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Sánchez del Saz J, Coderch Carretero J, García Coiradas J, García Crespo R. Watch out your pins! Periprosthetic femoral fracture at tracking pin site early after robotic-assisted knee arthroplasty treated with dual nail-plate fixation. Trauma Case Rep 2025; 57:101182. [PMID: 40491444 PMCID: PMC12146869 DOI: 10.1016/j.tcr.2025.101182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2025] [Indexed: 06/11/2025] Open
Abstract
Robotic-assisted orthopedic surgeries are gaining popularity due to several factors such as its potential for enhanced precision and alignment in prosthetic implant placement, as well as its better pain control and reduction in hospital stay time. However, complications such as pin-related periprosthetic fractures, though rare, highlight the importance of technical precision during pin placement and adequate postoperative monitoring. We present the case of a 76-year-old obese female patient who presented to the Emergency Department with severe pain and deformity around the knee two months after robotic-assisted total knee arthroplasty following a fall from standing height. Radiographs revealed a displaced femoral periprosthetic fracture at tracking pin sites without associated implant instability. Surgical management involved combined nail-plate fixation, which promoted both early weight-bearing and functional recovery. At one year postoperatively, the patient achieved satisfactory fracture healing and functional outcomes, with a Knee Society Score of 92 and an EuroQol-5D index value of 0.78. Combined nail-plate osteosynthesis, though more invasive compared to other fixation methods, could be an effective strategy for managing distal femoral fractures following robotic-assisted arthroplasty, especially in obese and elderly patients, due to its biomechanical advantages, supporting early mobilization and weight-bearing with reliable fracture healing.
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Affiliation(s)
- Jaime Sánchez del Saz
- Trauma Surgery Unit, Hospital Universitario Clínico San Carlos, Calle Profesor Martín Lagos, s/n, Madrid 28040, Spain
| | - Jaime Coderch Carretero
- Trauma Surgery Unit, Hospital Universitario Clínico San Carlos, Calle Profesor Martín Lagos, s/n, Madrid 28040, Spain
| | - Javier García Coiradas
- Trauma Surgery Unit, Hospital Universitario Clínico San Carlos, Calle Profesor Martín Lagos, s/n, Madrid 28040, Spain
| | - Rodrigo García Crespo
- Knee Surgery Unit, Hospital Universitario Clínico San Carlos, Calle Profesor Martín Lagos, s/n, Madrid 28040, Spain
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De Mauro D, Smakaj A, Casiraghi A, Galante C, Bove F, Arduini M, Vicenti G, Addevico F, Fratus A, Macellari N, Caredda M, Buono C, Maccauro G, Rovere G, Liuzza F. Double plating versus nail-plate construct in AO 33C distal femur fractures: treatment choice affects knee alignment, clinical outcomes, and quality of life-a multicenter study. J Orthop Traumatol 2025; 26:22. [PMID: 40175637 PMCID: PMC11965052 DOI: 10.1186/s10195-025-00834-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2024] [Accepted: 03/01/2025] [Indexed: 04/04/2025] Open
Abstract
BACKGROUND Distal femur fractures present a significant challenge for orthopedic surgeons, accounting for approximately 5% of all femoral fractures. Among the most commonly reported combined techniques in the literature are the double-plate technique and the retrograde nailing plus lateral plating, the nail-plate construct (NPC). The aim of our study is to compare surgical data, quality of life, and functional outcomes in 33-C fractures treated with either double-plate constructs or a retrograde nailing plus lateral plate. MATERIALS AND METHODS A multicenter retrospective observational study was conducted in accordance with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Diagnoses were made on the basis of the AO classification, utilizing traditional radiological assessments. Patients were categorized into two groups on the basis of the surgical treatment they received: The NPC group comprised patients who underwent surgery with nail-plate construct, while the Plate group consisted of those who had surgery with double plating. RESULTS A total of 42 patients were included in the study. The NPC group comprised 26 patients with a mean age of 58.4 ± 18.8 years, while the Plate group consisted of 16 patients with a mean age of 61.3 ± 16.4 years. Significant differences were observed in knee extension recovery (p = 0.010) and lateral distal femur angle (LDFA) (p < 0.001). Linear regression showed a significant influence from treatment choice on all the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales, as well as in all domains of the European Quality of Life Five Dimensions Five-Level Version (EQ-5D-5L), except for the Daily Self-Care domain. CONCLUSIONS Nail-plate constructs seems to lead to significantly better outcomes in AO type C distal femur fractures, compared with double plating, in terms of knee function and quality of life. Significant differences are shown also in anatomical outcomes, especially in extension gap, and LDFA. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Domenico De Mauro
