Technical Trick: Dual Plate Fixation of Periprosthetic Distal Femur Fractures

The impact of medial-first dual plating for reduction of distal femoral fractures: a retrospective comparative cohort study

In dual-plate fixation of distal femoral fractures (DFF), reducing the relatively spared medial side first and using this metaphyseal-medial condylar segment as a template to reduce the lateral side may effectively facilitate reduction. This study evaluated the effectiveness of the medial-first dual-plate fixation in DFF. A retrospective study was conducted on 77 patients who underwent open reduction and internal fixation (ORIF) for DFF at a single institution between April 2012 and 2021. The patients were divided into a group in which medial-side ORIF was first performed followed by a lateral-ORIF (group M) and a lateral-ORIF only performed (group L). The demographic data, fracture classification, clinical outcomes, including operative time, estimated blood loss, complications, patient satisfaction, and pain level, and radiographic outcomes of the two groups were compared. There was no difference in the demographics or fracture classification between group M (n = 27) and group L (n = 50). The operative time was similar in the two groups. Group M had a significantly smaller articular gap, better union rate, shorter time to union, and stronger maintenance of coronal and sagittal alignment (P < 0.05). There were no significant differences in estimated blood loss, complications, reoperation rate, patient satisfaction, or pain level between the two groups. Medial-first dual-plate fixation showed better radiographic and comparable clinical results compared to lateral single-plate fixation in treating DFF. Medial-first dual-plate fixation facilitates the reduction and is believed to increase the reduction quality.

Femoral component retention in Rorabeck type III periprosthetic knee fracture with plating fixation and bone cement augmentation. A new surgical technique and four cases reported

Although dual implant constructs have recently been explored with promising results in very distal periprosthetic femur fractures (PPKF), the gold standard treatment of Rorabeck and Taylor type III PPKF remains a distal femur replacement or a highly constrained rotating hinge implant. However, this surgery is very aggressive and expensive for functionally low-demanding elderly patients. A new surgical technique using locking plates with polymethyl methacrylate cement augmentation is described to retain the femoral component avoiding its replacement. Four patients were treated and followed up for more than one year postoperative without any complications, their femoral component was retained without any loosening and the mobility in the Barthel Index remained unchanged.

Dual Plating for Periprosthetic Distal Femoral Fractures Using the Extensile Medial or Lateral Parapatellar Approach

Periprosthetic distal femoral fractures (PDFFs) are increasing in incidence, typically affecting frail elderly patients who have complex needs. Although the use of distal femoral endoprostheses in the management of these fractures is increasing exponentially, concerns about their longevity and mechanical failures in younger patients should limit their use to older patients with limited life expectancies. In this study, we report the surgical technique for dual plating PDFFs using an extensile medial or lateral parapatellar approach and illustrate this technique with case examples. We describe the results of a case series of 15 patients who underwent dual plating for acute PDFF from 2015 to 2021 (87% female, median age 78 years; interquartile range 73-88) at a median follow-up duration of 2.4 years (interquartile range 2.0-4.2).

Double plating is a suitable option for periprosthetic distal femur fracture compared to single plate fixation and distal femoral arthroplasty

Aims

The purpose of this study was to compare reoperation and revision rates of double plating (DP), single plating using a lateral locking plate (SP), or distal femoral arthroplasty (DFA) for the treatment of periprosthetic distal femur fractures (PDFFs).

Methods

All patients with PDFF primarily treated with DP, SP, or DFA between 2008 and 2022 at a university teaching hospital were included in this retrospective cohort study. The primary outcome was revision surgery for failure following DP, SP, or DFA. Secondary outcome measures included any reoperation, length of hospital stay, and mortality. All basic demographic and relevant implant and injury details were collected. Radiological analysis included fracture classification and evaluation of metaphyseal and medial comminution.

