Fixation Of Distal Femoral Fractures Research Articles

The effect of coronal plane angulation on patient reported outcome measures of operatively treated distal femur fractures: A multi-center prospective evaluation

ObjectivesThe goal of this trial was to determine whether coronal plane angulation affects functional and clinical outcomes after the fixation of distal femur fractures. DesignMulticenter, randomized controlled trial Setting20 academic trauma centers Patients/Participants156 patients with distal femur fractures were enrolled. 123 patients were followed 12 months. There was clinical outcome data available for 105 patients at 3 months, 95 patients at 6 months and 81 patients at one year. InterventionLateral locked plating or retrograde intramedullary nailing Main outcome measurementsRadiographic alignment, functional scoring including SMFA, Bother Index, and EQ-5D. Clinical scoring of walking ability, need for ambulatory support and ability to manage stairs. ResultsAt 3 months, there was no difference between groups (varus, neutral or valgus) with respect to any of the clinical functional outcome scores measured. At 6 months, compared to those with neutral alignment, patients with varus angulation had a worse Stair Climbing score (4.33 vs. 2.91, p = 0.05). At 12 months, the average patient with neutral or valgus alignment needed less ambulatory support than the average patient in varus. Walking distance ability was no different between the groups at any time point.With respect to the validated patient-based outcome scores, we found no statistical difference in in the SMFA, Bother, or EQ-5D between patients with valgus or varus mal-alignment and those with neutral alignment at any time point (p > 0.05). Regardless of coronal angulation, the SMFA trended towards lower (improved) scores over time, while EQ-5D scores for patients with varus angulation did not improve over time. ConclusionsValgus angulation and neutral angulation may be better tolerated in terms of clinical outcomes like stair climbing and need for ambulatory support than varus angulation, though patient reported outcome measures like the SMFA, Bother Index and EQ-5D show no statistical significance. Most patients with distal femur fractures tend to improve during the first year after injury but many remain significantly affected at 12 months post injury.

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

Distal femur fractures account for 3-6% of all femur fractures. Internal fixation of most distal femur fractures with an anatomic lateral locking plate should permit some motion at the metaphyseal portion of the fracture when secondary bone healing is planned by the operating surgeon. While several studies have been performed evaluating union rates for distal femur fractures with stainless steel and titanium plates, the timing of callus formation between stainless steel and titanium implants used as bridge plates for distal femur fractures (AO/OTA 33-A and -C) has been investigated to a lesser extent. We hypothesize that callus will be visualized earlier with post-operative radiographs with titanium versus stainless steel bridge plates. We retrospectively reviewed a consecutive cohort of patients over 18 years of age with acute AO/OTA 33-A and 33-C fracture patterns treated with an isolated stainless steel or titanium lateral bridge plate within 4 weeks of injury by a single fellowship-trained orthopedic trauma surgeon from 2011 to 2020 at one academic Level 1 trauma center. An independent, fellowship-trained orthopedic trauma attending surgeon reviewed anterior-posterior (AP) and lateral radiographs from every available post-operative clinic visit and graded them using the Modified Radiographic Score for Tibia (mRUST). Twenty-five subjects were included in the study with 10 with stainless steel and 15 with titanium plates. There were no significant differences in demographics between both groups, including age, sex, BMI, injury classification, open versus closed, mechanism, and laterality. Statistically significant increased mRUST scores, indicating increased callus formation, were seen on 12-week radiographs (8.4 vs. 11.9, p = 0.02) when titanium bridge plates were used. There were no statistically significant differences in mRUST scores at 6 or 24-weeks, but scores in the titanium group were higher in at every timepoint. In conclusion, we observed greater callus formation at 12 weeks after internal fixation of 33-A and 33-C distal femur fractures treated with titanium locked lateral distal femoral bridge plates compared to stainless steel plates. Our data suggest that titanium metallurgy may have quicker callus formation compared to stainless steel if an isolated, lateral locked bridge plate is chosen for distal femur fracture fixation.

