative complications), shorter hospital stays, and lower total hospitalization costs than patients in the delayed surgery group. Our results showed that early surgery within two days of hospital admission for geriatric distal femur fracture was not associated with a reduction in 30-day mortality but was associated with reductions in postoperative complications and total hospitalization costs.

Distal Femoral Replacement as a Primary Treatment Method for Distal Femoral Fractures in the Elderly

Distal femoral fractures account for 3-6% of all femoral fractures with a similar demographic as patients suffering from proximal femoral fractures. The mortality risk can be high in such injuries, which has prompted NHS England to extend the scope of the Best Practice Tariff to include all fragility fractures of the femur. Poor bone quality, intra-articular extension, and significant comminution can make these fractures difficult to manage with fixation techniques, while early mobilisation is a key outcome in the treatment of this injury. In this study, a comprehensive literature search was performed based on keywords, and abstracts were reviewed to identify relevant articles. The following factors were analysed: time to surgery, time to full weight-bearing, the average hospital stay, post-operative mobility status, and complications. A total of 233 abstracts were identified using the pre-determined search criteria, and, subsequently, articles were excluded following author review. A total of 10 relevant articles were included in this review, with five used for review and comparison between distal femoral replacement (DFR) and fixation. This resulted in a sample of 200 patients treated with DFR with over 87% ambulatory at follow-up and a re-operation rate of 13.3% compared to 78% and 13.5%, respectively, in those treated with open reduction internal fixation (ORIF) procedure. Despite a limited pool of evidence, the literature suggests that DFR offers an option that potentially allows immediate weight-bearing and leaves most patients ambulatory at follow-up. Although DFR is more costly than other operative techniques, it avoids complications associated with fixation such as non-union and can reduce the risk of further surgery through direct complications or a need for delayed arthroplasty, which is deemed more complex secondary to fixation. Early mobilisation is a key step in reducing morbidity and mortality among this cohort of patients, and a procedure such as DFR should be more widely considered to help achieve this outcome.

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.

Complex Multiplanar Fracture of the Distal Femur with an Undescribed Pattern: A Case Report and Review of the Literature

Distal femur fractures in younger age groups are associated with high-impact injury leading to severe comminution and soft tissue injuries. Most of the intra-articular distal femur fractures occur as a result of axial loading accompanied by a variable amount of flexion. An 18-year-old male patient who had met with a road traffic accident was brought to the trauma center. Radiographic examination revealed a fracture of the distal femur, predominantly involving the lateral condyle without any evidence of metaphyseal comminution, and lateral view showed a complete separation of both the condyles from the proximal shaft. This type of fracture pattern did not fit into any of the current classification systems of distal femoral fractures. The medial and lateral approaches were carried out simultaneously instead of the anterior midline approach, owing to the poor skin condition over the anterior aspect of the knee. These fractures are difficult to treat due to high articular involvement and present a tedious task for the surgeon. Anatomical reduction with preserved articular cartilage is the key to a good outcome in such complex fractures. Atypical fracture types are not uncommon, and they can be incorporated into existing or future classification systems, which may contribute to a better understanding and management of these fractures.

Unusual Morphology of a Distal Femur Fracture

Fractures of the distal femur are rare but serious injuries that often follow a distinct pattern, occurring more frequently in both younger and older populations. In younger individuals, these fractures usually result from high-energy trauma, while in the elderly, they are often caused by domestic accidents. A 65-year-old female with a history of type 2 diabetes, hypertension, anxiety, and dyslipidemia fell on the stairs, impacting her right knee. She experienced intense pain and was unable to walk. Examination showed a swollen right knee without abrasions, tenderness, or neurovascular compromise. X-rays revealed a displaced fracture of the medial femoral condyle, with a fracture line extending to the diaphysis, and a non-displaced lateral femoral condyle fracture. The case underscores a significant distal femur fracture in an elderly patient following a low-energy impact. Early diagnosis and surgical stabilization are vital for good outcomes in femoral condylar fractures. Goals include anatomical reduction and restoring limb alignment while preserving vascularity. The choice of surgical methods depends on fracture configuration and surgeon preference. Surgery is the gold standard for displaced fractures.

