Abstract
Purpose
Distal femoral fractures account for 4–6% of fragility fractures. These may be managed using a combined nail-plate construct (NPC). The use of NPCs is gaining traction. Whilst several theoretical advantages exist, there is little evidence reporting on binary or patient-reported outcomes.
The aim of the current study was to perform a systematic review of the available literature pertaining to NPCs and their treatment of native distal femoral fractures, appraising the outcomes and focusing on the rationale for their increasing uptake in recent literature.
Methods
A comprehensive search of MEDLINE, EMBASE, Clinical Key, PubMed and Cochrane library was performed from date of inception up to in August 9, 2022. All study languages were included initially. A further Google Scholar search review was performed to identify any other studies not identified in the database interrogation.
Studies were eligible if they reported on the use of nail-plate constructs in managing distal femoral fractures. Any outcome metric was permitted.
The study was conducted in accordance with PRISMA guidelines. Risk of bias was assessed using the Methodological Index for non-randomised Studies tool.
Quantitative analysis was performed using a log odds ratio random effects model. The Knapp–Hartung adjustment was utilised if the total number of included studies was < 5. Study effect sizes and appropriate plots were constructed to illustrate the outcomes data.
Results
A total of four studies were eligible for inclusion. Study data was extracted and summarised with their relevant outcomes presented. The literature review demonstrated that the use of NPCs led to significantly earlier full weight bearing (p < 0.001) and had reduced non-union rates over a single construct, without affecting infection rates (12.5% vs. 5.6%; p = 0.289) and significantly lower implant failure rates (10.5% vs. 0%; p = 0.011). A meta-analysis is performed of available studies and Forrest plots presented.
Conclusion
The use of NPC in the management of native osteoporotic DFFs is gaining traction but the available evidence is of low grade with significant heterogeneity in small cohorts of patients. We suggest that a large-scale, multicentre prospective study should be performed, with agreed functional and radiological outcome metrics, to provide a more robust evidence base.
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References
Canton G, Giraldi G, Dussi M, Ratti C, Murena L (2019) Osteoporotic distal femur fractures in the elderly: Peculiarities and treatment strategies. Acta Biomed 90(12):25–32
Myers P, Laboe P, Johnson KJ, FredericksCrichlow PDRJ, Maar DC et al (2018) Patient mortality in geriatric distal femoral fractures. J Orthop Trauma 32(3):111–115
Court-Brown CM (2006) Caesar B epidemiology of adult fractures: a review. Injury 37:691–697
Lieder CM, Gaski GE, Virkus WW, Kempton LB (2021) Is immediate weight-bearing safe after single implant fixation of elderly distal femur fractures. J Orthop Trauma 35(1):49–55
Kubiak EN, Beebe MJ, North K, Hitchcock R, Potter MQ (2013) Early weight bearing after lower extremity fractures in adults. J Am Acad Orthop Surg 21(12):727–738
Ariza-Vega P, Jiminez-Moleon JJ, Kristensen MT (2014) Non weight-bearing status compromises the functional level up to 1 year after hip fracture surgery. Am J Phys Med Rehabil 93(8):641–648
Warren J, Sundaram K, Anis H et al (2019) The association between weight-bearing status and early complications in hip fractures. Eur J Orthop Surg Traumatol 29(7):1419–1427
Richardson C, Bretherton CP, Raza M, Zargaran A, Eardley WG, Trompeter AJ, Collaborators FFPOM (2022) The fragility fracture postoperative mobilisation multicentre audit the reality of weightbearing practices following operations for lower limb fragility fractures. The Bone Joint Journal. 104(8):972–979
Van Staa TP, Dennison EM, Luefkens HG, Cooper C (2001) Epidemiology of fractures in England and Wales. Bone 29(6):517–522
Streubel PN, Ricci WM, Wong A, Gardner MJ (2011) Mortality after distal femur fractures in elderly patients. Clin Orthop Relat Res 469(4):1188–1196
