Single Lateral Plate Research Articles

Comparative study of single vs. dual plating in distal femur fracture

Abstract Background: Despite recent advances in techniques and implants, the treatment of intra-articular, multifragmentary distal femoral fractures OTA type C remains a challenge. Fracture shortening with extension and varus deformities of the distal articular surface is typical. During the fixation of such injuries, the surgeon aims to achieve anatomical articular reduction and preserve the blood supply while providing rigid, stable, fixation that is strong enough to withstand early functional mobilization. Objectives: The purpose is to compare and evaluate the functional outcome, subjective outcome, radiological outcome of union, and complications of single vs. dual plating. Materials and Methods: An observational study was conducted from 2021 to 2022 among patients presenting with all distal femur fractures OTA type C in the age group 20–65 years. About 20 patients were managed by single plating with a lateral surgical approach, and 20 were managed by dual plating with a modified swashbuckler approach. Results: The dual plating group showed better functional results than the single plating group according to the knee society score. The age distribution of patients was bimodal, and there was no significant difference between the sex ratio of males and females in both groups. Comparing the range of motion, the dual plating group showed excellent results. The mean union time in the dual plating group was statistically significant. In the single plating group, complications such as varus deformity, wound dehiscence, and implant failure were observed in some cases.Complications in some cases of dual plating induced wound dehiscence and infection. Conclusions: On comparing the dual plating cases with the single plating, we found that the dual plating group is superior to that of the single plating group both in terms of functional outcome and the extent of complications. Also, the dual plating group has a better knee range of motion. The medial and lateral locking plate technique demonstrates a higher union rate with possible lower rates of revision surgery compared to a single lateral plate in highly comminuted distal femur fractures.

Double-plating approach in the management of isolated distal femoral fractures

<p><strong>Background</strong>: Fractures above 9 cm of the articular surface of distal femur are defined as distal femoral fractures which accounts for an estimated 4%-6% of all femur fractures. Stable fixation can be achieved by dual plating of distal femoral fracture. The indications of a dual- lateral and medial plate medial are comminuted distal femur fractures (AO type C3), medial supra-condylar void and bone loss of more than 3 cm, medial Hoffa fracture, inter-condylar comminuted bicondylar fractures, non-union after failed fixation with single lateral plate, poor bone quality.</p><p><strong>Methods</strong>: The retrospective research study of 35 cases of distal femoral fractures which were treated with lateral and medial plates in post graduate institute Swasthiyog Pratishthan, Miraj (G. S. Kulkarni Hospital, Miraj). The study period was from September 2020 to May 2022. The average follow-up was 8 months.</p><p><strong>Results</strong>: 1 year after operation, knee function was evaluated by Oxford knee score along with Mean EQ-5D-5 L score. Functionally the mean oxford knee score was 41.53±1.69, with a maximum Oxford Knee Score of 48. Mean EQ-5D-5 L score was 83.8 (72-82). Average time to union was 9 months (6-12 months). Four (17.4%) cases needed autologous bone graft. <strong></strong></p><p><strong>Conclusions</strong>: Double incision dual-plating approach for distal femoral fractures is effective and provides stable construct without reduction loss allowing early rehabilitation. Single lateral plating of distal femur fractures was associated with relatively higher failure rate. Addition of medial plate along with lateral plate reduces chances of fixation failure.</p>

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 of 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 a AO Foundation/Orthopaedic Trauma Association (AO/OTA) 33 distal femur or periprosthetic fracture of the knee. The last follow-up functional outcome was recorded according to Sanders scoring system.Results:Twelve patients 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 returned to their previous life style or work activity; average Sanders Score was 34.9. No major intraoperative or postoperative complications were recorded.Conclusions:The modified swashbuckler approach allows anatomical reduction and appropriate fixation with a theoretically reduced severance of the blood supply to the patella and preserves the integrity of extensor mechanism. (www.actabiomedica.it)

Оsteosynthesis for compound distal femur fractures with medial instability: сomparative analysis of conventional and innovative minimally invasive techniques

