Supracondylar Distal Femur Fractures Research Articles

Evaluation of functional outcome in patients treated with locking compression plate for distal femur fractures

Distal femur fractures are always a challenge to an orthopedic surgeon. They may be unstable and comminuted. Thin cortex, wide medullary canal, relative osteopenia and short distal segment adds to the complexity. The present study assessed the functional outcome of using locking compression plate fixation for fractures of distal end of femur in patients admitted to JMMC orthopedics department satisfying the inclusion and exclusion criteria from December 2017 to may 2019. Twenty cases were taken in this study. Serial follow up was done at 4, 8, 12, 24 weeks and functional outcome was assessed at the end of 24 weeks using NEERS criteria. 18 patients were treated with open reduction and internal fixation. 2 of the fractures were stabilized via MIPPO technique. No patients had implant failure and none of the cases were complicated by deep infection. 5 of the 20 patients had ‘Excellent’ Neers scores and 14 had ‘Good’ scores. Only one patient had ‘Fair’ score.
 Conclusion: Locking compression plate fixation is a safe procedure for supracondylar fractures of distal femur with good functional outcome. It can be done on a routine basis with a minimum risk of complications.
 Keywords: Functional Outcome, LCP, Open Reduction Internal Fixation, Prospective Study, Supracondylar Fracture.

Risk of reverse golf club deformity with medial plating of distal femur fracture.

This study described a deformity induced by medial plating of supracondylar distal femur fractures using plates that are precontoured for other anatomic locations. OTA/AO 33A fractures were created in 12 sawbone femurs and fixed with either a proximal humerus locking plate (PH), an ipsilateral lateral tibial plateau plate (LTP), or an ipsilateral medial distal tibial plate (MDT). A motion capture system measured changes in length and rotation of the distal femur as the plate was applied. Each plate underwent four trials and the mean and standard deviation (SD) for each measurement was reported. An analysis of variance with post hoc Tukey test compared malreduction measures between plate types. All plates consistently created a varus deformity. There was lateral lengthening with a compensatory medial shortening and an increase in the lateral distal femoral angle. The distal fracture fragment was laterally translated, and internally rotated. The PH plate had significantly greater lateral length (27.39mm SD 4.78, p = 0.007), shorter medial length (13.57mm SD 4.99, p = 0.028), greater lateral translation (28.82mm SD 5.70, p = 0.010) and greater widening of the lateral distal femoral angle (28.54° SD 4.98, p < 0.001) than the LTP and MDT plates. The MDT plate had significantly greater angulation anteriorly (8.40° SD 1.07, p < 0.001) and laterally (7.63° SD 3.10, p = 0.002) than the PH and LTP plates. There was no significant difference between plates in internal rotation (PH: 3.07° SD 2.79; LTP: 2.05° SD 1.05; MDT 3.81° SD 3.56; p = 0.659). When dual plating supracondylar distal femur fractures, poor plate positioning and a mismatch between plate contour and the slope of the medial distal femur can lead to varus angulation, internal rotation, and lateral translation or a "reverse golf club deformity". After comparing three types of precontoured plates, the authors recommend initial evaluation of the ipsilateral proximal tibial plate when placing a plate along the medial distal femur. IV.

Technical Factors Contributing to Nonunion in Supracondylar Distal Femur Fractures Treated with Lateral Locked Plating: A Risk-Stratified Analysis.

To identify technical factors associated with nonunion after operative treatment with lateral locked plating. Retrospective cohort study. Ten Level 1 trauma centers. Six hundred fifteen adult patients with supracondylar distal femur fractures (OTA/AO Type 33A or C). Lateral locked plating. Surgery for nonunion. We observed nonunion rates of 2% in a low-risk of nonunion group (n = 129), 4% in a medium-risk group (n = 333), and 14% in a high-risk group (n = 153). Varus malreduction with an anatomic lateral distal femoral angle (aLDFA) greater than 84 degrees, was associated with double the odds of nonunion (OR, 2.1; 95% CI, 1.1 to 4.2; P = 0.03). Malreduction by medial translation of the articular block increased the odds of nonunion, with 30% increased odds per 4 mm of medial translation (95% CI, 1.0 to 1.6; P = 0.03). Working length increased the odds of nonunion primarily in the medium risk group, with an 18% increase in nonunion per 10 mm increase in working length (95% CI, 1.0 to 1.4; P = 0.01). Proximal screw density was protective against nonunion (OR, 0.71; 95% CI, 0.53 to 0.92; P = 0.02). Lateral plate length and type of plate material were not associated with nonunion. Malreduction is a surgeon-controlled variable associated with nonunion after lateral locked plating of supracondylar distal femur fractures. Longer working lengths were associated with nonunion, suggesting that simple bridge plating may be less likely to succeed for longer fractures. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

Axial and Rotational Malreduction (Golf Club Deformity) in Distal Femur Fractures.

