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Dual plate fixation results in improved union rates in comminuted distal femur fractures compared to single plate fixation.

ABSTRACT: Purpose:The 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. Methods:A 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. Results:Twenty-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). Conclusion:Based 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 evidence:Level 3. Retrospective Cohort Study.

SUBMITTER: Bologna MG

PROVIDER: S-EPMC7068022 | biostudies-literature | 2020 Mar-Apr

REPOSITORIES: biostudies-literature

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Dual plate fixation results in improved union rates in comminuted distal femur fractures compared to single plate fixation.

Bologna Matthew Gregory MG Claudio Mariano Garay MG Shields Kelly J KJ Katz Curren C Salopek Traci T Westrick Edward Ryan ER

Journal of orthopaedics 20190915

<h4>Purpose</h4>The 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.<h4>Methods</h4>A retrospecti ...[more]

PMID: 32189888

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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.

Project description:BACKGROUND:Geriatric acetabular fractures require fixation with sufficient primary stability to allow for immediate full-weight bearing. Minimally-invasive procedures would be desirable in order to keep perioperative morbidity low. The purpose of this study was to compare the biomechanical strength of lag screw-only fixation of anterior column posterior hemi-transverse (ACPHT) acetabular fractures to standard anatomical plate fixation. METHODS:Standardized ACPHT fractures were created in fourth generation synthetic pelvis models and stabilized by either an anatomical buttress plate (n?=?4) or by a screw-only construct (n?=?4). In a validated setup, a cyclic loading protocol was applied with increasing axial force (3200?cycles, 175?N to 2250?N). Construct survival, acetabular fracture motion, and mode of failure were assessed. RESULTS:The median number of cycles needed until failure of the construct occurred was 2304?cycles (range, 2020 to 2675) in the plate fixation group and 3200?cycles (range, 3101 to 3200) for the screw fixation constructs (p?=?.003). With regard to energy absorbed until failure, the plate fixation group resisted to 1.57?×?106?N*cycles (range, 1.21?×?106 to 2.14?×?106) and the screw fixation group to 3.17?×?106?N*cycles (range, 2.92?×?106 to 3.17?×?106; p?=?.001). All plate fixation specimens failed with a break-out of the posterior-column screw in the quadrilateral wing of the anatomical plate within a maximum load of 1750?N while the screw fixation constructs all survived loading of at least 2100?N. Acetabular fracture gap motion, acetabular rim angle, and medial femoral head subluxation as measures of fracture displacement were all not different between the two groups (p?>?0.1). CONCLUSIONS:In this in vitro biomechanical study, screw-only fixation of an ACPHT acetabular fracture resulted in at least as good construct survival as seen for standard buttress plate fixation. Both methods resisted sufficiently to forces that would be expected under physiologic conditions.

Project description:Optimal acute management of the highly comminuted distal ulna head/neck fracture sustained in conjunction with an unstable distal radius fracture requiring operative fixation is not well established. The purpose of the present study was to determine the clinical, radiographic, and functional outcomes following acute primary distal ulna resection for comminuted distal ulna fractures performed in conjunction with the operative fixation of unstable distal radius fractures. Between 2000 and 2007, 11 consecutive patients, mean age 62 years (range, 30-75) were treated for concomitant closed, comminuted, unstable fractures of the distal radius and ulna metaphysis. All 11 patients underwent distal ulna resection through a separate dorsal ulnar incision with ECU tenodesis following surgical fixation of the distal radius fracture. According to the Q modifier of the Comprehensive Classification of Fractures, there were six comminuted fractures of the ulnar neck (Q3) and five fractures of the head/neck (Q5). Operative fixation of the distal radius fracture included volar plate fixation in four patients and spanning external fixation with supplemental percutaneous Kirschner wires in seven patients. At a mean of 42 months (range, 18-61 months) postoperatively, clinical, radiographic, and wrist-specific functional outcome with the modified Gartland and Werley wrist score were evaluated. At latest follow-up, mean wrist range of motion measured 53 degrees flexion (range, 35-60 degrees), 52 degrees extension (range, 30-60 degrees), 81 degrees pronation (range, 75-85 degrees), and 77 degrees supination (range, 70-85 degrees). Mean grip strength measured 90% of the contralateral, uninjured extremity (range, 50-133%). No patient had distal ulna instability. Final radiographic assessment demonstrated restoration of distal radius articular alignment. According to the system of Gartland and Werley as modified by Sarmiento, there were seven excellent and four good results. No patient has required a secondary surgical procedure. Acute primary distal ulna resection yields satisfactory clinical, radiographic, and functional results in appropriately selected patients and represents a reliable alternative to open reduction and internal fixation when anatomic restoration of the distal ulna/sigmoid notch cannot be achieved. Primary distal ulna resection with distal radius fracture fixation may help avoid secondary procedures related to distal ulna fixation or symptomatic post-traumatic distal radioulnar joint arthrosis.

Project description:Of all distal radius fractures, 25 % are complete articular fractures (AO/OTA type C fractures). Two thirds of those fractures are displaced and require reduction. According to several International Guidelines, adequately reduced intra-articular distal radius fractures are best treated non-operatively with plaster immobilisation, while surgical fixation is suggested only when the articular step exceeds 2 mm after reduction. However, these recommendations are based on studies that did not differentiate between intra- and extra-articular distal radius fractures. Thus, no clear consensus about the best treatment for patients with displaced intra-articular distal radius fractures can be reached. Despite the lack of evidence, an increase in internal fixation of intra-articular distal radius fractures has been observed over the last decade. The aim of this study is to determine the difference in functional outcome following open reduction and plate fixation compared with non-operative treatment with closed reduction and plaster immobilisation in patients with a displaced intra articular distal radius fracture.This multicentre randomised controlled trial will randomise between open reduction and internal plate fixation (intervention group) and closed reduction and plaster immobilisation (control group). All consecutive adult patients from 18 to 65 years with a displaced intra-articular distal radius fracture (AO/OTA type C), which has been adequately reduced at the Emergency Department according to the Dutch National Guidelines, are eligible for inclusion in this study. The primary outcome is function and pain of the wrist assessed with the Patient-Rated Wrist Evaluation score (PRWE). Secondary outcomes are the Disability of the Arm, Shoulder and Hand score (DASH), pain, quality of life (SF-36), range of motion, grip strength, radiological parameters, complications, crossovers and cost-effectiveness of both treatments. A total of 90 patients will be included in this study.Although displaced intra-articular distal radius fractures are common, there is still no evidence on the optimal treatment for these fractures in patients aged 18 to 65 years. Therefore we aim to determine the difference in functional outcome between open reduction and plate fixation and closed reduction and plaster immobilisation.This study is registered at ClinicalTrials.gov ( NCT02651779 ) on January 4(th) 2016.

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Dual plate fixation results in improved union rates in comminuted distal femur fractures compared to single plate fixation.

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Dual plate fixation results in improved union rates in comminuted distal femur fractures compared to single plate fixation.

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