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

BackgroundThe stiffness of locked plates suppresses healing process, prompting the introduction of far cortical locking to address this issue. This study aimed to demonstrate the clinical efficacy of far cortical locking constructs in treating distal femoral fractures in an Asian population. MethodsThis multicenter prospective observational study was conducted at four university hospitals between February 2018 and February 2021. Demographic data, the presence of metaphyseal comminution, and surgical fixation details were recorded. Clinical outcomes, including single-leg standing, EQ-5D, and EQ-VAS scores, and radiologic outcomes, including the RUST score of each cortex, were evaluated and compared according to the presence of metaphyseal comminution. ResultsThere were 37 patients (14 men and 23 women) with a mean age of 67.3 ± 11.8 years. Twenty-two patients had metaphyseal comminution (59%), and 15 presented simple fractures in metaphyseal areas. Four patients (13%) could stand on one leg > 10s at 6 weeks, and 24 patients (92%) at 1 year. EQ-5D increased from 0.022 ± 0.388 to 0.692 ± 0.347, and the mean EQ-VAS 51.1 ± 13.1 to 74.1 ± 24.1 between discharge (n = 37) and post-operative 1 year (n = 33), respectively. RUST score presented increment for time, from 6.2 ± 1.8 at 6 week to 11.6 ± 1.1 at 1 year. Radiological healing demonstrated rapid increase from week 6 (16/28, 43%) to month 3 (27/31, 87%), with no obvious increase was observed in 6 months (23/26, 89%) or 12 months (25/28, 89%). Simple metaphyseal fractures presented significantly higher RUST scores at 6 weeks and 3 months, but there was no difference in RUST scores at 6 months or 1 year according to metaphyseal comminution. ConclusionsPlate constructs with far cortical locking screws provided safe and effective fixation for distal femoral fractures, with consistent radiological and clinical results, regardless of metaphyseal comminution.

The effect of body weight on interfragmentary fracture strain in plate fixation of distal femur fractures: A finite element analysis

IntroductionDistal femur fractures are difficult to successfully treat due to high rates of nonunion. Obesity is an independent prognostic risk factor for nonunion. Advances in finite element analyses (FEAs) have allowed researchers to better understand the performance and behavior of constructs at the bone-implant interface under a variety of conditions. The purpose of this study is to determine the impact of body weight on fracture strain in a lateral locking plate construct for supracondylar femur fractures and whether additional construct rigidity is beneficial to optimize fracture strain in high body mass patients. HypothesisWe hypothesized that increased loads would produce a higher interfragmentary strain (IFS), which could be decreased by shortening the working length of the construct. Materials and methodsA 3D finite element analysis was performed on two separate femur models with a comminuted supracondylar distal femur fracture fixed with a lateral distal femoral locking plate in bridging mode with Ansys software. Axial forces were varied to recreate the effect of load from normal and high body mass patients. Working length and screw density of the construct were varied for each condition. Measurements of interfragmentary strain and shear motion (SM) were compared. ResultsDoubling the axial load from 70kg (control) to 140kg (high body mass) increased the interfragmentary strain by an average of 76% for the three working lengths (3.38%±1.67% to 4.37%±0.88% at the baseline working length (BWL), 1.42%±1.00% to 2.87%±2.02% at the intermediate working length (IWL) and 0.62%±0.22% to 1.22%±0.42% at the short working length (SWL)). On average, decreasing the working length in the 140kg load reduced the mean IFS to within 15% of the mean IFS of the 70kg load at the longer working length (2.87%±2.02% at IWL 140kg versus 3.38%±1.67% at BWL 70kg and 1.22%±0.45% SWL 140kg versus 1.42±1.00% IWL 70kg). DiscussionIncreased axial load increases interfragmentary strain in an AO/OTA 33A distal femur fracture fixed with a lateral distal femoral locking plate. Decreasing the working length of the fixation construct in the high body mass model decreased interfragmentary strain. Higher loading conditions reflective of high body mass patients should be considered in studies investigating optimization of fracture strain. Level of proofV; Finite Element Analysis (FEA).

Nail Plate Constructs are Associated with Decreased Rates of Reoperation in Complex Distal Femur Fractures.

