Aims. Debate continues regarding the optimum management of periprosthetic distal femoral fractures (PDFFs). This study aims to determine which operative treatment is associated with the lowest perioperative morbidity and mortality when treating low (Su type II and III) PDFFs comparing lateral locking plate fixation (LLP-ORIF) or distal femoral arthroplasty (DFA). Methods. This was a retrospective cohort study of 60 consecutive unilateral (PDFFs) of Su types II (40/60) and III (20/60) in patients aged ≥ 60 years: 33 underwent LLP-ORIF (mean age 81.3 years (SD 10.5), BMI 26.7 (SD 5.5); 29/33 female); and 27 underwent DFA (mean age 78.8 years (SD 8.3); BMI 26.7 (SD 6.6); 19/27 female). The primary outcome measure was reoperation. Secondary outcomes included perioperative complications, calculated blood loss, transfusion requirements, functional mobility status, length of acute hospital stay, discharge destination and mortality. Kaplan-Meier survival analysis was performed. Cox multivariate regression analysis was performed to identify risk factors for reoperation after LLP-ORIF. Results. Follow-up was at mean 3.8 years (1.0 to 10.4). One-year mortality was 13% (8/60). Reoperation was more common following LLP-ORIF: 7/33 versus 0/27 (p = 0.008). Five-year survival for reoperation was significantly better following DFA; 100% compared to 70.8% (95% confidence interval (CI) 51.8% to 89.8%, p = 0.006). There was no difference for the endpoint mechanical failure (including radiological loosening); ORIF 74.5% (56.3 to 92.7), and DFA 78.2% (52.3 to 100, p = 0.182). Reoperation following LLP-ORIF was independently associated with medial comminution; hazard ratio (HR) 10.7 (1.45 to 79.5, p = 0.020). Anatomical reduction was protective against reoperation; HR 0.11 (0.013 to 0.96, p = 0.046). When inadequately fixed fractures were excluded, there was no difference in five-year survival for either reoperation (p = 0.156) or mechanical failure (p = 0.453). Conclusion. Absolute reoperation rates are higher following LLP fixation of low PDFFs compared to DFA. Where LLP-ORIF was well performed with augmentation of medial comminution, there was no difference in survival compared to DFA. Though necessary in very low fractures, DFA should be used with caution in patients with greater life expectancies due to the risk of longer term aseptic loosening. Cite this article: Bone Joint J 2021;103-B(4):635–643

Aims. Several 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. Methods. We 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. Results. We were able to include 299 fractures in 291 patients. Altogether, 31/299 fractures (10%) developed nonunion. In the first analysis, pseudo-R. 2. 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-R. 2. was 0.06 and AUC was 0.67. Plate length was the most important variable in the prediction. Conclusion. The 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. Cite this article: Bone Jt Open 2023;4(8):584–593

Aims. This study assessed the impact of COVID-19 on hip and distal femur fracture patient outcomes across three successive UK lockdown periods over one year. Methods. A single-centre retrospective cohort study was performed at an acute NHS Trust. Hip and distal femur fracture patients admitted within the first month from each of the three starting dates of each national lockdown were included and compared to a control group in March 2019. Data were collected as per the best practice tariff outcomes including additional outcomes as required. Data collection included COVID-19 status, time to theatre, 30-day mortality, presence of acute kidney injury (AKI) and pneumonia, and do not attempt cardiopulmonary resuscitation (DNACPR) status. Data were analyzed using an independent-samples t-test or chi-squared test with Fisher’s exact test where applicable. A p-value of < 0.05 was considered statistically significant. Results. A total of 95 patients during the pandemic were included and 20 were COVID-positive. Patients experienced a statistically significant increase in time to theatre in Lockdown 1 compared to 2019 (p = 0.039) with a decrease with successive lockdown periods by Lockdown 3. The 30-day mortality increased from 8.8% in 2019 to 10.0% to 14.8% in all lockdown periods. COVID-positive patient mortality was 30.0% (p = 0.063, odds ratio (OR) = 4.43 vs 2019). The rates of AKI and pneumonia experienced were higher for patients during the pandemic. The highest rates were experienced in COVID-positive patients, with 45.0% of patients with AKI versus 27.0% in 2019 (p = 0.38, OR = 1.80), and 50.0% of patients diagnosed with pneumonia versus 16.2% in 2019 (p = 0.0012, OR = 5.17). The percentage of patients with a DNACPR increased from 30.0% in 2019 to 60.7% by Lockdown 3 (p = 0.034, OR = 3.61). Conclusion. COVID-positive hip and distal femur fracture patients are at a higher risk of mortality due to AKI and pneumonia. Patient outcomes have improved with successive lockdowns to pre-pandemic levels. Cite this article: Bone Jt Open 2021;2(12):1017–1026

Introduction. Distal femur fracture fixation in elderly presents significant challenges due to osteoporosis and associated comorbidities. There has been an evolution in the management of these fractures with a description of various surgical techniques and fixation methods; however, currently, there is no consensus on the standard of care. Non-union rates of up to 19% and mortality rates of up to 26 % at one year have been reported in the literature. Delay in surgery and delay in mobilisation post-operatively have been identified as two main factors for high rate of mortality. As biomechanical studies have proved better stability with dual plating or nail-plate combination, a trend has been shifting for past few years towards rigid fixation to allow early mobilisation. Our study aims to compare outcomes of distal femur fractures managed with either single plate (SP), dual plating (DP) or nail-plate construct (NP). Methods. A retrospective review of patients aged above 65 years with distal femur fractures (both native and peri-prosthetic) who underwent surgical management between June 2020 and May 2023 was conducted. Patients were divided into three groups based on mode of fixation - single plate or dual plating or nail-plate construct. AO/OTA classification was used for non-periprosthetic, and Unified classification system (UCS) was used for periprosthetic fractures. Data on patient demographics, fracture characteristics, surgical details, postoperative complications, re-operation rate, radiological outcomes and mortality rate were evaluated. Primary objective was to compare re-operation rate and mortality rate between 3 groups at 30 days, 6 months and at 1 year. Results. A cohort of 32 patients with distal femur fractures were included in this study. 91% were females and mean age was 80.97 (range 68–97). 18 (53%) were non-periprosthetic fracture and 14 (47%) were periprosthetic fractures.18 patients underwent single plate fixation (AO/OTA 33A – 8, 33B/C – 2, UCS V3B – 5, V3C – 3),10 patients had dual plate fixation (AO/OTA 33A – 1, 33B/C – 4, UCS V3B – 3, V3C – 2) and 4 patients underwent nail-plate combination fixation (AO/OTA 33A – 4). 70.5% patients had surgery within 36 hours of admission and 90% within 48 hours. Analysis showed no re-operation at 30 days, 6 months in all 3 groups. At 1 year one patient had re-operation in dual-plating periprosthetic group (Distal femur replacement done for failed fixation). Three patients (16%) in single plate group had re-operation at 2 years (2 for peri-implant fracture and 1 for infection). None of the patients treated with Nail-plate combination had re-operation. Mortality rate at 30 days was 0% in among all the 3 groups. At 6 months, it was 16% in single plate group and 0% in DP and NP groups at 6 months and at 1 year mortality rate was 27% in SP group, 10% in DP and 0% in NP group. Combined mortality rate was 0% at 30 days, 9% at 6 months and 18.7% at one year. Conclusion. Our analysis provides insights into fixation methods of distal femur fractures in elderly patients. We conclude that a lower re-operation rate and mortality rate can be achieved with early surgery and rigid fixation with either dual plating or nail-plate construct to allow early mobilisation. Further prospective studies are warranted to confirm these findings and guide the selection of optimal surgical strategies for these challenging fractures

Aims. The purpose of this study was to compare reoperation and revision rates of double plating (DP), single plating using a lateral locking plate (SP), or distal femoral arthroplasty (DFA) for the treatment of periprosthetic distal femur fractures (PDFFs). Methods. All patients with PDFF primarily treated with DP, SP, or DFA between 2008 and 2022 at a university teaching hospital were included in this retrospective cohort study. The primary outcome was revision surgery for failure following DP, SP, or DFA. Secondary outcome measures included any reoperation, length of hospital stay, and mortality. All basic demographic and relevant implant and injury details were collected. Radiological analysis included fracture classification and evaluation of metaphyseal and medial comminution. Results. A total of 111 PDFFs (111 patients, median age 82 years (interquartile range (IQR) 75 to 88), 86% female) with 32 (29%) Su classification 1, 37 (34%) Su 2, and 40 (37%) Su 3 fractures were included. The median follow-up was 2.5 years (IQR 1.2 to 5.0). DP, SP, and DFA were used in 15, 66, and 30 patients, respectively. Compared to SP, patients treated with DP were more likely to have metaphyseal comminution (47% vs 14%; p = 0.009), to be low fractures (47% vs 11%; p = 0.009), and to be anatomically reduced (100% vs 71%; p = 0.030). Patients selected for DFA displayed comparable amounts of medial/metaphyseal comminution as those who underwent DP. At a minimum follow-up of two years, revision surgery for failure was performed in 11 (9.9%) cases at a median of five months (IQR 2 to 9): 0 DP patients (0%), 9 SP (14%), and 2 DFA (6.7%) (p = 0.249). Conclusion. Using a strategy of DP fixation in fractures, where the fracture was low but there was enough distal bone to accommodate locking screws, and where there is metaphyseal comminution, resulted in equivalent survival free from revision or reoperation compared to DFA and SP fixation. Cite this article: Bone Jt Open 2024;5(6):489–498

Aims. Postoperative malalignment of the femur is one of the main complications in distal femur fractures. Few papers have investigated the impact of intraoperative malalignment on postoperative function and bone healing outcomes. The aim of this study was to investigate how intraoperative fracture malalignment affects postoperative bone healing and functional outcomes. Methods. In total, 140 patients were retrospectively identified from data obtained from a database of hospitals participating in a trauma research group. We divided them into two groups according to coronal plane malalignment of more than 5°: 108 had satisfactory fracture alignment (< 5°, group S), and 32 had unsatisfactory alignment (> 5°, group U). Patient characteristics and injury-related factors were recorded. We compared the rates of nonunion, implant failure, and reoperation as healing outcomes and Knee Society Score (KSS) at three, six, and 12 months as functional outcomes. We also performed a sub-analysis to assess the effect of fracture malalignment by plates and nails on postoperative outcomes. Results. The rates of nonunion and reoperation in group U were worse than those in group S (25.0% vs 14.3%; 15.6% vs 5.6%), but the differences were not significant (p = 0.180 and p = 0.126, respectively). Mean KSS in group U at all follow-up periods was significantly worse that in group S (75.7 (SD 18.8) vs 86.0 (SD 8.7); p < 0.001; 78.9 (SD 17.2) vs 89.1 (SD 9.8); p < 0.001; 85.0 (SD 11.9) vs 91.1 (SD 7.2); p = 0.002, respectively). In the sub-analysis of plates, mean KSS was significantly worse in group U at three and six months. In the sub-analysis of nails, the rate of reoperation was significantly higher in group U (28.6% vs 5.8%; p = 0.025), and mean KSS at six and 12 months was significantly worse in Group U. Conclusion. To obtain good postoperative functional results, intraoperative alignment of the coronal plane should be accurately restored to less than 5°. Cite this article: Bone Jt Open 2022;3(2):165–172

Introduction. The incidence of distal femoral fractures amongst elderly patients is likely to rise due to increased life expectancy. This study reports on the outcome of a series of distal femoral fractures treated by retrograde femoral nailing and then to compare the results for these patients with a series of patients with a proximal femoral fracture. Materials and/Methods. In this longitudinal cohort study, 36 patients with extra-articular distal femoral fractures were treated with a solid retrograde femoral nail. Data was collected prospectively and then compared to proximal femoral fractures (2426) treated by the same surgeon treated over the same time period. Results. Within the distal femoral group 97% of the patients were female, with a mean age of 81 years. The mean length of hospital stay amongst the distal femoral group was slightly higher (19 days) compared to the proximal femoral group (18 days). All the post-operative complications were higher amongst the distal femoral group which included deep vein thrombosis 8% vs 2%, pneumonia 5% vs 3%, superficial wound infection 5% vs 3% and deep wound infection 2% vs 1%. 5% of patients in the proximal femoral group required revision surgery whereas none in the distal femoral group did. The survival analysis curve indicated to an increased trend in mortality amongst the distal femoral group however due to the small sample size this did not reach statistical significance. Conclusions. Our study shows that there is a significant morbidity and mortality amongst patients who have sustained a distal femoral fracture. Given the significant risk that elderly patients have we propose that distal femoral fractures should be treated with prompt surgical fixation with an emphasis on early rehabilitation and safe discharge

