Surgical management and weight-bearing recommendations for geriatric distal femur fractures

Objective

To investigate current practices among orthopaedic trauma surgeons in treating geriatric distal femur fractures and evaluate current postoperative weight-bearing recommendations.

Methods

A 26-question survey was emailed to Major Extremity Trauma Research Consortium surgeon members to characterize current practice with different fixation methods for distal femur fractures and the surgeon-directed postoperative weight-bearing recommendations for each approach.

Results

Surveys were completed by 123 orthopaedic trauma surgeons with a response rate of 37% (123/332). Retrograde intramedullary nailing (IMN) was commonly performed by 88% of surgeons, and lateral locked plate was commonly performed by 74% of surgeons. Retrograde IMN with a lateral plate was commonly performed by 51% of surgeons. Dual femoral plating was commonly performed by 18% of surgeons and sometimes performed by 39% of surgeons. Surgeons were significantly more likely to allow immediate postoperative weight-bearing for retrograde IMN (P < 0.001), retrograde IMN with lateral plate (P < 0.001), and dual plate (P < 0.001) as compared with locked lateral plate. Most surgeons (79%) would be interested in participating in a randomized controlled trial (RCT) investigating single implant versus dual implant for distal femur fractures and believe that a trial incorporating immediate weight-bearing is important.

Conclusion

A variety of implants are commonly used to treat geriatric distal femur fractures. Patients with distal femur fracture commonly have weight-bearing restrictions in the immediate postoperative period. A large proportion of orthopaedic trauma surgeons have clinical equipoise for an RCT to investigate the impact of surgical construct and weight-bearing on geriatric distal femur fracture patient recovery.

Clinical Algorithm for the Management of Ipsilateral Proximal and Shaft Femur Fractures Using Single or Dual Implants

Purpose of the study The current study had two goals: first, it compared the radiological and functional results of the ipsilateral shaft and proximal femur fractures treated by using two different methods, i.e., single implant vs dual implants. The second goal was to devise a clinical algorithm for guiding and managing such fractures. Methods This study was conducted in a level 1 trauma center and included 34 patients with concomitant ipsilateral fractures of the proximal femur and shaft of the femur. The patients were divided into two groups as per our clinical algorithm. Group I, comprising of 16 patients, were treated with a single implant like the proximal femoral nail (PFN) or proximal femoral nail antirotation (PFNA2). Group II of dual implants, comprising of 18 patients, were treated with two types of implants separately for proximal and shaft fracture. Results All patients were followed at monthly intervals up to six months, then at three monthly intervals up to one year, with a minimal follow-up of one year of every patient. On clinical evaluation by Friedman-Wyman criteria, in group I, seven patients had a fair outcome, eight patients had a good outcome, and one patient had a poor outcome, while in group II, eight patients had a fair outcome, nine patients had a good outcome, and one patient had a poor outcome. No patient developed non-union or avascular necrosis of the femoral head in any of the groups. Conclusion For concurrent ipsilateral diaphyseal and proximal femur fractures, both dual and single implants are equally effective alternatives if properly applied as per our clinical algorithm. Implant selection primarily depends on the pattern of injury, and our clinical algorithm can be a suitable guide for guiding the selection of implants.

Outcome Analysis of Dual Implant Osteosynthesis for Ipsilateral Proximal and Shaft Femur Fractures: Do We Need Cephalomedullary Nails?

Introduction

Most surgeons prefer a single implant for segmental proximal and diaphyseal femur fractures, although results are controversial and still no consensus for proper management is present. This prospective study analyses the functional and radiological outcome of managing 17 patients with ipsilateral shaft and proximal femur fractures by dual implant osteosynthesis at our center.

Methods

Over a two-year period, we managed 17 patients with a mean age of 35 years, with cancellous cannulated screws or dynamic hip screws for intracapsular femur fractures and improvised proximal femoral nail for extracapsular proximal femur fractures. Distal femoral locking plates or distal femoral nails were used for shaft femur fractures depending upon fracture morphology. The patients had a maximum follow-up of 18 months.

Results

A total of 80% of patients had a good functional outcome (using the Friedman-Wyman scoring system) while 60% had an excellent Harris Hip Score. The mean time taken for the bone union for proximal femur fractures was 4.75 months and for shaft femur fractures, it was 6 months.

Conclusion

We had a satisfactory functional and clinical outcome of managing these fractures with two implants, one focusing biomechanically on each fracture. This principle of dual implant osteosynthesis can reliably be used in such difficult fracture patterns and it negates the use of the single cephalomedullary nail for fixating both fractures.