Management of extra articular distal femoral fractures with nail plate combination
Ashok Sharma, Deepak Varma, Umesh Vyas, Arvind Kumar Bohra, Shiv Bhagwan Sharma
Department of Orthopedics, SRGH, Jhalawar, Rajasthan, India
|Date of Submission||16-Oct-2021|
|Date of Acceptance||05-Jan-2022|
|Date of Web Publication||15-Jun-2022|
Dr. Ashok Sharma
Room No. 507, New PG Hostel, Jhalawar Medical College, Jhalawar – 326 001, Rajasthan
Source of Support: None, Conflict of Interest: None
Background: Junctional distal femur fractures are considered difficult to unite and often can led to a degree of disability. The incidence of malunion, nonunion, and infection is relatively high in many reported series. In elderly patients, low-energy distal femur fractures can cause devastating injuries, carrying high rates of morbidity and mortality. Operative fixation can be more challenging in comminuted fractures of osteoporotic bones. The management of junctional fractures of the distal femur by using the nail plate combination (NPC) technique can provide stable, well-balanced fixation, allowing for immediate weight-bearing and early mobilization and improve quality of life. Materials and Methods: A prospective randomized study including 16 patients with distal femur extraarticular and junctional fractures, was conducted in the department of orthopedic surgery Jhalawar medical college and SRG hospital Jhalawar, from May 2019 to June 2021. There were 9 male and 7 female patients, age range from 43 years to 70 years, with a mean age being 53 years. The average length of follow-up was 18.5 months (12 months to 24 months). Results: Patients followed up at 1 month, 3 months, 6 months, annually thereafter. Regular fracture healing was observed in 15 cases. Delayed union seen in 1 case who had infection postoperatively, which was treated with debridement and antibiotics as culture and sensitivity. mild rotational misalignment (~5°) seen in one case and there was no axial misalignment (Varus/valgus angulations) was found in any case. There were no implant failures. Conclusion: In our study, functional results trended toward better outcomes in nails plates combinations in terms of knee flexion, early weight-bearing, less union time, and better alignment. NPC system could take the challenges such as poor bone stock, severe comminution both metaphyseal and diaphyseal region.
Keywords: Distal femur fractures, junctional distal femoral fractures, nail plate combination
|How to cite this article:
Sharma A, Varma D, Vyas U, Bohra AK, Sharma SB. Management of extra articular distal femoral fractures with nail plate combination. J Orthop Traumatol Rehabil 2022;14:50-4
|How to cite this URL:
Sharma A, Varma D, Vyas U, Bohra AK, Sharma SB. Management of extra articular distal femoral fractures with nail plate combination. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2022 Jun 29];14:50-4. Available from: https://www.jotr.in/text.asp?2022/14/1/50/347356
Distal femur fractures are fractures involving the distal one-third of the femur, i.e., the region from diaphyseal-metaphyseal junction to knee joint line which is terminal 10–15 cm of the distal femur. Its incidence is 3%–6% of all femoral fractures. These fractures reflect the distribution of bimodal age, as it is associated with higher energy processes such as road traffic accident/motor vehicle accident in younger patients and low energy processes such as fall from bed, falls during walking in older osteoporotic patients. High-energy mechanism injuries are associated with the risk of nonunion because of disrupting the soft tissue envelope, so great care should be taken during the treatment of these conditions. In osteoporotic cases, complex and comminuted fractures are usually associated with poor outcomes.
The pattern of fracture and displacement depends on the mechanism of injury and biomechanics. The forces acting on fracture fragments by adductors, quadriceps, gastrocnemius, and hamstrings muscles can cause displacement and angulation. Gastrocnemius muscle pull can lead to rotation and spread in intercondylar fracture. The adductors can cause coronal plane deformities, depending on the location, variety, and relationship of the fracture to the adductor tubercle. Elderly patients with a high degree of osteopenia, deformities become more severe, so our fixation system is desired to be sturdy enough to resist these deforming forces and offer strong fixation even in comminuted fractures. The popliteal artery lies relatively fixed and in close relation (posteromedial) to the distal femur and hence though rarely (approximately 0.2%), can be damaged by a posteriorly angulated fracture.
There are various methods of management of distal femoral extraarticular fractures, including conservative and operative methods such as internal fixation by 95° angle blade plate, C-C screws, dynamic condylar screw and plate, condylar buttress plates, nail-plate construct, distal femoral locking plate, antegrade and retrograde intramedullary (IM) nail.,
Although distal femoral locking plate system has shown promising results in both intra- and extra-articular fractures of the distal femur especially in osteoporotic bones., femur nail system has advantages such as direct fracture reduction, being an IM load sharing device allowing early load-bearing and allowing percutaneous placement avoiding blood supply disruption. Hence, the addition of both systems in combination (nail and plate) can provide added benefits of each system.
Extraarticular distal femoral junctional fracture is a frequent site for malunion, nonunion and delayed union because biomechanically various muscle pull can cause displacement of the fracture fragments. All cases of our study were managed by nail-plate combination which had the added benefit of providing stable fixation in comminuted fractures also. The goals of our treatment are to achieve stable fixation, anatomic reduction, restoration of limb alignment, length, rotation, followed by provide early union and mobilization.