Compound fractures of distal femurfrequently lack me-dial stability, which can lead to failure of traditional plate fixation via lateral surgical approach. Aim of the study.To evaluate efficiency (mid-term functional results) of minimally invasive double plate osteosynthesis in cases of compound distal femoral fractures with medial insta-bility in comparison with conventional osteosynthesis technique. Materials and methods. 40 patients were included in three-site study. 20 patients with compound distal femoral fractures (1st group) underwent minimally invasive double plate osteosynthesis with prospective analysis of functional outcomes 6, 9, and 12 months af-ter surgery. Another 20 patients with similar fractures (2nd group) underwent conventional osteosynthesis with single lateral plate with retrospective evaluation of long-term functional outcomes of the treatment at 18 to 48 months after surgery. Clinical analysis of functional results in both groups was performed using KSS and Ly-sholm scales, anatomical results were evaluated by com-parison of valgus deformity degree of progression with control x-rays. Comparative analysis of the outcomes of surgical treatment in both clinical groups was performed using statistical tests for evaluating normal distribution and non-parametric tests for statistical hypothesis test-ing. Results. Statistically significant (p<0.01) increase of KSS and Lysholm scales was registered in patients of the first group throughout the duration of the study. The number of good and excellent outcomes according to KSS scale in patients of the first group was 90%, and 85% in patients of the second group. The number of good and excellent outcomes according to Lysholm scale was 70% in both groups. The degree of valgus deformity pro-gression was significantly lower in 1st group of patients, including patients with 33-C3 type of fractures. Data cap-tured indicate effectiveness of suggested osteosynthesis method

Distal femoral fractures: A comparison between single lateral plate fixation and a combined femoral nail and plate fixation

ObjectivesDistal femoral fractures occur in patients with osteoporotic bone and also as a consequence of high energy trauma. The recognised treatment options include closed or open reduction of the fracture and fixation using a locking plate or a femoral nail. Both these fixation modalities have some drawbacks. There is a risk of metalwork failure with single lateral locking plates and limited distal fixation with intramedullary nails. Since January 2018, we started using augmented fixation of distal femoral fractures using a combination of a retrograde femoral nail and a lateral locking plate. This study compares the outcomes of single lateral femoral plating (SLP) and combined nail-plate fixation (NPF). MethodsThis is a single centre retrospective case control study including all patients who sustained distal femoral fractures (OTA 33-A2, 33-A3, 33-C, 33-V3B and 33-V3D) over the study period. Outcomes for SLP were compared to NPF. The principal outcome measure was fracture union. Secondary outcome measures were reoperation rate, mortality and post-operative weight bearing status. Results67 distal femoral fractures were included in the study. 19 patients had peri‑prosthetic fractures. 40 were treated by SLP, 27 were managed with NPF. 23 (58%) patients in the SLP group were given instructions to non-weight bear or Toe touch weight bear for 6 weeks post-surgery compared to 1 (4%) in the NPF group (p = 0.000004). 7 (18%) patients treated with SLP had metalwork failure due to a non-union compared to none treated with NPF (p = 0.04). 11 fractures in the SLP group failed to unite compared to no non-unions in the NPF group (p = 0.01). These differences were magnified when assessing older (>50 years old) patients. ConclusionsAugmented fixation of distal femoral fractures using a nail plate fixation provided significantly higher union and enabled early weightbearing compared to single plate fixation. We recommend nail plate fixation for the treatment of distal femoral fractures, particularly in osteoporotic fractures.

SINGLE LATERAL PLATE VERSUS DOUBLE PLATING OF COMMINUTED SUPRACONDYLAR FEMORAL FRACTURES

Background: Fractures of the distal femur are rare and severe. For an extra-articular fracture, all therapeutic options are possible and mini-invasive surgery can be performed. In case of an intra-articular fracture, open reduction and internal plate fixation should be performed. Objective: To evaluate the functional and radiological outcomes of 20 patients with comminuted supracondylar fractures managed by either single or double plating. Patients and Methods: A prospective randomized clinical study was done in the period between November 2019 and September 2020 involving 20 cases with distal femoral fractures. All patients were operated at Al-Azhar University Hospitals and Al-Helal Hospital. Patients were divided into two groups/ preoperatively. The patients were randomly allocated for treatment with either: Group I managed by single lateral plate ,or group II managed by double plating. Results: There were insignificant differences between the two groups regarding range of movement, pain, knee society score and complications. Conclusion: Although both lateral and double plating fixation using dual approach for type C2 and C3 distal femoral fractures were efficient and safe methods of management, double plating recommended in these cases, i.e. medial supracondylar bone loss, low transcondylar bicondylar fracture, medial Hoffa fracture, per prosthetic distal femur fractures, nonunion after failed fixation with single lateral plate, poor bone quality and comminuted distal femur fractures C3.