- Department of Orthopedics, Ageing and Rheumatological Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
- Department of Orthopedics and Geriatrics Sciences, Università Cattolica del Sacro Cuore, Largo Francesco Vito, 8, 00168, Rome, Italy
- Department of Public Health, Orthopedic Unit, Federico II University, 80131, Naples, Italy
| | - Amarildo Smakaj
- Department of Orthopedics and Geriatrics Sciences, Università Cattolica del Sacro Cuore, Largo Francesco Vito, 8, 00168, Rome, Italy
- Department of Biomedicine and Prevention, Orthopedic Unit, Tor Vergata University, 00133, Rome, Italy
| | - Alessandro Casiraghi
- Orthopedics and Traumatology Unit, ASST Degli Spedali Civili, 25123, Brescia, Italy
| | - Claudio Galante
- Orthopedics and Traumatology Unit, ASST Degli Spedali Civili, 25123, Brescia, Italy
| | - Federico Bove
- Orthopedics and Traumatology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162, Milan, Italy
| | - Mario Arduini
- Orthopedics and Traumatology Unit, Ospedale Sant'Eugenio, 00144, Rome, Italy
| | - Giovanni Vicenti
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, Aldo Moro University, 70121, Bari, Italy
- Orthopedics and Traumatology Unit, Azienda Ospedaliero Universitaria Consorziale Policlinico "Giovanni XXIII", 70124, Bari, Italy
| | - Francesco Addevico
- Orthopedics and Traumatology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162, Milan, Italy
| | - Abramo Fratus
- Orthopedics and Traumatology Unit, ASST Degli Spedali Civili, 25123, Brescia, Italy
| | - Nicola Macellari
- Department of Orthopedics and Geriatrics Sciences, Università Cattolica del Sacro Cuore, Largo Francesco Vito, 8, 00168, Rome, Italy
| | - Matteo Caredda
- Department of Orthopedics and Geriatrics Sciences, Università Cattolica del Sacro Cuore, Largo Francesco Vito, 8, 00168, Rome, Italy
- Orthopedics and Traumatology Unit, Ospedale Sant'Eugenio, 00144, Rome, Italy
| | - Claudio Buono
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, Aldo Moro University, 70121, Bari, Italy
- Orthopedics and Traumatology Unit, Azienda Ospedaliero Universitaria Consorziale Policlinico "Giovanni XXIII", 70124, Bari, Italy
| | - Giulio Maccauro
- Department of Orthopedics, Ageing and Rheumatological Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
- Department of Orthopedics and Geriatrics Sciences, Università Cattolica del Sacro Cuore, Largo Francesco Vito, 8, 00168, Rome, Italy
| | - Giuseppe Rovere
- Department of Orthopedics and Geriatrics Sciences, Università Cattolica del Sacro Cuore, Largo Francesco Vito, 8, 00168, Rome, Italy.
- Department of Clinical Sciences and Translational Medicine, Orthopedics and Traumatology Unit, Tor Vergata University, 00133, Rome, Italy.
| | - Francesco Liuzza
- Department of Orthopedics, Ageing and Rheumatological Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
- Department of Orthopedics and Geriatrics Sciences, Università Cattolica del Sacro Cuore, Largo Francesco Vito, 8, 00168, Rome, Italy
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Flecher X, Ehlinger M. Response to the letter from Xiaohua Jiang, Yabin Liu and Guowu Chen. Orthop Traumatol Surg Res 2025; 111:104047. [PMID: 39542087 DOI: 10.1016/j.otsr.2024.104047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Accepted: 11/06/2024] [Indexed: 11/17/2024]
Affiliation(s)
- Xavier Flecher
- Aix-Marseille University, Assistance publique des hôpitaux de Marseille, Institut du mouvement et de l'appareil locomoteur, 270, boulevard Sainte-Marguerite, 13009 Marseille, France; AP-HM Hôpital Nord, Chemin des Bourrely, 13015 Marseille, France.
| | - Matthieu Ehlinger
- Service d'orthopédie et de traumatologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France
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Dimitroulias A, Force A, Tarpada S, Bogdan Y, Sen MK. Linking a nail and a plate for distal femur fractures: a technical trick. OTA Int 2024; 7:e350. [PMID: 39507634 PMCID: PMC11540426 DOI: 10.1097/oi9.0000000000000350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 09/16/2024] [Accepted: 09/24/2024] [Indexed: 11/08/2024]
Abstract
The use of nail-plate constructs has been suggested for treatment of elderly patients with distal femur fractures to facilitate stable fixation and early ambulation. In this article, we describe a technique to link the 2 implants without the use of fluoroscopic "perfect-circle" technique. This technique can be used with implants from different manufacturers.