To determine if nail plate constructs have lower rates of reoperation to promote bone healing than lateral locking plates in the treatment of distal femur fractures. Retrospective Cohort. Single Level 1 trauma centerPatients/Participants: 312 consecutive patients treated operatively for native distal femur fractures (OTA/AO 33A or 33C). Reduction and fixation of distal femur fractures with either a lateral locked plate (LLP) or a nail plus plate construct (NPC). reoperation to promote bone healing at any time after definitive fixation. 279 fractures were treated with LLP and were compared with and 33 fractures treated with NPC constructs. Patient demographics, injury severity score (ISS), and frequency utilization of each construct between different types of OTA/AO classified distal femur fractures were similar. The reoperation rate to promote bone healing was 18.7% (51/273) for LLPs, and 3% (1/33) for NPC constructs. There was no significant difference in surgical site infection (SSI) (p = 0.67). Utilization of NPC technique demonstrated a significant decrease in rates of reoperation to promote bone healing compared to LLP alone in the treatment of OTA/AO 33A and 33C distal femur fractures. Augmented fixation with NPCs should be considered to treat complex distal femur fractures as it is associated with lower rates of reoperation to promote bone healing in comparison to LLP. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Best of Both Worlds? Fixation of Distal Femur Fractures with the Nail-Plate Construct.

Distal femoral fractures are a significant injury sustained by low- and high-energy trauma. Common treatment practices are lateral locking plate or intramedullary nail fixation, with disadvantages including risk of non and malunion and limited post-operative weightbearing status. Combining both techniques as a nail-plate construct (NPC) theoretically achieves enhanced fixation to allow immediate weightbearing. The aim of this study is to examine radiographic union, malunion and patient-reported outcomes in distal femur NPC fixation. Single-center retrospective study including all patients >18 years who sustained distal femur fractures treated with NPC. Primary outcomes were radiographic union, malunion and patient reported outcome measures at minimum 1-year follow-up. Secondary outcome measures included post-operative mobility, length of stay and complications. Relevant variables of normality are reported as mean with standard deviation. Subgroup analysis of patients aged <65 and ≥65 years are provided. Sixteen patients were included in the study. Rate of radiographic union was 100%. There was no case of malunion. All patients were allowed to bear full weight immediately post-operatively. Mean length of stay was 9.50 days, with 37.5% of patients discharged directly home. The majority (85.7%) of patients returned to pre-injury mobility. Early post-operative complications occurred in three patients. Three patients returned to theater. The mean EQ-5D-5L index value was 0.713, with 71.4% describing no problems with self-care and 85.7% reporting no or slight problems with usual daily activities. The NPC provided stable fixation permitting full weightbearing post-operatively with no cases of non or malunion. Return to pre-injury mobility and activity are encouraging. Based on these results we support the use of nail-plate construct fixation in the management of distal femur fractures.

Bridge Plate Fixation of Distal Femur Fractures: Defining Deficient Radiographic Callus Formation and its Associations.

To determine whether deficient early callus formation can be defined objectively based on association with an eventual nonunion and specific patient, injury, and treatment factors. Final healing outcomes were documented for 160 distal femur fractures treated with locked bridge plate fixation. Radiographic callus was measured on postoperative radiographs until union or nonunion had been declared by the treating surgeon. Deficient callus was defined at 6 and 12 weeks based on associations with eventual nonunion via receiver operator characteristic analysis (ROC). A previously described computational model estimated fracture site motion based on the construct employed. Univariable and multivariable analyses then examined the association of patient, injury, and treatment factors with deficient callus formation. There were 26 nonunions. Medial callus area at 6 weeks < 24.8 mm2 was associated with nonunion (12 of 39, 30.8%) vs. (12 of 109, 11.0%), p = 0.010. This association strengthened at 12 weeks with medial callus area < 44.2 mm2 more closely associated with nonunion (13 of 28, 46.4%) vs (11 of 120, 9.2%), p < 0.001. Multivariable logistic regression analysis found limited initial longitudinal motion (OR 2.713 (1.12 to 6.60), p = 0.028)) and Charlson Comorbidity Index (1.362 (1.11 to 1.67), p = 0.003) were independently associated with deficient callus at 12 weeks. Open fracture, mechanism of injury, smoking, diabetes, plate material, bridge span, and shear were not significantly associated with deficient callus. Deficient callus at 6 and 12 weeks is associated with eventual nonunion and such assessments may aid future research into distal femur fracture healing. Deficient callus formation was independently associated with limited initial longitudinal fracture site motion derived through computational modeling of the surgical construct, but not more routinely discussed parameters such as plate material and bridge span. Given this, improved methods of in vivo assessment of fracture site motion are necessary to further our ability to optimize the mechanical environment for healing.