Dual Plating of the Distal Femur: Indications and Surgical Techniques.

Dual-plating of the distal femur is required in some cases to achieve stable fixation. The indications of a medial plate in addition to the lateral plate are medial supracondylar bone loss, low trans-condylar bicondylar fractures, medial Hoffa fracture, peri-prosthetic distal femur fractures, non-union after failed fixation with single lateral plate, poor bone quality and comminuted distal femur fractures (AO type C3). We recommend orthogonal plate configuration with locked plates by a single incision or dual incision approach as per surgeon choice.

Dual plate fixation results in improved union rates in comminuted distal femur fractures compared to single plate fixation

PurposeThe treatment of distal femur fractures with extensive metaphyseal comminution is frequently complicated by high rates of nonunion and varus collapse. Dual plating with lateral and medial locking plates for these types of fractures has shown promising results in the recent literature. We hypothesize that dual plating of comminuted distal femur fractures leads to higher union rates and lower revision rates compared to an isolated lateral locking plate. MethodsA retrospective medical chart review between January 2015 and December 2017 was conducted. Inclusion criteria included patients 18 years of age and older who sustained a complex distal femur fracture (AO/OTA 33-C2/33-C3 or periprosthetic fracture with significant metaphyseal comminution) and at least 6 months of follow up. Patients with simple fracture patterns, alternative fixation methods, and inadequate follow up were excluded. All patients in the single plating group were treated with a lateral distal femoral locking plate using a lateral approach. In the patients treated with dual plating, an extensile parapatellar approach was utilized for fracture reduction and placement of an adjunctive medial plate. Demographic information, fracture types, injury severity score (ISS), medical comorbidities, type of surgical fixation, union rates, complications, knee range of motion, time to follow up, and need for revision surgery were extrapolated from the medical charts for analysis. ResultsTwenty-one patients were included in the study. Thirteen patients underwent single plate fixation and 8 underwent dual plate fixation. There were no significant differences in demographics, number of co-morbidities, fracture classification, or ISS between single and dual plate groups (p > 0.05 for all). There was a statistically significant difference in union rates between the single plate group (6 nonunions, 4 unions, and 3 delayed unions) and the dual plate group, with no nonunions or delayed unions (p = 0.0049). Although not statistically significant, 4 patients treated with single plating underwent revision ORIF, compared to none in the dual plating group (p = 0.13). There were no significant differences in time to follow up, time to full weight bearing, or infection rates (p > 0.1 for all). ConclusionBased on these results, the medial and lateral locked plating technique demonstrates a higher union rate, with possible lower rates of revision surgery, compared to a single lateral plate in highly comminuted distal femur fractures. Level of evidenceLevel 3. Retrospective Cohort Study.

Finite Element Analysis of Different Double-Plate Angles in the Treatment of the Femoral Shaft Nonunion with No Cortical Support opposite the Primary Lateral Plate