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Affiliation(s)
- Apostolos Dimitroulias
- Division of Orthopedic Surgery, Department of Surgery, Jacobi Medical Center/NYCHHC, Bronx, NY
| | - Ashley Force
- Department of Orthopedic Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Sandip Tarpada
- Department of Orthopedic Surgery, R. Adam's Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD
| | - Yelena Bogdan
- Division of Orthopedic Surgery, Department of Surgery, Jacobi Medical Center/NYCHHC, Bronx, NY
| | - Milan K. Sen
- Division of Orthopedic Surgery, Department of Surgery, Jacobi Medical Center/NYCHHC, Bronx, NY
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Babhulkar S, Trikha V, Babhulkar S, Gavaskar AS. Current Concepts in Management of Distal Femur Fractures. Injury 2024; 55 Suppl 2:111357. [PMID: 39098785 DOI: 10.1016/j.injury.2024.111357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 12/23/2023] [Accepted: 01/14/2024] [Indexed: 08/06/2024]
Abstract
Recent studies report the overall incidence of distal femur fractures as 8.7/100,000/year. This incidence is expected to rise with high energy motor vehicle collisions and elderly osteoporotic fractures in native and prosthetic knees keep increasing. These fractures are more common in males in the younger age spectrum while females predominate for elderly osteoporotic fractures. Surgical treatment is recommended for these fractures to maintain articular congruity, enable early joint motion and assisted ambulation. Over the last two decades, development of minimally invasive and quadriceps sparing surgical approaches, availability of angle stable implants have helped achieve predictable healing and early return to function in these patients. Currently, laterally positioned locked plate is the implant of choice across all fracture patterns. Retrograde with capital implantation of intramedullary nails with provision for multiplanar distal locking is preferred for extra-articular and partial articular fractures. Even with these advancements, nonunion after distal femur fracture fixation can be as high as 19%. Further recent research has helped us understand the biomechanical limitations and healing problems with lateral locked plate fixation and intramedullary nails. This has lead to development of more robust constructs such as nail-plate and double plate constructs aiming for improved construct strength and to minimise failures. Early results with these combination constructs have shown promise in high risk situations such as fractures with extensive metaphyseal fragmentation, osteoporosis and periprosthetic fractures. These constructs however, run the risk of being over stiff and can inhibit healing if not kept balanced. The ideal stiffness that is needed for fracture healing is not clearly known and current research in this domain has lead to the development of smart implants which are expected to evolve and may help improve clinical results in future.
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Affiliation(s)
- Sushrut Babhulkar
- Centre for Trauma & Joint Reconstruction Surgery, Sushrut Instt of Medical Sciences, Ramdaspeth, Nagpur, India.
| | - Vivek Trikha
- All India Institute of Medical Sciences, New Delhi, India, 110029
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Saraglis G, Khan A, Sharma A, Pyakurel S, Rabbani SFE, Arafa MSA. The linked nail/plate construct for the management of distal femur fractures in the elderly. SICOT J 2024; 10:20. [PMID: 38819290 PMCID: PMC11141519 DOI: 10.1051/sicotj/2024016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 04/23/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Distal femoral fractures represent a challenging injury, with many different factors such as the method of fixation, complexity of fracture pattern, and patient co-morbidities affecting the outcome. Lots of surgical treatment options have been described, but recently double construct fixation, using a nail/plate combination, has received lots of attention, a technique that leads to faster weight-bearing, low risk of metalwork failure, and non-union. The purpose of this study was to investigate the effectiveness of the linked nail/plate construct in the management of complex distal femur fractures and to investigate if the above technique leads to faster recovery and earlier radiographic union. MATERIALS AND METHODS In total 15 cases were included in the study, that underwent a combined nail/plate construct for a distal femur fracture between January 2021 and December 2022. Only cases with a linked nail/plate construct were included, with a minimum follow-up of 1 year. Open femur fractures, single implant fixation cases, and revision procedures were excluded. RESULTS In this cohort study, 11 cases were periprosthetic distal femur features, and 4 cases were distal femur fractures around a native knee joint. The mean age group was 74 years, 86.6% of the patients had a BMI > 25 and the mean time to fracture union was 24 weeks (range from 20 to 26 weeks). All cases healed uneventfully and the complication rate was 6.6%, including 1 case of superficial infection which resolved completely with oral antibiotics. CONCLUSION The increasing age population, the complexity of distal femoral fractures along with the increasing physiological demands of the elderly population, drive the need for double fixation constructs that allow early mobilization and enhance fracture stability. In our study, the linked nail/plate construct seems to provide adequate stability and excellent union rates (100%) with no associated increased risk of complications.