Aim and objectives
- To study the efficacy of nail plate combination (NPC) for distal femoral extraarticular fracture and its functional evaluation in distal femoral fractures.
- To assess the functional outcome of the patient’s range of motion of the knee and after the union of fractures
- To assess the functional and radiological outcomes.
|Materials and Methods|
This study was conducted in patients aged >18 years having extraarticular distal femoral fractures reporting to the Orthopedics Department of Shree Rajendra General Hospital and Medical College Jhalawar from May 2019 to June 2021. There were a total of 16 patients out of whom 9 were male and 7 were female. The average length of follow-up was 18.5 months (12 months to 24 months).
- Age of patient >18 years
- Gustilo type I and II open or closed fractures
- Extraarticular distal femur fractures.
- Pathological fractures
- Gustilo type III open fractures
- Patients with vascular injury
- Floating knee
- Contraindication to anesthetic drugs.
- Patient not willing for surgery.
- Patients with adequate anatomical reduction and stabilization.
All patients were thoroughly assessed including history recording, physical examination, preanesthetic workup, and patient workup.
AP, lateral and oblique radiographs were obtained; in some selected cases where intra-articular extension of fracture is suspected which can be difficult to visualize on radiographs alone; a computed tomography (CT) scan was also done. Particularly with high-energy mechanism trauma its necessary to evaluate for an ipsilateral hip region fracture and spine injury by examining the patient clinically and by taking radiographs of lumbosacral spine lateral view, pelvis with both hip AP view. Attention should be given for possible Hoffa’s fragment (intra-articular fracture in the coronal plane of the condyle).
Surgical options and surgical procedure
Invasive or Minimal invasive surgery can be performed for an extra-articular fracture, in our study all cases managed with antegrade I/L femur nail with plate (phillos plate or metadiaphyseal plate).
Surgical techniques of antegrade femur interlocking nail with plating
The patient was taken on a traction table. All patients of extra-articular distal femoral fractures were managed with antegrade interlocking femur nail with plating in our study. The entry was made at the pyriform fossa, guidewire inserted, and guidewire passed distal to fracture site after reduction. We used power reamers for reaming with the sequent increase in the size of the reamer. Care was taken to always place our guidewire in the center in AP and lateral view of fluoroscopy. Longest size nail inserted to increase working length. To enhance stability the nail was advanced as distal as possible into the condyle. According to Antekeier et al. for successful IM nailing, the distance should be more than 3 cm between fracture site and most proximal screw for distal fixation, which can withstand a million loading cycles. The large diameter of the nails is important because distal cortical contact enhances system stability and reduces the strain that are absorbed by locking screws and nails. We used the perfect circle technique for distal 2 lockings, docking is done at fracture site for compression. With the help of ZIG, we made proximal lockings.
For plate application, a separate mid-lateral subvastus incision was given over the lateral aspect of the distal femur starting from Gerdy’s tubercle to proximally as exposure required. Sharp dissection was taken down. Now the iliotibial band was identified and incised in line with the skin incision. The vastus lateralis muscle was lifted off to expose the lateral aspect of the femur. With the help of the periosteum elevator, muscle and periosteum were separated from the bone to insert plate by minimally invasive technique. We used k-wires to temporarily balance the plate, now the plate was secured with locking screws distally. During insertion of distal locking of plate, we tried to insert one screw through the empty hole in nail also, so that nail and plate act as a single construct. We then fixed 3–4 miss-the nail proximal screws by open or minimally invasive technique. After the fixation was done, wound was washed thoroughly. We also instilled local antibiotics to prevent infection. Wound was closed in multiple layers with the help of vicryl and skin monofilament sutures. Drain was not used. 2 cases of Open or compound fractures, were partially closed and vacuum-assisted closure was also done to prevent infection, secondary close of wound after 3-5 days. After dressing properly, the GT slab was applied to the knee at 15°–20° of flexion. Final radiological evaluation and mechanical axis alignment were checked to reveal good length and rotation of the femur with appropriately placed hardware.
Postoperatively limb was elevated to decrease the swelling. Bilateral limb care is important because of the risk of developing DVT in the contralateral limb also. Always evaluate another limb also if it is painful. IV antibiotics and subcutaneous enoxaparin were given for 5 days postoperatively. Check dress was done after 48 h and isometric quadriceps and knee bending exercises were started. First follow-up was done on the 12th to 14th postoperative days, Stitches were removed at 1st follow-up. Toe touching and partial weight-bearing with the help of crutches were allowed after the first follow-up. Full weight-bearing was avoided for 15 weeks or until fracture healing is visible radiographically and clinically. Using NPC allows for early partial weight-bearing. We called these patients for follow-up at 4, 12, 24 weeks, and annually thereafter, to evaluate clinical and radiological outcomes [Figure 1] and [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d.
|Figure 1: Case 1 Radiological outcome. (a) Preoperative X-ray. (b) Postoperative X-ray. (c) Follow up X-ray at union (15 weeks)
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|Figure 2: Radiological outcome, Distal femoral fracture in a case operated previously with short pfn for trochantric fracture, now managed with nail-plate combination. (a) Preoperative X-ray. (b) Postoperative X-ray. (c) X-ray at union. (d) Functional outcome
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The study was conducted in the Department of Orthopedics, Jhalawar Medical College and Shree Rajendra General Hospital Jhalawar, from May 2019 to May 2021. There were 9 male and 7 female patients, age range from 30 years to 70 years, mean age 53 years.