Although the use of constrained cemented arthroplasty to treat distal femoral fractures in elderly patients has some practical advantages over the use of techniques of fixation, concerns as to a high rate of loosening after implantation of these prostheses has raised doubts about their use. We evaluated the results of hinged total knee replacement in the treatment of 54 fractures in 52 patients with a mean age of 82 years (55 to 98), who were socially dependent and poorly mobile. Within the first year after implantation 22 of the 54 patients had died, six had undergone a further operation and two required a revision of the prosthesis. The subsequent rate of further surgery and revision was low. A constrained knee prosthesis offers a useful alternative treatment to internal fixation in selected elderly patients with these fractures, and has a high probability of surviving as long as the patient into whom it has been implanted

Aims. The aim of this study was to assess the feasibility of conducting a full-scale, appropriately powered, randomized controlled trial (RCT) comparing internal fracture fixation and distal femoral replacement (DFR) for distal femoral fractures in older patients. Patients and Methods. Seven centres recruited patients into the study. Patients were eligible if they were greater than 65 years of age with a distal femoral fracture, and if the surgeon felt that they were suitable for either form of treatment. Outcome measures included the patients’ willingness to participate, clinicians’ willingness to recruit, rates of loss to follow-up, the ability to capture data, estimates of standard deviation to inform the sample size calculation, and the main determinants of cost. The primary clinical outcome measure was the EuroQol five-dimensional index (EQ-5D) at six months following injury. Results. Of 36 patients who met the inclusion criteria, five declined to participate and eight were not recruited, leaving 23 patients to be randomized. One patient withdrew before surgery. Of the remaining patients, five (23%) withdrew during the follow-up period and six (26%) died. A 100% response rate was achieved for the EQ-5D at each follow-up point, excluding one missing datapoint at baseline. In the DFR group, the mean cost of the implant outweighed the mean cost of many other items, including theatre time, length of stay, and readmissions. For a powered RCT, a total sample size of 1400 would be required with 234 centres recruiting over three years. At six months, the EQ-5D utility index was lower in the DFR group. Conclusion. This study found that running a full-scale trial in this country would not be feasible. However, it may be feasible to undertake an international multicentre trial, and our findings provide some guidance about the power of such a study, the numbers required, and some challenges that should be anticipated and addressed. Cite this article: Bone Joint J 2019;101-B:1408–1415

The augmentation of fixation with bone cement is increasingly being used in the treatment of severe osteoporotic fractures. We investigated the influence of bone quality on the mechanics of augmentation of plate fixation in a distal femoral fracture model (AO 33 A3 type). Eight osteoporotic and eight non-osteoporotic femoral models were randomly assigned to either an augmented or a non-augmented group. Fixation was performed using a locking compression plate. In the augmented group additionally 1 ml of bone cement was injected into the screw hole before insertion of the screw. Biomechanical testing was performed in axial sinusoidal loading. Augmentation significantly reduced the cut-out distance in the osteoporotic models by about 67% (non-augmented mean 0.30 mm (. sd. 0.08) vs augmented 0.13 mm (. sd. 0.06); p = 0.017). There was no statistical reduction in this distance following augmentation in the non-osteoporotic models (non-augmented mean 0.15 mm (. sd. 0.02) vs augmented 0.15 mm (. sd. 0.07); p = 0.915). In the osteoporotic models, augmentation significantly increased stability (p = 0.017). Cite this article: Bone Joint J 2013;95-B:1406–9

Helical plates potentially bypass the medial neurovascular structures of the thigh. Recently, two plate designs (90°- and 180°-helix) proved similar biomechanically behaviour compared to straight plates. Aims of this study were: (1) Feasibility of MIPO-technique with 90°- and 180°-helical plates on the femur, (2) Assessment of distances to adjacent anatomical structures at risk, (3) Comparison of these distances to using medial straight plates instead, (4) Correlation of measurements performed in anatomic dissection with CT-angiography.

MIPO was performed in ten cadaveric femoral pairs using either a 90°-helical 14-hole-LCP (Group1) or a 180°-helical 15-hole-LCP-DF (Group2). CT angiography was used to evaluate the distances between the plates and the femoral arteries as well as the distances between the plates and the perforators. Subsequently, the specimens were dissected, and the distances were determined again manually. Finally, all helical plates were removed, and all measurements were repeated after application of straight medial plates (Group3).

Closest overall distances between plates and femoral arteries were 15 mm (11 − 19 mm) in Group1, 22 mm (15 − 24 mm) in Group2 and 6 mm (1 − 8 mm) in Group3 with a significant difference between Group1 and Group3 (p < 0.001). Distances to the nearest perforators were 24 mm (15 − 32 mm) in Group1 and 2 mm (1 − 4 mm) in Group2. Measurement techniques (visual after surgery and CT-angiography) demonstrated a strong correlation of r² = 0.972 (p < 0.01).

MIPO with 90°- and 180°-helical plates is feasible and safe. Attention must be paid to the medial neurovascular structures with 90°-helical implants and to the proximal perforators with 180°-helical implants. Helical implants can avoid medial neurovascular structures compared to straight plates although care must be taken during their distal insertion. Measurements during anatomical dissection correlate with CT-angiography.

Purpose: surgical fixation distal femoral fractures has been associated withnonunion and varus collapse. the soft tissue stripping esulted from this fracture and caused by the surgical approach have been factorassociated with delayed union and infection. the limited soft tissue exposure has been lauded as a solution to this fracture. however, it has occurred with new fixation as well (locked plate) this study is an attempt to look at the fixation from the surgical approach prospective. does the liss system improve the results of this difficult fracture? is there truly a difference in the outcome of this fracture utilizing the locked plate system or the percieved difference due to surgical mini invasive approach. Method: one hundred and forty patientswere screened, and only 53 were randomized and treated in six academic centers over five years. all c3 fractures were excluded from the study as they were felt not to be treatable by the dcs device, but they were treated and fixed appropiately. thirty five females and 18 males were included and appropiately randomized. Results: fifty three patients were randomized, 28 had the liss implant while 25 had the dcs utilized. there were three nonunions in the liss group, plus two patients required an early reoperation in the early post operative periods ( second – fifth post op. day) due to an early loss of reduction. further more, one patient developed a knee arthrofibrosis that required arthroscopic joint release with subsequent implant failure. that necessiated a reoperation. in the dcs group there was only one nonunion, that required reoperation. this translated into reoperation rate of 21%in the liss group compared to 4% with dcs. Conclusion: this prospective multicenter randomized trial showeda significant difference when comparing the liss device to the dcs system in minimal invasive approach of distal femoral fractures fixation

Aims

The aim of this study was to investigate the rate of revision for distal femoral arthroplasty (DFA) performed as a primary procedure for native knee fractures using data from the Australian Orthopaedic Association National Joint Arthroplasty Registry (AOANJRR).

This multi-center randomized prospective trial examined fixation for distal femoral fractures by standardizing the surgical approach as minimally invasive. Fifty three patients at six Canadian trauma centers were randomized via the Lead Centre (Halifax Infirmary, Dal-housie University, Halifax, CANADA) into 2 groups of 28 LISS and 25 DCS respectively. The AO C3 group was excluded from randomization. In the LISS group, three fractures went on to non-union and two fractures were complicated by early loss of fixation. A further LISS patient had removal of all metalwork when removal of individual prominent screws proved impossible due to cold-welding. In the DCS group, one fracture was complicated by non-union. The difference between the two groups proved very statistically significant. (P< 0.05). In this trial, the LISS proved more technically demanding and a higher re-operation rate was evident. At the Lead Centre, the LISS has been abandoned in favor of the DCS or LCP Condylar Plate performed via a minimally invasive approach

We discuss the role of primary knee arthroplasty in supracondylar and intercondylar fractures of the femur in elderly patients with reference to 13 cases. This method of treatment is shown to be effective and to have good results. It is recommended for all type C and some type A supracondylar fractures in old people.

Aims

Fractures of the distal femur can be challenging to manage and are on the increase in the elderly osteoporotic population. Management with casting or bracing can unacceptably limit a patient’s ability to bear weight, but historically, operative fixation has been associated with a high rate of re-operation. In this study, we describe the outcomes of fixation using modern implants within a strategy of early return to function.

The April 2024 Trauma Roundup. 360. looks at: The infra-acetabular screw in acetabular fracture surgery; Is skin traction helpful in patients with intertrochanteric hip fractures?; Reducing pain and improving function following hip fracture surgery; Are postoperative splints helpful following ankle fracture fixation?; Biomechanics of internal fixation in Hoffa fractures: a comparison of four different constructs; Dual-plate fixation of periprosthetic distal femur fractures; Do direct oral anticoagulants necessarily mean a delay to hip fracture surgery?; Plate or retrograde nail for low distal femur fractures?

Aims. Endoprosthetic reconstruction with a distal femoral arthroplasty (DFA) can be used to treat distal femoral bone loss from oncological and non-oncological causes. This study reports the short-term implant survivorship, complications, and risk factors for patients who underwent DFA for non-neoplastic indications. Methods. We performed a retrospective review of 75 patients from a single institution who underwent DFA for non-neoplastic indications, including aseptic loosening or mechanical failure of a previous prosthesis (n = 25), periprosthetic joint infection (PJI) (n = 23), and native or periprosthetic distal femur fracture or nonunion (n = 27). Patients with less than 24 months’ follow-up were excluded. We collected patient demographic data, complications, and reoperations. Reoperation for implant failure was used to calculate implant survivorship. Results. Overall one- and five-year implant survivorship was 87% and 76%, respectively. By indication for DFA, mechanical failure had one- and five-year implant survivorship of 92% and 68%, PJI of 91% and 72%, and distal femur fracture/nonunion of 78% and 70% (p = 0.618). A total of 37 patients (49%) experienced complications and 27 patients (36%) required one or more reoperation. PJI (n = 16, 21%), aseptic loosening (n = 9, 12%), and wound complications (n = 8, 11%) were the most common complications. Component revision (n = 10, 13.3%) and single-stage exchange for PJI (n = 9, 12.0 %) were the most common reoperations. Only younger age was significantly associated with increased complications (mean 67 years (SD 9.1)) with complication vs 71 years (SD 9.9) without complication; p = 0.048). Conclusion. DFA is a viable option for distal femoral bone loss from a range of non-oncological causes, demonstrating acceptable short-term survivorship but with high overall complication rates. Cite this article: Bone Jt Open 2022;3(3):173–181

The management of periprosthetic distal femur fractures is an issue of increasing importance for orthopaedic surgeons. Because of the expanding indications for total knee arthroplasty (TKA) and an aging population with increasingly active lifestyles there has been a corresponding increase in the prevalence of these injuries. The management of these fractures is often complex because of issues with obtaining fixation around implants and dealing with osteopenic bone or compromised bone stock. In addition, these injuries frequently occur in frail, elderly patients, and the early restoration of function and ambulation is critical in these patients. There remains substantial controversy with respect to the optimal treatment of periprosthetic distal femur fractures, with some advocating for Locked Plating (LP), others Retrograde Intramedullary Nailing (RIMN) and finally those who advocate for Distal Femoral Replacement (DFR). The literature comparing these treatments, has been infrequent, and commonly restricted to single-center studies. The purpose of this study was to retrospectively evaluate a large series of operatively treated periprosthetic distal femur fractures from multiple centers and compare treatment strategies. Patients who were treated operatively for a periprosthetic distal femur fracture at 8 centers across North America between 2003 and 2018 were retrospectively identified. Baseline characteristics, surgical details and post-operative clinical outcomes were collected from patients meeting inclusion criteria. Inclusion criteria were patients aged 18 and older, any displaced operatively treated periprosthetic femur fracture and documented 1 year follow-up. Patients with other major lower extremity trauma or ipsilateral total hip replacement were excluded. Patients were divided into 3 groups depending on the type of fixation received: Locked Plating, Retrograde Intramedullary Nailing and Distal Femoral Replacement. Documented clinical follow-up was reviewed at 2 weeks, 3 months, 6 months and 1 year following surgery. Outcome and covariate measures were assessed using basic descriptive statistics. Categorical variables, including the rate of re-operation, were compared across the three treatment groups using Fisher Exact Test. In total, 121 patients (male: 21% / female: 79%) from 8 centers were included in our analysis. Sixty-seven patients were treated with Locked Plating, 15 with Retrograde Intramedullary Nailing, and 39 were treated with Distal Femoral Replacement. At 1 year, 64% of LP patients showed radiographic union compared to 77% in the RIMN group (p=0.747). Between the 3 groups, we did not find any significant differences in ambulation, return to work and complication rates at 6 months and 1 year (Table 1). Reoperation rates at 1 year were 27% in the LP group (17 reoperations), 16% in the DFR group (6 reoperations) and 0% in the RIMN group. These differences were not statistically significant (p=0.058). We evaluated a large multicenter series of operatively treated periprosthetic distal femur fractures in this study. We did not find any statistically significant differences at 1 year between treatment groups in this study. There was a trend towards a lower rate of reoperation in the Retrograde Intramedullary Nailing group that should be evaluated further with prospective studies. For any figures or tables, please contact the authors directly