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Affiliation(s)
- Georgios Saraglis
- Department of Trauma and Orthopaedics, Bedfordshire NHS Foundation Trust, Bedford Hospital South Wing, Kempston Road Bedford MK429DJ United Kingdom
| | - Anwar Khan
- Department of Trauma and Orthopaedics, Bedfordshire NHS Foundation Trust, Bedford Hospital South Wing, Kempston Road Bedford MK429DJ United Kingdom
| | - Amit Sharma
- Department of Trauma and Orthopaedics, Bedfordshire NHS Foundation Trust, Bedford Hospital South Wing, Kempston Road Bedford MK429DJ United Kingdom
| | - Sagar Pyakurel
- Department of Trauma and Orthopaedics, Bedfordshire NHS Foundation Trust, Bedford Hospital South Wing, Kempston Road Bedford MK429DJ United Kingdom
| | - Sayed Fazal Elahi Rabbani
- Department of Trauma and Orthopaedics, Bedfordshire NHS Foundation Trust, Bedford Hospital South Wing, Kempston Road Bedford MK429DJ United Kingdom
| | - Mohamed Shawky Abdelhamid Arafa
- Department of Trauma and Orthopaedics, Bedfordshire NHS Foundation Trust, Bedford Hospital South Wing, Kempston Road Bedford MK429DJ United Kingdom
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Kheiran A, Elbashir M, McDonald C, Elsayed H, Sheikh N, Plakogiannis C. Total femoral spanning for distal femur "fragility" fractures utilising nail-plate fixation "short-term experience of a district general hospital". EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2003-2013. [PMID: 38509381 DOI: 10.1007/s00590-024-03883-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 02/18/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE Our primary objective was to investigate the time to radiological union following linked nail-plate fixation of distal femur "fragility" fractures. Secondary objectives were to evaluate all-cause reoperations, 90-day mortality, rate of blood transfusion and the impact on quality of life. METHODS In this retrospective study of all adults (≥ 65 years) with native or periprosthetic distal femur fragility fractures, underwent a linked nail-plate fixation, data were retrieved on fracture classifications, clinical frailty score, blood transfusion, length of hospital stay, 90-day mortality, time to radiological union, overall complication rates and EuroQoL-5D. RESULTS In total, 18 out of 23 patients completed sequential follow-up. Radiological union was observed in 14 patients (median 143 days; range 42-414). Three patients underwent reoperations. There were no implant failures or a subsequent periprosthetic fractures. Ninety-day mortality was 17.4%. Eighteen patients required blood transfusion. The QoL was significantly lower after index surgery (0.875 vs. 0.684; p < 0.01). CONCLUSION Based on our observation, with short-term follow-up, the linked nail-plate yields optimal stability to allow immediate weight bearing, in a cohort with moderate frailty. It is reproducible, with variable radiological union rates. The concept of "total femoral spanning" reduces the risk of subsequent periprosthetic fractures. The additional intervention has increased the rates of allogenic blood transfusion. There is significant impact on overall QoL, with almost 50% being more dependent in self-care.
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Affiliation(s)
- Amin Kheiran
- Department of Trauma and Orthopaedics, Kettering General Hospital, Rothwell Rd, Kettering, NN16 8UZ, UK
| | - Mohamed Elbashir
- Department of Trauma and Orthopaedics, Kettering General Hospital, Rothwell Rd, Kettering, NN16 8UZ, UK
| | - Colin McDonald
- Department of Trauma and Orthopaedics, Kettering General Hospital, Rothwell Rd, Kettering, NN16 8UZ, UK
| | - Hassan Elsayed
- Department of Trauma and Orthopaedics, Kettering General Hospital, Rothwell Rd, Kettering, NN16 8UZ, UK
| | - Nomaan Sheikh
- Department of Trauma and Orthopaedics, Kettering General Hospital, Rothwell Rd, Kettering, NN16 8UZ, UK
| | - Christos Plakogiannis
- Department of Trauma and Orthopaedics, Kettering General Hospital, Rothwell Rd, Kettering, NN16 8UZ, UK.