Objectives We evaluated the biomechanical outcome of different plate fixation strategies (the single plate construct, 45° double-plate construct, 90° double-plate construct, 135° double-plate construct, and 180° double-plate construct) used for the fixation of the femoral shaft nonunion with no cortical support opposite the primary lateral plate. This may help surgeons choose the optimal therapy to the femoral shaft nonunion. Methods The femoral shaft nonunion with no medial support and the models of lateral plate and medial plate was constructed in 3-matic software and UG-NX software, respectively. We then assembled the single plate and different double plates to the fracture model separately to form the fixation models. After meshing the models' elements, we used the ABAQUS software to perform the finite element analysis. Values of the von Mises Stress (VMS) distribution of the implant, peak VMS, and model displacement and deformation were used to capture the mechanical factors in this study. Results Our results indicated that the peak von Mises Stress (VMS) of the lateral plate was concentrated in middle surface of the lateral plate near the fragment of each group. The peak VMS was 5201.0 MPa (the single-plate construct), 3490.0 MPa (45° double-plate construct), 1754.0 MPa (90° double-plate construct), 1123.0 MPa (135° double-plate construct), and 816.5 MPa (180° double-plate construct). The additional short plate dispersed some stress leading to the decrease in the peak VMS of the lateral plate. As angle formed by the double plates increased, the dispersed function of the additional plate was becoming obvious. The bending angles of the lateral plate were 18° versus 12° versus 3° versus 2° versus 1° (the single-plate construct versus 45° double-plate construct versus 90° double-plate construct versus 135° double-plate construct versus 180° double-plate construct). Conclusions Our study indicated that increasing the angle between the plates in a double-plate construct improves the stability of the construct over a single lateral plate when there is no cortical support opposite to the lateral plate. The strongest fixation occurred when the angle between the two plates was greater than ninety degrees.

Single lateral versus medial and lateral plates for treating displaced scapular body fractures: a retrospective comparative study

This study compared the outcomes and complications of single lateral plating vs. dual plating for treating displaced scapular body fractures. Open reduction and internal fixation using locking plates was performed in 45 patients with displaced scapular fractures. A single lateral plate fixed in the lateral border was used in 22 patients (group A), and dual plates fixed in both the lateral and medial borders were used in 23 (group B). The average follow-up duration in both groups was 20 months. A remarkable difference was seen between the 2 groups in mean operative time and blood loss, although the Disabilities of the Arm, Shoulder and Hand and Constant Shoulder scores at the final follow-up were similar. The prominence rate of the hardware was 27.3% (6 of 22) in group A and 65.2% (15 of 23) in group B. The plate removal rate was 31.8% (7 of 22) in group A and 78.3% (18 of 23) in group B. Open reduction using a single plate on the lateral border for treating displaced scapular body fractures can lead to good functional outcomes, shorter operative time, less blood loss, and fewer plate-related complications compared with the dual-plating technique.

Enhancing fixation strength in periprosthetic femur fractures by orthogonal plating—A biomechanical study

Orthogonal plate osteosynthesis enhances fixation stability in periprosthetic femur fractures. Another option are locking attachment plates (LAP) allowing bicortical locking screw placement lateral to the prosthesis stem. Stability of lateral plate osteosynthesis with two LAP (2LAP) was compared to anterolateral orthogonal plate osteosynthesis (OP) with one LAP in a periprosthetic femur fracture model. In six pairs of fresh frozen human femora with cemented Charnley hip prosthesis, a transverse osteotomy was set distal to the tip of the prosthesis simulating a Vancouver type B1 fracture. Each pair was instrumented using a plate tensioner with either one lateral plate and two LAP, or two orthogonal anterolateral plates and one LAP. Stiffness was determined in a four-point-bending test prior to cyclic testing (2Hz) with physiologic profile and progressively increasing load up to catastrophic construct failure. Paired t-test and Wilcoxon-signed-rank test were used for statistical evaluation at a level of significance p = 0.05. The OP construct exhibited a significantly higher number of cycles and load to failure (39,627 cycles ± 4,056; 4,463 N ± 906) compared to the 2LAP construct (32,927 cycles ± 3,487; 3,793 N ± 849), p < 0.01. Mediolateral bending and torsional stiffness of the OP (1610 N/mm ± 249; 16.9 Nm/mm ± 6.3) were significantly higher compared to 2 LAP (1077 N/mm ± 189; 12.1 Nm/mm ± 3.9), p = 0.03 for both comparisons. Orthogonal plate osteosynthesis is a valuable option in periprosthetic fracture surgery, offering increased stability compared to a single lateral plate fixed with two LAP.