Results

A total of 111 PDFFs (111 patients, median age 82 years (interquartile range (IQR) 75 to 88), 86% female) with 32 (29%) Su classification 1, 37 (34%) Su 2, and 40 (37%) Su 3 fractures were included. The median follow-up was 2.5 years (IQR 1.2 to 5.0). DP, SP, and DFA were used in 15, 66, and 30 patients, respectively. Compared to SP, patients treated with DP were more likely to have metaphyseal comminution (47% vs 14%; p = 0.009), to be low fractures (47% vs 11%; p = 0.009), and to be anatomically reduced (100% vs 71%; p = 0.030). Patients selected for DFA displayed comparable amounts of medial/metaphyseal comminution as those who underwent DP. At a minimum follow-up of two years, revision surgery for failure was performed in 11 (9.9%) cases at a median of five months (IQR 2 to 9): 0 DP patients (0%), 9 SP (14%), and 2 DFA (6.7%) (p = 0.249).

Conclusion

Using a strategy of DP fixation in fractures, where the fracture was low but there was enough distal bone to accommodate locking screws, and where there is metaphyseal comminution, resulted in equivalent survival free from revision or reoperation compared to DFA and SP fixation.

Dual Plate Fixation of Periprosthetic Distal Femur Fractures

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.

Technical Trick: Supplemental Medial Column Screw Fixation of Distal Femur Fractures Treated With a Laterally Based Locked Plate

SUMMARY

Given known failure rates after lateral plating of distal femur fractures, there is an increasing interest in augmenting fixation to improve outcomes. The addition of medial plates or intramedullary nails have been described with promising results, decreasing nonunion and varus collapse rates. However, the use of dual implants increases implant costs, adds surgical complexity, and requires a second surgical approach that may increase morbidity. A supplemental, percutaneously placed, medial column screw may provide a less invasive means of improving stability and achieving fracture union compared with lateral plating alone.

How resources affect management of periprosthetic fractures of the distal femur: perspectives from Israel, South Sudan, and South Africa

Periprosthetic fractures of the distal femur have significant morbidity in both total hip and total knee arthroplasty (THA and TKA, respectively). The incidence of these fractures is growing, with the predominant mechanism of injury being a fall from a standing height and therefore considered fragility fractures. In many countries, improved public funding and a flourishing private health care sector, when coupled with increased life expectancy, translates to more older patients receiving both TKA and THA and therefore an increased prevalence of periprosthetic fractures and their associated complications. These fractures may occur below a long stem THA, above a TKA, or between the two (so-called "interprosthetic fracture"). We will outline fracture classification, risk factors, diagnosis, and treatment options, highlighting perspectives on treating these fractures in Israel, South Africa, and South Sudan. These countries represent differing access to resources, varied comorbidity factors, and differing health care systems. The points of difference and the points of similarity will be considered.

Distal Femoral Replacement versus Operative Fixation for Periprosthetic Distal Femur Fractures: A Systematic Review and Meta-Analysis

BACKGROUND

Open reduction and internal fixation (ORIF) and distal femoral replacement (DFR) have been utilized in the management of periprosthetic distal femur fractures. At present, much of the literature has been limited to small retrospective series. The purpose of the current investigation was to present the results of pooled data to determine the complication rates associated with ORIF and DFR.

METHODS

Publications from 2010 to 2020 describing 10 or more periprosthetic distal femur fractures treated with ORIF (ie, single plate, intramedullary nail, and dual fixation) or DFR were included, resulting in 32 publications and 1,258 fractures (977 ORIF and 281 DFR). Occurrence of surgical complications, reoperations, and medical complications were evaluated and compared.

RESULTS

The rate of surgical complications (ORIF versus DFR, 20.5 versus 14.9%, P = 1.0) and reoperations (12.9 versus 12.5%, P = 1.0) following DFR were similar. However, pooled analyses demonstrated that patients treated with DFR had a higher medical complication rate (ORIF versus DFR, 8.5 versus 23.1%, P = .0006).

CONCLUSION

ORIF and DFR for the treatment of periprosthetic distal femur fractures have similar surgical complication and reoperation profiles. While this review found an increased rate of medical complication following DFR, there are limitations in quality reporting in the literature, which should be considered when interpreting the study's findings. Failed ORIF can be salvaged with DFR, but the difficulty of this reoperation is dependent on the ORIF technique that was used. With future prospective studies, this review can help guide management of these fractures.