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Andring NA, Kaupp SM, Henry KA, Helmig KC, Babcock S, Halvorson JJ, Pilson HT, Carroll EA. Dual Plate Fixation of Periprosthetic Distal Femur Fractures. J Orthop Trauma 2024; 38:36-41. [PMID: 37684010 DOI: 10.1097/bot.0000000000002695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 09/10/2023]
Abstract
OBJECTIVES Dual implants for distal femur periprosthetic fractures is a growing area of interest for these challenging fractures with dual plating (DP) emerging as a viable construct for these injuries. In the current study, an experience with DP constructs is described. METHODS DESIGN Retrospective case series with comparison group. SETTING Level 1 academic trauma center. PATIENT SELECTION CRITERIA Adults >50 years old sustaining comminuted OTA/AO 33-A2 or 33-A3 DFPF treated with either DP or a single distal femur locking plating (DFLP). Patients with simple 33-A1 fractures were excluded. Prior to 2018, patients underwent DFLP after which the treatment of choice became DP. OUTCOME MEASURES AND COMPARISONS Reoperation rate, alignment, and complications. RESULTS 34 patients treated with DFLP and 38 with DP met inclusion and follow up criteria. Average follow up was 18.2 ± 13.8 months in the DFLP group and 19.8 ± 16.1 months in the DP group ( P = 0.339). The average patient age in the DFLP group was 74.8 ± 7.3 years compared to 75.9 ± 11.3 years in the DP group. There were no statistical differences in demographics, fracture morphology, loss of reduction, or reoperation for any cause ( P >.05). DP patients were more likely to be weight bearing in the twelve-week postoperative period ( P <0.001) and return to their baseline ambulatory status ( P = 0.004) compared to DFLP patients. CONCLUSIONS Dual plating of distal femoral periprosthetic fractures maintained coronal alignment with a low reoperation rate even with immediate weight bearing and these patients regained baseline level of ambulation more reliably as compared to patients treated with a single distal femoral locking plate. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Espey R, Stevenson L, Tucker A. Combined nail-plate constructs in the management of osteoporotic native distal femoral fractures: a systematic review of the available evidence. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3215-3223. [PMID: 37106139 DOI: 10.1007/s00590-023-03552-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE Distal femoral fractures account for 4-6% of fragility fractures. These may be managed using a combined nail-plate construct (NPC). The use of NPCs is gaining traction. Whilst several theoretical advantages exist, there is little evidence reporting on binary or patient-reported outcomes. The aim of the current study was to perform a systematic review of the available literature pertaining to NPCs and their treatment of native distal femoral fractures, appraising the outcomes and focusing on the rationale for their increasing uptake in recent literature. METHODS A comprehensive search of MEDLINE, EMBASE, Clinical Key, PubMed and Cochrane library was performed from date of inception up to in August 9, 2022. All study languages were included initially. A further Google Scholar search review was performed to identify any other studies not identified in the database interrogation. Studies were eligible if they reported on the use of nail-plate constructs in managing distal femoral fractures. Any outcome metric was permitted. The study was conducted in accordance with PRISMA guidelines. Risk of bias was assessed using the Methodological Index for non-randomised Studies tool. Quantitative analysis was performed using a log odds ratio random effects model. The Knapp-Hartung adjustment was utilised if the total number of included studies was < 5. Study effect sizes and appropriate plots were constructed to illustrate the outcomes data. RESULTS A total of four studies were eligible for inclusion. Study data was extracted and summarised with their relevant outcomes presented. The literature review demonstrated that the use of NPCs led to significantly earlier full weight bearing (p < 0.001) and had reduced non-union rates over a single construct, without affecting infection rates (12.5% vs. 5.6%; p = 0.289) and significantly lower implant failure rates (10.5% vs. 0%; p = 0.011). A meta-analysis is performed of available studies and Forrest plots presented. CONCLUSION The use of NPC in the management of native osteoporotic DFFs is gaining traction but the available evidence is of low grade with significant heterogeneity in small cohorts of patients. We suggest that a large-scale, multicentre prospective study should be performed, with agreed functional and radiological outcome metrics, to provide a more robust evidence base.
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Affiliation(s)
- Robert Espey
- Musgrave Park Hospital, Stockmans Lane, Belfast, BT9 7JB, UK
| | - Lewis Stevenson
- Ulster Hospital Dundonald, Upper Newtownards Road, Belfast, BT16 1RH, UK
| | - Adam Tucker
- Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, UK.