To describe malreduction of supracondylar distal femur fractures stabilized with lateral femoral locking plates and determine whether a mismatch in axial lateral distal femur anatomy and lateral distal femoral plate design contributes to supracondylar distal femoral fracture malreduction. OTA/AO 33A were simulated in 7 cadaver femurs and fixed with a lateral distal locking femoral plate placed flush to the lateral femoral condyle (group 1). In group 2, the anterior flange of the plate was externally rotated 10 degrees in relation to the lateral condyle. A motion capture system measured translation and rotation of the articular segment as shaft screws were applied, reducing plate to femoral diaphysis. Articular segment movement was compared between groups using paired Student t test, P &lt; 0.05. A large database of 3D scans of 800 femurs was used to define the relationship of the lateral femoral condyle to the lateral cortical surface of the human femur. Malreduction was observed with anatomic plate application results from medial translation (17 mm) and external rotation (12.2 degrees) (group 1). Modifying plate geometry to match lateral femur anatomy (group 2) improved medial translation by 46% and external rotation by 80%. An analysis of the shape of the 800 distal femurs showed that the average posterior anterior inclination is 16.5 degrees. Anatomic application of distal femoral plates results in significant malreduction. Modifying the plate design to accommodate 10 degrees slope of lateral distal femur results in partial correction of deformity. Future studies should investigate other means of correcting the malalignment, especially considering the 16.5-degree posterior anterior inclination of the condyle.

Nail diameter significantly impacts stability in combined plate-nail constructs used for fixation of supracondylar distal femur fractures.

Objectives:Plate-nail (PN) combinations have been described for fixation of supracondylar distal femur fractures. Small diameter retrograde intramedullary nails (rIMN) are commonly used. The purpose of this study was to investigate the effect of nail diameter on construct stability. We hypothesized that a larger diameter rIMN would not significantly change the stiffness of the PN construct when tested in torsional or axial loading.Methods:Twelve synthetic osteoporotic femurs were used to compare nail diameters in an extraarticular supracondylar distal femur fracture model (Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen type 33-A3). Constructs were fixed with a 12-hole 4.5 mm pre-contoured lateral distal femoral locking plate combined with either a 9 mm (n = 6) or an 11 mm (n = 6) retrograde intramedullary nail (rIMN). Specimens were cyclically loaded in torsion and axial compression. The primary outcome was construct stiffness, calculated using the average slope of the force-displacement curves.Results:The 11 mm PN construct was approximately 1.6 times stiffer than the 9 mm PN construct averaged across all torsional loads (2.39 +/− 0.41 Nm/deg vs 1.44 +/− 0.17 Nm/deg) and approximately 1.3 times stiffer than the 9 mm PN construct averaged across all axial loads (506.84 +/− 44.50 N/mm vs 376.77 +/− 37.65 N/mm). There were no construct failures.Conclusions:In this biomechanical model, nail diameter had a significant effect on both torsional and axial stiffness in PN constructs. While the use of smaller diameter rIMNs has been proposed to allow for easier placement of implants, the effect on overall construct stiffness should be considered in the context of the patient, their fracture and desired postoperative weight bearing recommendations. Level of Evidence: N/A

A comparative study of functional outcome of extra articular distal femur fractures treated, with retrograde nailing versus locking compression plate

Aim: To compare the functional outcome of supracondylar fractures of distal femur managed by Supracondylar nailing (retrograde) and locking femoral compression plate. Introduction: Before 1980, supracondylar fractures of the femur were treated with nonlocking plates. Plaster immobilization and traction were modes of treatment for non-operative patients. Nowadays, the knowledge of internal fixation has evolved as to treat complex fractures by cancellous screws, 95-degree blade plates, dynamic condylar screw and plate, condylar buttress plates, locking femoral compression plates and supracondylar nailing (retrograde). Trending procedures for supracondylar fractures of the femur are supracondylar nail (retrograde) and locking femoral compression plate. Materials and Methods: Totally 30 patients of extra-articular distal femur fractures treated in Rajah Mathai Medical College from May 2019 to June 2021. Patients were treated by random allocation as 15 patients by retrograde nailing and the other 15 patients by distal femur locking compression plate. Functional outcome was compared between them according to Neer’s Scoring System at 24 weeks. Results: In our study, the patients were screened up to 1 year. The assessment was based on both radiologically and clinical scoring. Neer's score was higher in nailing (54%) compared to plating (46%). Conclusion: From our study, nailing proved to have a good functional outcome in terms of early weight-bearing, knee flexion and less union time. Both nailing and plating have excellent results with proper preoperative planning.