Mode of injury was as a result of high energy trauma in 11 patients and low energy trauma in 5 patients [Table 1]. Radiological evaluation was done by recording various data including valgus / varus tilt, anterior / posterior tilt , rotational mal-alignment, time of union and implant loosening and failure [Figure 1] and [Figure 2]a, [Figure 2]b, [Figure 2]c.
The average union time was 14.75 weeks [Table 2]. Regular fracture healing was observed in 15 cases. Delayed union was seen in 1 case who had infection postoperatively, which was treated with debridement and antibiotics according to culture and sensitivity. No axial misalignment was noted in any case, mild rotational misalignment (~5°) was seen in one case. There were no implant failures noted.
Functional evaluation [Figure 2]d done using Neer’s scoring system in our NPC study, 10 patients showed excellent results (62.5%) and five patients showed good results (31.25%), one patient showed fair (6.25%) results and none of the patients fell under poor criteria (0%) [Table 3].
62.5% of cases out of those operated with NPC had >110°, 31.25% of cases had 91°–109° and 6.25% of cases had <90° of knee flexion. The mean knee flexion achieved was 114° [Table 4].
In This study special attention was given to the combined usage of both IM nailing and plating for distal femoral fixation. Results of many studies showed that IM nailing revealed a more stable construct compared to plate fixation in terms of axial and torsional loading and load to failure testing for extraarticular distal femoral fractures. The combined usage of both implants nail and plate provides even more stable construction.
Internal fixation is always superior to nonoperative treatment for distal femoral fractures, but these fractures are challenging regarding implant, technical decisions, and ability to manage complications. Despite internal fixation, delayed union or nonunion are not uncommon in distal femoral extraarticular junctional fractures, especially when there was no medial cortical support present.
Various measurement scales have been described by different authors to determine functional outcomes after surgical treatment of extraarticular distal femoral fractures. NEER, HOSPITAL FOR SPECIAL SURGERY SCORE,, LYSHOLM GILLQUIST SCORING SYSTEM, HAMMER SCORE are some of the rating scales which are commonly used. We used Neer’s scores because it evaluates important outcome variables such as functions related to activities of daily living pain, return to work, gross anatomic alignment, mechanical alignment, and radiographic evaluation of union.
Herrera et al. (in a series of 29 cases with a total of 415 distal femur fractures), found a nonunion rate for IM nail is 1.5% whereas for locking plates 5.3%.
According to Papadokostakis et al., IM nailing is a reliable treatment method with fewer complications for distal femoral fracture management. In a study by Handolin et al., they found that IM nails have been shown good results in the osteoporotic bone as well., Strong internal fixation is difficult to achieve in older osteoporotic patients due to poor bones quality and comminution.,
According to a study by Zlowodzki et al. in comparison to the nail, plate provides better distal fixation in osteoporotic bones. To study the load and strength of the implant, a biomechanical study was conducted by using artificial cortical bone with a density of 1.64 g/cm3. Research findings suggest that plating in distal femoral fractures provides greater torsional stability, while IM devices show greater axial strength.,,,
In our study, the nail-plate construct provides the least gap motion and the highest stiffness, by combining IM nail with plate augmentation, NPC provides the added advantages of these two techniques in fracture fixation, while their potential complications can be minimized. The IM nail acts as a load-sharing device and reduces shear strength in the fracture area and maintains alignment in the fracture area. Whereas the plate augmentation may provide stability by controlling continuous excess motion at the fracture site and comminuted unstable fractures fragments. Hence, NPC provides stability as well as maintains alignment also.
Treatment of distal femur fracture is challenging because of the inherent complexity of the injury as well as the deforming forces that act on fixation. Careful patient evaluation and fracture characterization are critical when choosing a treatment plan. Both dsplaced, as well as unstable fractures distal femoral fractures should be managed surgically unless contraindicated because complications rates are still higher if managed nonoperatively. To enhance biomechanical stiffness and strength of the construct, combined usage of IM nail and plate is important for distal femoral extraarticular fractures.
Soft-tissue injury can compromise the patient outcome. Functional assessment with Neer’s scoring system has been found useful in evaluating the results. Good results can be achieved by adhering to the principles of stabilization with a strong internal fixation and proper physiotherapy.
Nail plate construct is our mainstay of surgical treatment because of its ability to obtain sturdy fixation and its resistance to inherent deforming forces. NPC system could take the challenges like poor bone stock, severe comminution both metaphyseal and diaphyseal region. In our study, the results of NPC for distal femoral fractures are superior in terms of union rate and functional outcome (knee flexion, early weight-bearing, and less knee pain) but inferior in terms of blood loss and implant cost.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]