Biomechanical comparison of distal femoral fracture fixation: Polyaxial vs. uniaxial locking screws with different blocking screw configurations in retrograde femoral nailing

IntroductionClinical studies have indicated reduced reliance on blocking screws with the introduction of polyaxial locking nails, yet the biomechanical superiority of polyaxial locking over blocking screws remains unverified, specifically for distal dia-metaphyseal femur fractures. HypothesisWe hypothesized that the combination of multiaxial locking using three screws and parallel locking reinforced by two blocking screws would result in superior outcomes compared to utilizing only parallel locking with two screws and one blocking screw. Materials and methodsThird-generation custom-made femur models representing AO/OTA 32 A1.2 dia-metaphyseal comminuted oblique fractures were divided into four groups (n=10/group). Group A employed distal fixation with three 4.5-mm polyaxial screws. Group B used two parallel locking screws and two blocking screws, Group C used two parallel locking screws and one blocking screw, and Group D used only two parallel screws. Specimens underwent axial and torsional load testing to assess fatigue strength, ultimate strength, axial stiffness (N/mm), torsional stiffness (N/mm/deg), axial load to failure (N), torsional load to failure (N/mm), coronal and sagittal angulations, and fracture site collapse. ResultsGroup C exhibited statistically superior torsional stiffness compared to Groups B and D (p=0.039 and p=0.034, respectively). Axial load to failure was highest in Group B and lowest in Group D (p=0.032). Group C demonstrated the highest torsional strength, while Group B exhibited the lowest (p=0.006). Coronal displacement was greatest in Group B, while Group A showed the highest resistance (p=0.009). Group A demonstrated the greatest resistance to fracture site collapse, with the weakest specimens observed in Groups B and C (p=0.01). DiscussionThe performance of a single laterally positioned blocking screw is comparable to using two blocking screws. Medial positioning of a second blocking screw is unnecessary for stability enhancement. Multiaxial locking prevents fracture site collapse and coronal plane angulation more effectively than other methods. Multiaxial locking and/or parallel screws with a single laterally positioned blocking screw provide superior stiffness and stability for treating unstable dia-metaphyseal distal femoral fractures. Level of evidenceN/A.

Does the type of medial plate fixation matter for supplemental fixation of distal femur fractures manage with a lateral pre-contoured locked plate? A Biomechanical study.

Fixation of distal femur fractures with a lateral pre-contoured locking plate provides stable fixation and is the standard treatment in most cases, allowing early range of motion with a high rate of union. However, in situations, the stability achieved with the lateral plate alone may be insufficient, predisposing to fixation failure. The objective of the study was to compare, in synthetic bone models, the biomechanical behaviour of the fixation with a distal femur lateral pre-contoured locking plate solely and associated with a 3.5mm proximal humeral locking plate applied upside down or a 4.5mm helical locking compression plate on the medial side. A total of 15 solid synthetic left femur samples were used. A metaphysical defect at the level of the medial cortex was simulated. The samples were randomly distributed into three groups equally. All groups received a 4.5/5.0mm single lateral 9-hole distal femur lateral pre-contoured locking plate. Group 1 had no supplementary plate. Group 2 received a supplementary 6-hole 3.5mm proximal humeral locking plate and Group 3 received a supplementary 4.5/5.0mm helical 14-hole narrow locking compression plate. Both supplementary plate types used in groups 2 and 3 contributed to increase the apparent stiffness of the construct, but pairwise comparison showed statically significant difference only between group 1 and 3. No significant difference was observed between groups 2 and 3. Both supplementary plates might be considered for improving the fixation in distal femur fracture in selected cases.

