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Garabano G, Pereira S, Juri A, Bidolegui F, Pesciallo CA. Distal femur fractures in elderly treated with internal fixation or distal femoral replacement - retrospective cohort study on 75 patients assessing functional outcomes, reoperations, and mortality. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024:10.1007/s00590-024-04027-0. [PMID: 38869628 DOI: 10.1007/s00590-024-04027-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 06/09/2024] [Indexed: 06/14/2024]
Abstract
PURPOSE This cohort study aimed to describe the functional outcomes, complications, and mortality of patients over 65 with acute distal femur fractures treated with open reduction and internal fixation (ORIF) or distal femoral replacement (DFR). METHODS We retrospectively analyzed all patients older than 65, operated consecutively for a distal femur fracture treated with ORIF or DFR. We included 75 patients (9 33A, 5 33B, and 61 33C AO/OTA fractures), 55 treated with ORIF, and 20 with DFR. We used Parker's mobility index (PMI) to assess functional outcomes at 1, 3, and 12 months and study closure. We analyzed complications, reoperations, and mortality at 30 days, one year, and at the end of the study. RESULTS The PMI was significantly higher in the DFR group at months 1 (p = 0.023) and 3 (p = 0.032). We found no significant differences between cohorts at one year and the end of follow-up. Postoperative complications were significantly more frequent in the ORIF group (38.10% vs. 10%, p = 0.022). Reoperations were similar in both cohorts (p = 0.98). Mortality at one month was 4% and 20% at one year, and at the end of follow-up, there were no significant differences between groups. CONCLUSION The outcomes of this study suggest that DFR offers a faster functional recovery with lower complication rates than those treated with ORIF. Additionally, both options have similar reoperation and mortality rates. Appropriately designed studies are needed to define the best treatment strategy for this type of patient.
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Affiliation(s)
- Germán Garabano
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina.
- Scientific Advisory Committee, British Hospital of Buenos Aires, Buenos Aires, Argentina.
| | - Sebastian Pereira
- Orthopaedic and Trauma Surgery Department, Hospital Sirio Libanes, Campana 4658, C1419, Buenos Aires, Argentina
| | - Andres Juri
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
| | - Fernando Bidolegui
- Orthopaedic and Trauma Surgery Department, Sanatorio Otamendi, Azcuénaga 870, C115AAB, Buenos Aires, Argentina
| | - Cesar Angel Pesciallo
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
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Hafeez K, Garg G, Anto M, Desai V. Distal Femur Replacement: An Option for Osteoporotic Fractures in the Elderly. Cureus 2023; 15:e50762. [PMID: 38116023 PMCID: PMC10728770 DOI: 10.7759/cureus.50762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 12/21/2023] Open
Abstract
Background A distal femur fracture (DFF) around the native or prosthetic knee is commonly seen in the osteoporotic elderly population. Surgical management is required to restore the function. Fracture fixation requires a period of restricted weight-bearing; however, distal femoral replacement (DFR) allows immediate weight-bearing and quicker recovery. Methods All patients who underwent distal femur replacement from 2020 to 2023 at our hospital were retrospectively reviewed. Data related to the patient's demographics, medical comorbidities, preinjury mobility status, perioperative management and length of stay were collected. Results Eleven patients with 13 distal femoral replacements were included. There were 10 periprosthetic and 3 native fractures around the distal femur. Two patients had bilateral periprosthetic fractures. The median age was 84 years (range 62-95) with all patients being females. Eight patients were living in their homes while three were care home residents. The median duration of surgery was 120 min. The mean blood loss was 350 ml. Patients were mobilised out of bed at a median of three days and were able to walk for 2 meters with a frame at a mean of 10 days (range 3-15) except for two patients whose mobility was limited to the chair. The mean length of hospital stay was 32 days (range 8-54). All patients were discharged back to their original destination except for one who was shifted to a care home instead of her own home. Conclusion In our opinion, distal femur replacement provided a more favourable outcome with respect to pain management, early rehabilitation with full weight-bearing immediately following the surgery and fewer complications. Furthermore, in our hands, the surgical time was short with limited blood loss.
