Journal of Orthopedic Surgery and Techniques

Treating Geriatric Distal Femur Fracture with Nail Plate Combination - Early Clinical Outcomes

Abstract

Distal femur fractures in geriatric patients present a complex clinical scenario due to osteoporosis and challenges with adherence to protected weight bearing protocols. The main objective of surgical intervention is to enable immediate full weight bearing to mitigate complications associated with immobilization. This study reports the early promising clinical outcomes in the treatment of five geriatric patients using a combination of retrograde femoral nail and lateral locking plate. All patients were allowed immediate full weight bearing after operation. At a mean follow up of 12.8 months, four out of the five patients maintained their ability to ambulate on level ground.

Keywords

Femur, Fragility, Geriatric, Implant

Introduction

Distal femur fractures in geriatric population are challenging clinical situations because of the prevalence of osteoporosis and the failure of compliance with protected weight bearing. They share similar patient demographics and mortality rate with proximal femur fractures [1]. Despite contemporary designs of lateral locking plates and retrograde femoral nails, local and systemic complications have been widely reported.

A newly advocated surgical option is the combination of retrograde intramedullary nail and locking plate. The technique maximizes the positive attributes of both implants, and allows immediate weight bearing post-operatively [2]. We postulate that this is beneficial to geriatric patients, with the merits of accelerating rehabilitation and hence maintaining the ambulation. This is believed to decrease the mortality and morbidity rates. We hereby report the experience of managing geriatric distal femur fractures with nail plate combination in our centre. The objectives of this investigation are to introduce this approach in treating acute distal femur fractures, and to evaluate the clinical outcomes.

Methodology

A single-centre retrospective chart review was conducted on 5 consecutive patients who underwent operative stabilization with nail plate combination for acute distal femur fractures between 2021 to 2023. The patients were selected based on the fracture patterns and surgeons’ preference. The inclusion criteria were age greater than 65 years and absence of prior surgical intervention for femoral fracture. Open fractures were excluded. The study was approved by the Central Institutional Review Board, and informed consent was obtained from all participating patients. The approval number for this study is CIRB-2024-029-4.

Surgical Techniques

Pre-operative treatment

All patients were stabilized, prescribed analgesics and optimized for operation upon admission. Their fractures were reduced and temporarily immobilised with plaster or skin traction device. Plain computed tomography scans were performed in fractures with intra-articular extension. The extent of metaphyseal comminution, the distance from the intercondylar notch to the most distal fracture line, and the orientation of intra-articular fracture were evaluated.

Surgical approach

Patients were in supine position with a bump underneath the ipsilateral buttock to prevent excessive external rotation. Draping of the contralateral limb was helpful in patients with significant comminution and bone void as this allowed estimation of the original limb length and rotation.

Lateral parapatellar approach was used. The approach allowed direct visualisation of the metaphyseal fragments, both condyles and the intercondylar notch when reduction of intra-articular fragments was required.

Reduction of intra-articular fractures and metaphyseal fractures

In cases with intra-articular fractures, the fragments were reduced and temporarily held with reduction clamps and multiple Kirschner wires. The reduced intra-articular block was then reduced to the proximal fragment. The lateral metaphyseal cortices would serve as a guide for restoring the femoral length and rotation. If significant comminution existed, the original femoral length and rotation were determined from the contralateral limb. The reduction was maintained with multiple large diameter Kirschner wires and large periarticular clamps (Figure 1).

Retrograde femoral nail and lateral locking plate placement

The lateral parapatellar approach allowed placement of the retrograde femoral nail under direct vision. The femur was sequentially reamed and the femoral nail was placed to splint the whole diaphysis. A lateral anatomical distal femur plate was placed with minimally invasive plate osteosynethesis (MIPO) technique submuscularly (Figure 2).

Creation of the nail plate combination

The nail plate combination was created by applying interlocking screws through both the locking holes of the plate and the nail. The distal targeting arm of the retrograde nail system was mounted on the femoral nail. The drill sleeves were inserted via the targeting arm onto the lateral cortex of the femur (see Figure 3). The rotation of the nail was adjusted so that the drill sleeve would line up one of the locking holes of the plate with the hole on the nail. From the authors’ experience, usually one to two screws can be positioned to lock both implants. Plates that allow poly-axial locking screw placement are advantageous in this situation.

The remaining periarticular locking holes of the plate were filled with locking screws. Some of the screw trajectories would inevitably be blocked by the femoral nail, and hence only unicortical purchase could be achieved. The authors recommended insertion of the remaining distal interlocking bolts of the nail in a medial to lateral fashion to increase medial purchase (See Figure 4).

Proximally, two interlocking bolts for the nail were inserted in a static-static mode. Uni-cortical periprosthetic screws were inserted along the proximal plate holes. A surgical drain was placed into the knee joint, the wound was closed in layers.

Post-operative rehabilitation

All patients were allowed full range of motion exercise and immediate full weight bearing after surgical drain removal.

Results

A total of 5 patients (4 females) were treated (see Table 1). Mean age of the cohort was 81 years (range 69-93). All patients sustained a distal femur fracture after a fall on level ground. One patient had an undisplaced fracture neck of the ipsilateral femur. All fractures were either comminuted or with intra-articular extension. A titanium supracondylar nail system and a titanium distal femur lateral locking plate were used in every case.