Retrograde intramedullary nailing or locked plating for stabilisation of distal femoral fractures? A comparative study of 193 patients

PurposeThe aim of this study was to evaluate the results of distal femoral fracture fixation of two different methods, lateral locking plate (LP) or an Intra-medullary nail (IMN), in patients managed in our institution. More specifically, to assess: (a) if there was a difference in functional outcomes between the LP and IMN groups; (b) whether the rate of complications was different between the two groups.MethodsBetween January 2009 and December 2018 adult patients with distal femoral fractures managed in our unit with either LP or IMN for extra and intra-articular fractures were eligible to participate. Demographic details, fracture type, procedures performed, time to union, complications and functional scores (Oxford Knee Score) were recorded and analysed. The mean follow up was 4 years (12–120 months).ResultsOut of 193 patients who met the inclusion criteria, 93 received an IMN whereas 100 patients were treated with LP. Mean age was 64.2 (18–99) and 70.1 (18–100) for the IMN and LP groups respectively. Overall, the two groups had similar demographics and there was no significant difference in the type of fractures sustained (p > 0.05). The Oxford Knee Score was highest for patients fixed with LP, mean 37.3 (6–48, SD 7.3) versus 28.4 (3–48, SD 14.4), (p = < 0.02) compared to the IMN group. In terms of complications, the rate of non-union was higher in the LP group 8.6% versus 4% in those patients treated with an IMN, p value < 0.01.ConclusionWhile the rate of non-union was higher in the LP group and the functional results were superior in the plating group.

Supplemental fixation of distal femur fractures: a review of biomechanical and clinical evidence

Background: Fixation of distal femur fractures with lateral locking plates has relatively high rates of clinical failure. Supplemental fixation has shown promising results, and may reduce rates of fixation failure or nonunion. This review aimed to assess the biomechanical and clinical evidence regarding the use of supplemental fixation of distal femur fractures. Methods: PubMed, Embase, and Cochrane databases were searched for English language studies up to December 4, 2020, identifying 1,829 studies. Biomechanical studies that assessed fracture displacement, load/cycles to failure, or construct stiffness and clinical studies that assessed fixation failure or nonunion after supplemental fixation of distal femur fractures were included. Studies with sample size ≤5, ORIF with non-locking plates, periprosthetic distal femoral fractures, nonunions or revision surgeries were excluded. Results: Seventeen studies were included, of which 8 were biomechanical and 9 clinical. Overall, biomechanical studies demonstrated increased construct stability and load to failure with various supplemental fixation strategies. Clinical studies demonstrated more mixed outcomes for nonunion and fixation failure rate among the various techniques. Conclusions: Biomechanical studies have demonstrated potential benefits of these strategies, but there remains a dearth of high-quality evidence evaluating their effect on clinical outcomes. Prospective RCTs are necessary to address these issues and confirm the results in the existing literature. Level of Evidence: IID

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

Fracture reduction and fixation of distal femur fractures are technically demanding. Postoperative malalignment is still commonly reported after minimally invasive plate osteosynthesis (MIPO). We evaluated the postoperative alignment after MIPO using a traction table with a dedicated femoral support. The study included 32 patients aged 65 years or older with distal femur fractures of all AO/OTA types 32 (c) and 33 (except 33 B3 and C3) and peri-implant fractures with stable implants. Internal fixation was achieved with MIPO using a bridge-plating construct. Bilateral computed tomography (CT) scans of the entire femur were performed postoperatively, and measurements of the uninjured contralateral side defined anatomical alignment. Due to incomplete CT scans or excessively distorted femoral anatomy, seven patients were excluded from analyses. Fracture reduction and fixation on the traction table provided excellent postoperative alignment. Only one of the 25 patients had a rotational malalignment of more than 15° (18°). The surgical setup for MIPO of distal femur fractures on a traction table with a dedicated femoral support facilitated reduction and fixation, resulting in a low rate of postoperative malalignment, despite a high rate of peri-implant fractures, and could be recommended for surgical treatment of distal femur fractures.

Risk factors for reoperation to promote union in 1,111 distal femur fractures.