Fracture-Related Infection of a Distal Femur Open Fracture Treated With a Supracutaneous Locking Plate

Fracture-related infection (FRI) is a challenging complication in open fractures. It can cause major disability to patients and a burden to the public health sector. A multidisciplinary approach is required to eradicate infection and improve the quality of life for patients. We present a case of an FRI in an open fracture of the distal femur treated using a supracutaneous locking plate, which is an uncommon technique. This technique yields excellent outcomes in controlling local infection and providing satisfactory stability, especially for a peri-articular distal femur fracture with FRI. Therefore, supracutaneous plating using a locking plate can be considered an alternative option to conventional external fixations in managing FRIs.

Distal Femur Replacement: An Option for Osteoporotic Fractures in the Elderly

Background A distal femur fracture (DFF) around the native or prosthetic knee is commonly seen in the osteoporotic elderly population. Surgical management is required to restore the function. Fracture fixation requires a period of restricted weight-bearing; however, distal femoral replacement (DFR) allows immediate weight-bearing and quicker recovery. Methods All patients who underwent distal femur replacement from 2020 to 2023 at our hospital were retrospectively reviewed. Data related to the patient's demographics, medical comorbidities, preinjury mobility status, perioperative management and length of stay were collected. Results Eleven patients with 13 distal femoral replacements were included. There were 10 periprosthetic and 3 native fractures around the distal femur. Two patients had bilateral periprosthetic fractures. The median age was 84 years (range 62-95) with all patients being females. Eight patients were living in their homes while three were care home residents. The median duration of surgery was 120 min. The mean blood loss was 350 ml. Patients were mobilised out of bed at a median of three days and were able to walk for 2 meters with a frame at a mean of 10 days (range 3-15) except for two patients whose mobility was limited to the chair. The mean length of hospital stay was 32 days (range 8-54). All patients were discharged back to their original destination except for one who was shifted to a care home instead of her own home. Conclusion In our opinion, distal femur replacement provided a more favourable outcome with respect to pain management, early rehabilitation with full weight-bearing immediately following the surgery and fewer complications. Furthermore, in our hands, the surgical time was short with limited blood loss.

Application of Cortical Bone Plate Allografts Combined with Less Invasive Stabilization System (LISS) Plates in Fixation of Comminuted Distal Femur Fractures

Background and Objectives: At present, the management of comminuted distal femur fractures remains challenging for orthopedic surgeons. The aim of this study is to report a surgical treatment for comminuted distal femur fractures using supplementary medial cortical bone plate allografts in conjunction with the lateral less invasive stabilization system (LISS) plates. Materials and Methods: From January 2009 to January 2014, the records of thirty-three patients who underwent supplementary medial cortical bone plate allografts combined with lateral LISS plates fixation were reviewed. Clinical and radiographic data were collected during regular postoperative follow-up visits. Functional outcomes were determined according to the special surgery knee rating scale (HSS) used at the hospital. Results: Thirty patients were followed for 13 to 73 months after surgery, with an average follow-up time of 31.3 months. The mean time to bone union was 5.4 months (range of 3-12 months) and the mean range of knee flexion was 105.6° (range of 80-130°). Of the remaining patients, 10 had a score of "Excellent", while 10 had a score of "Good". Three patients had superficial or deep infections, one patient had nonunion that required bone grafting, and one patient had post-traumatic knee arthritis. Conclusions: Based on these promising results, we propose that supplementary medial cortical bone plate allografts combined with lateral LISS plate fixation may be a good treatment option for comminuted distal femur fractures. This treatment choice not only resulted in markedly improved stability on the medial side of the femur, but also satisfactory outcomes for distal femoral fractures.

A modified anterolateral swashbuckler approach for distal femoral fractures: description and outcomes

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.