Tahami M, Vaziri AS, Tahmesabi MN, Vosoughi F, Khalilizad M, Shakiba S (2022) Pesantez RF Practical approach to the native distal femur fractures in the elderly: A rapid review over the recent trends. Injury 53:2389–2394
Smith JRA, Halliday R, Aquilina AL, Morrison RJM, Yip CK, McArthur J et al (2015) Distal femoral fractures: The need to review the standard of care. Injury 46(6):1084–1088
Ehlinger M, Ducrot G, Adam P, Bonnomet F (2013) Distal femur fractures. Surgical techniques and a review of the literature. Orthop Traumatol Surg Res 99:53–60
Smith TO, Hedges C, MacNair R, Schankat K, Wimhurst JA (2009) The clinical and radiological outcomes of the LISS plate for distal femoral fracture a systematic review. Injury 40(10):1049–1063
Moher D Liberati A, Tetzlaff J, Altman DG for the PRISMA Group (2009): Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement BMJ;39:b2535
Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J (2003) Methodological index for non-randomized studies (MINORS): Development and validation of a new instrument. ANZ J Surg 73:712–716
Röver C, Knapp G, Friede T (2015) Hartung-Knapp-Sidik-Jonkman approach and its modification for random-effects meta-analysis with few studies. BMC Med Res Methodol 1:1–7. https://doi.org/10.1186/s12874-015-0091-1
Garala K, Ramoutar D, Li J, Syed F, Arastu M, Ward J, Patil S (2022) Distal femoral fracture: a comparison between single lateral plate fixation and a combined femoral nail and plate fixation. Injury 53:634–639
Spitler CA, Bergin PF, Russell GV, Graves ML (2018) Endosteal substitution with an intramedullary rod in fractures of the femur. J Orthop Trauma 32:S25–S29
Passias BJ, Emmer TC, Sullivan BD, Gupta A, Myers D, Skura BW, Taylor BC (2021) Treatment of distal femur fractures with a combined nail-pate construct: Techniques and outcomes. J Long term Eff Med Implants 31(3):15–26
Liporace FA, Yoon RS (2019) Nail plate combination technique for native and periprosthetic distal femur fractures. J Orthop Trauma 33:e64–e68
Yoon RS, Patel JN, Liporace FA (2019) Nail and Plate Combination Fixation for Periprosthetic and Interprosthetic Fractures. J Orthop Trauma 33(6):S18–S20
Mueller MGE (2019) Nail plate constructs for periprosthetic distal femur fractures. J Knee Surg 32(5):403–406
Egol KA, Delsole E, Mandel J, Konda S (2019) Repair of distal femoral periprosthetic nonunion: linked nail plate construct. J Orthop Trauma 33:S30–S31
Hussain MS, Dailey SK, Avilucea FR (2018) Stable fixation and immediate weight-bearing after combined retrograde intramedullary nailing and open reduction internal fixation of noncomminuted distal interprosthetic femur fractures. J Orthop Trauma 32(6):e237–e240
Kanabur P, Sandilands SM, Whitmer KK, Owen TM, Coniglione FM, Shuler TE (2017) Nail and locking plate for peri-prosthetic fractures. J Orthop Trauma 31(12):e425–e431
Attum B, Douleh D, Whiting PS et al (2017) Outcomes of distal femur non unions treated with a combined nail/plate construct and autogenous bone grafting. J Orthop Trauma 31(9):e301-304
Bezwada HP et al (2004) Periprosthetic supracondylar femur fractures following total knee arthroplasty. J Arthroplasty 19(4):453–458
Sun ZH, Liu YJ, Li H (2014) Femoral stress and strain changes post-jip, -knee and -ipsilateral hip/knee arthroplasties: a finite element analysis. Orthop Surg 6:137–144
Shawen SB, Belmont PJ, Klemme WR, Topoleski T, Xenos JS, Orchowski JR (2003) Osteoporosis and anterior femoral notching in periprosthetic supracondylar femoral fractures: a biomechanical analysis. JBJS Am 1:115–121
Zalzal P, Backstein D, Gross AE, Papini M (2006) Notching of the anterior femoral cortex during total knee arthroplasty: characteristics that increase local stresses. J Arthroplasty 21(5):737–743
Stoffel K, Sommer C, Lee M, Zhu TY, Schweiger K, Finkemeier C (2022) Double fixation for complex distal femoral fracture EFORT. Open Rev 7:274–286
Auston D, Donohue D, Stoops K et al (2018) Long segment blocking screws increases the stability of retrograde nail fixation in geriatric supracondylar femur fractures: Eliminating the bell-clapper effect. J Orthop Trauma 32:559–564