The June 2023 Trauma Roundup. 360. looks at: Aspirin or low-molecular-weight heparin for thromboprophylaxis?; Lateral plating or retrograde nailing for distal femur fractures?; Sciatic nerve palsy after acetabular fixation: what about patient position?; How reliable is the new OTA/AO classification for trochanteric hip fractures?; Young hip fractures: is a medial buttress the answer?; When is the best time to ‘flap’ an open fracture?; The mortality burden of nonoperatively managed hip fractures

The December 2023 Trauma Roundup. 360. looks at: Distal femoral arthroplasty: medical risks under the spotlight; Quads repair: tunnels or anchors?; Complex trade-offs in treating severe tibial fractures: limb salvage versus primary amputation; Middle-sized posterior malleolus fractures – to fix?; Bone transport through induced membrane: a randomized controlled trial; Displaced geriatric femoral neck fractures; Risk factors for reoperation to promote union in 1,111 distal femur fractures; New versus old – reliability of the OTA/AO classification for trochanteric hip fractures; Risk factors for fracture-related infection after ankle fracture surgery

Abstract. Introduction. Distal Femoral Fractures around a Total Knee Replacement have a reported incidence of 0.25–2.3% of primary TKRs. Literature suggests that these fractures have high complication rates such as non union and revision. Methodology. A retrospective case note review was undertaken of all patients who sustained a distal femoral fracture around a TKR from April 2014-April 2021. Data parameters collected included patient demographics, classification of fracture, management, post op mobility, fracture union and mortality. Results. 52 distal femoral fractures were recorded, out of which 5 patients had bilateral fractures. The average age was 83.6 years (61–101). 41 fractures were managed operatively with 61% undergoing ORIF, 37% undergoing Distal Femoral Replacement & 2% undergoing a retrograde IM Nail. The median LOS was 22 days (11–85) for patients treated with DFR versus 10 (3–75) for those undergoing an ORIF. 60% of DFR patients were discharged home compared to 56% of those who underwent an ORIF. All the DFR patients were FWB post op compared to ORIF 24%. Conclusion. Over a 7 year study period, 52 distal femoral fractures were reviewed. Despite FWB status post op, patients undergoing a DFR had a longer length of stay and less were discharged home compared to the ORIF group. Given the cost of a distal femoral replacement (£4485-6500) compared to £212-297 for a locking plate, in order to get patients FWB post operatively potentially dual plating (medial and lateral) may need to be considered if the fracture is amenable to improve stability & allow FWB

The April 2023 Trauma Roundup. 360. looks at: Displaced femoral neck fractures in patients aged 55 to 70 years: internal fixation or total hip arthroplasty?; Tibial plateau fractures: continuous passive motion approves range of motion; Lisfranc fractures: to fuse or not to fuse, that is the question; Is hardware removal after clavicle fracture plate fixation beneficial?; Fixation to coverage in Grade IIIB open fractures – what’s the time window?; Nonoperative versus locking plate fixation in the proximal humerus; Retrograde knee nailing or lateral plate for distal femur fractures?

The June 2024 Trauma Roundup. 360. looks at: Skin antisepsis before surgical fixation of limb fractures; Comparative analysis of intramedullary nail versus plate fixation for fibula fracture in supination external rotation type IV ankle injury; Early weightbearing versus late weightbearing after intramedullary nailing for distal femoral fracture (AO/OTA 33) in elderly patients: a multicentre propensity-matched study; Long-term outcomes with spinal versus general anaesthesia for hip fracture surgery; Operative versus nonoperative management of unstable medial malleolus fractures: a randomized clinical trial; Impact of smoking status on fracture-related infection characteristics and outcomes; Reassessing empirical antimicrobial choices in fracture-related infections; Development and validation of the Nottingham Trauma Frailty Index (NTFI) for older trauma patients

This edition of Cochrane Corner looks at some of the work published by the Cochrane Collaboration, covering interventions for treating distal femur fractures in adults; ultrasound and shockwave therapy for acute fractures in adults; and local corticosteroid injection versus placebo for carpal tunnel syndrome

Introduction and Objective. Distal femoral fractures are commonly treated with a straight plate fixed to the lateral aspects of both proximal and distal fragments. However, the lateral approach may not always be desirable due to persisting soft-tissue or additional vascular injury necessitating a medial approach. These problems may be overcome by pre-contouring the plate in helically shaped fashion, allowing its distal part to be fixed to the medial aspect of the femoral condyle. The objective of this study was to investigate the biomechanical competence of medial femoral helical plating versus conventional straight lateral plating in an artificial distal femoral fracture model. Materials and Methods. Twelve left artificial femora were instrumented with a 15-hole Locking Compression Plate – Distal Femur (LCP-DF) plate, using either conventional lateral plating technique with the plate left non-contoured, or the medial helical plating technique by pre-contouring the plate to a 180° helical shape and fixing its distal end to the medial femoral condyle (n=6). An unstable extraarticular distal femoral fracture was subsequently simulated by means of an osteotomy gap. All specimens were tested under quasi-static and progressively increasing cyclic axial und torsional loading until failure. Interfragmentary movements were monitored by means of optical motion tracking. Results. Initial axial stiffness was significantly higher for helical (185.6±50.1 N/mm) versus straight (56.0±14.4) plating, p<0.01. However, initial torsional stiffness in internal and external rotation remained not significantly different between the two fixation techniques (helical plating:1.59±0.17 Nm/° and 1.52±0.13 Nm/°; straight plating: 1.50±0.12 Nm/° and 1.43±0.13Nm/°), p≥0.21. Helical plating was associated with significantly higher initial interfragmentary movements under 500 N static compression compared to straight plating in terms of flexion (2.76±1.02° versus 0.87±0.77°) and shear displacement under 6 Nm static rotation in internal (1.23±0.28° versus 0.40±0.42°) and external (1.21±0.40° versus 0.57±0.33°) rotation, p≤0.01. In addition, helical plating demonstrated significantly lower initial varus/valgus deformation than straight plating (4.08±1.49° versus 6.60±0.47°), p<0.01. Within the first 10000 cycles of dynamic loading, helical plating revealed significantly bigger flexural movements and significantly lower varus/valgus deformation versus straight plating, p=0.02. No significant differences were observed between the two fixation techniques in terms of axial and shear displacement, p≥0.76. Cycles to failure was significantly higher for helical plating (13752±1518) compared to straight plating (9727±836), p<0.01. Conclusions. Although helical plating using a pre-contoured LCP-DF was associated with higher shear and flexion movements, it demonstrated improved initial axial stability and resistance against varus/valgus deformation compared to straight lateral plating. Moreover, helical plate constructs demonstrated significantly improved endurance to failure, which may be attributed to the less progressively increasing lever bending moment arm inherent to this novel fixation technique. From a biomechanical perspective, helical plating may be considered as a valid alternative fixation technique to standard straight lateral plating of unstable distal femoral fractures

With an aging population and increase in total knee arthroplasty, periprosthetic distal femur fractures (PDFFs) have increased. The differences between these fractures and native distal femur fractures (NDFF) have not been comprehensively investigated. The purpose of this study was to compare the demographic, fracture, and treatment details of PDFFs compared to NDFFs. A retrospective study of patients ≥ 18 years old who underwent surgical treatment for either a NDFF or a PDFF from 2010 to 2020 at a level 1 trauma center was performed. Demographics, AO/OTA fracture classification, quality of reduction, fixation constructs, and unplanned revision reoperation were compared between PDFF patients and NDFF patients using t-test and Fisher's exact test. 209 patients were identified with 70 patients having a PDFF and 139 patients having a NDFF. Of note, 48% of NDFF had a concomitant fracture of the ipsilateral knee (14%) or tibial plateau (15%). The most common AO/OTA classification for PDFFs was 33A3.3 (71%). NDFFs had two main AO/OTA classifications of 33C2.2 (28%) or 33A3.2. (25%). When controlling for patient age, bone quality, fracture classification, and fixation, the PDFF group had increased revision reoperation rate compared to NDFF (P < 0.05). PDFFs tend to occur in elderly patients with low bone quality, have complete metaphyseal comminution, and be isolated; whereas, NDFF tend to occur in younger patients, have less metaphyseal comminution, and be associated with other fractures. When controlling for variables, PDFF are at increased risk of unplanned revision reoperation. Surgeons should be aware of these increased risks in PDFFs and future research should focus on these unique fracture characteristics to improve outcomes

Aims. The aim of this study was to report the patterns of symptoms and insufficiency fractures in patients with tumour-induced osteomalacia (TIO) to allow the early diagnosis of this rare condition. Methods. The study included 33 patients with TIO who were treated between January 2000 and June 2022. The causative tumour was detected in all patients. We investigated the symptoms and evaluated the radiological patterns of insufficiency fractures of the rib, spine, and limbs. Results. The mean age of the patients was 57 years (24 to 87), and the mean duration of pain from onset to time of presentation was 3.9 years (0.75 to 23). The primary symptoms were low back pain (ten patients), chest wall pain (eight patients), and hip pain (eight patients). There were symptoms at more sites at the time of presentation compared with that at the time of the onset of symptoms. Bone scans showed the uptake of tracer in the rib (100%), thoracic and lumbar vertebrae (83%), proximal femur (62%), distal femur (66%), and proximal tibia (72%). Plain radiographs or MRI scans identified femoral neck fractures in 14 patients, subchondral insufficiency fractures of the femoral head and knee in ten and six patients, respectively, distal femoral fractures in nine patients, and proximal tibial fractures in 12 patients. Thoracic or lumbar vertebral fractures were identified in 23 of 29 patients (79.3%) when using any imaging study, and a biconcave deformity was the most common type of fracture. Conclusion. Insufficiency fractures in patients with TIO caused spinal pain, chest wall pain, and periarticular pain in the lower limbs. Vertebral fractures tended to be biconcave deformities, and periarticular fractures of the hips and knees included subchondral insufficiency fractures and epiphyseal or metaphyseal fractures. In patients with a tumour, the presence of one or more of these symptoms and an insufficiency fracture should suggest the diagnosis of TIO. Cite this article: Bone Joint J 2023;105-B(5):568–574

The objective of this study was to use patient-specific finite element modeling to measure the 3D interfragmentary strain environment in clinically realistic fractures. The hypothesis was that in the early post-operative period, the tissues in and around the fracture gap can tolerate a state of strain in excess of 10%, the classical limit proposed in the Perren strain theory. Eight patients (6 males, 2 females; ages 22–95 years) with distal femur fractures (OTA/AO 33-A/B/C) treated in a Level I trauma center were retrospectively identified. All were treated with lateral bridge plating. Preoperative computed tomography scans and post-operative X-rays were used to create the reduced fracture models. Patient-specific materials properties and loading conditions (20%, 60%, and 100% body weight (BW)) were applied following our published method.[1]. Elements with von Mises strains >10% are shown in the 100% BW loading condition. For all three loading scenarios, as the bridge span increased, so did the maximum von Mises strain within the strain visualization region. The average gap closing (Perren) strain (mean ± SD) for all patient-specific models at each body weight (20%, 60%, and 100%) was 8.6% ± 3.9%, 25.8% ± 33.9%, and 39.3% ± 33.9%, while the corresponding max von Mises strains were 42.0% ± 29%, 110.7% ± 32.7%, and 168.4% ± 31.9%. Strains in and around the fracture gap stayed in the 2–10% range only for the lowest load application level (20% BW). Moderate loading of 60% BW and above caused gap strains that far exceeded the upper limit of the classical strain rule (<10% strain for bone healing). Since all of the included patients achieved successful unions, these findings suggest that healing of distal femur fractures may be robust to localized strains greater than 10%