Preliminary testing of a novel bilateral plating technique for treating periprosthetic fractures of the distal femur

BackgroundCurrent stabilization methods for periprosthetic fractures of the distal femur are inadequate in achieving fracture fixation, with complication rates as high as 29%. A major contributor to poor outcomes is that these methods rely only on screw purchase in the bone to maintain fracture reduction. We designed, manufactured and evaluated a novel plating method that utilizes the femoral prosthesis to enhance stability for treatment of distal femoral periprosthetic fractures. MethodsMedial and lateral plates were designed and manufactured based on geometry of a synthetic femur and femoral prosthesis. The two plates were linked via a compression screw and a small tab on each plate that inserted into pre-existing slots on the prosthesis. Mechanical tests (500N compression or 250N anterior directed cantilever bending), were performed on synthetic femurs with simple transverse fractures (3mm gap) just superior to the distal femoral prosthesis that were stabilized using either the prototype plates or a single lateral plate. Translational movements of the fracture site during loading were measured using 3D motion tracking. FindingsWith the single lateral plate, the distal fragment experienced a resultant displacement of 0.40mm under cantilever bending and 0.61mm under compression (13% and 20% respectively of fracture gap width). With the bilateral plates, fracture gap motion was significantly reduced to 0.13mm under bending and compression (4.3% of the fracture gap). InterpretationOur results indicate that a bilateral plating method is capable of improving stabilization of periprosthetic fractures compared to the traditional lateral plating technique.

Comparative study of single lateral locked plating versus double plating in type C bicondylar tibial plateau fractures.

Background:Bicondylar tibial plateau fractures are complex injuries and treatment is challenging. Ideal method is still controversial with risk of unsatisfactory results if not treated properly. Many different techniques of internal and external fixation are used. This study compares the clinical results in single locked plating versus dual plating (DP) using two incision approaches. Our hypothesis was that DP leads to less collapse and change in alignment at final followup compared with single plating.Materials and Methods:61 cases of Type C tibial plateau fractures operated between January 2007 and June 2011 were included in this prospective study. All cases were operated either by single lateral locked plate by anterolateral approach or double plating through double incision. All cases were followed for a minimum of 24 months radiologically and clinically. The statistical analysis was performed using software SPSS 10.0 to analyze the data.Results:Twenty nine patients in a single lateral locked plate and 32 patients in a double plating group were followed for minimum 2 years. All fractures healed, however there was a significant incidence of malalignment in the single lateral plating group. Though there was a significant increase in soft tissue issues with the double plating group; however, there was only 3.12% incidence of deep infection. There was no significant difference in Hospital for special surgery score at 2 years followup.Conclusion:Double plating through two incisions resulted in a better limb alignment and joint reduction with an acceptable soft tissue complication rate.

Low transcondylar fractures of the distal humerus: results of open reduction and internal fixation

This study presents the outcomes of low transcondylar fractures of the distal humerus treated by open reduction and internal fixation. Between 1996 and 2010, 263 distal humeral fractures were managed at our institution. Patients with a true low transcondylar fracture treated by open reduction and internal fixation were included. Fourteen patients form the basis of this study. Fracture fixation was achieved through a triceps-sparing approach, a triceps tongue, or an olecranon osteotomy. Internal fixation was performed with parallel plates, orthogonal plates, a single lateral plate, or a single medial plate. The clinical outcome was measured with pain levels, range of motion, and the Mayo Elbow Performance Score. Radiographs at latest follow-up were assessed for union, delayed union, nonunion, and hardware failure. At most recent follow-up, 11 patients had no pain, 2 had mild pain, and 1 had moderate pain. The mean Mayo Elbow Performance Score was 85. The mean arch of motion was 95°. Complications included nonunion, delayed union, wound complications, deep infection, and heterotopic ossification. Stable internal fixation of low transcondylar fractures is perceived as difficult to achieve because of the very small size of the distal fragment. However, the results of our study indicate that internal fixation of low transcondylar fractures of the distal humerus is associated with a high union rate and satisfactory clinical results. Elbow arthroplasty does not need to be considered for most patients with a low transcondylar distal humeral fracture.