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Pfister B, Wilson A, Drobetz H. Best of Both Worlds? Fixation of Distal Femur Fractures with the Nail-Plate Construct. Orthop Surg 2023; 15:3326-3334. [PMID: 37866825 PMCID: PMC10694005 DOI: 10.1111/os.13927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/16/2023] [Accepted: 09/21/2023] [Indexed: 10/24/2023] Open
Abstract
OBJECTIVES 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. METHODS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Benjamin Pfister
- Orthopaedic Surgery DepartmentLismore Base HospitalLismoreNSWAustralia
| | - Anthony Wilson
- Orthopaedic Surgery DepartmentLismore Base HospitalLismoreNSWAustralia
| | - Herwig Drobetz
- Orthopaedic Surgery DepartmentLismore Base HospitalLismoreNSWAustralia
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11
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Hong CC, Pearce CJ, Lau ETC, Gardner A. Augmented fixation in distal femur fractures: how does it fare? Singapore Med J 2023; 64:634-639. [PMID: 35739631 PMCID: PMC10645003 DOI: 10.11622/smedj.2022086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 07/28/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Choon Chiet Hong
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore
| | - Christopher Jon Pearce
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore
| | - Eugene Tze-Chun Lau
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore
| | - Antony Gardner
- Department of Orthopaedic Surgery, Ng Teng Fong General Hospital, National University Health System, Singapore
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Kim DH, Jang HS, Kwak SH, Jung SY, Jeon JM, Ahn TY, Lee SH. Surgical outcomes of segmental diaphyseal forearm fractures in adults: a small case series on plate osteosynthesis, intramedullary nailing, and other surgical methods. BMC Musculoskelet Disord 2023; 24:731. [PMID: 37710239 PMCID: PMC10500880 DOI: 10.1186/s12891-023-06857-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 09/06/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Segmental fractures often result from high-energy or indirect trauma that causes bending or torsional forces with axial loading. We evaluated surgical outcomes of patients with forearm segmental diaphyseal fractures. METHODS We retrospectively analyzed data from patients with forearm segmental fractures for which they underwent surgery at the Pusan National University Trauma Center from March 2013 to March 2022. We also analyzed accompanying injuries, injury severity score (ISS), injury mechanism, occurrence of open fracture, surgical technique, and treatment results. RESULTS Fifteen patients were identified, one with bilateral segmental diaphyseal forearm bone fracture, for a total of 16 cases. Nine of the patients were male. The overall mean age was 50 years, and the mean follow-up period was 16.2 months. Six cases who underwent surgery using plate osteosynthesis achieved bone union without length deformity at final follow-up. Three of seven patients who underwent intramedullary nailing alone underwent reoperation due to nonunion. Six cases achieved bone union at final follow-up, three of which showed length deformity. Three patients underwent surgery using a hybrid method of IM nailing, plates, and mini cables. One patient who underwent surgery with a plate and one patient who underwent surgery with IM nailing alone showed nonunion and were lost to follow-up. CONCLUSION Plate osteosynthesis is considered the gold standard for treatment of adult forearm diaphyseal segmental fractures. In this study, IM nailing was associated with high rates of non-union and length deformity. However, the combination of IM nailing and a plate-cable system may be an acceptable alternative in segmental diaphyseal forearm fracture, achieving a union rate similar to that provided by plate fixation.
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Affiliation(s)
- Dong Hee Kim
- Departments of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Hyo Seok Jang
- Department of Orthopedic Surgery, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Sang Ho Kwak
- Department of Orthopedic Surgery, SNU Seoul Hospital, Seoul, Republic of Korea
| | - Sung Yoon Jung
- Department of Orthopedic Surgery, College of Medicine, Dong-A University Hospital, Busan, Republic of Korea
| | - Jong Min Jeon
- Departments of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Tae Young Ahn
- Department of Orthopedic Surgery, Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Sang Hyun Lee
- Department of Orthopedic Surgery, Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Republic of Korea.
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Saxena V, Akshay V, Panwar A, Kumar S. Management of Non-union Distal Femur Fractures With Augmentation Nail Plate Construct. Cureus 2023; 15:e37173. [PMID: 37153270 PMCID: PMC10162696 DOI: 10.7759/cureus.37173] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 05/09/2023] Open
Abstract
Background and objective A non-union distal femur fracture is a challenging fracture to treat. Common treatment modalities for non-union distal femur fractures include dual plating, intramedullary nails, ilizarov, and hybrid fixators. Despite the availability of a wide armamentarium of constructs, the clinical and functional outcome of these modalities is often complicated by significant morbidity, joint stiffness, and delayed union. The augmentation of the intramedullary nail with a locking plate results in a robust architecture, improving the likelihood of union. The use of this nail plate construct improves biomechanical stability and restores limb alignment, which enables early rehabilitation and weight bearing and lowers the likelihood of fixation failure. Methodology A prospective study was conducted at the Government Institute of Medical Science, Greater Noida, from January 2021 to January 2022 on 10 patients with non-union of the distal femur. All the patients were operated on with nail plate construct. The minimum follow-up period was 12 months. Results A total of 10 patients with a mean age of 55 years were included. Six were earlier treated with an intramedullary nail and four with extramedullary implants. All patients were managed with implant removal and fixation with nail plate construct and bone grafting. The average duration of the union was 10.3 months. The International Knee Documentation Committee (IKDC) score improved from 30.6 preoperatively to 67.3 postoperatively. Only one patient developed a superficial infection, which was managed by wound debridement and targeted antibiotic therapy. Conclusion In our experience, this relatively novel technique of combining nail plate constructs offers encouraging outcomes in the management of non-union of distal femur fractures, especially in elderly and osteopenic patients.
