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Single-stage bilateral distal femur replacement for traumatic distal femur fractures.

ABSTRACT: Treatment of periprosthetic distal femur fractures and comminuted intraarticular distal femur fractures with previous arthritis remains a difficult challenge for orthopedic surgeons. Previous case series have shown that distal femur replacement (DFR) can effectively compensate for bone loss, relieve knee pain, and allow for early ambulation in both of these fracture patterns. Owing to the typical low-energy mechanism of these injuries, a bilateral injury treated with DFR is rarely encountered. We present a patient with traumatic open left Rorabeck III/Su III periprosthetic distal femur fracture and closed right intraarticular distal femur fracture (AO fcation 33-C2) with end-stage arthrosis treated with single-stage bilateral DFR. We suggest that in patients with similar injuries, single-stage bilateral DFR can provide the benefits of early mobilization and accelerated recovery.

SUBMITTER: Neal DC

PROVIDER: S-EPMC6470367 | biostudies-literature | 2019 Mar

REPOSITORIES: biostudies-literature

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Single-stage bilateral distal femur replacement for traumatic distal femur fractures.

Neal David C DC Sambhariya Varun V Tran Apollo A Rahman Shawn K SK Dean Thad J TJ Wagner Russel A RA Sanchez Hugo B HB

Arthroplasty today 20181205 1

Treatment of periprosthetic distal femur fractures and comminuted intraarticular distal femur fractures with previous arthritis remains a difficult challenge for orthopedic surgeons. Previous case series have shown that distal femur replacement (DFR) can effectively compensate for bone loss, relieve knee pain, and allow for early ambulation in both of these fracture patterns. Owing to the typical low-energy mechanism of these injuries, a bilateral injury treated with DFR is rarely encountered. W ...[more]

PMID: 31020017

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Project description:PurposeThe treatment of distal femur fractures with extensive metaphyseal comminution is frequently complicated by high rates of nonunion and varus collapse. Dual plating with lateral and medial locking plates for these types of fractures has shown promising results in the recent literature. We hypothesize that dual plating of comminuted distal femur fractures leads to higher union rates and lower revision rates compared to an isolated lateral locking plate.MethodsA retrospective medical chart review between January 2015 and December 2017 was conducted. Inclusion criteria included patients 18 years of age and older who sustained a complex distal femur fracture (AO/OTA 33-C2/33-C3 or periprosthetic fracture with significant metaphyseal comminution) and at least 6 months of follow up. Patients with simple fracture patterns, alternative fixation methods, and inadequate follow up were excluded. All patients in the single plating group were treated with a lateral distal femoral locking plate using a lateral approach. In the patients treated with dual plating, an extensile parapatellar approach was utilized for fracture reduction and placement of an adjunctive medial plate. Demographic information, fracture types, injury severity score (ISS), medical comorbidities, type of surgical fixation, union rates, complications, knee range of motion, time to follow up, and need for revision surgery were extrapolated from the medical charts for analysis.ResultsTwenty-one patients were included in the study. Thirteen patients underwent single plate fixation and 8 underwent dual plate fixation. There were no significant differences in demographics, number of co-morbidities, fracture classification, or ISS between single and dual plate groups (p > 0.05 for all). There was a statistically significant difference in union rates between the single plate group (6 nonunions, 4 unions, and 3 delayed unions) and the dual plate group, with no nonunions or delayed unions (p = 0.0049). Although not statistically significant, 4 patients treated with single plating underwent revision ORIF, compared to none in the dual plating group (p = 0.13). There were no significant differences in time to follow up, time to full weight bearing, or infection rates (p > 0.1 for all).ConclusionBased on these results, the medial and lateral locked plating technique demonstrates a higher union rate, with possible lower rates of revision surgery, compared to a single lateral plate in highly comminuted distal femur fractures.Level of evidenceLevel 3. Retrospective Cohort Study.

Project description:AimsSeveral previously identified patient-, injury-, and treatment-related factors are associated with the development of nonunion in distal femur fractures. However, the predictive value of these factors is not well defined. We aimed to assess the predictive ability of previously identified risk factors in the development of nonunion leading to secondary surgery in distal femur fractures.MethodsWe conducted a retrospective cohort study of adult patients with traumatic distal femur fracture treated with lateral locking plate between 2009 and 2018. The patients who underwent secondary surgery due to fracture healing problem or plate failure were considered having nonunion. Background knowledge of risk factors of distal femur fracture nonunion based on previous literature was used to form an initial set of variables. A logistic regression model was used with previously identified patient- and injury-related variables (age, sex, BMI, diabetes, smoking, periprosthetic fracture, open fracture, trauma energy, fracture zone length, fracture comminution, medial side comminution) in the first analysis and with treatment-related variables (different surgeon-controlled factors, e.g. plate length, screw placement, and proximal fixation) in the second analysis to predict the nonunion leading to secondary surgery in distal femur fractures.ResultsWe were able to include 299 fractures in 291 patients. Altogether, 31/299 fractures (10%) developed nonunion. In the first analysis, pseudo-R2 was 0.27 and area under the receiver operating characteristic curve (AUC) was 0.81. BMI was the most important variable in the prediction. In the second analysis, pseudo-R2 was 0.06 and AUC was 0.67. Plate length was the most important variable in the prediction.ConclusionThe model including patient- and injury-related factors had moderate fit and predictive ability in the prediction of distal femur fracture nonunion leading to secondary surgery. BMI was the most important variable in prediction of nonunion. Surgeon-controlled factors had a minor role in prediction of nonunion.

Project description:Introduction:Open comminuted distal femur fractures are notorious for septic or aseptic non-union. The recommended fixed angle distal femur locking plate in such situations can lead to a septic non-union due to its extensive approach and further periosteal stripping. Supracondylar nails, though have a minimally invasive approach, are not suitable for type C2 and C3 (AO/ASIF) fractures. A monolateral fixator as damage control followed by plating may be recommended. But if wound healing is delayed it results in difficult articular reduction, poor alignment and a stiff knee. We therefore used ilizarov circular external fixators (ICEF) for such open fractures (type C1, C2 and C3) and analysed its radiological and functional outcomes. Materials and methods:25 male patients, with a mean age of 31.04?±?6.62 years (range, 22-44 years), with open grade III type C distal femoral fractures were treated with ICEF. There were 7 fractures of type C1and C3 each, 11 were of type C2. Articular reduction and compression was achieved with inter-fragmentary screws through minimal open technique by extending the open wound and then stabilising the fracture with ICEF. The main outcomes evaluated were union, range of motion, final shortening, Knee Society scoring and ASAMI scoring system for radiological and functional outcomes. Results:The mean follow-up period was 19.12?±?1.14 months. All fractures except two united at a mean period of 30?±?3.02 weeks, without the need of bone grafts. The bony assessment (according to ASAMI score) was excellent in 8 cases (33.33%), good in 9 cases (37.5%) and fair in 5 cases (20.83%), while there were 2 poor clinical end results. The functional results were excellent in 6 cases (25%), good in 9 cases (37.5%) fair in 6 cases (25%) poor in 3 cases (12.5%). The complications included shortening, extension lag and pin tract infections. Conclusion:With the encouraging results, the use of ICEF with minimal internal fixation in grade III open comminuted distal femur fractures as a primary definitive treatment is a valuable alternative.

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Single-stage bilateral distal femur replacement for traumatic distal femur fractures.

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Single-stage bilateral distal femur replacement for traumatic distal femur fractures.

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