Distal Femoral Arthroplasty Versus Open Reduction Internal Fixation for Comminuted Osteoporotic Supracondylar Distal Femur Fractures

Purpose: The purpose of the article is to review the treatment of comminuted distal femur fractures and examine the risks and benefits of distal femoral replacement/arthroplasty (DFA) for the treatment of complicated osteopenic supracondylar femur fractures. Method: An OVID MEDLINE, PubMed, and Cochrane Database of Systematic Reviews literature search was conducted with search terms distal femur fracture, distal femoral replacement, osteoporosis, fixation, and functional outcomes. Forty-six articles pertinent to the topic were retrieved. These articles serve as the basis for the clinical review portion of the article. A patient representing the clinical question was selected for inclusion in the case study. Verbal consent was obtained, consistent with the guidelines from the Journal of Orthopaedics for Physician Assistants. Results: There is a paucity of evidence-based literature to justify the use of distal femoral replacement/DFA for the management of comminuted supracondylar distal femur fractures. Further study is needed to document the role of DFA for frail, elderly patients. Conclusion: Open reduction internal fixation has been used to treat distal femur fractures. The techniques of locked plating (with or without variable angle construct), percutaneous fixation, and intramedullary nailing are well established for the treatment of fractures of the distal femur. The use of distal femoral replacement/DFA has been shown to decrease weight-bearing limitations, decrease immobility, minimize the use of a brace, and maximize function after complicated fractures with osteoporosis. Further research is needed to identify the role of DFA for the treatment of comminuted distal femur fractures in the elderly population.

Ballistic Supracondylar Distal Femur Fractures Have Lower Rates of Intra-articular Extension Than Blunt Distal Femur Fractures.

To compare the relative frequencies of intra-articular extension of supracondylar distal femur fractures in blunt versus ballistic trauma and the diagnostic accuracy of conventional radiography in identifying intra-articular extension in these fractures. A retrospective review. Urban academic trauma center. Thirty-eight patients were included for analysis, with 19 blunt and 19 ballistic mechanism distal femur fractures. Fleiss' kappa score was calculated in determining interobserver reliability of the OTA/AO classification. Radiographic specificity and sensitivity were compared using Fischer exact testing. Quantitative data were compared using 2-tailed t-testing for continuous variables and chi-square tests for proportions. Rate of intra-articular extension of ballistic versus blunt supracondylar femur fractures. Seventeen of 19 patients (89.5%) with blunt trauma had intra-articular involvement compared with 5 of 19 patients (26.3%) with ballistic trauma (P = 0.001). For blunt fractures, preoperative radiographs were 94% sensitive for the detection of intra-articular extension compared with 100% sensitive for ballistic fractures (P = 1.000). We identified one case, in the blunt cohort, where the operative plan changed from intramedullary nail to open reduction and internal fixation as a result of the additional coronal plane fracture pattern identified on CT. There were no such occurrences in the ballistic cohort. The rate of intra-articular extension for ballistic supracondylar femur fractures is lower than blunt distal femur fracture. There were low rates of missed intra-articular fractures and changes in operative plans after reviewing CT imaging for both blunt and ballistic distal femur fractures. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Supplemental Fixation of Supracondylar Distal Femur Fractures: A Biomechanical Comparison of Dual-Plate and Plate-Nail Constructs

This biomechanical study compares the effectiveness of dual-plate (DP) and plate-nail (PN) constructs for fixation of supracondylar distal femur fractures in synthetic and cadaveric specimens. Twenty-four synthetic osteoporotic femurs were used to compare 4 constructs in an extra-articular, supracondylar fracture gap model (OTA/AO type 33-A3). Constructs included: (1) distal lateral femoral locking plate (DLFLP), (2) retrograde intramedullary nail (rIMN), (3) DLFLP + medial locking compression plate (DP construct), and (4) DLFLP + rIMN (PN construct). DP and PN constructs were then directly compared using 7 matched pairs of cadaveric femurs. Specimens underwent cyclic loading in torsion and compression. Biomechanical effectiveness was measured by quantifying the load-dependent stiffness of each construct. In synthetic osteoporotic femurs, the DP construct had the greatest torsional stiffness (1.76 ± 0.33 Nm/deg) followed by the rIMN (1.67 ± 0.14 Nm/deg), PN construct (1.44 ± 0.17 Nm/deg), and DLFLP (0.68 ± 0.10 Nm/deg) (P < 0.01). The DP construct also had the greatest axial stiffness (507.9 ± 83.1 N/mm) followed by the PN construct (371.4 ± 41.9 N/mm), DLFLP (255.0 ± 45.3 N/mm), and rIMN (109.2 ± 47.6 N/mm) (P < 0.05). In cadaveric specimens, the DP construct was nearly twice as stiff as the PN construct in torsion (8.41 ± 0.58 Nm/deg vs. 4.24 ± 0.41 Nm/deg, P < 0.001), and over one-and-a-half times stiffer in compression (2148.1 ± 820.4 vs. 1387.7 ± 467.9 N/mm, P = 0.02). DP constructs provided stiffer fixation than PN constructs in this biomechanical study of extra-articular distal femur fractures. In the clinical setting, fracture morphology, desired healing mode, surgical approach, and implant cost should be considered when implementing these fixation strategies.