Introduction. Distal femur fractures have traditionally been stabilized with either lateral locking plate or retrograde intramedullary nail. Dual-plates and nail-plate combination fixation have the theoretical biomechanical advantage, faster union and allows patients to weight bear immediately. The aim of this study is to compare single vs combination fixation, and evaluate outcomes and complications. Method. We retrospectively reviewed all patients over 60, admitted to Christchurch Hospital, between 1st Jan 2016 and 31st Dec 2022, with an AO 33A/33B/33C distal femur fracture. Patient demographics, fracture characteristics, operation details, and follow up data were recorded. Primary outcomes are union rate, ambulatory status at discharge, and surgical complications. Secondary outcomes include quality of reduction, operation time and rate of blood transfusions. Results. 114 patients were included. (92 single fixation, 22 combination fixation). Baseline demographic data and fracture characteristics did not differ between the cohorts. There was no difference in the rate of union or time to union between the two cohorts. Combination fixation patients were allowed to weight-bear as tolerated significantly more than single fixation patients (50% vs 18.9%, p=0.003). There was no difference in length of hospital stay, transfusion, complication and mortality rates. Medial translation of the distal articular block was significantly lower in the combination fixation cohort (1.2% vs 3.4%, p=0.021). Operation time was significantly longer in the combination fixation cohort (183mins vs 134mins, p<0.001). Discussion. The results show no difference in achieving union or time to union, despite better quality of fracture reduction with dual fixation. This differs to previously published literature. The clear benefit of combination fixation is immediate weight-bearing. As expected, operation times were longer with combination fixation, however this did not translate to more complications. Conclusion. Combination fixation allows earlier weight bearing, at the cost of longer operation times

Aims. Dual plating of distal femoral fractures with medial and lateral implants has been performed to improve construct mechanics and alignment, in cases where isolated lateral plating would be insufficient. This may potentially compromise vascularity, paradoxically impairing healing. This study investigates effects of single versus dual plating on distal femoral vascularity. Methods. A total of eight cadaveric lower limb pairs were arbitrarily assigned to either 1) isolated lateral plating, or 2) lateral and medial plating of the distal femur, with four specimens per group. Contralateral limbs served as matched controls. Pre- and post-contrast MRI was performed to quantify signal intensity enhancement in the distal femur. Further evaluation of intraosseous vascularity was done with barium sulphate infusion with CT scan imaging. Specimens were then injected with latex medium and dissection was completed to assess extraosseous vasculature. Results. Quantitative MRI revealed a mean reduction of 21.2% (SD 1.3%) of arterial contribution in the lateral plating group and 25.4% (SD 3.2%) in the dual plating group (p = 0.051); representing a mean decrease in arterial contribution of 4.2%. The only significant difference found between both experimental groups was regionally, at the lateral aspect of the distal femur with a mean drop in arterial contribution in the lateral plating group of 18.9% (SD 2.6%) versus 24.0% (SD 3.2%) in the dual plating group (p = 0.048), representing a mean decrease in arterial contribution of 5.1%. Gross dissection revealed complete destruction of periosteal vessels underneath either medial or lateral plates in both groups. The network of genicular branches contributing to the posterior and distal femoral condyles was preserved in all specimens. A medial vascular pedicle was found dividing from the superficial femoral artery at a mean 12.7 cm (SD 1.7) proximal to the medial epicondyle and was undisrupted in the dual plating group. Conclusion. Lateral locking-plate application resulted in mean 21.2% reduction in distal femur vascularity. Addition of medial plates did not further markedly decrease vascularity. As such, the majority of the vascular insult occurred with lateral plating alone. Supplemental medially based fixation did not lead to marked devascularization of the distal femur, and should therefore be considered in the setting of comminution and poor bone stock in distal femoral fractures. Further clinical research is required to confirm the results of this study. Cite this article: Bone Joint J 2020;102-B(4):530–538

Introduction and Objective. Plating of geriatric distal femoral fractures with Locking Compression Plate Distal Femur (LCP–DF) often requires augmentation with a supplemental medial plate to achieve sufficient stability allowing early mobilization. However, medial vital structures may be impaired by supplemental medial plating using a straight plate. Therefore, a helically shaped medial plate may be used to avoid damage of these structures. Aim of the current study was to investigate the biomechanical competence of augmented LCP–DF plating using a supplemental straight versus helically shaped medial plate. Materials and Methods. Ten pairs of human cadaveric femora with poor bone quality were assigned pairwise for instrumentation using a lateral anatomical 15-hole LCP–DF combined with a medial 14-hole LCP, the latter being either straight or manually pre-contoured to a 90-degree helical shape. An unstable distal femoral fracture AO/OTA 33–A3 was simulated by means of osteotomies. All specimens were biomechanically tested under non-destructive quasi-static and destructive progressively increasing combined cyclic axial and torsional loading in internal rotation, with monitoring by means of optical motion tracking. Results. Initial axial stiffness and torsional stiffness in internal and external rotation for straight double plating (548.1 ± 134.2 N/mm, 2.69 ± 0.52 Nm/° and 2.69 ± 0.50 Nm/°) was significantly higher versus helical double plating (442.9 ± 133.7 N/mm, 2.07 ± 0.32 Nm/° and 2.16 ± 0.22 Nm/°), p≤0.04. Initial interfragmentary axial displacement and flexural rotation under 500 N static loading were significantly smaller for straight plating (0.11 ± 0.14 mm and 0.21 ± 0.10°) versus helical plating (0.31 ± 0.14 mm and 0.68 ± 0.16°), p<0.01. However, initial varus deformation under this loading remained not significantly different between the two fixation methods (straight: 0.57 ± 0.23°, helical: 0.75 ± 0.34°), p=0.08. During dynamic loading, within the course of the first 4000 cycles the movements of the distal fragment in flexion were significantly bigger for helical over straight plating (1.03 ± 0.33° versus 0.40 ± 0.20°), p<0.01. However, no significant differences were observed between the two fixation methods in terms of varus, internal rotation, axial and shear displacements at the fracture site, and number of cycles to failure. Conclusions. Augmented lateral plating of unstable distal femoral fractures with use of supplemental helically shaped medial plate was associated with more elastic bone-implant construct behavior under static and dynamic loading compared to straight double plating. Both fixation methods resulted in comparable number of cycles to failure. From a biomechanical perspective, the more elastic helical double plating may be considered as useful alternative to straight plating, potentially reducing stress risers at the distal bone-implant interface due to its ameliorated damping capacities

Aims. The modified Radiological Union Scale for Tibia (mRUST) fractures score was developed in order to assess progress to union and define a numerical assessment of fracture healing of metadiaphyseal fractures. This score has been shown to be valuable in predicting radiological union; however, there is no information on the sensitivity, specificity, and accuracy of this index for various cut-off scores. The aim of this study is to evaluate sensitivity, specificity, accuracy, and cut-off points of the mRUST score for the diagnosis of metadiaphyseal fractures healing. Methods. A cohort of 146 distal femur fractures were retrospectively identified at our institution. After excluding AO/OTA type B fractures, nonunions, follow-up less than 12 weeks, and patients aged less than 16 years, 104 sets of radiographs were included for analysis. Anteroposterior and lateral femur radiographs at six weeks, 12 weeks, 24 weeks, and final follow-up were separately scored by three surgeons using the mRUST score. The sensitivity and specificity of mean mRUST score were calculated using clinical and further radiological findings as a gold standard for ultimate fracture healing. A receiver operating characteristic curve was also performed to determine the cut-off points at each time point. Results. The mean mRUST score of ten at 24 weeks revealed a 91.9% sensitivity, 100% specificity, and 92.6% accuracy of predicting ultimate fracture healing. A cut-off point of 13 points revealed 41.9% sensitivity, 100% specificity, and 46.9% accuracy at the same time point. Conclusion. The mRUST score of ten points at 24 weeks can be used as a viable screening method with the highest sensitivity, specificity, and accuracy for healing of metadiaphyseal femur fractures. However, the cut-off point of 13 increases the specificity to 100%, but decreases sensitivity. Furthermore, the mRUST score should not be used at six weeks, as results show an inability to accurately predict eventual fracture healing at this time point. Cite this article: Bone Jt Open 2021;2(10):796–805

Orthopaedic injuries in the knee are often associated with vascular injury. When these vascular injuries are missed devastating there are devastating outcomes like limb ablation. Pulse examination in these patients is not sensitive to exclude vascular injuries. That often lead to clinicians opting for Computed Tomography Angiogram (CTA) to exclude vascular. this usually leads to a burden in Radiology Department. This study aimed to evaluate the prevalence of vascular injury in patient with orthopaedic injury in the knee. The computed tomography (CT) done in patients with distal femur fracture, knee dislocation and proximal tibia fractures were retrieved from the picture archiving and comunication system (PACS). The CTs were done between June 2017 and June 2022. The computed tomography angiogram (CTA) reports were reviewed to determine cases that vascular injury. A sample size of 511 cases was collected. 386 cases were done CTA and 125 cases were not done CTA. There were 218 tibial plateau fractures, 79 knee dislocations, 72 distal metaphyseal femur fractures, 61 floating knees, 55 distal femure intraarticular and 26 proximal metaphyseal tibia fractures. The mechanisms of injury in these were gunshot, fall from standing height, fall from height, MVA, MBA, PVA and sports. Prevalance was 9.17% (47) of the total injuries in the knee. Prevalance in patients who were sent for CTA was 12.08%. Routine CTA in patients with injuries in the knee is not recomended. The use of ankle brachial index may decrease the number of CTA done

Abstract. Introduction. We aimed to compare the outcomes of elderly patients with periarticular distal femur or supracondylar periprosthetic fractures treated with either open reduction internal fixation or distal femoral replacement. Methods. A retrospective review of patients over 65 years with AO Type B and C fractures of the distal femur or Su type I and II periprosthetic fractures treated with either a DFR or ORIF was undertaken. Outcomes including Length of Stay, PROMs (Oxford Knee Score and EQ 5D), infection, union, mortality, complication and reoperation rates were assessed. Data on confounding variables were also collected for multivariate analysis. Patients below 65 years and extra articular fractures were excluded. Results. 23 patients (11 in DFR group and 12 in ORIF group) fulfilled inclusion criteria and were included in the analysis. There was no difference between the DFR and ORIF groups with respect to SDI, demographic variables, ASA grade, FCI, preoperative Hb and renal function. There was no difference in 30 day mortality, reoperation rates, 30 day readmission rates and LOS between the two groups. Mean follow up was 12.7 and 15.9 months respectively in the DFR and ORIF groups. At final follow up after accounting for all confounding variables on multivariate analysis, functional outcomes using OKS (adjusted mean: 29.5 vs 15.8) and Health related Quality of Life outcomes using EQ 5D (adjusted mean: 0.453 vs −0.07) were significantly better in the DFR group. Conclusion. DFR for periarticular and periprosthetic distal femoral fractures in the elderly are associated with better patient reported outcomes

Background. Patients suffering a distal femoral fracture are at a high risk of morbidity and mortality. Currently this cohort is not afforded the same resources as those with hip fractures. This study aims to compare their mortality rates and assess whether surgical intervention improves either outcome or mortality following distal femoral fractures. Methods. Patients over sixty-five admitted with a distal femoral fracture between June 2007 and 2012 were retrospectively identified. Patients mobility was categorised as unaided, walking aid, zimmer frame, or immobile. The 30-day, six-month, and one-year mortality rates were recorded for this group as well as for hip fractures during the same period. Results. 68 patients were included in the study. 85% of the patients were female and the mean age was 84 years. 8 patients (12%) had an underlying total knee arthroplasty. 43 patients (63%) were managed non-operatively and of those treated surgically 7 had plate fixation (28%) and 18 had intramedullary nailing (72%). The mortality rate for all patients with distal femoral fractures was 7% at 30 days, 26% at six months, and 38% at one year, higher than hip fractures during the same period by 8%, 13%, and 18%, respectively. Patients managed surgically had lower mortality rates and higher mobility levels. Conclusion. Patients suffering a distal femoral fracture have a high mortality rate and surgical intervention seems to improve both mobility and mortality. Currently this group of patients obtains less attention and resources than hip fracture patients. Further research assessing the impact of increasing resources on this group of patient is required. Level of evidence. IV. Conflict of Interests. The authors confirm that they have no relevant financial disclosures or conflicts of interest. Ethical approval was not sought as this was a systematic review