Kwak DK, Oh SH, Lee SJ, Lee SH, Lee YM, Yoo JH (2022) Effect of the additional anteroposterior blocking screw on nail/medullary canal mismatch after cephalomedullary nailing in unstable pertrochanteric fracture. A Finite Element Analysis Bone Joint Res 11(3):152–161
Sala C, Mercer D, DeCoster TA et al (2011) Experimental and probabilistic analysis of distal femoral periprosthetic fracture: a comparison of locking plate and intramedullary nail fixation Part a: Experimental investigation. Comput Methods Biomech Biomed Engin 14:157–164
Sala C, Mercer D, DeCoster TA et al (2011) Experimental and probabilistic analysis of distal femoral periprosthetic fracture: a comparison of locking plate and intramedullary nail fixation Part a: Experimental investigation. Comput Methods Biomech Biomed Engin 14:175–182
Wright DJ, DeSanto DJ, McGarry MH, Lee TQ, Scolaro JA (2020) Supplemental fixation of supracondylar distal femoral fractures: a biomechanical comparison of dual-plates and plate-nail constructs. J Orthop Trauma 34:434–440
Başcı O, Karakaşlı A, Kumtepe E, Güran O, Havıtçıoğlu H (2015) Combination of anatomical locking plate and retrograde intramedullary nail in distal femoral fractures: comparison of mechanical stability. Joint Dis Related Surg. 26(1):021–026
Fontenot PB, Diaz M, Stoops K, Barrick B, Santoni B, Mir H (2019) Supplementation of lateral locked plating for distal femur fractures: a biomechanical study. J Orthop Trauma 33:642–648
Koso RE, Terhoeve C, Steen RG, Zura R (2018) Healing, nonunion, and re-operation after internal fixation of diaphyseal and distal femoral fractures: a systematic review and meta-analysis. Int Orthop 42:2675–2683
Neradi D, Sodavarapu P, **dal K, Kumar D, Kumar V (2022) Locked plating versus retrograde intramedullary nailing for distal femur fractures: a systematic review and meta-analysis. Arch Bone Jt Surg 10(2):141–152
Yoon BH, Park IK, Kim Y, Oh HK, Choo SK, Sung YB (2021) Incidence of non union after surgery of distal femoral fractures using contemporary fixation device: a meta-analysis. Arch Orthop Trauma Surg 141:225–233
Dunbar RP, Egol KA, Jones CB, Ertl JP, Mullis B, Perez E, Collinge CA, Ostrum R, Humphrey C, Gardner MJ, Ricci WM (2022) Locked lateral plating vs. retrograde nailing for distal femur fractures: a prospective multicenter randomized trial. J Orthop Trauma 17:10–97
Salazar B, Babian AR, DeBaun MR, Githens MF, Chavez GA, Goodnough LH, Gardner MJ, Bishop JA (2021) Distal femur replacement versus surgical fixation for the treatment of geriatric distal femur fractures: a systematic review. J Orthop Trauma 35(1):2–9
Maloney G, Pan T, van Eck CF, Patel D, Tarkin I (2016) Geriatric distal femur fracture: are we underestimating the rate of local and systemic complications? Injury 47(8):1732–1736
Vemulapalli KC, Pechero GR, Warner SJ, Achor TS, Gary JL, Munz JW et al (2022) Is retrograde nailing superior to lateral locked plating foe complete articular distal femoral fractures? Injury 53(2):640–644
Claireaux HA, Searle HK, Parsons NR, Griffin XL (2022) Interventions for treating fractures of the distal femur in adults Cochrane database. Syst Rev 10(10):CD010606
Ryan R (2016) Cochrane consumers and communication review group: meta-analysis (Dec 2016) (available online at https://cccrg.cochrane.org/sites/cccrg.cochrane.org/files/public/uploads/meta-analysis_revised_december_1st_1_2016.pdf
Lee C, Brodke D, O’Hara N, Devana S, Hernandez A, Burke C et al (2023) Risk factors for reoperation to promote union in 1111 distal femur fractures. J Orthop Trauma 37(4):168–174
Scott JW (2001) Scott’s parabola. BMJ 323(7327):1477
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RE was involved in methodology, literature review, drafting of manuscript. LS helped in drafting/editing of manuscript. AT contributed to conceptualisation, literature review, study supervision.
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Espey, R., Stevenson, L. & Tucker, A. Combined nail-plate constructs in the management of osteoporotic native distal femoral fractures: a systematic review of the available evidence. Eur J Orthop Surg Traumatol 33, 3215–3223 (2023). https://doi.org/10.1007/s00590-023-03552-8
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DOI: https://doi.org/10.1007/s00590-023-03552-8