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Affiliation(s)
- Kamran Hafeez
- Orthopaedics, Kings Mill Hospital, Sutton in Ashfield, GBR
| | - Gourav Garg
- Orthopaedics, Kings Mill Hospital, Sutton in Ashfield, GBR
| | - Mariette Anto
- Orthopaedics, Kings Mill Hospital, Sutton in Ashfield, GBR
| | - Vikram Desai
- Orthopaedics, Kings Mill Hospital, Sutton in Ashfield, GBR
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Dekeyser GJ, Martin BI, Marchand LS, Rothberg DL, Higgins TF, Haller JM. Geriatric Distal Femur Fractures Treated With Distal Femoral Replacement Are Associated With Higher Rates of Readmissions and Complications. J Orthop Trauma 2023; 37:485-491. [PMID: 37296092 PMCID: PMC10524623 DOI: 10.1097/bot.0000000000002638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Compare mortality and complications of distal femur fracture repair among elderly patients who receive operative fixation versus distal femur replacement (DFR). DESIGN Retrospective comparison. SETTING Medicare beneficiaries. PATIENTS/PARTICIPANTS Patients 65 years of age and older with distal femur fracture identified using Center for Medicare & Medicaid Services data from 2016 to 2019. INTERVENTION Operative fixation (open reduction with plating or intramedullary nail) or DFR. MAIN OUTCOME MEASUREMENTS Mortality, readmissions, perioperative complications, and 90-day cost were compared between groups using Mahalanobis nearest-neighbor matching to account for differences in age, sex, race, and the Charlson Comorbidity Index. RESULTS Most patients (90%, 28,251/31,380) received operative fixation. Patients in the fixation group were significantly older (81.1 vs. 80.4 years, P < 0.001), and there were more an open fractures (1.6% vs. 0.5%, P < 0.001). There were no differences in 90-day (difference: 1.2% [-0.5% to 3%], P = 0.16), 6-month (difference: 0.6% [-1.5% to 2.7%], P = 0.59), and 1-year mortality (difference: -3.3% [-2.9 to 2.3], P = 0.80). DFR had greater 90-day (difference: 5.4% [2.8%-8.1%], P < 0.001), 6-month (difference: 6.5% [3.1%-9.9%], P < 0.001), and 1-year readmission (difference: 5.5% [2.2-8.7], P = 0.001). DFR had significantly greater rates of infection, pulmonary embolism, deep vein thrombosis, and device-related complication within 1 year from surgery. DFR ($57,894) was significantly more expensive than operative fixation ($46,016; P < 0.001) during the total 90-day episode. CONCLUSIONS Elderly patients with distal femur fracture have a 22.5% 1-year mortality rate. DFR was associated with significantly greater infection, device-related complication, pulmonary embolism, deep vein thrombosis, cost, and readmission within 90 days, 6 months, and 1 year of surgery. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Graham J Dekeyser
- Department of Orthopedic Surgery, Oregon Health Sciences University, Portland, OR; and
| | - Brook I Martin
- University of Utah Department of Orthopaedic Surgery, Salt Lake City, UT
| | - Lucas S Marchand
- University of Utah Department of Orthopaedic Surgery, Salt Lake City, UT
| | - David L Rothberg
- University of Utah Department of Orthopaedic Surgery, Salt Lake City, UT
| | - Thomas F Higgins
- University of Utah Department of Orthopaedic Surgery, Salt Lake City, UT
| | - Justin M Haller
- University of Utah Department of Orthopaedic Surgery, Salt Lake City, UT
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Routledge JC, Bashir O, Elbeshbeshy M, Saber AY, Aqil A. Management of Distal Femur Fractures: Replacement Versus Surgical Fixation Versus Conservative Management. Cureus 2023; 15:e45333. [PMID: 37849599 PMCID: PMC10577514 DOI: 10.7759/cureus.45333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2023] [Indexed: 10/19/2023] Open
Abstract