A study on functional outcome of distal femoral fractures with distal femur locking compression plate

Background: Historically it is difficult to treat intercondylar and supracondylar distal femur fractures. The aim of this study is to assess the clinical and radiological functional outcome of distal femoral both extraarticular and intraarticular fractures types(A,B,C) treated with locking compression plate. Material and Methods: We reviewed 30 distal femoral fractures treated with distal femoral locking compression plates between 2018 to 2019. There were 20 male and 10 female with mean age of 48 yrs(range 21 – 70). More patients were of type A2 (AO classification) and had been caused by high energy trauma. Results: out of 30 patients, 11 had excellent, 13 had good and 6 had fair outcome. 6 patients had limb length discrepancy and 10 patients had extension lag. Three patient had valgus deformity and three patients had varus deformity. Conclusion: It provides better fixation of fracture in elderly patient with osteoporosis. Post operative early passive mobilisation of the knee gives good range of motion. Operative time is lessened as the locking compression is pre contoured and does not require anatomical fracture reduction.

Any Cortical Bridging Predicts Healing of Supracondylar Femur Fractures After Treatment With Locked Plating.

To determine the accuracy and reliability of radiographic cortical bridging criteria in predicting the final healing of supracondylar femur fractures after treatment with locked plating. Retrospective review. Two Level 1 trauma centers. Patients who presented with supracondylar femur fractures (OTA/AO 33A, C) and were treated with locking plate fixation between January 1, 2004, and January 1, 2011. The final study population included 82 fractures after excluding patients with open physes (n = 4), nondisplaced fractures (n = 4), early revision for technical failure (n = 4), or inadequate follow-up (n = 42). Distal femur locking plate fixation. Postoperative radiographs until final follow-up were assessed for cortical bridging at each cortex on anterior-posterior and lateral views. Images were analyzed independently by 3 orthopaedic traumatologists to allow for assessment of reliability. Final determination of union required both radiographic and clinical confirmation. Assessment for any cortical bridging was the earliest accurate predictor of final union (95.1% accuracy at 4 months postoperatively), compared with criteria requiring bicortical bridging (93.9% accuracy at 6 months) and tricortical bridging (78% accuracy at 21 months). Any cortical bridging demonstrated a higher interobserver reliability (kappa = 0.73) relative to bicortical (kappa = 0.27) or tricortical bridging (kappa = 0.5). Our results for plate fixation of supracondylar distal femur fractures mirror those previously described for intramedullary nailing of tibia shaft fractures. Any radiographic cortical bridging by 4 months postoperatively is an accurate and reliable predictor of final healing outcome after locking plate fixation of supracondylar femur fractures. Assessment for bicortical or tricortical bridging is less reliable and inaccurate during the first postoperative year. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Analysis of management of supracondylar femur fracture by locking compression plate

Background: Supracondylar fractures of femur present a huge surgical challenge. The introduction of locking compression plate (LCP) has brought a remarkable change in the management of supracondylar fractures of distal femur. Aim: The aim of this study was to evaluate the rate of union, functional outcome and complications of these fractures treated with open reduction and internal fixation with a locking compression plate. Materials and method: The present study was conducted in the Department of Orthopedics, RIMS, Ranchi during June 2014 to December 2015. A 40 adult patients with closed supracondylar fractures of distal femur (Muller Type-A) and treated by locking compression plate were included in this study. Variables of each patients were recorded and analyzed with respect to age, sex, fracture type, mode of injury, limb involvement, associated injuries, timing and duration of operation, duration of hospital stay in days, follow up, complications and final outcomes. Patients were evaluated both clinically as well as radiologically at 6 weeks interval for first 6 months, then every 3 months for next 6 months and then at every 6 months. Results: The mean age of patients was 27.50 yrs. Out of 40 patients, 26 (65%) were male and 14 (35%) were female. The right femur was involved in 22 (55%) patients, and left in 16 (40%) patients while both femur was involved in only 2 (5%) patients. Clinical union was seen at 12.65 weeks (10-30 weeks) in all cases. Radiologically bridging callus was seen at 12th post-operative week and complete radiological union at a mean time of 25.73 weeks (20 - 40 weeks). 34 (85%) patients had excellent, 4 (10%) patients had good outcome and 2 (5%) patients had failure in the final result. Conclusion: Locking compression plate fixation is a safe procedure for supracondylar fractures of distal femur with an excellent functional outcome, early clinical and radiological union and it can be done on a routine basis with a minimum risk of complications.