Distal femur fractures (DFF) are common, especially in the elderly and high energy trauma patients. Lateral locked osteosynthesis constructs have been widely used, however non-union and implant failures are not uncommon. Recent literature advocates for the liberal use of supplemental medial plating to augment lateral locked constructs. However, there is a lack of proprietary medial plate options, with some authors supporting the use of repurposing expensive anatomic pre-contoured plates. The aim of this study was to investigate the feasibility of a readily available cost-effective medial implant option. A retrospective analysis from January 2014 to June 2022 was performed on DFF (primary or revision) managed with supplemental medial plating with a Large Fragment Locking Compression Plate (LCP) T-Plate (~$240 AUD) via a medial sub-vastus approach. The T-plate was contoured and placed superior to the medial condyle. A combination of 4.5mm cortical, 5mm locking and/or 6.5mm cancellous screws were used, with oblique screw trajectories towards the distal lateral cortex of the lateral condyle. All extra-articular fractures and revision fixation cases were allowed to weight bear immediately. The primary outcome was union rate. This technique was utilised on sixteen patients; 3 acute, 13 revisions; mean age 52 years (range 16-85), 81% male, 5 open fractures. The union rate was 100%, with a median time to union of 29 weeks (IQR 18-46). The mean follow-up was 15 months. There were two complications: a deep infection requiring two debridements and a prominent screw requiring removal. The mean range of motion was 1–108. o. . Supplemental medial plating of DFF with a Large Fragment LCP T-Plate is a feasible, safe, and economical option for both acute fixation and revisions. Further validation on a larger scale is warranted, along with considerations to developing a specific implant in line with these principles

The Nottingham Hip Fracture Score (NHFS) is validated to predict mortality after fragility neck of femur fractures (NOF). Risk stratification supports informed consent, peri-operative optimisation and case prioritisation. With the inclusion of fragility distal femur fractures (DFF) in the BPT, increasing attention is being placed on the outcome of these injuries. Developing on the lessons learnt over the past decades in NOF management is key. This study assesses the validity of the NHFS in predicting mortality after fragility DFFs. A multi-centre study of 3 high volume fragility fracture units was performed via a retrospective analysis of prospectively collected databases. Patients aged 60 years-of-age who presented with AO 33.A/B/C native DFF, or V.3.A/B periprosthetic DFF over an 86-month period between September 2014 and December 2021 and underwent surgical treatment were eligible for inclusion. Open and/or polytrauma (ISS >15) were excluded. All operations were performed or supervised by Consultant Orthopaedic Surgeons and were reviewed peri-operatively by a 7-day MDT. Patients with a NHFS of gt;=5 were stratified into a high-risk of 30-day mortality cohort, with all others being œlow-risk. 285 patients were eligible for inclusion with 92 considered to be low-risk of 30-day mortality, these tended to be younger female patients admitted from their own homes. 30-day mortality was 0% in the low-risk cohort and 6.2% (12/193) in the high-risk group. 1-year mortality was 8.7% (8/92) and 35.7% (69/193) in the low and high-risk groups respectively. Area Under the Curve (AUC) analyses of Receiver Operator Characteristic (ROC) curves demonstrated the greatest ability to predict mortality at 30-days for the high-risk cohort (0.714). The NHFS demonstrates a good ability to predict 30-day mortality in those patients with a NHFS =5 after a surgically managed fragility DFF. With comparable mortality outcomes to those documented from fragility NOF

Introduction. Plate fixation for distal femoral fractures is a commonly used method of fracture stabilisation. Many orthopaedic surgeons traditionally do not allow their patients to weight bear for the first 6 weeks after surgery, fearing of loss of fracture reduction and metalwork failure. The aim of this study is to investigate whether the post-operative weight bearing status after plate fixation influences the outcome in terms of loss of reduction and metalwork failure. Materials & Methods. A retrospective data collection from all patients who treated in our hospital surgically for distal femoral fractures, from January 2015 until June 2017. Inclusion criteria were the operative treatment of these fractures with plate fixation. Patients who were treated with retrograde nail, primary total knee replacement or screw fixation were excluded from the study. Patient, injury and surgery demographic data was collected. The immediate post-operative weight bearing status of these patients was noted. Weight bearing status was divided into two groups – Group 1 (Non and touch weight bear – the non-weight bearing group) and Group 2 (Weight bear as tolerated / Full weight bear – the weight bearing group). Radiological data about fracture displacement or metalwork failure was collected at the six weeks and three months follow up after the operation, using a standardised measurement for displacement performed independently by two authors (EI, TA). Results. Of 70 patients, a total of 51 fractures treated with plate fixation were included to the study. The mean age of the cohort was 64.3 ±20.7 years with the majority of the patients being female (63%). Most of the patients (40%) had a complete articular distal femoral fracture, AO Type 33C. Thirty-nine patients (76%) were treated with one lateral distal femoral plate. The total number of the patients in group 1 was 32 (68%); with 17 patients (32%) in group 2. The weight bearing status did not correlate with the fracture type or the fixation type (p>0.05). None of the 6 weeks follow up radiographs revealed fracture displacement in both study groups. Four of the patients from the non-weight bearing group had >1mm displacement at the 3 months' follow-up radiographs. Fisher's exact test revealed no statistically significant difference between the two study groups in both follow-up time points (p=0.55). Two of the patients in the non-weight bearing group had their plate broken at the 3 months follow up and required revision fixation. Conclusion. By reviewing the outcomes in terms of fracture displacement and metalwork failure following plate fixation of distal femoral fractures, early weight bearing of these patients do not jeopardise the outcome of the operation

Introduction. Aneurysmal bone cysts commonly found in lower limbs are locally aggressive masses that can lead to bony erosion, instability and fractures. This has major implications in the lower limbs especially in paediatric patients, with potential growth disturbance and deformity. In this case series we describe radical aneurysmal bone cyst resection and lower limb reconstruction using cable transport and syndesmosis preservation. Materials & Methods. Case 1 - A 12-year-old boy presented with a two-week history of atraumatic right ankle pain. An X-ray demonstrated a distal tibia metaphyseal cyst confirmed on biopsy as an aneurysmal bone cyst. The cyst expanded on interval X-rays from 5.5cm to 8.5cm in 9 weeks. A wide-margin en-bloc resection was performed leaving a 13.8cm tibial defect. A cable transport hexapod frame and a proximal tibial osteotomy was performed, with syndesmosis screw fixation. The transport phase lasted 11 months. While in frame, the boy sustained a distal femur fracture from a fall. The femur and the docking site were plated at the same sitting and frame removed. At one-year post-frame removal he is pain-free, with full ankle dorsiflexion but plantarflexion limited to 25 degrees. He has begun graduated return to sport. Results. Case 2 - A 12-year-old girl was referred with a three-month history of lateral left ankle swelling. X-ray demonstrated an aneurysmal bone cyst in the distal fibula metaphysis. The cyst grew from 4.2 × 2.3cm to 5.2 × 3.32cm in 2 months. A distal fibula resection (6.2cm) with syndesmosis fixation and hexapod cable transport frame were undertaken. The frame was in situ for 13 weeks and during this time she required an additional osteotomy for premature consolidation and had one pin site infection. After 13 weeks a second syndesmosis screw was placed, frame removed, and a cast applied. 3 months later she had fibular plating, BMAC and autologous iliac crest bone graft for slow union. At 3 years post-operative she has no evidence of recurrence, is pain-free and has no functional limitation. Conclusions. We describe two cases of ankle syndesmosis preservation using cable transport for juxta-articular aneurysmal bone cysts. This allows wide resection to prevent recurrence while also preserving primary ankle stability and leg length in children. Both children had a minor complication, but both had an excellent final outcome. Cable bone transport and prophylactic syndesmosis stabilization allows treatment of challenging juxta-articular aneurysmal bone cysts about the ankle. These techniques are especially useful in large bone defects

Background. Distal femoral fractures are 10 times less common than hip fractures. 12-month mortality has been reported as 25–30% but there is no longer-term data. In Northumbria hip fractures have a 5-year mortality of 68%. Objectives. To analyse 5-year mortality in distal femur fractures in the Northumbrian NHS trust, and identify risk factors for mortality. To compare the results to literature standards and Northumbrian hip fracture data. Methods. This retrospective observational study included patients admitted with distal femur fractures (AO type 3.3), including periprosthetic fractures, between 01/01/05 and 31/12/07. Patient information, which included age, gender, co-morbidities and date of death, was collected through hospital coding and analysis of notes. Co-morbidity data was only available for 53 patients. Mortality rates were calculated, and stratified according to age, gender and co-morbidities. The results were analysed using backwards-multivariate linear regression to determine the significance. Results. 83 patients (74 female) were identified and the population had a mean age of 80 years (range 60–102). The overall 5-year mortality was 72%. Mortality increased with age and being female may be a risk factor. Dementia and COPD were the only statistically significant predictors of mortality. Conclusions. This study shows a 5-year mortality of 72% in patients over 60 with distal femur fractures. 1-year mortality rates (20%) are lower than the defined literature standards, showing the trust is performing well. 5-year mortality was higher than that of hip fractures in Northumbria, highlighting the vulnerability of this patient group

Background. Hip fracture care has evolved, largely due to standardisation of practice, measurement of outcomes and the introduction of the Best Practice Tariff, leading to the sustained improvements documented by the National Hip Fracture Database (NHFD). The treatment of distal femoral fractures in this population has not had the same emphasis. This study defines the epidemiology, current practice and outcomes of distal femoral fractures in four English centres. Methods. 105 patients aged 50 years or greater with a distal femoral fracture, presenting to four UK major trauma centres between October 2010 and September 2011 were identified. Data was collected using an adapted NHFD data collection tool via retrospective case note and radiograph review. Local ethics approval was obtained. Results. Mean age was 77 years (range 50–99), with 86% female. 95% of injuries were sustained from a low energy mechanism, and 72% were classified as either 33-A1 or 33-C1. The mean Parker mobility score and Barthel Independence Index were 5.37 (0–9) and 75.5 (0–100) respectively. Operative management was performed in 84%, and 86% had their surgery within 36 h. Three quarters were fixed with a peri-articuar locking plate. There was no consensus on post operative rehabilitation, but no excess of complications in the centres where weight bearing as tolerated was the standard. 45% were seen by an orthogeriatrician during their admission. Mean length of stay was 29 days. Mortality at 30 days, 6 months, and 1 year was 7%, 16% and 18% respectively. Conclusions. This study demonstrates that the distal femoral and hip fracture populations are similar, and highlights the current disparity in their management. The metrics and standards of care currently applied to hip fractures should be applied to the treatment of distal femoral fractures. Optimal operative treatment and rehabilitation remains unclear, and further research is in progress. Level of evidence. 2b. Ethics. Local approval was obtained

Constrained acetabular inserts provide a solution for both complex primary and revision hip arthroplasty, but there have been ongoing concerns for high risk of failure and their longevity. The Stryker® Trident acetabular insert is pre-assembled with its constrained ring. We believe this to be the largest series of constrained acetabular inserts with a minimum of 5 year follow-up. We retrospectively reviewed all Stryker® Trident ‘All-Poly’ constrained acetabular inserts cemented into bone in our unit between 2008 and 2016. We collated demographic details and reviewed all patients’ radiographs and clinical notes. Indications for surgery, latest Oxford Hip Scores (OHS) and clinical and radiographic complications were identified. 117 consecutive Stryker® Trident ‘All-Poly’ constrained inserts were cemented into bone in 115 patients during the study period with a mean age of 80 (47–97). Most common indications for surgery were recurrent dislocation (47), complex primary arthroplasty (23), revision arthroplasty (19) and failed hemiarthroplasty (12). 41 patients required revision of the acetabular component only. Follow-up was a minimum of 5 years (mean 8.6, range 5–13). There were three 30-day mortalities and six 1-year mortalities. The mean latest OHS was 37 (24–45). Four cups failed in three patients, one at the cement-bone interface, two at the cement-prosthesis interface and one at the bipolar interface. These were treated conservatively in three patient and with excision arthroplasty in one patient. There were four peri-prosthetic fractures, one Vancouver C distal femur fracture treated conservatively and three Vancouver B1 fractures, two treated conservatively and one treated with open reduction internal fixation. There was breakage of one constrained ring with no adverse effects and one superficial wound infection requiring oral antibiotics only. This series demonstrated that despite the elderly and complex nature of these patients’ clinical situations, constrained acetabular inserts offer a useful and pragmatic solution, with relatively low complications, including in our series a cup failure rate of 3% and peri-prosthetic fracture rate of 3%

The aim of the study was to describe the failure rate of locking plates used for internal fixation of distal femoral fractures and to identify independent predictors of failure. A consecutive series of 147 patients presenting to the study unit during an 8 year period with a distal femoral fracture were identified from a prospectively compiled trauma database. There were 117 females and 30 males, with a mean age of 70.7 years (13 to 99 years), of which 77 were periprosthetic fractures and 70 were supracondylar fractures around native knees. There were 35 failures of fixation. The commonest cause was non-union (n=31). The survival of the plate 2 years post-surgery was 74percnt; (95percnt; CI 64percnt; to 84percnt;), which remained static to a mean follow of 5 years. There was no difference in failure of fixation according to gender (p=0.32) or if there was a periprosthetic fracture (p=0.8). Younger age (61.8 vs. 73.6 years, p=0.004), increasing level of comorbidity (p=0.02), and fracture comminution (p=0.001) were all significant predictors of failure of fixation. Cox regression analysis confirmed younger age (p=0.04), increasing comorbidity (p=0.002), and fracture comminution (p=0.002) as independent predictors of failure of fixation and non-union after adjusting for confounding. The failure of locking plates for distal femoral fractures occurs in more than one in five patients. The independent predictors could be used to identify those patients at greatest risk of failure of the locking plate, who may benefit from alternative methods of fixation, primary bone grafting, or interventions that may aid union