INTRODUCTION Distal femur fractures are a frequently encountered injury, especially among the ageing population. Previous studies have identified that these fractures can be managed with a variety of methods and techniques which has led to an ongoing debate and investigation to decipher the optimal approach to manage these fractures. AIM The purpose of this study was to compare outcomes of patients managed with either distal femur replacements (DFRs), surgical fixation (SF) or conservative management. Outcomes measured included length of hospital stay, readmission rates, 30-day mortality and Oxford Knee Score. METHODS A retrospective review was conducted, of patients admitted with distal femur fractures between June 2020 and October 2022 at Huddersfield Royal Infirmary Hospital. Patients with both native and peri-prosthetic joints were included. All patient's medical data, including imaging and operative records, were reviewed. RESULTS A total of 42 patients were identified. There were six males and 36 females with a mean age of 78 years, a median age of 76 and a range of 35-102 years. Of these fractures, 15 were peri-prosthetic, and 27 were native joints. Of the patients, 30 had an SF, five had a DFR and the remaining seven were conservatively managed. Those managed with an SF had an average length of stay of 18 days, an Oxford score of 24 and two patients were readmitted within 30 days of discharge. For the DFR, the average length of stay was 16 days, an Oxford score of 22 and no patients were readmitted within 30 days. For the conservatively managed patients 21 days, an Oxford score of 25 and two patients were readmitted within 30 days of discharge. There was no 30-day mortality across all groups. CONCLUSIONS From our study, we can conclude that patients who managed with a DFR had the shortest length of stay in a hospital and the lowest readmission rates when compared to alternative management techniques. There was minimal difference found between the Oxford scores between all three groups. This study shows that DFR can be a safe and reliable strategy to manage distal femur fractures. Additional research is required to further compare the outcomes of these different methods of repair.
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Affiliation(s)
- Jamie C Routledge
- Orthopaedics and Trauma, Huddersfield Royal Infirmary, Huddersfield, GBR
| | - Oladimeji Bashir
- Orthopaedics and Trauma, Huddersfield Royal Infirmary, Huddersfield, GBR
| | | | - Ahmed Y Saber
- Orthopaedics and Trauma, Huddersfield Royal Infirmary, Huddersfield, GBR
| | - Adeel Aqil
- Orthopaedics and Trauma, Huddersfield Royal Infirmary, Huddersfield, GBR
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Outcome Evaluation of Distal Femoral Fractures Following Surgical Management: A Retrospective Cohort Study. J Pers Med 2023; 13:jpm13020350. [PMID: 36836584 PMCID: PMC9960625 DOI: 10.3390/jpm13020350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/07/2023] [Accepted: 02/16/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Distal femur fractures are challenging in surgical management as the outcome is crucial for restoring the biomechanical stability and longitudinal axis of the leg and function of the knee joint. METHODS A retrospective review of all distal femoral fractures treated in a level I trauma center over a decade was performed. The radiographs were reviewed for fracture entity, osseous healing, implant failure, mechanical axis, and degenerative joint changes. Clinical outcome was reviewed regarding postoperative complications and postoperative range of motion of the knee joint. RESULTS 130 patients who were managed with screw fixation (n = 35), plating systems (n = 92) or intramedullary nailing systems (n = 3) remained for evaluation. Mean follow up was 26 months. Clinical outcome was significantly better for flexion degrees following screw fixation (p = 0.009). Delayed fracture union (p = 0.002) or non-union (p = 0.006) rates were significantly higher in plate osteosynthesis. Mild pathologic deformity for varus and valgus collapse was found following plate osteosynthesis. CONCLUSIONS Screw fixation shows fewer postoperative complications than plate fixation and is favored for extra and partial intraarticular distal femur fractures. Plating constructs remain the superior fixation method in complex distal femur fractures but are associated with higher rates of non-union and leg axis deviation.