All patients were allowed to weight bear immediately post-operatively. Mean follow-up was 12.8 months (range, 4-18 months). All fractures healed at an average of 25.6 weeks (range, 16-33 weeks).

There were no postoperative infections, medical complications, surgical complications or mortality. Three patients maintained their premorbid ambulation, while two had lost one level in the Modified Functional Ambulation Categories (MFAC). Overall, four out of five patient remained independent ambulators on level ground. Main patient outcomes are shown in Table 2 and Table 3 (Figure 5a and Figure 5b).

Discussion

Distal femur fractures exhibit a bimodal distribution and account for 4-6% of all osteoporotic fractures. These fractures in the geriatric population are associated with a 1-year mortality rate ranging from 13 to 30% [3]. These are comparable to those of hip fractures, making distal femur fractures an increasingly important health care problem in the aging society.

Retrograde femoral nails and lateral locking plates have been the two main surgical treatments in the recent two decades. With a better understanding of secondary bone healing and distal femoral anatomy, modern anatomically contoured distal femoral locking plates with a comparable modulus of stiffness to bone and minimally invasive insertion techniques was used to promote biologic osteosynthesis. However, high complication rates and overall poor patient outcomes were still reported in the geriatric population. Up to 24% non-union rate and a high incidence of loss of independent ambulation, have been reported [4]. Retrograde femoral nails, despite improvement in distal fixation with multiplanar distal locking blots and advanced locking screw options, a non-union rate of 4% have been reported in a recent meta-analysis [5].

Biomechanical study has provided insights on the observed suboptimal outcomes. Salas, et al. employed finite element analysis to replicate weight bearing in an osteoporotic distal femoral model stabilized with lateral locking plate and retrograde intramedullary nail separately [6]. A comparison of the two constructs revealed notable disparities in their modes of failure. Higher likelihood of implant fracture was found in the lateral locking plate, whereas failure of the surrounding cortex was more probable with the retrograde intramedullary nail.

Some authors advocated medial and lateral double plating which has a higher stiffness than single plating, in hope to decrease varus collapse and hardware failure. However, the excessive stiffness is not advantageous in comminuted fractures, and a series showed that 17% patients required revision with bone graft due to non-union at 6 months post-operatively [7].

The utilization of a nail plate combination for distal femur fractures aims to evenly distribute loads at the bone-construct interface. The retrograde femoral nail functions as a load-sharing device, allowing micromotion at the fracture site, which was proved advantageous in osteoporotic metaphyseal fractures. When combined with a laterally based, load-bearing locking plate, the overall stiffness increases to resist the multiplanar deforming forces.

A handful of retrospective studies on nail plate combination emerged since 2019. Liporace, et al. reported a series of 15 patients with a mean age of 74-years-old, with a majority of periprosthetic fracture, who was treated with nail plate combination and was allowed immediate weight bearing. No non-union and hardware failure were observed in the series [8].

Passias, et al. retrospectively compared the clinical outcomes of 8 patients treated with nail plate combination to those treated with lateral plate and nailing. Open fractures and periprosthetic fractures were included. It showed that the clinical outcomes in the middle aged patients (average age 59-year-old) were comparable in all three groups, except longer operation time and fluoroscopy durations in the nail plate combination [9].

A multicentre retrospective study compared 30 nail plate combinations with a matched group of patients who received lateral plating, and reported no non-union or mal-union and less unplanned operation in the former group [10]. However, the majority of the patients were middle aged and sustained high energy trauma, with a substantial ratio of open fractures.

To our knowledge, our series were the first case series of geriatric native distal femur fracture receiving nail plate combination. Our early results suggested that it is a promising treatment option, in terms of high union rate, preservation of ambulatory status and low mortality rate. We postulate that a stable construct that allows immediate weight bearing and promotes biological osteosynthesis is the cornerstone of excellent patient outcomes. Geriatric patients have a low likelihood to comply with protected weight bearing. A prescription of protected weight bearing to this population eventually leads to either non ambulatory at all or premature weight bearing, which can lead to immobilisation related complication and hardware breakage respectively.

Distal femur fractures have an overlapping patient demographics and fracture related mortality rate as hip fractures [1]. The rationale of treatment decision should be the same, which is to maximise the chance of immediate full weight bearing. Our experience echoed with the previous literature that the nail plate combination provides stable fixation to allow weight bearing. The additional costs and longer operation time should be noticed. We purposed that it is most beneficial to geriatric patients with significant comminution in the metaphysis. Patients should be ambulatory before the injury and had a reasonable rehabilitation potential to justify the extra-surgical risks and medical costs.

This investigation has several limitations, primarily related to the retrospective nature of our study, along with the small patient number and significant bias due to surgeon preference for specific hardware and fixation strategies at the time of intervention. Nonetheless, this is one of the few literatures focusing on this technique in hope to improve the outcomes in the geriatric population. We strongly recommend conducting additional high-powered, prospective investigations to further elucidate the outcomes of this nail plate combination for the acute management of native distal femur fractures.

Conclusion

The use of a nail plate combination has demonstrated success as an alternative treatment for the acute management of geriatric distal femur fractures. It is reliable and reproducible to allow immediate weight bearing. This technique is particularly advantageous for geriatric patients with comminuted metaphyseal fractures.

Conflicts of Interest Statement

There are no conflicts of interest to declare among the authors.

Funding/Support Statement

There is no external funding to this study.

References

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