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Affiliation(s)
- Vikas Saxena
- Department of Orthopedics, Government Institute of Medical Sciences, Greater Noida, IND
| | - Varun Akshay
- Department of Orthopedics, Government Institute of Medical Sciences, Greater Noida, IND
| | - Akshay Panwar
- Department of Orthopedics, Government Institute of Medical Sciences, Greater Noida, IND
| | - Satendra Kumar
- Department of Surgery, Government Institute of Medical Sciences, Greater Noida, IND
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Nail plate combination in fractures of the distal femur in the elderly: A new paradigm for optimum fixation and early mobilization? Injury 2023; 54:288-291. [PMID: 36400628 DOI: 10.1016/j.injury.2022.11.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Distal femoral fractures in elderly or osteoporotic patients constitute a challenging injury, especially in the settings of fracture comminution or periprosthetic fractures. A recent trend in the treatment of these difficult injuries is the double fixation with a nail and a plate, a strategy that comes with advantages including faster weight-bearing and lower risk for non-union. Although biomechanical studies have demonstrated the superiority of nail-plate constructs, there is a paucity in the literature regarding the indications and results of treatment. A review of the literature to date was carried out to identify which group of patients would benefit the most from this type of reconstruction and to evaluate the clinical outcomes.
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15
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Li QW, Wu B, Chen B. Modified fixation for periprosthetic supracondylar femur fractures: Two case reports and review of the literature. World J Clin Cases 2022; 10:12328-12336. [PMID: 36483801 PMCID: PMC9724516 DOI: 10.12998/wjcc.v10.i33.12328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 09/16/2022] [Accepted: 10/26/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Periprosthetic supracondylar femoral fractures (PSFs) present a challenge in terms of optimizing fixation in patients with poor bone quality. Surgical treatment and peri-operative management of PSFs in the elderly remain a burden for orthopedic surgeons. Among different treatment options, locking plate (LP) and retrograde intramedullary nail (RIMN) have shown favorable results. However, reduced mobility and protected weight-bearing are often present in the postoperative older population. With a purpose of allowing for early weight-bearing, a modified nail plate combination (NPC) was redesigned for PSF management.
CASE SUMMARY In our cases, two elderly osteoporotic female underwent total knee arthroplasty (TKA), and then suffered from low energy trauma onto their knees after falling to the floor. Plain radiographs or computed tomography scans demonstrated oblique or transverse PSFs, both of which occurred at the distal femur above TKA. The modified NPC technique was performed for treatment of PSFs. The patient was made foot flat weight bearing in 1 wk. At 6-mo follow-up, the union was ultimately achieved using modified NPC with satisfactory implant outcomes.
CONCLUSION Neither LP nor RIMN alone may provide adequate support to allow for union in circumstances where the patient has severely osteopenic bone. Therefore, developing a modified implant offer an alternative choice for treating PSFs. These two cases revealed that this technique is a viable option for the geriatric osteoporotic PSFs, offering safe, early weight bearing and favorable clinical outcomes.
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Affiliation(s)
- Qin-Wen Li
- Department of Orthopedics, The People's Hospital of Three Gorges University, The First People's Hospital of Yichang, Yichang 443000, Hubei Province, China
| | - Bin Wu
- Department of Orthopedics, The People's Hospital of Three Gorges University, The First People's Hospital of Yichang, Yichang 443000, Hubei Province, China
| | - Bo Chen
- Department of Orthopedics, The People's Hospital of Three Gorges University, The First People's Hospital of Yichang, Yichang 443000, Hubei Province, China
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Jacobs RC, Schmitz MW, Swiontkowski MF. Intramedullary Nail and Plate Combination Technique for Peri-Implant Both-Bone Forearm Fractures. Cureus 2022; 14:e28828. [PMID: 36225435 PMCID: PMC9535688 DOI: 10.7759/cureus.28828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2022] [Indexed: 11/05/2022] Open
Abstract
A 35-year-old female patient with cerebellar ataxia presented with a right periprosthetic both-bone forearm fracture after a ground-level fall. Her surgical history was significant for multiple both-bone forearm fractures treated by open reduction and internal fixation. Subsequent treatment with a combination of intramedullary nailing and plate fixation for each bone provided successful fracture union while allowing immediate return to weight-bearing and range of motion. This case report demonstrates that intramedullary nailing and plate fixation of both-bone forearm fractures provides complete protection of the radius and ulna in recurrent, peri-implant both-bone forearm fractures. This technique is a valuable treatment option in the setting of a patient at risk for recurrent injury of the forearm.