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Laubach LK, Sharma V, Krumme JW, Larkin K, Satpathy J. Novel classification system for periprosthetic distal femoral fractures: a consideration for comminution. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-022-03468-9. [PMID: 36635567 DOI: 10.1007/s00590-022-03468-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/20/2022] [Indexed: 01/13/2023]
Abstract
PURPOSE Comminution is an aspect of periprosthetic distal femoral fractures (PDFFs) that can influence postoperative outcomes and treatment selection, but is not included in current classification systems. We propose a new classification system for PDFFs based on comminution and cortical reads. This study aims to prove its reliability and efficacy to predict fracture severity and guide treatment. METHODS A retrospective chart review of patients treated with single or dual locking plates for PDFFs was performed. Two fellowship-trained orthopedic joint reconstruction specialists used available imaging to classify each PDFF as either type 1 (minimal or no comminution allowing for reconstruction of medial and lateral cortices), type 2 (comminution reasonably allowing for reconstruction of either medial or lateral cortex), and type 3 (extensive comminution not allowing reasonable reconstruction of medial or lateral cortex). Each PDFF was then analyzed for radiographic outcomes including lateral distal femoral angle (LDFA) and the posterior distal femoral angle (PDFA). RESULTS Interobserver reliability assessed by Cohen's Kappa statistic was 0.707, and average intraobserver reliability was 0.843, showing substantial reliability. Type 3 PDFFs had greater varus deformity than type 1 (p = 0.0457) or 2 (0.0198). CONCLUSION The proposed classification system accounts for comminution, demonstrates strong interobserver and intraobserver reliability, and can be used to guide treatment in regard to single versus dual plating. LEVEL OF EVIDENCE Retrospective comparative study, Level IV.
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Affiliation(s)
- Logan K Laubach
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, PO Box 980153, Richmond, VA, 23298, USA
| | - Viraj Sharma
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, PO Box 980153, Richmond, VA, 23298, USA
| | - John W Krumme
- KC Orthopedic Alliance, UMKC, 3651 College Blvd, Leawood, KS, 66211, USA
| | - Kevin Larkin
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, PO Box 980153, Richmond, VA, 23298, USA
| | - Jibanananda Satpathy
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, PO Box 980153, Richmond, VA, 23298, USA.
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Poelmann J, Kloen P. Modified use of the proximal humeral internal locking system (PHILOS) plate for distal femoral nonunions. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:425-433. [PMID: 35061100 PMCID: PMC9930358 DOI: 10.1007/s00590-022-03203-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/29/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Nonunion is a common complication after a distal femoral fracture (DFF). Standard treatment consists of revision plating and/or bone grafting. Single lateral plating for a distal femoral nonunion can be insufficient in case of a persistent medial gap and compromised bone stock. Alternatively, dual plating can be used to treat a distal femoral nonunion, but to date there is no Gold standard. The aim of our study was to report our results after use of a minimally invasively placed proximal humeral internal locking system (Philos) plate as a medial buttress in the treatment of a distal femoral nonunion. METHODS Fifteen adult patients with a distal femoral nonunion were prospectively entered in a trauma database and retrospectively assessed. All patients underwent a similar operation, which included removal of failed hardware, nonunion debridement, fixation with a lateral plate, and a medial Philos plate combined with bone grafting. Data collected included union rate, time to union, complications and functional outcome. RESULTS In twelve out of fifteen patients (80%), the fracture united after our index operation. Median time to union was 4.8 months (range 1.6-15). Three patients (20%) needed additional bone grafting surgery. One patient underwent a Judet quadricepsplasty. CONCLUSION This study suggests that the Philos plate is a safe and effective adjunct as a medial buttress plate for distal femoral nonunions.
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Affiliation(s)
- Josje Poelmann
- Department of Orthopedic Surgery, Amsterdam University Medical Center, Meiberdreef 9, Amsterdam, 1105AZ, The Netherlands.
