Are extreme distal periprosthetic supracondylar fractures of the femur too distal to fix using a lateral locked plate?

Abstract

It is unclear whether there is a limit to the amount of distal bone required to support fixation of supracondylar periprosthetic femoral fractures. This retrospective multicentre study evaluated lateral locked plating of periprosthetic supracondylar femoral fractures and compared the results according to extension of the fracture distal with the proximal border of the femoral prosthetic component. Between 1999 and 2008, 89 patients underwent lateral locked plating of a supracondylar periprosthetic femoral fracture, of whom 61 patients with a mean age of 72 years (42 to 96) comprising 53 women, were available after a minimum follow-up of six months or until fracture healing. Patients were grouped into those with fractures located proximally (28) and those with fractures that extended distal to the proximal border of the femoral component (33). Delayed healing and nonunion occurred respectively in five (18%) and three (11%) of more proximal fractures, and in two (6%) and five (15%) of the fractures with distal extension (p = 0.23 for delayed healing; p = 0.72 for nonunion, Fisher's exact test). Four construct failures (14%) occurred in more proximal fractures, and three (9%) in fractures with distal extension (p = 0.51). Of the two deep infections that occurred in each group, one resolved after surgical debridement and antibiotics, and one progressed to a nonunion. Extreme distal periprosthetic supracondylar fractures of the femur are not a contra-indication to lateral locked plating. These fractures can be managed with internal fixation, with predictable results, similar to those seen in more proximal fractures.

Predictive factors of distal femoral fracture nonunion after lateral locked plating: A retrospective multicenter case-control study of 283 fractures

“…Reports describing the use of LLP for the treatment of established nonunion may have also contributed to a perception that risk of nonunion with the use of locked plating was decreased when compared to retrograde nailing or alternative techniques [29][30][31][32]. More recently, though, concern has developed as the reported rates of nonunion after LLP fixation of distal femur fractures now vary over the larger range of 0-21% and problems with healing have been reported to be as high as 32% in a recently published review of the literature [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19]. Another recent study reports worse outcomes with LLP than with the standard 95-degree-angled blade plate in the treatment of distal femur fractures [20].…”

“…Initial studies using LLP reported promising outcomes with nonunion rates in the range of 0-14% but mostly fewer than 6% [2][3][4][5][6][7][8][9][10][11][12][13][14][15]. However, in recent years, initial success rates have given way to more concerning outcomes with reported nonunion rates reaching as high as 17-21%, with reports of decreased callus formation, problems with healing of up to 32%, and other complications [16][17][18][19][20]. The increase in reported nonunion rates is of recent interest.…”

Periprosthetic Distal Femur Fractures: Review of Current Treatment Options

“…Streusel et al compared PDFF fixation with distal femoral locking plates in fractures proximal to the femoral component in 28 patients and in 33 patients where the fracture propagated distal to the well-fixed component. No difference was observed in malunion, nonunion, delayed healing, hardware failure, or infection; thus demonstrating the utility of locking screws in extreme distal PDFF [31]. Importantly, the use of minimally invasive techniques have demonstrated higher union rates, earlier return to pre-injury functional status, and fewer soft-tissue complications [26,32,33].…”

Periprosthetic Fractures after Total Knee Arthroplasty

“…Extreme distal periprosthetic supracondylar fractures can be adequately fixed using a lateral locking plate. 46 Periprosthetic patellar fractures are not common.…”