Indirect Reduction and Plate Fixation, without Grafting, for Periprosthetic Femoral Shaft Fractures About a Stable Intramedullary Implant

The application of indirect reduction techniques has improved fracture-healing and reduced the need for bone-grafting compared with the outcomes of older, direct reduction techniques. We investigated the results of such indirect reduction techniques for the treatment of periprosthetic femoral shaft fractures. Fifty consecutive patients with a femoral shaft fracture about a stable intramedullary implant (a Vancouver Type-B1 fracture) were treated with a protocol that included open reduction with use of indirect reduction techniques and internal fixation with a single lateral plate without structural allografting or other bone-grafting. Four patients died in the early postoperative period, and five had inadequate follow-up. The remaining forty-one patients (average age, seventy-two years) were evaluated clinically and radiographically at an average of twenty-four months. All fractures healed in satisfactory alignment at an average of twelve weeks (range, seven to twenty-three weeks) after the index procedure. One patient had one fractured cable and two others had one fractured screw, but all of the fractures healed without evidence of implant loosening or malalignment. There was one deep infection in the perioperative period. Thirty of the forty-one patients returned to their baseline ambulatory status. The results of this study support the use of indirect open reduction and internal fixation with a single extraperiosteal lateral plate, without the use of allograft struts, for the treatment of a femoral shaft fracture about a stable intramedullary implant.

INDIRECT REDUCTION AND PLATE FIXATION, WITHOUT GRAFTING, FOR PERIPROSTHETIC FEMORAL SHAFT FRACTURES ABOUT A STABLE INTRAMEDULLARY IMPLANT

Background: The application of indirect reduction techniques has improved fracture-healing and reduced the need for bone-grafting compared with the outcomes of older, direct reduction techniques. We investigated the results of such indirect reduction techniques for the treatment of periprosthetic femoral shaft fractures. Methods: Fifty consecutive patients with a femoral shaft fracture about a stable intramedullary implant (a Vancouver Type-B1 fracture) were treated with a protocol that included open reduction with use of indirect reduction techniques and internal fixation with a single lateral plate without structural allografting or other bone-grafting. Four patients died in the early postoperative period, and five had inadequate follow-up. The remaining forty-one patients (average age, seventy-two years) were evaluated clinically and radiographically at an average of twenty-four months. Results: All fractures healed in satisfactory alignment at an average of twelve weeks (range, seven to twenty-three weeks) after the index procedure. One patient had one fractured cable and two others had one fractured screw, but all of the fractures healed without evidence of implant loosening or malalignment. There was one deep infection in the perioperative period. Thirty of the forty-one patients returned to their baseline ambulatory status. Conclusions: The results of this study support the use of indirect open reduction and internal fixation with a single extraperiosteal lateral plate, without the use of allograft struts, for the treatment of a femoral shaft fracture about a stable intramedullary implant. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Indirect Reduction and Plate Fixation, without Grafting, for Periprosthetic Femoral Shaft Fractures About a Stable Intramedullary Implant

The application of indirect reduction techniques has improved fracture-healing and reduced the need for bone-grafting compared with the outcomes of older, direct reduction techniques. We investigated the results of such indirect reduction techniques for the treatment of periprosthetic femoral shaft fractures. Fifty consecutive patients with a femoral shaft fracture about a stable intramedullary implant (a Vancouver Type-B1 fracture) were treated with a protocol that included open reduction with use of indirect reduction techniques and internal fixation with a single lateral plate without structural allografting or other bone-grafting. Four patients died in the early postoperative period, and five had inadequate follow-up. The remaining forty-one patients (average age, seventy-two years) were evaluated clinically and radiographically at an average of twenty-four months. All fractures healed in satisfactory alignment at an average of twelve weeks (range, seven to twenty-three weeks) after the index procedure. One patient had one fractured cable and two others had one fractured screw, but all of the fractures healed without evidence of implant loosening or malalignment. There was one deep infection in the perioperative period. Thirty of the forty-one patients returned to their baseline ambulatory status. The results of this study support the use of indirect open reduction and internal fixation with a single extraperiosteal lateral plate, without the use of allograft struts, for the treatment of a femoral shaft fracture about a stable intramedullary implant. Therapeutic Level IV.