| | - Peter Kloen
- grid.509540.d0000 0004 6880 3010Department of Orthopedic Surgery, Amsterdam University Medical Center, Meiberdreef 9, Amsterdam, 1105AZ The Netherlands
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Aebischer AS, Hau R, de Steiger RN, Holder C, Wall CJ. Distal femoral arthroplasty for native knee fractures : results from the Australian Orthopaedic Association National Joint Replacement Registry. Bone Joint J 2022; 104-B:894-901. [PMID: 35775178 DOI: 10.1302/0301-620x.104b7.bjj-2021-1136.r3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIMS The aim of this study was to investigate the rate of revision for distal femoral arthroplasty (DFA) performed as a primary procedure for native knee fractures using data from the Australian Orthopaedic Association National Joint Arthroplasty Registry (AOANJRR). METHODS Data from the AOANJRR were obtained for DFA performed as primary procedures for native knee fractures from 1 September 1999 to 31 December 2020. Pathological fractures and revision for failed internal fixation were excluded. The five prostheses identified were the Global Modular Arthroplasty System, the Modular Arthroplasty System, the Modular Universal Tumour And Revision System, the Orthopaedic Salvage System, and the Segmental System. Patient demographic data (age, sex, and American Society of Anesthesiologists grade) were obtained, where available. Kaplan-Meier estimates of survival were used to determine the rate of revision, and the reasons for revision and mortality data were examined. RESULTS The AOANJRR identified 153 primary DFAs performed for native knee fractures in 151 patients during the study period, with 63.3% of these (n = 97) performed within the last five years. The median follow-up was 2.1 years (interquartile range 0.8 to 4.4). The patient population was 84.8% female (n = 128), with a mean age of 76.1 years (SD 11.9). The cumulative percent revision rate at three years was 10%. The most common reason for revision was loosening, followed by infection. Patient survival at one year was 87.5%, decreasing to 72.8% at three years postoperatively. CONCLUSION The use of DFA to treat native knee fractures is increasing, with 63.3% of cases performed within the last five years. While long-term data are not available, the results of this study suggest that DFA may be a reasonable option for elderly patients with native knee fractures where fixation is not feasible, or for whom prolonged non-weightbearing may be detrimental. Cite this article: Bone Joint J 2022;104-B(7):894-901.
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Affiliation(s)
| | - Raphael Hau
- Eastern Health Clinical School, Monash University, Melbourne, Australia.,Department of Surgery, University of Melbourne, Northern Medical School, Melbourne, Australia
| | - Richard N de Steiger
- Department of Surgery, Epworth Healthcare, University of Melbourne, Melbourne, Australia.,Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia
| | - Carl Holder
- South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia
| | - Christopher J Wall
- Department of Orthopaedics, Toowoomba Hospital, Toowoomba, Australia.,School of Medicine Rural Clinical School, University of Queensland, Toowoomba, Australia
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Nino S, Parry JA, Avilucea FR, Haidukewych GJ, Langford JR. Retrograde intramedullary nailing of comminuted intra-articular distal femur fractures results in high union rate. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1577-1582. [PMID: 34623470 DOI: 10.1007/s00590-021-03140-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Retrograde intramedullary nailing of intra-articular distal femur fractures with metaphyseal and/or epiphyseal comminution is controversial and considered a contraindication to nailing. The purpose of this study was to report union rate, complications, and secondary procedures after open reduction and retrograde intramedullary nailing of comminuted, intra-articular, distal femur fractures. MATERIALS AND METHODS A retrospective review performed at an urban level one trauma center identified 16 patients AO/Orthopedic Trauma Association (OTA) 33-C2 and 33-C3 femur fractures treated with open reduction, lag screws, and retrograde intramedullary nail fixation. Radiographic union, complications, secondary operations were reviewed. RESULTS At the 3-month follow-up 12 (86%) of the 14 patients with radiographs had healed. At last follow-up, all 16 femur fractures achieved radiographic union after the index procedure. No patient required a revision procedure for delayed union or nonunion. Complications occurred in 6 (38%) patients, including failed distal interlocking screws (n = 2), knee arthrofibrosis (n = 3), superficial wound infection (n = 1), and wound dehiscence (n = 1). Three (19%) patients required secondary procedures, which included knee manipulation under anesthesia (n = 3), distal interlocking screw removal (n = 2), and closure of a wound dehiscence (n = 1). CONCLUSIONS Comminuted intra-articular distal femur fractures that can be successfully treated with retrograde IMN fixation will reliably go on to union with a complication rate that is favorable to that reported for plate fixation. LEVEL OF EVIDENCE Level IV, retrospective case-series.
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Affiliation(s)
- Samantha Nino
- Department of Orthopaedics, Orlando Health, Orlando, FL, USA
| | - Joshua A Parry
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock St, MC 0188, Denver, CO, 80204, USA.
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