Physical Rehabilitation Subsequent to Fixation of Ilizarov Ring Fixator for the Management of Distal Femur Fracture: A Case Report

Distal femur fractures are severe all over the world. The goal of the study was to assess the effect of physiotherapy on ROM, strength, and improving quality of life. Due to the anatomy of distal femur fracture, the Ilizarov ring fixator is useful as it helps maintain mobility and stability. Distal femur fractures are most treated surgically compared to non-surgical treatment. The use of external fixators differs according to the patient's condition and the stability of the patient. This study's objective was to evaluate the effectiveness of an evidence-based procedure prepared for the management of distal femur fracture and chronic osteomyelitis femur. In some cases, due to discharging sinus, the patient requires long-term treatment followed by a home physiotherapy rehabilitation program. The objective was to assess the effects of Ilizarov circular external fixators (ICEF) on distal femur fracture.

Dual Implants for Geriatric Distal Femur Fractures Results in Greater Healthy Days at Home

OBJECTIVES

To compare Healthy Days At Home (HDAH90) within 90 days of hospital discharge after single implant (SI) or dual implant (DI) fixation in geriatric distal femur fractures.

METHODS

Design: Retrospective Review.

SETTING

Three Level I Trauma Centers.

PATIENT SELECTION CRITERIA

Geriatric (age ≥ 60 years) distal femur fracture patients (OTA/AO 33 A, C) operatively treated with SI (lateral plate or retrograde intramedullary nail (IMN)) or DI (two plates or plate and IMN) between January 2018-January 2024 were included.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was HDAH90, which was calculated from date of surgery to 90 days follow-up and accounted for days after mortality, skilled nursing facilities (SNF), readmissions, and secondary surgeries. HDAH90, days at SNF, 90-day readmission, 90-day mortality, return to baseline ambulatory status at 180-days, and length of hospitalization were compared between patients with SI or DI. A binary logistic multivariate regression was used to compare outcomes while controlling for age, gender, dependence on assistive device, periprosthetic fracture, and post-operative weight bearing status.

RESULTS

The 229 SI patients were 2 years younger than the 70 DI patients (73 vs. 75 years, p=0.03). The DI cohort had more female patients (82.9% vs 70.7%, p=0.044), and more periprosthetic fractures (55.7% vs. 35.4%, p=0.002). There was no other demographic, fracture characteristic, or preoperative ambulatory differences between groups (p>0.05). Following regression analysis, DI patients had greater HDAH90 (55 vs 45, p=0.024) and fewer days at SNF (22 vs 32, p=0.026) than SI patients. There were no differences in 90-day readmission (DI odds 1.36, p=0.353), 90-day mortality (DI odds 0.94 p=0.935), return to baseline ambulatory status at 180 days (DI 1.64, p=0.433), and length of hospitalization (DI 10 days vs SI 9 days, p=0.579).

CONCLUSIONS

Geriatric patients treated with dual implants for distal femur fractures experienced an additional 10 Healthy Days at Home90 as compared to those treated with single implants. Given that a 10-day difference is clinically significant in geriatric fractures for Healthy Days at Home90, using dual implant constructs may represent an improvement in care for distal femur patients.

LEVEL OF EVIDENCE

III, prognostic.

Prediction of fracture nonunion leading to secondary surgery in patients with distal femur fractures

Aims

Several previously identified patient-, injury-, and treatment-related factors are associated with the development of nonunion in distal femur fractures. However, the predictive value of these factors is not well defined. We aimed to assess the predictive ability of previously identified risk factors in the development of nonunion leading to secondary surgery in distal femur fractures.

Methods

We conducted a retrospective cohort study of adult patients with traumatic distal femur fracture treated with lateral locking plate between 2009 and 2018. The patients who underwent secondary surgery due to fracture healing problem or plate failure were considered having nonunion. Background knowledge of risk factors of distal femur fracture nonunion based on previous literature was used to form an initial set of variables. A logistic regression model was used with previously identified patient- and injury-related variables (age, sex, BMI, diabetes, smoking, periprosthetic fracture, open fracture, trauma energy, fracture zone length, fracture comminution, medial side comminution) in the first analysis and with treatment-related variables (different surgeon-controlled factors, e.g. plate length, screw placement, and proximal fixation) in the second analysis to predict the nonunion leading to secondary surgery in distal femur fractures.