Outcomes of dual plating for unstable distal femoral fractures: a subgroup comparison between periprosthetic and non-periprosthetic fractures

PURPOSE

This study aimed to evaluate the outcomes of dual plating for unstable distal femoral fractures via a subgroup analysis between periprosthetic and non-periprosthetic fractures.

METHODS

This retrospective cohort study analyzed the outcomes of dual plating for unstable distal femoral fractures among 49 consecutive patients (43 women and 6 men) enrolled from July 2008 to August 2020. The patients were divided into periprosthetic (group P, n = 29) and non-periprosthetic (group N, n = 20) groups. The radiographic outcomes included the mechanical lateral distal femoral angle (mLDFA) and union rate based on the computed tomography findings. The clinical parameters included the knee range of motion and knee society score (KSS).

RESULTS

The mean patient age was 71.1 years, and the average follow-up period was 37 months (range, 12-138 months). Union was achieved in 47 patients (96%). The average final mLDFA was 90.5° in group P and 88.3° in group N. The average final knee range of motion was 130° in group P and 107° in group N. The average final KSS was 73.8 in group P and 87.1 in group N.

CONCLUSION

Dual plating for distal femoral fractures yielded an excellent union rate and limb alignment with a low complication rate.

Successful Plate Fixation with Long Intramedullary Fibula Bone Graft for Periprosthetic Femur Fracture: A Case Report

Background and objectives: Treatment of a displaced or comminuted periprosthetic distal femur fracture is challenging, especially in patients with osteoporosis. In this case report, we shared our successful surgical experience of using a long intramedullary fibula bone graft in a plate fixation surgery for a periprosthetic distal femur fracture in an extremely elderly patient with osteoporosis. Case report: A 95-year-old woman with severe osteoporosis (bone mineral density level: −3.0) presented with right knee pain and deformity after a fall, and a right periprosthetic distal femur fracture was identified. The patient underwent an open reduction and an internal plate fixation surgery with the application of a long intramedullary fibular bone graft. Due to a solid fixation, immediate weight-bearing was allowed after the surgery. She could walk independently without any valgus or varus malalignment or shortening 3 months after the surgery. A solid union was achieved 4 months postoperatively. Conclusions: We present a case wherein a long intramedullary allogenous fibula strut bone graft was used successfully to treat a right periprosthetic femur fracture in an extremely elderly patient. A long allogenous fibula bone graft can act not only as a firm structure for bridging the bone defect but also as a guide for precise component alignment. We believe this treatment option for periprosthetic fractures is beneficial for achieving biological and mechanical stability and facilitates early mobilization and weight-bearing for the patient.

New Classification for Periprosthetic Distal Femoral Fractures Based on Locked-Plate Fixation Following Total Knee Arthroplasty: A Multicenter Study

BACKGROUND

This study aimed to establish a new classification using locked-plate fixation for periprosthetic distal femoral fracture (PDFF) following total knee arthroplasty (TKA) and to determine when dual locked-plate fixation is necessary through defining this classification.

METHODS

One-hundred fifteen consecutive PDFFs that underwent operative treatment were reviewed from 2011 to 2019 with minimum 1-year follow-up. Most PDFFs were fixed with single or dual locked-plate fixations using the minimally invasive plate osteosynthesis technique. Based on preoperative radiographs, PDFFs were classified according to the level of main fracture line relative to the anterior flange of femoral component: type I and II, main fracture line located proximal and distal to the anterior flange; and type III, component instability regardless of fracture line requiring revisional TKA. Furthermore, type II fractures were subclassified based on the direction of fracture beak as follows: type II_L, lateral-beak; type II_M, medial-beak. The incidence, treatment methods, and complications were analyzed according to the classification.