Management of bone defects is a common surgical challenge encountered following any high energy trauma. Femur fractures with bone loss account for 22% of all the fractures with bone loss/defect, and 5% to 10% of distal femur fractures are open injuries. It was estimated in 2008, that, more than 4.5 million open fractures occur annually in India. In this retrospective study, patients who received bone allograft from our tissue bank between May 2012 and September 2015 were analysed. Of the 553 allografts issued, at that point in time, 26 were used in patients who underwent reconstruction for distal Femur fractures primarily. Fractures with defect or bone loss from 12 cc (1cm) to 144 cc (12cm) were treated with either Internal or External fixation and bone allograft. Morcellised cancellous, or a cortical strut, were used to fill or reconstruct the defect or void. The radiological outcome in terms of fracture union was assessed and Knee society score was used to assess the functional outcome. Complications such as non- union, infection, stiffness and need of revision or additional procedures were also assessed. Osseous consolidation was achieved in all the 26 patients with a Median time of 24 weeks (16 to 60). The Median Functional Knee Society Score was 80, indicating satisfactory functional outcome. Infection was noted in one patient, but it was not attributed to the allograft. Additional minor procedures like bone marrow infiltration, corticotomy for bone lengthening were required in 10 patients. Our studycomprises the largest group of patients treated primarily with Allograft to reconstruct or fill the void of bone loss encountered with distal Femur fracture. Reconstruction of massive bone defects, in patients of distal Femur fractures, with bone allograft, shows encouraging results. The surgeon can achieve the goal of restoring form and function of these difficult injuries in a single stage and the technique will provide the freedom to reconstruct the bony defect up to 150 cc (12 cm length) and recreate the anatomy to near normal. This allows for early mobilisation of patients and restoration of their daily routine at the earliest

Background. Plate fixation is one of several options available to surgeons for the management of pediatric femur fractures. Recent literature reports distal femoral valgus can be a complication following lateral plate fixation of femur fractures. We report on a case of extreme distal femoral valgus deformity and a lateral dislocation of the patella four years after having plate fixation of a left distal femoral fracture. Method. A single case was anonymised and retrospectively reviewed through examination of clinical and radiographic data. Results. A 15 year old male presented with 35 degree femoral valgus deformity, one inch leg length discrepancy, painful retained hardware and a lateral dislocation of the patella four years after undergoing lateral plate fixation of a left distal femur fracture. The fracture site healed after plate insertion, but later the patient reported worsening in alignment of lower extremity and complained of pain in the limb. Antero-posterior and lateral radiographs of the femur revealed 35 degrees of left distal femoral valgus. The previous femoral plate migrated proximally and was encased in bone. Due to plate migration, screws that were originally in the distal femoral metaphysis were protruding through the femoral shaft into soft tissues of the medial thigh. Successful treatment involved removal of prominent distal screws and use of a Taylor Spatial external fixator frame to correct the deformity. Lateral soft tissue release was performed to allow patellar relocation. At 12 weeks follow up leg alignment was restored, pain resolved and the patient was mobilising. Conclusion. Femoral valgus is a possible complication of lateral plate fixation in up to 30% of pediatric distal femur fractures. With this patient's combination of deformities as an example, we suggest early hardware removal after fracture union, preventing deformities developing. If plate removal is not chosen, then continued close monitoring of the patient is necessary until skeletal maturity. Level of Evidence. Type 4 (case report)

Debate surrounds the optimum operative treatment of periprosthetic distal femoral fractures (PDFFs) at the level of well fixed femoral components; lateral locking plate fixation (LLP-ORIF) or distal femoral replacement (DFR). To determine which attributed the least peri-operative morbidity and mortality we performed a retrospective cohort study of 60 consecutive unilateral PDFFs of Su types II (40/60) and III (20/60) in patients ≥60 years; 33 underwent LLP-ORIF and 27 underwent DFR. The primary outcome measure was reoperation. Secondary outcomes included perioperative complications and functional mobility status. Kaplan Meier survival analysis was performed. Cox multivariable regression analysis identified risk factors for reoperation after LLP-ORIF. Mean length of follow-up was 3.8 years (range 1.0–10.4). One-year mortality was 13% (8/60). Reoperation rate was significantly higher following LLP-ORIF: 7/33 vs 0/27, p=0.008. For the endpoint reoperation, five-year survival was better following DFR: 100% compared to 70.8% (51.8 to 89.8 95%CI) (p=0.006). For the endpoint mechanical failure (including radiographic loosening) there was no difference at 5 years: ORIF 74.5% (56.3 to 92.7); DFR 78.2% (52.3 to 100), p=0.182). Reoperation following LLP-ORIF was independently associated with medial comminution: HR 10.7 (1.45 to 79.5, p=0.020). Anatomic reduction was protective against reoperation: HR 0.11(0.013 to 0.96, p=0.046). When inadequately fixed fractures were excluded differences in survival were no longer significant: reoperation (p=0.156); mechanical failure (p=0.453). Reoperation rates are higher following LLP-ORIF of low PDFFs compared to DFR. Where adequate reduction, proximal fixation and augmentation of medial comminution is used there is no difference in survival between LLP-ORIF and DFR

Introduction. IM (Intra Medullary) nail fixation is the standard treatment for diaphyseal femur fractures and also for certain types of proximal and distal femur fractures. Despite the advances in the tribology for the same, cases of failed IM nail fixation continue to be encountered routinely in clinical practice. Common causes are poor alignment or reduction, insufficient fixation and eventual implant fatigue and failure. This study was devised to study such patients presenting to our practice and develop a predictive model for eventual failure. Materials and Methods. 57 patients who presented with failure of IM nail fixation (± infection) between Jan 2011 – Jun 2020 were included in the study and hospital records and imaging reviewed. Those fixed with any other kinds of metalwork were excluded. Classification for failure of IM nails – Type 1: Failure with loss of contact of lag screw threads in the head due to backing out and then rotational instability, Type 2A: Failure of the nail at the nail and lag screw junction, Type 2B: Failure of the screws at the nail lag screw junction, Type 3: Loosening at the distal locking sites with or without infection. X-rays reviewed and causes/site of failure noted. Results. Total patients - 57. Demography - Average age - 58.9 years, 22 Males and 35 females. Eleven patients were noted to have an infection at the fracture site that needed oral or IV antibiotics.16 patients - at least 1 cerclage wire for fracture reduction and fixation + IM Nail. Subtrochanteric fractures (42/57) were the most common to fail. In those fractures with postero-medial comminution, locking of the lag screw in position thus preventing backout can prevent failure. In type 2 failures, preventing varus fixation by early open reduction and temporary fixation with plates and screws can achieve improved results. Those with type 3 failures with periosteal reaction should be considered to be infected until proven otherwise. Conclusions. This classification for failure of IM nails in the femur can be used as a predictive model for failures and allow early recognition and intervention to tackle them

The Less Invasive Stabilisation System (LISS) was introduced with the aim to decrease the incidence of fracture nonunion and the need for primary bone grafting. We aim to describe the cases of nonunion of osteoporotic distal femoral fractures treated with the LISS at our institution and to review the cases of nonunion published in the literature. Three cases of nonunion of osteoporotic distal femoral fractures treated with the LISS at our institution were identified. A thorough retrospective analysis of the available clinical information was performed. To identify all published papers on LISS, an exhaustive literature search was performed. The Medline and PubMed databases were searched for the following keywords: femoral fractures, distal femoral fractures, supracondylar, LISS, less invasive stabilization system and femoral no nunions. The search period was 1996 to 2008. All relevant studies were analysed. Low energy trauma was responsible for the closed fractures encountered in our patients. Two patients sustained fractures around a joint arthroplasty: one fracture above a total knee arthroplasty and one fracture below a total hip arthroplasty. The operative technique consisted of indirect reduction on the traction table and minimally invasive percutaneous osteosynthesis. The postoperative radiographic alignment was satisfactory for all fractures. Aseptic nonunion was diagnosed in all patients. Implant failure occurred in two patients with fracture of the proximal screws in one case and fracture of the distal screws in the second case. No case s of failure of distal locking screws have previously been described in the literature. No other complications were identified. The literature search identified 21 cases of fracture nonunion. Six of these fractures occurred in osteoporotic bones as a result of low energy trauma. All 6 fractures were above a total knee arthroplasty. The LISS is a new implant who has shown good results in the management of difficult distal femoral fractures. Its use is however not without problems: concerns with regards to inadequate or excessive rigidity and a demanding surgical technique are just some of the issues

Introduction. The treatment of distal femoral fractures has undergone several changes during the past century, from non-operative techniques to more recently minimally-invasive internal fixation. The Less Invasive Stabilisation System (LISS) is an internal fixation plate that combines closed fixation of the distal femur using an anatomically pre-contoured plate with locked unicortical screws. Study aim. The purpose of this multicentre study was to review the use of the LISS plate in three regional centres with respect to fracture healing between different severities of fractures. Materials and methods. Patients treated with a LISS plate for a distal femoral fracture (AO/OTA Type 33A1 to 33C3) between 1st January 2004 and 1st June 2008 were recruited. Demographic data plus mechanism of injury, type of fracture, injury severity scores (ISS) and complications were documented. Subgroup statistical analysis using SPSS for Windows v. 17 was conducted to determine differences in the mean ISS, operating time, length of hospitalisation and ultimately, the time taken for union between groups of different fracture severities (Type 33A vs. Type 33C fractures). A P value of less than 0.05 was considered to be significant. Results. Across the 3 regional centres, a total of 88 patients presented with a distal femoral fracture, of which 44 were treated with a LISS plate. The mean age of the patients was 66.1 (range 9 - 99), with 15 males and 29 females. There were 14 Type 33A1, 13 Type 33A2, 6 Type 33A3, 1 Type 33B2, 1 Type 33C1, 5 Type 33C2 and 4 Type 33C3 fractures. Union was achieved within an average of 14.7 weeks (range 8 - 25) in 33 cases. Five cases exhibited non-union and were managed by a retrograde nail or another locking compression plate. Six cases developed delayed union. Subgroup analysis revealed that patients with Type 33C (n = 10) fractures presented with a significantly greater mean ISS score (12.7 vs. 10.0, p = 0.031), endured longer operating time (203.7 minutes vs. 125.8 minutes, p = 0.016) and spent longer in hospital compared to Type 33A (n = 33) fractures (35.3 days vs. 12.5 days, p = 0.004). However, no difference in the mean time for radiological union between the groups was observed (16.4 weeks vs. 13.6 weeks, p = 0.058). Discussion. We observed an overall success rate of 75% (33 out of 44 cases) as fractures reached radiological union within an average of 14.7 weeks. Interestingly, despite a greater mean ISS score and operating time among Type 33C fractures, the subgroup analysis confirmed that the LISS plate is a robust treatment option across all fracture severities, as this did not translate as longer time to union compared to Type 33A fractures. However, there were 5 cases of non-union and 6 cases of delayed union in our series. These may have arisen due to lack of precision in surgical technique, as we observed 8 cases of suboptimal implant positioning. Three cases involved distal screws lacking contact with the medial cortex of the femur. Overall, our data suggest a favourable outcome for the LISS plate in the treatment of distal femoral fractures

Distal femoral fractures in elderly patient occurred with lower energy injury due to preexisting osteoporosis. Gonarthrosis is frequently accompanied in these patients, and which is difficult to treatment and hard to restore function. Traditionally, the fractures in osteoarthritic knee are treated by open reduction and internal fixation (ORIF) and total knee arthroplasty (TKA) for osteoarthritis is considered after bone union of the prior fractures. However two-stage procedure makes some problems when TKA is performed following long immobilization, previous scar, implant removal, prolonged hospital stay, and increased cost. Several authors have reported acceptable results of primary TKA with concomitant ORIF using long stem with hinged, constrained type or posterior stabilized prosthesis, but which generally need substantial bone removal for notch preparation and is disadvantageous for the fractured extremity. We report 5 patients who were treated with primary TKA with concomitant ORIF for osteoarthritic knee accompanied by distal femoral fracture using ADVANCE Medial Pivot knee (Wright Medical, Arlington, TN) in which prosthesis stem extension can be used without notch cutting. All patents were women with mean age of 79 (69–87 years). There was 1 case of medial femoral condylar fracture, 2 cases of supracondylar fractures and 2 cases of supracondylar/intercondylar femoral fractures. Fracture is well reduced in all cases and well united. The range of motion was good (mean 1–112, flexion contracture 0–5, maximal flexion 90–130) at mean follow-up of 12.6 months (range, 5–33 months). We believe that one-stage primary TKA using medial pivot knee is a reasonable alternative treatment for osteoarthritic knees accompanied by distal femoral fractures if a surgeon is experienced in fracture management and arthroplasty

