Distal 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).This 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.67 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.Augmented 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. 

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

Introduction Given the recent criticisms in the literature regarding Synthes Variable Angle Locking Compression Condylar Plate (VA-LCP), the purpose of this study was to evaluate functional outcome, fracture healing, and complications of distal femoral intra-articular fractures using this device. Methods Patients with distal femoral fractures treated with 4.5 mm VA-LCP Curved Condylar Plate were included in this retrospective study. Follow-ups were at 4 weeks, 3 months, 6 months and 1 year. For the clinical and functional assessment of the knee, WOMAC, Koos Knee Survey, the Knee Score Society and the SF-12 questionnaire were used. Radiographically we assessed the fracture healing and the angles of the operated limb compared to the healthy contralateral limb. Complications have also been described. Results Forty-two patients with distal femoral fractures were included in the study. The mean follow-up was 8 months. Most cases (57%) reported a type 33-A fracture. Radiological healing was achieved in 33 cases; the mean time required to heal was 13 weeks. Three patients had an early postoperative complication and four cases had a late complication. Five cases required additional surgical procedures. Most patients (47.2%) achieved a complete flexion of 130° or more. WOMAC mean value 27.4%, KSS mean value 77.6 for the clinical part and 60 for the functional part, KOOS mean score 60.1, SF-12 mean score 46.1 for MCS and 35.5 for PCS. Discussion The results of this retrospective study suggest that VA-LCP Curved Condylar Plates have a good functional outcome and fracture healing similar to other standard distal femoral locking plates. VA technology allows greater versatility in fractures internal fixation regardless of the plate design. Fixation devices or Prosthesis implants previously placed may be avoided, as in periprosthetic fractures. Moreover, we have not recorded any early mechanical damage. Conclusions Osteosynthesis with Synthes 4.5 mm VA-LCP Curved Condylar Plate demonstrated to have no early mechanical failure rate with good clinical and radiological results.

Treatment of distal femur fractures with VA-LCP condylar plate: A single trauma centre experience.

This prospective study evaluated the functional outcome and union rates of open distal femoral fractures managed with anatomic lateral locking plates. Thirty-four patients with open distal femur fractures with mean age of 40.8 years (range 20–65 years) were included in the study. Patients with Gustilo–Anderson grade IIIC fractures and those managed with non-locking modalities were excluded. In total, 70.6% (n = 24) of the fractures were Type IIIA and 55.9% (n = 19) were AO/OTA Type C3 fractures. In 23.5% (n = 8) patients, knee spanning external fixator was applied initially before definitive fixation. Patients were followed up for a mean period of 11.6 months (range 8–22.5 months). Functional outcome was evaluated using Sanders Score. In the primary plating group, 69.2% (n = 18) fractures united at an average of 27 weeks (range 21–40 weeks), while eight patients had non-union and required bone grafting. All eight patients with external fixator underwent lateral locked plating with bone grafting and united at an average time of 39.6 weeks (range 31–50 weeks). There were two cases each of infection and screw failure. The final mean Sanders Score was 30.1 (range19–40) with 73.5% (n = 25) patients having good to excellent functional outcomes. Lateral locking plates offer excellent stability to allow fracture union in open distal femoral fractures. A proactive approach to identify and manage potential healing difficulties is advisable to promote bone healing.

Functional outcome of open distal femoral fractures managed with lateral locking plates.

Objectives Distal 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). Methods This 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. Results 67 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. Conclusions Augmented 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.

Neglected epiphyseal fracture-separations of the distal femur are rare. Still reported in developing countries, they lead to therapeutic issues. The objective of the study is to describe their characteristics and to propose treatment options. Ten years of ongoing study was held in our orthopedics department. All patients with a neglected epiphyseal fracture-separations of the distal femur after a knee trauma were included in the study. Pre-operative and post-operative data were collected and analyzed. A total of 13 cases of neglected traumatic epiphyseal fracture-separations of the distal femur were found among 8616 in-patients of the department. It was mainly boys (9M/4F) around 16 years that were received 14 weeks after knee trauma. Most of the injuries were an AO-type 33-E/2.1 (Simple Salter-Harris’ type II) (n=12) distal femur malunion (n=10). Associated complications were cutaneous opening (n=7), superficial infection (n=4), deep infection (n=4). Fractures were management surgically (n=12) by an open osteoclasis procedure (n=9), debridement (n=7) and a thigh amputation (n=1). The outcome was better if an open osteoclasis procedure was early performed in closed distal femur mal-union with a complementary rehabilitation program. Specialized trauma care facilities must be increased, and trauma education programs must be undertaken to avoid neglected epiphyseal fracture-separations of the distal femur in developing countries.