RESULTS

Incidences of type I, II_L, II_M, and III were 64.4%, 8.7%, 24.3%, and 2.6%, respectively. Meanwhile, most PDFFs in type I and II were treated with lateral single locked-plate fixations, except for type II_M, which was treated with either single or dual locked-plate fixations. Overall complications were significantly higher in type II (28.9%) than in type I (10.8%, P = .019). In type II_M, bone union-related complications were significantly higher in single locked-plate fixation (50.0%) than in dual locked-plate fixation (5.6%; P = .013).

CONCLUSION

The new classification provides practical and obvious strategies for the treatment of PDFF following TKA using locked-plate fixation. For type II_M fracture, dual plate fixation is necessary to prevent fixation failure or nonunion.

Treatment of B1 Distal Periprosthetic Femur Fractures

The burden of periprosthetic distal femoral fractures is projected to increase accordingly with the increase in total knee arthroplasties (TKAs) performed globally in the future. Less invasive plating and intramedullary (IM) nailing techniques still seem to provide similar outcomes based on current literature. Double-plating and combination techniques may prove to be beneficial in the future pending further large-scale studies but currently have not demonstrated superiority over single plating and IM nailing based on current evidence. Distal femoral replacement may provide a useful option for future treatment, provided it is performed by a trained knee arthroplasty surgeon.

Maintaining the Neutral Axis in the Treatment of Distal Femur Fractures Via Dual Plate or Nail Plate Combination Technique: When and How?

SUMMARY

Distal femur fractures in the elderly have been historically treated with locked plating or retrograde intramedullary nailing with good, reliable results. However, in certain more complex fracture patterns (native or periprosthetic), increased density of fixation via dual-plate or nail plate combination can help achieve immediate weight-bearing. It can also potentially increase rates of union by shifting and maintaining the neutral axis, distributing forces more evenly across the fracture site. Here, we discuss the indications, pros and cons of both dual-plate and nail plate combination techniques in a concise case-based format.

Supplemental medial small fragment fixation adds stability to distal femur fixation: A biomechanical study

INTRODUCTION

Bridge plating of distal femur fractures with lateral locking plates is susceptible to varus collapse, fixation failure, and nonunion. While medial and lateral dual plating has been described in clinical series, the biomechanical effects of dual plating of distal femur fractures have yet to be clearly defined. The purpose of this study was to compare dual plating to lateral locked bridge plating alone in a cadaveric distal femur gap osteotomy model.

MATERIALS AND METHODS

Gap osteotomies were created in eight matched pairs of cadaveric female distal femurs (average age: 64 yrs (standard deviation ± 4.4 yrs); age range: 57-68 yrs;) to simulate comminuted extraarticular distal femur fractures (AO/OTA 33A). Eight femurs underwent fixation with lateral locked plates alone and were matched with eight femurs treated with dual plating: lateral locked plates with supplemental medial small fragment non-locking fixation. Mechanical testing was performed on an ElectroPuls E10000 materials testing system using a 10 kN/100 Nm biaxial load cell. Specimens were subject to 25,000 cycles of cyclic loading from 100-1000 N at 2 Hz.

RESULTS

Two (2/8) specimens in the lateral only group failed catastrophically prior to completion of testing. All dual plated specimens survived the testing regimen. Dual plated specimens demonstrated significantly less coronal plane displacement (median 0.2 degrees, interquartile range [IQR], 0.0-0.5 degrees) compared to 2.0 degrees (IQR 1.9-3.3, p = 0.02) in the lateral plate only group. Dual plated specimens demonstrated greater bending stiffness compared to the lateral plated group (median 29.0 kN/degree, IQR 1.5-68.2 kN/degree vs median 0.50 kN/degree, IQR 0.23-2.28 kN/degree, p = 0.03).

CONCLUSION

Contemporary fixation methods with a distal femur fractures are susceptible to mechanical failure and nonunion with lateral plates alone. Dual plate fixation in a cadaveric model of distal femur fractures underwent significantly less displacement under simulated weight bearing conditions and demonstrated greater stiffness than lateral plating alone. Given the significant clinical failure rates of lateral bridge plating in distal femur fractures, supplemental fixation should be considered, and dual plating of distal femurs augments mechanical stability in a clinically relevant magnitude.