To identify modifiable and non-modifiable risk factors for reoperation to promote union after distal femur fracture. Multicenter retrospective cohort study. Ten Level-I trauma centers. Patients with OTA/AO 33A or C distal femur fractures (n = 1,111). Surgical fixation of distal femur fracture. Fixation constructs were classified as lateral plate, dual plate, nail, or nail plate combination. The outcome of interest was unplanned reoperation to promote union. There was an 11% (121/1111) rate of unplanned reoperation to promote union. In the multivariate analysis, predictive factors included BMI (odds ratio [OR] = 1.18; 95% confidence interval [CI]: 1.06 - 1.32; p < 0.01), intra-articular fracture (OR = 1.57; 95% CI: 1.01 - 2.45; p = 0.04), type III open injury (OR = 2.29; 95% CI: 1.41 - 3.72; p < 0.01), the presence of medial comminution (OR = 1.85; 95% CI: 1.14 - 3.06; p = 0.01), and medial translation on post-operative radiographs (OR = 1.23 per one tenth of condylar width; 95% CI: 1.01 - 1.48; p = 0.03). Construct type was not significantly predictive. 11% of distal femur fractures underwent unplanned reoperation to promote union. BMI, intra-articular fracture, type III open injury, medial comminution, and medial translation on postoperative radiographs were predictive factors. Construct type was not associated with unplanned reoperation, however this conclusion was limited by small numbers in the dual plate and nail plate groups. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictors of deep infection after distal femur fracture: a multicenter study.

To identify potentially modifiable risk factors for deep surgical site infection after distal femur fracture. Multicenter retrospective cohort study. Ten Level-I trauma centers. Patients with OTA/AO 33A or C distal femur fractures (n = 1,107). Surgical fixation of distal femur fracture. The outcome of interest was deep surgical site infection. There was a 7% (79/1107) rate of deep surgical site infection. In the multivariate analysis, predictive factors included alcohol abuse (odds ratio [OR] = 2.36; 95% confidence interval [CI]: 1.17 - 4.46; p = 0.01), intra-articular injury (OR = 1.73; 95% CI: 1.01 - 3.00; p = 0.05), vascular injury (OR = 3.90; 95% CI: 1.63 - 8.61; p < 0.01), the use of topical antibiotics (OR = 0.50; 95% CI: 0.25 - 0.92; p = 0.03), and the duration of the surgery (OR = 1.15 per hour; 95% CI: 1.01 - 1.30; p = 0.04). There was a nonsignificant trend toward an association between infection and type III open fracture (OR = 1.73; 95% CI: 0.94 - 3.13; p = 0.07), and lateral approach (OR = 1.60; 95% CI: 0.95 - 2.69; p = 0.07). The most frequently cultured organisms were methicillin-resistant Staphylococcus aureus (22%), methicillin-sensitive Staphylococcus aureas (20%), and Enterobacter cloacae (11%). 7% of distal femur fractures developed deep surgical site infections. Alcohol abuse, intra-articular fracture, vascular injury, and increased surgical duration were risk factors, while the use of topical antibiotics was protective. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Technical Trick: Supplemental Medial Column Screw Fixation of Distal Femur Fractures Treated with a Laterally Based Locked Plate.

Given known failure rates after lateral plating of distal femur fractures, there is an increasing interest in augmenting fixation to improve outcomes. The addition of medial plates or intramedullary nails have been described with promising results, decreasing nonunion and varus collapse rates. However, the use of dual implants increases implant costs, adds surgical complexity, and requires a second surgical approach that may increase morbidity. A supplemental, percutaneously placed, medial column screw may provide a less invasive means of improving stability and achieving fracture union compared with lateral plating alone.

Medial and lateral dual plating of native distal femur fractures: a systematic literature review.