Management of neglected distal femur epiphyseal fracture-separation

Given the recent controversy in the literature and the alarming reports of early mechanical failure associated with the use of the Synthes 4.5 mm VA-LCP Curved Condylar Plate in acute distal femur fractures, the goal of our study was to examine the outcomes and mechanical failure rates of this implant in a larger patient population. Patients 18 years of age and older who underwent plate fixation of their acute distal femoral fracture using the Synthes 4.5 mm VA-LCP Curved Condylar Plate were included in this retrospective study. The study data was collected through a retrospective chart review and review of the existing radiographic studies. Primary outcome measure was mechanical hardware failure while secondary outcome measures included nonunion, malunion, and medical and surgical complications. A total of 74 patients (77 fractures) were included in this study. The fractures were classified according to the OTA/AO classification as 33-A2 (n = 6), 33-A3 (n = 19), 33-C1 (n = 5), 33-C2 (n = 25), and 33-C3 (n = 22). Thirty-two out of 77 fractures presented as open fractures (41.6%). A mechanical failure was observed in 7 patients (9.1%). Twenty additional patients needed a re-operation of the surgical site including two nonunion repairs, one malunion repair, 15 staged treatments of traumatic segmental bone defects, and two soft tissue debridements. In our experience, the Synthes 4.5 mm VA-LCP Curved Condylar Plate is a safe and effective implant with a relatively low mechanical failure rate.

Outcomes of distal femur fractures treated with the Synthes 4.5 mm VA-LCP Curved Condylar Plate

The relationship between elevated body mass index (BMI) and adverse outcomes in joint arthroplasty is well established in the literature. This paper aims to challenge the conventional thought of excluding patients from a total knee or hip replacement based on BMI alone. Instead, we propose using the metabolic syndrome (MetS) and its defining components to better identify patients at high risk for intraoperative and postoperative complications.Patients who underwent primary, elective total knee and total hip arthroplasty were identified in the 2015-2020 American College of Surgeons National Surgical Quality Improvement Program database. Several defining components of MetS, such as hypertension, diabetes, and obesity, were compared to a metabolically healthy cohort. Postoperative outcomes assessed included mortality, length of hospital stay, 30-day surgical and medical complications, and discharge.The outcomes of 529,737 patients from the American College of Surgeons National Surgical Quality Improvement Program who underwent total knee and total hip arthroplasty were assessed. MetS is associated with increased complications and increased mortality. Both hypertension and diabetes are associated with increased complications but have no impact on mortality. Interestingly, while obesity was associated with increased complications, there was a significant decrease in mortality.Our results show that the impact of MetS is more than the sum of its constitutive parts. Additionally, obese patients experience a protective effect, with lower mortality than their nonobese counterparts. This study supports moving away from strict BMI cutoffs alone for someone to be eligible for an arthroplasty surgery and offers more granular data for risk stratification and patient selection. 

The Impact of Metabolic Syndrome and Obesity on Perioperative Total Joint Arthroplasty Outcomes: The Obesity Paradox and Risk Assessment in Total Joint Arthroplasty

The Association Between Distal Screw and Articular Subsidence in the Open Treatment of Intra-articular Distal Radius Fractures.

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Outcomes of distal femur fractures treated with the Synthes 4.5 mm VA-LCP Curved Condylar Plate

The Impact of Metabolic Syndrome and Obesity on Perioperative Total Joint Arthroplasty Outcomes: The Obesity Paradox and Risk Assessment in Total Joint Arthroplasty

The Association Between Distal Screw and Articular Subsidence in the Open Treatment of Intra-articular Distal Radius Fractures.