Background: Aim of this study was to evaluate and compare clinical and radiological outcome of distal femur fracture stabilization using retrograde nailing or LISS plating. Materials and Methods: In a retrospective study from 2003–2008 we analyzed 115 patients with distal femur fractures who had been treated by retrograde i.m. nailing (60 patients) or LISS plating (55 patients). Mean age was 55 years in the two cohort groups. Mechanism of injury was high energy impact in 57 % (SCN 53 %; LISS 76 %) and low energy injury in 43 % of all evaluated patients (SCN 47 %; LISS 33 %). Fractures were classified according to AO classification: There were 52 type A fractures (SCN 31; LISS 21) and 63 type C fractures (SCN 28; LISS 35). Interestingly severe articular fractures (type C2 and C3) were found much more often in LISS group (15 patients; 27 %) compared to 5 patients (8 %) in the SCN group. Results: Fracture healing within 3 months was observed in type A fractures in over 90 % of the cases (SCN 29 patients, 89 %; LISS 20 patients, 95 %). A distinct diffrence was found in type C fractures. Whereas still nearly 90 % consolidation was evaluated in the SCN group (25 patients; 89 %), LISS plate group showed only 41 % (14 patients). Nonunion was found in type A fractures in only one patient per group (SCN and LISS 3 %) and in 2 patients in type C fractures treated with SCN (7 %). As expected 35 % (11 patients) nonunions were found in type C fractures treated with LISS. Both, the nail and the LISS group required additional bone grafting for successful healing (SCN 2; LISS 8). Functional outcome using the KOOS score demonstrated in type A fractures a score of 263 in the nail and 260 in the LISS plate group, and in type C fractures 257 in the nail and 218 in the LISS group. Loosening of screws without disturbing fracture healing (SCN 12 %; LISS 2 %). Deep infection (SCN 2 %; LISS 7 %), axis deviation of more than 10 degrees in the coronal or sagittal plane in 5 % in the nail and 12 % in the plate group were treated. Conclusion: Both, retrograde i.m. nailing and LISS plating are adequate treatment options for distal femur fractures. No differences in outcome between implants regarding fracture healing, nonunion, and infection were found in type A fractures. A distinct difference occurred in type C fractures. According to high rate of severe articular and open fractures a high rate of nonunions and infections was found in the LISS group. Locked plating can be utilized for all distal femur fractures including complex type C fractures, periprosthetic fractures and osteoporotic fractures. I.m. nailing provides favorable intramedullary stability and can be successfully implanted in bilateral or multisegmental fractures of the distal femur as well as in extraarticular and type C1 to C2 fractures

Introduction. The incidence of distal femoral fractures in the geriatric population is growing and represents the second most common insufficiency fracture of the femur following fractures around the hip joint. Fixation of fractures in patients with poor bone stock and early mobilisation in feeble and polymorbide patients is challenging. Development of a fixation approach for augmentation of conventional LISS (less invasive stabilization system) plating may result in superior long-term clinical outcomes and enhance safe weight bearing. Objectives. The aim of this study was to investigate the biomechanical competence of two different techniques of augmented LISS plating for treatment of osteoporotic fractures of the distal femur in comparison to conventional LISS plating. Materials & methods. Unstable distal femoral fracture AO/OTA 33-A3 was set in artificial femora with low density simulating osteoporotic bone. Three study groups, consisting of 10 specimens each, were created for instrumentation with a 9-hole LISS plate, a LISS plate with an additional 3D-printed polyactide cylindrical intramedullary graft, as well as a LISS plate plus a medial 3.5mm LCP (locking compression plate) - double plating. All specimens were non-destructively tested under axial (20–150N) and torsional (0–4Nm) quasi-static loading. Each construct was tested with two different working length (WL) configurations (long and short) of the LISS plate. Relative movements between the most medial superior and inferior osteotomy aspects were investigated via three-dimensional motion tracking analysis. Results. Interfragmentary displacement along the femur axis (mm) under 150N axial loading was 2.03±0.23/1.65±0.27 for LISS with long/short WL, 0.18±0.06/0.18±0.04 for double plating with long/short WL, and 0.40±0.05/0.30±0.05 for LISS plus graft with long/short WL. Shear interfragmentary displacement (mm) under 4Nm torsional loading in internal rotation was 1.16±0.17/0.92±0.11 for LISS with long/short WL, 0.40±0.10/0.43±0.07 for double plating with long/short WL, and 1.09±0.13/0.82±0.11 for LISS plus graft with long/short WL. Double plating revealed significantly smaller longitudinal and shear displacement compared to the other two techniques for long and short WL, respectively (P≤0.010). In addition, LISS plus graft fixation was with significantly less longitudinal displacement in comparison to conventional LISS plating for long and short WL, respectively (P≤0.001). Long WL resulted in significantly higher longitudinal and shear displacement compared to short WL for LISS and LISS plus graft (P≤0.032), but not for double plating (P=1.000). Conclusion. Intramedullary grafting resulted in significantly increased fracture stability under axial loading in comparison to conventional LISS plating. However, it was not efficient enough to achieve comparable stability to double plating

Purpose: Non-union and secondary reduction loss complicate open distal femur fractures with bone loss. We hypothesize that locking plates decrease subsequent bone grafting in these injuries, yet maintain alignment; immediate post-fixation radiographic features predict primary union. Method: From 2001 to 2004 inclusive, 34 adults with 36 open AO/OTA C-type distal femur fractures were reviewed. All were treated with locking plates and 3-month minimum follow-up. Union required radiographic bridging callus on 2/4 cortices combined with lack of symptoms. Alignment was assessed on initial and united radiographs. Antibiotic beads within a metaphyseal defect defined clinically important bone loss. Results: Eleven of 20 fractures with bone loss (55%) underwent staged bone grafting to achieve union, versus two of 16 fractures without bone loss (13%). The presence of antibiotic beads was significantly associated with staged bone grafting (p< 0.01). Of those with bone loss and staged grafting, three had posterior cortical bone loss, and only three had medial and posterior cortical bone loss, and five had segmental defects. Of nine fractures with bone loss not requiring grafting, all had radiographic posterior cortical contact; seven had radiographic medial cortical contact. Posterior (p< 0.001) and medial (p< 0.025) cortical continuity were associated with injuries not requiring bone graft. Thirty-four had accurate frontal plane reductions; thirty-five had accurate sagittal plane reductions. Complications included two non-unions, and one reduction loss. Conclusion: Despite metaphyseal bone loss, locking plates obviate the need for routine bone grafting of some open distal femur fractures. Those with radiographic posterior cortical contact and/or medial cortical contact are strongly correlated with primary union

Background. Currently about 4–6% of all femur fractures consist of distal femoral fractures. Different methods and implants have been used for the surgical treatment of distal femoral fractures, including intramedullary nails. Retrograde nail. By contrast with antegrade nails, surgical approach or retrograde nailing exposes the knee joint which may lead to tendency of infection and increased knee pain. Present study aims to compare the biomechanical behaviour of distal angular condyler femoral intramedullary nail (DACFIN), retrograde nail and plate fixation. Methods. Fifteen 4th generation Saw bones were used to evaluate the biomechanical differences between the groups (Group 1: Plate fixation, Group 2: Retrograde nailing, Group 3: DACFIN; (n=5)). Biomechanical test was performed by using an electromechanical test device Shimadzu (AG-IS 5kN, Japan). Displacement values were recorded by using a Non-contact Video Extensometer (DVE-101/201, Shimadzu, Japan) during the loading each femur with 5 cycles of 500 N at a rate of 10 N/s to determine axial stiffness. The faliure stiffness was measured by axial load to each constructat a displacement rate of 5 mm/min. Torsional loading applied to all groups in amount of 6 Nm of torque with a velocity of 18 degrees/min. Results. The mean torsion stiffness value of Group 3 (6.33 Nm/degree) was signifacantly higher than Group 1 (1.18 Nm/degree) and Group 2 (2.11Nm/degree), p<0.05). The failure stiffness, Group 3 (1725 N/mm) was significantly higher than Group 1 (1275 N/ mm) and Group 2 (1290 N/mm). However, In axial stiffness, the mean value of Group 2 (2554 N/mm) was higher than Group 3 (1822 N/mm), and signifantly higher than Group 1(468 N/mm), p<0.05). Conclusions. DACFIN is more stiffer than retrograde nail and plate fixation during torsional and failure load conditions. But in axial stiffness retrograde nail was stiffer. DACFIN provide intramedullary femur condyle fracture fixations without open knee joint. Level of evidence. Level 5. Disclosure. Authors declare that there is no conflict of interest related to the present study

Distal femoral physeal fractures can cause of growth distrurbance which frequently requires further surgical intervention. The aim of this study was to determine if tibial tuberosity ossification at the time of injury can predict further surgery in patients who have sustained a physeal fracture of the distal femur. We retrospectively investigated all patients who had operative treatment for a distal femoral physeal fracture at a paediatric level one trauma center over a 17 year period. Logistic regression analysis was performed investigating associations between the need for further surgery to treat growth disturbance and tibial tuberosity ossification, age, Salter Harris grade, mode of fixation or mechanism of injury. 74 patients met the inclusion criteria. There were 57 boys (77%) and 17 girls (23%). The average age at time of injury was 13.1 years (range 2.-17.1 years). Following fixation, 30 patients (41%) underwent further surgery to treat growth disturbance. Absence of tibial tuberosity fusion to the metaphysis was significantly associated with need for further surgery (p = < 0 .001). Odds of requiring secondary surgery after tibial tuberosity fusion to metaphysis posteriorly (compared with not fused) were 0.12, 95% CI (0.04, 0.34). The estimate of effect of tibial tuberosity ossification on reoperation rates did not vary when adjusted for gender, mechanism, fixation and Salter Harris grade. When accounting for age, the odds of further operation if the tibial tuberosity is fused to the metaphysis posteriorly (compared with not fused) were 0.28, 95% CI (0.08, 0.94). Tibial tuberosity ossification stage at time of injury is a predictor of further surgery to treat growth disturbance in paediatric distal femoral fractures. Children with distal femoral physeal fractures whose tibial tuberosity was not fused to the metaphysis posteriorly were 8.3 times more likely to require further surgery

The June 2012 Trauma Roundup. 360. looks at: nerve injuries of warfare; the medical complications of earthquakes; the measuring of tissue pressures in compartment syndrome; the risk of plunging through the bone when drilling; bony nonunion and negative pressure therapy; surgery for the posteriorly dislocated hip; whether to use the sliding screw or intramedullary nail for the trochanteric fracture; antegrade interlocking nailing for the distal femoral fracture; and gunshot wounds to the pancreas

Introduction. Post traumatic arthritis of the knee can be a conseguence of distal femur fracture and retained hardware can complicate any further surgical option including arthroplasty. Both staged surgical procedures to remove before the hardware or simultaneous procedure of arthroplasty and removal of hardware have been indicated with an increased risk of complications. Aim of this study is to present a consecutive series of TKA following distal femur fracture using a computer assisted technique without the removal of retained hardware assessing both the efficacy of navigation in managing these complex cases as “routinary” primary arthroplasties. Material and Methods. A consecutive series of 16 patients treated with a computer assisted TKR following femoral fracture and with retained hardware were included in the study (group A). The interval between the fracture and operation averaged 5.8 years (range 1–12 years), the retained hardwares was an intramedullary nail in 6 cases, distal lateral plates in 7 cases and screws in 4 cases. All patients in group A were matched with a patient who had undergone to a computer assisted TKR using the same implant and software because of atraumatic knee arthritis in the same period (group B). Patients were matched in terms of age, gender, pre-operative range of motion, pre-operative arthritis severity according to Albaack classification, type and grade of deformity and implant features (cruciate retaining or sacrificing). There were 10 male and 6 female for each group, the mean pre-operative age was 64.3 years (range: 54–72) for the group A and 65.4 years (range: 53–74) for the group B. The mean pre-operative flexion was 85.5 degrees (range: 65–115) and 88.1 degrees (range: 70–115) for the post traumatic group and the matched group respectively. Results. There were no statistical significant differences in surgical time, hospital staying, intra/post operative complications. Likewise at a mean follow-up of 47 months no statistically significant difference was seen for the Knee Society, Functional, GIUM and WOMAC scores between the 2 groups. Implant alignment was similar between the 2 groups with similar radiological parameters. Conclusions. The results of this study demonstrated that knee arthritis following distal femoral fracture can be safely managed using computer assisted TKA without any need of hardware removal and obvious costs savings. The Authors achieved both same results and same complication rate of similar uncomplicated primary TKR