Results

We were able to include 299 fractures in 291 patients. Altogether, 31/299 fractures (10%) developed nonunion. In the first analysis, pseudo-R2 was 0.27 and area under the receiver operating characteristic curve (AUC) was 0.81. BMI was the most important variable in the prediction. In the second analysis, pseudo-R2 was 0.06 and AUC was 0.67. Plate length was the most important variable in the prediction.

Conclusion

The model including patient- and injury-related factors had moderate fit and predictive ability in the prediction of distal femur fracture nonunion leading to secondary surgery. BMI was the most important variable in prediction of nonunion. Surgeon-controlled factors had a minor role in prediction of nonunion.

Computer Navigation-assisted Bilateral Total Knee Arthroplasty with Osteosynthesis in Single Sitting in Patients Presenting with Distal Femur Fracture with Pre-existing Knee Arthritis: A Case Series

Background

Intra-articular and periarticular distal femur fractures with pre-existing osteoporosis (OP) and osteoarthritis (OA) pose a significant challenge to ambulatory patients because of the higher chances of implant failure and severe disability of OA. To reduce OA-related morbidity, we advocate simultaneous total knee arthroplasty (TKA) with fracture fixation instead of fracture fixation alone using computer-assisted navigation to achieve proper ligament balance, restoration of the mechanical axis, and component alignment.

Case Report

A case series of four patients (male - 2 and females - 2) with periarticular fractures of the distal femur with severe OA and OP were primarily fixed with different modalities such as distal femur locking plates, cannulated-cancellous screw, and Herbert screw followed by computer navigation-assisted cruciate retaining TKA. All patients had Kellgren Lawrence grade ≥3 OA and underwent bilateral TKA. All patients were aggressively treated for OP using pulsed PTH therapy. Patients were found to have a faster recovery with the initiation of early partial weight bearing with crutches postoperatively in all patients, followed by unassisted weight bearing once radiological union was seen.

Conclusion

Based on satisfactory quality evidence and navigation-assisted cruciate-retaining TKA appears to be a useful treatment option for distal femoral fractures with pre-existing OA and OP. This is cost-effective and is associated with the least morbidity and excellent patient satisfaction.

Meta-analysis of the clinical efficacy and safety of single versus dual plate in the treatment of comminuted distal femur fractures

OBJECTIVE

Through meta-analysis, this study aims to comprehensively evaluate the efficacy of single-plating and double-plating in the treatment of comminuted fractures of the distal femur.

METHODS

Computer searches of PubMed, Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), China Biology Medicine (CBM), VIP, and Wanfang digital journals were performed, and the timeframe for the searches was from the establishment of each database to July 2023 for each of the databases. Meta-analysis was performed using RevMan 5.4 software provided by the Cochrane Library, and the review process was registered in the PROSPERO database.

RESULTS

A total of ten studies were included for statistical analysis. One randomised controlled study and nine retrospective cohort studies with a total of 563 patients were included. The double-plate group was superior to the single-plate group in terms of knee mobility at 6 months postoperatively, overall postoperative complications, and the rate of healing of knee deformity. However, it increased the operation time and intraoperative bleeding, and the difference between the two groups was statistically significant (P < 0.05). There was no significant difference between the two groups in terms of excellent knee function rate, fracture healing time, plate fracture, postoperative infection, delayed fracture healing, and non-union (P ≥ 0.05).

CONCLUSION

Double plate fixation for comminuted fractures of the distal femur can improve knee mobility at 6 months postoperatively, reduce overall postoperative complications, and decrease the incidence of malunion healing. However, it increases operative time and bleeding. Randomised studies are needed to provide strong evidence in the future.