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Stoffel K, Sommer C, Lee M, Zhu TY, Schwieger K, Finkemeier C. Double fixation for complex distal femoral fractures. EFORT Open Rev 2022; 7:274-286. [PMID: 35446259 PMCID: PMC9069857 DOI: 10.1530/eor-21-0113] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
For complex distal femoral fractures, a single lateral locking compression plate or retrograde intramedullary nail may not achieve a stable environment for fracture healing. Various types of double fixation constructs have been featured in the current literature. Double-plate construct and nail-and-plate construct are two common double fixation constructs for distal femoral fractures. Double fixation constructs have been featured in studies on comminuted distal femoral fractures, distal femoral fracture with medial bone defects, periprosthetic fractures, and distal femoral non-union. A number of case series reported a generally high union rate and satisfactory functional outcomes for double fixation of distal femoral fractures. In this review, we present the state of the art of double fixation constructs for distal femoral fractures with a focus on double-plate and plate-and-nail constructs.
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Affiliation(s)
- Karl Stoffel
- Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland
| | - Christoph Sommer
- Department of Surgery, Kantonsspital Graubuenden, Chur, Switzerland
| | - Mark Lee
- Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, California, USA
| | - Tracy Y Zhu
- AO Innovation Translation Center, AO Foundation, Davos, Switzerland
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Technical Trick: Dual Plate Fixation of Periprosthetic Distal Femur Fractures. J Orthop Trauma 2021; 35:e148-e152. [PMID: 32569069 DOI: 10.1097/bot.0000000000001869] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2020] [Indexed: 02/02/2023]
Abstract
Treatment of periprosthetic distal femur fractures remains challenging due to assuring adequate distal fixation. Traditional treatment options include lateral locked plating and retrograde nailing, although recently dual implant constructs have been explored with promising results. Allowing immediate weight-bearing in this patient population has benefits with regards to rehabilitation and outcome. Recent literature has focused on nail-plate constructs, however plate-plate constructs are preferred at our institution as they do not require arthroplasty component compatibility, facilitate the coronal plane reduction, and allow for immediate weight-bearing.
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Biomechanical evaluation of retrograde docking nailing to a total hip arthroplasty stem in a periprosthetic femur fracture model. Injury 2021; 52:53-59. [PMID: 33129493 DOI: 10.1016/j.injury.2020.10.086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/11/2020] [Accepted: 10/17/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Slotted nails allow a connection to a total hip arthroplasty (THA) stem and act as intramedullary load carrier. This study compares construct stiffness, cycles to failure and failure load between a retrograde slotted femur nail construct docked to a THA stem and a lateral locking plate in a human periprosthetic femur fracture model. MATERIALS AND METHODS In seven pairs of fresh-frozen human anatomic femora with cemented THA, a transverse osteotomy was set simulating a Vancouver type B1 fracture. The femora were instrumented pairwise with either a retrograde slotted nail coupled to the prosthesis stem, or a locking plate plus a locking attachment plate. Four-point mediolateral bending, torsional and axial bending construct stiffness was investigated via non-destructive tests. Cyclic testing under progressively increasing physiologic loading was performed at 2 Hz until catastrophic construct failure. RESULTS Mediolateral bending stiffness did not differ significantly between the two groups (P=0.17) but exhibited a biphasic profile with significantly increased stiffness in both groups (P<0.01). Nail constructs provided a significantly lower torsional stiffness (0.49 ± 0.66 Nm/°) than plate constructs (1.70 ± 0.86 Nm/°), P=0.03. Axial bending stiffness did not differ significantly between the groups (Nail: 605 ± 511 N/mm; Plate: 381 ± 428 N/mm), P=0.61. Cycles to failure and failure load were significantly higher for the plate constructs (25'700 ± 8'341; 3'070 ± 1334 N) compared with the nail constructs (20'729 ± 7'949; 2'573 ± 1295 N), P=0.04. CONCLUSION The docking nail construct provides an intramedullary fixation with connection to the prosthesis stem; however, it is biomechanically weaker in stable fractures compared to the plate construct.
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Abstract
Nail plate combination technique can be applied in the setting of periprosthetic and interprosthetic fractures to promote reliable healing with a biomechanically favorable construct. Here, technical aspects and discussion of the technique are reviewed through a case of an 87-year-old woman who suffered from an interprosthetic "floating" total knee arthroplasty (TKA); a supracondylar distal femur fracture in between a total hip arthroplasty and a TKA, with a proximal tibial metaphyseal fracture below the TKA tibial base plate.
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