Lateral locked plating (LLP) development has improved outcomes for distal femur fractures. However, there is still a modest rate of nonunion in fractures treated with LLP alone, with higher nonunion risk in high-energy fractures, intra-articular involvement, poor bone quality, severe comminution, or bone loss. Several recent studies have demonstrated both the safety and the biomechanical advantage of dual medial and lateral plating (DP). The purpose of this study was to evaluate the clinical outcomes of DP for native distal femoral fractures by performing a systematic review of the literature. Studies reporting clinical outcomes for DP of native distal femur fractures were identified and systematically reviewed. Publications without full-text manuscripts, those solely involving periprosthetic fractures, or fractures other than distal femur fractures were excluded. Fracture type, mean follow-up, open versus closed fracture, number of bone grafting procedures, nonunion, reoperation rates, and complication data were collected. Methodologic study quality was assessed using the Coleman methodology score. The initial electronic review and reverse inclusion protocol identified 1484 publications. After removal of duplicates and abstract review to exclude studies that did not discuss clinical treatment of femur fractures with dual plating, 101 potential manuscripts were identified and manually reviewed. After final review, 12 studies were included in this study. There were 199 fractures with average follow-up time of 13.72 months. Unplanned reoperations and nonunion occurred in 19 (8.5%) and 9 (4.5%) cases, respectively. The most frequently reported complications were superficial infection (n = 6, 3%) and deep infection (n = 5, 2.5%) postoperatively. Other complications included delayed union (n = 6, 3%) not requiring additional surgical treatment and knee stiffness in four patients (2%) necessitating manipulation under anesthesia or lysis of adhesions. The average Coleman score was 50.5 (range 13.5-72), suggesting that included studies were of moderate-to-poor quality. Clinical research interest in DP of distal femoral fractures has markedly increased in the past few decades. The current data suggest that DP of native distal femoral fractures is associated with favorable nonunion and reoperation rates compared with previously published rates associated with LLP alone. In the current review, DP of distal femoral fractures was associated with acceptable rates of complications and generally good functional outcomes. More high-quality, directly comparable research is necessary to validate the conclusions of this review.

Distal femur nonunion: Risk factors and validation of RUST scores

Abstract Objectives: (1) The purpose of this study was to investigate immediate postoperative weight-bearing status and other potential risk factors for nonunion after locked plating of distal femur fractures and (2) to compare clinical and radiographic union using the previously validated Radiographic Union Scale for Tibia (RUST) and modified RUST scores. Design: This is a retrospective cohort analysis. Setting: Academic Level-1 trauma center. Patients/Participants: Ninety patients with distal femur fractures (OTA/AO 33-A, including periprosthetic) treated with lateral locked plating over a 10-year period. Intervention: Distal femur fracture fixation with lateral locked plating; surgical intervention to facilitate bone healing in cases of nonunion. Main Outcome Measurements: Nonunion rate, construct rigidity scores, RUST, and modified RUST scores. Results: Seventy-eight of 90 patients (87%) achieved clinical union (13% nonunion rate). Rigidity score was significantly associated with risk of nonunion (P = 0.003). No significant association was detected between nonunion and postoperative weight-bearing status (P = 0.77) or other previously identified risk factors. Patients who achieved fracture union had significantly higher mean (SD) RUST (10.67 [1.37] vs. 6.53 [1.48], P &lt; 0.001) and modified RUST (13.47 [2.20] vs. 6.94 [1.79], P &lt; 0.001) scores than patients who developed nonunion. Sensitivity (Sn) analyses identified a RUST score threshold of 9 for diagnosing clinical union (Sn 93.6% and specificity [Sp] 91.7%) and a modified RUST score threshold of 8 (Sn 93.6%, Sp 91.7%). Conclusions: Immediate postoperative weight-bearing status does not seem to affect nonunion rates. We observed a statistically significant association between rigidity score and nonunion. This study supports the utility of the RUST and modified RUST scores in distal femur metaphyseal fractures. Level of Evidence: Therapeutic Level IV.

Orthogonal plating of distal femur fractures: A biomechanical comparison with plate-nail and parallel plating constructs

PurposeThis study compared the biomechanical properties of orthogonal plating with plate-nail and parallel plating constructs for supracondylar distal femur fractures. MethodsA supracondylar distal femur fracture was simulated using 15 synthetic osteoporotic femurs. Constructs included: (1) plate-nail (lateral locked distal femoral plate + retrograde intramedullary nail); (2) parallel plating (lateral locked distal femoral plate + medial 4.0 mm compression plate); and (3) orthogonal plating (lateral locked distal femoral plate + posterior one-third tubular plate). Specimens underwent nondestructive loading, fatigue loading, and loading to failure. Gapping at the fracture was measured using a three-dimensional motion capture system. Baseline torsional and axial stiffness, stiffness and strain after fatigue loading, and load to failure were determined. A case example of orthogonal plating is also presented. ResultsThere was no difference in baseline torsional (p = 0.51) and axial stiffness (p = 0.53). Stiffness after fatigue loading was highest with parallel plating, with no difference between the plate-nail and orthogonal plating constructs (p = 0.84). Strain after fatigue loading was lowest in the parallel plating group (0.54 ± 0.19%), followed by the plate-nail (2.89 ± 0.83%) and orthogonal plating groups (3.04 ± 0.51%). ConclusionOrthogonal plating demonstrated comparable baseline stiffness to plate-nail and parallel plating constructs, and similar biomechanical performance in fatigue loading to plate-nail constructs. All specimens had ≤3% strain after fatigue loading, suggesting sufficient stability for fracture healing. The benefits of enhanced stability from dual-implant fixation may be achieved through orthogonal plating while avoiding an additional medial surgical approach, and therefore warrants further investigation as a novel alternative for distal femur fracture fixation.

Outcomes of Distal Femur Fractures Treated with Retrograde Indigenous Intramedullary Supracondylar (IMSC) Nailing

Introduction Fractures of the distal femur are complex injuries that pose a challenge to orthopaedic surgeon. Significant advances have been made in treatment of these fractures. Out of various options for surgical treatment, retrograde intramedullary nailing has several benefits compared to other methods of fixation. Amongst the routinely available IMSC nails which have a specific design, we used an indigenous IMSC nail with unique design. Materials And Methodology We conducted a retrospective study among 40 patients with distal femur fractures treated with this indigenous IMSC nail in our institute from May 2019 to October 2021. The patients were followed up in outpatient department till June 2022. Data was retrieved from case record forms and hospital information computer software. The study was conducted after obtaining permission from institutional review board. Results All the patients in our study were assessed using knee society score and functional knee score. Average knee society score at final follow up was 88.75/100 and average functional knee score at final follow up was 86.50/100 which showed excellent results. The results were better for extra-articular fractures. Average operative time, blood loss, time for radiological union and rate of complications were considerably less. Discussion Retrograde intramedullary nailing has been developed in order to address previous problems associated with distal femur fracture fixation. It has several advantages over plate fixation. Indigenous IMSC nail used in our study has added benefits over the routine IMSC nail due to its structure, number of screw holes in the distal part of nail, alignment of screw holes inside nail and unique thread design of the screws. Thus, it provides multi-planar fixation of fracture rather than in only one plane as achieved by routine IMSC nail giving excellent rotational stability to bone-implant construct.

Geriatric Distal Femur Fracture Management Protocols: A Review and Evidence-based Template

Objectives: Provide a framework for the development of a “Code Femur” protocol for geriatric distal femur fractures.&#x0D; Design: Literature Review and Evidence Based Note Templates&#x0D; Intervention: Distal Femur Fracture Fixation and Medical Management&#x0D; Main Outcome Measurement: Post operative Mortality&#x0D; Results: Geriatric distal femur fractures are rising in number among osteoporotic fractures in the growing elderly population. Current hip fracture literature recommends fixation of proximal femur fractures in 24-48 hours to reduce mortality and the literature surrounding distal femur fractures in this population in trending in this direction as well. The goals of distal femur fracture surgery are early mobilization and fracture stabilization in addition to managing the multiple medical co-morbidities that these patients may have. This review discusses the treatment options available for geriatric distal femur fractures that allow for early mobilization and examines the benefits of early operative care.&#x0D; Conclusion: Geriatric Distal Femur Fractures present similar challenges to management as the geriatric hip fracture and a proper understanding of medical co-management and early appropriate surgery through the development of a distal femur fracture program similar to hip benefits warrants consideration.&#x0D; Level of Evidence: Level IV, Systematic Review&#x0D; Keywords: Code Femur, Geriatric, Distal Femur Fracture, Post-operative Mortality, Co-Morbidity