Introduction. The most common treatment options for fixation of osteoporotic distal femur fractures are retrograde nails and locking plates. There are proponents of more elastic titanium plates as well as more rigid steel plates; No clear superiority of one over the other has been established. We aimed to evaluate the mechanical differences between stainless steel and titanium locking plates in the fixation of distal femur fractures in osteoporotic bone. We hypothesized that due to its higher elasticity titanium locking plates can absorb more energy and are therefore less likely to “cut” into the bone compared to stainless steel locking plates resulting in improved metaphyseal osteoporotic fracture fixation. Methods. We used eight matched pairs of osteoporotic fresh-frozen human cadaveric femurs (age >70 years, all female). Within each pair we randomized one femur to be fitted with a Less Invasive Stabilization System (LISS-Titanium locking plate) and one with a Distal Locking Condylar Plate (DLCP-Stainless steel locking plate). A fracture model simulating an AO 33-A3 fracture was created (extraarticular comminuted fracture) and specimens were subsequently subjected to step-wise cyclic axial loading to failure. We used an advanced three dimensional tracking system (Polhemus Fastrak) to monitor the movement of the distal fragment relative to the real time distal plate position allowing us to evaluate distal implant cut-out. Results. During cyclic testing, seven of the eight pairs of matched femurs, the DLCP failed before the LISS plate (p=0.03). All constructs were able to withstand cyclical loading up to 800N. The overall plastic deformation as measured by the displacement of the Instron crosshead experienced by the titanium plate constructs was significantly lower compared to the stainless steel plate construct: The plastic deformation of the LISS plates was 39% lower compared to the Locking Condylar plates after cycle testing at 400 Newtons and 70% lower at 800N. Furthermore during the 800N cycle testing the LISS plating system showed a significantly lower rate of plastic deformation not only for the entire bone-implant construct, but also between the plate and the distal fragment than the locking condylar plate (=less distal implant cut-out). Conclusions. The use of a more advanced three dimensional tracking system, fresh-frozen osteoporotic matched human specimen and the ability to test all constructs to failure allowed us a more thorough comparison of titanium versus stainless steel implants compared to previous studies. The titanium locking plates provided an overall superior fixation of osteoporotic distal femur fractures with less distal implant cut-out, a better elastic recoil, and a slower rate of residual plastic deformation

Distal femoral fracture fixation has historically been associated with high rates of reoperation because of mal-union, non-union and implant failure. We hypothesised that recent advances in distal femoral locking plate design and material along with an improved understanding of biomechanical principles would improve outcome. In a 5-year retrospective study utilising electronic patient records and serial radiographs (including recall by letter where there was no radiological evidence of union) we identified a series of 129 distal femoral fractures treated with modern locking plates in 123 patients. The majority were female (80%), elderly (mean 73 years) and infirm (72/123 ASA 3 or more). A consultant performed the operation in 67% of cases. 49% were followed to radiological union, while 25% died within the follow up period. Reoperation rate for implant failure was 4%, with all failures occurring early (within 5 months). Our follow up correlates with the infirm elderly population concerned. Our cohort shares many similarities with hip fracture patients and we propose that this group should receive equal surgical priority and optimum management also be rewarded by enhanced tariffs. Modern locking plates used in combination with the correct biomechanical principles are performing well in our centre

Introduction. The management of peri-prosthetic distal femur fractures following TKR (Total Knee Replacement) in the elderly remains a challenge with little or no consensus on the best available treatment. Various methods have been described in the management of these complex fractures. Our study compares the outcome and cost of distal femoral arthroplasty to that of Fixation (Plating/Retrograde Nailing). Methods. We retrospectively reviewed our database for patients admitted with peri-prosthetic distal femoral fractures between 2005–2013 (n=61). The patients were stratified into 2 groups based on method of management. The Distal Femoral Arthroplasty group (Group A) had 21 patients, with a mean age of 78 years (68–90. The Fixation group (Group B) had 40 patients, with a mean age of 74 years, 23 of those had plating of the fracture, while 17 had a retrograde nail inserted. Pain scores, Length of stay, intra-operative blood loss, and weight bearing status, were compared. Functional outcomes were also assessed using Oxford knee scores, KSS scores, VAS pain assessment and range of motion from last follow up appointment. Minimum follow-up was 2 years. Cost analysis was done for both groups, which included implant costs, consumable costs (man power included), theatre utilisation time and length of hospital stay. The calculation was done based on the PbR (payment by results) system and “best practise tariffs 2010–11” utilised by the NHS (National Health Service) in England. Results. In group A, the average surgical time was 116 minutes with mean blood loss of 400 ml. In group B, the mean surgical time was 123 minutes with average blood loss of 800 ml. The mean length of hospital stay in group A was 9 days whereas in group B was 32 days. All patients were fully weight bearing by day 1.5(range 1–3 days) in group A, compared to a mean of 11 weeks in group B. Mean Oxford score was 28 and KSS score was 70 in group A compared to 27 and 68 in group B. The pain score on VAS was 2 for group A and 1.5 for group B. The mean ROM of the knee was 95° in group A and 85° in group B. We had 4 complications in group A. There were 2 deaths due to medical co-morbidities, 1 superficial infection, and 1 DVT. In the fixation group, there were 6 deaths due to medical co-morbidities, 1 failure of fixation, 6 mal-unions, 1 non-union and 2 infections. Overall, the distal femoral arthroplasty procedure costs approximately £10000, and the fixation group costs were on average of £9800. Discussion & Conclusion. Distal femoral arthroplasty allowed early mobilisation, thus avoiding prolonged hospital stay and reducing the risk of inpatient related morbidity. Complication rates were lower than the fixation group and the overall costs were comparable to that of fixation. Distal femoral arthroplasty appears to be a promising alternative treatment to internal fixation in elderly patients with distal femoral peri-prosthetic fractures. With appropriate patient selection, the prosthesis is likely to survive for the duration of patient's lifetime

Periprosthetic femoral fractures are increasing in incidence, and typically occur in frail elderly patients. They are similar to pathological fractures in many ways. The aims of treatment are the same, including 'getting it right first time' with a single operation, which allows immediate unrestricted weightbearing, with a low risk of complications, and one that avoids the creation of stress risers locally that may predispose to further peri-implant fracture. The surgical approach to these fractures, the associated soft-tissue handling, and exposure of the fracture are key elements in minimizing the high rate of complications. This annotation describes the approaches to the femur that can be used to facilitate the surgical management of peri- and interprosthetic fractures of the femur at all levels using either modern methods of fixation or revision arthroplasty.

Cite this article: Bone Joint J 2023;105-B(6):593–601.

Much has been written about the use of different treatment modalities in the management of distal femoral fractures. These articles, however, do not include the use of the Ilizarov frame amongst the modalities described. We have experience in the use of the Ilizarov frame in the definitive treatment of both non-union and acute fracture of the distal femur. We report our experience and conclusions. The medical records of all patients who had undergone Ilizarov frame management for acute distal femoral fracture or established non-union were reviewed. Demographic data, the complications of surgery, duration of treatment with the frame and recorded outcome were noted. All patients were further assessed (either in clinic or by telephone interview) and completed a Short Musculoskeletal Function Assessment Form. We have treated 17 patients (11 male, 6 female), 8 were acute compound fractures and 9 non union/infected ORIF’s of the distal femur. All patients have had their frames removed and were united. The mean age at the time of frame application was 36.6 years (range 18.7–58.7). The mean time from frame application to union was 230 days (range 81–514). Noted major complications included refracture in two patients, persisting infection in one, chronic regional pain syndrome in one and limited range of movement in all (mean knee movement of 62 ranging from 2–100). Two patients have had above knee amputations and a further patient has requested above knee amputation. Short Musculoskeletal Function Assessment Form shows significant dysfunction with a mean score of 42.9/100 (range 8.15–82.85). Treatment of distal femoral fractures is notoriously difficult. Other treatment modalities (i.e. Intra Medullary (IM) supracondylar nail) offer many advantages over Ilizarov frame use

Fractures of distal femur and tibia treated with Open Reduction and Internal Fixation (O.R.I.F.) are frequently complicated in the postoperative period. Minimal Invasive Plate Osteosynthesis (MIPO) is developing for subcutaneous plating. The purpose of this study is to demonstrate the improvement in dropping the risks of complications following internal fixation of closed fractures of the lower limb using MIPO in comparison with conventional O.R.I.F. procedure. From January 1998 to May 1999 we collected 32 cases of lower limb fractures (10 distal femur, 15 pilon, 7 distal tibia) treated with O.R.I.F procedure (Group I). The mean age was 47.6 years (range 23–76). From June 1999 we started to perform MIPO in closed fractures of lower limb with conventional devices (36 cases). From March 2001 we performed part of our minimal invasive surgery (54 cases) with new devices with angular stability (Less Invasive Stabilization System, Synthes) that offer more tools for subcutaneous osteosynthesis and more mechanical stability of the implants. Our 90 cases formed Group II. The mean age was 53.2 years (range 21–80). The mean follow up was 18 months. We used bone grafts in only 1 case of severe pilon fracture. In Group I we got 2 infections in pilon fractures, 3 delayed union in distal tibial fractures, 1 non-union in distal femoral fracture, 1 varus deformity in distal femoral fracture and 2 DVT. In Group II we had no infection, no delayed or non-union (a mean consolidation time of 8–10 weeks for pilon fractures, 6 weeks for distal tibia fractures, 10–12 for distal femoral and proximal tibia ones). 2 cases of varus deformity in 1 pilon fractures (1 MIPO); 1 DVT in distal tibial fracture; 2 cases of varus deformity of distal femoral fracture (1 DCS). Conventional O.R.I.F. surgery showed some limits: wide exposure, damage to vascular supply of soft tissues and bone, blood loss, high risk of infections, not indicated in polytrauma patient: international literature reported high rate of postoperative complications. The findings of this study justify the effort to follow this procedure also because the new devices available improved mechanical stability and facilitated this technique In conclusion, minimal invasive surgery is a demanding technique with undoubted advantages: it reduces surgical exposures and risk of infection; it respects the biology of callus and soft tissues, it reduces the necessity of bone graft and is particularly indicated in polytrauma patients

Introduction: The interlocking retrograde ostheosynthesis was developed by Drs. Green, Selingson and Henry to address the whole spectrum of fractures localised to distal femur. The primary indications were in supracondylar fractures type A (AO), than in supra and inter-condylarfractures type C (AO). Secondary indications may be in periprosthetic fractures, non-union, fractures of femoral shaft, which cannot be nailed with antegrade technique (politrauma, ipsilateral femoral neck fracture or obese patient). Methods: In our department between 2001–2004, 24 distal femoral fractures were nailed with retrograde technique; 16 type A (AO), 8 type C (AO) and 1 peri-prostetique fractures 5 cm. distal to femoral stem. We have used a retro nail which allows us proximal interlocking with 2 screws and distal interlocking with screws or bolts if it is comminution or ostheoporosis. The fractures reduction was achived with traction on the fracture table or by manual manipulation. The insertion of the nail was percutaneous through a 5 cm incision centered on the patellar tendon those the blood loss was minimized. If there was an intercondylar fracture extension first we have reduced this and fixed with 2 percutaneos screws and then we have nailed the fracture. We have measured the whole blood loss, operating time, union period and knee ROM at 6 months. Also we have analysed the whole distal femoral alignment and the articular surface reduction. Results: We have achieved union in all fractures, 17 were anatomic (varus/valgus< 5°), 5 malunion with valgus more than 5° and 2 mallunion with hiperextension. The malunion in hiperextension was obtained in eldery patients with important ostheoporosis and cominution. The operating time was on average 75 min. The average blood loss was 250 ml, the ROM at 6 months was 125 ° (70°–140°). During recovery period we have started early ROM with partial weight bearing which shortened the recovery time. Discussion & conclusions: We believe that retrograde ostheosinthesis is a good method of treatment for distal femoral fractures but a proper selection of fractures must be done. The percutaneous technique is less invasive for these fractures, which are very difficult to treat, and in long-term results they alter the knee biomechanics. The reduction of the articular surface is essential and this must be done every time, if this is not possible using the retro nail we must change the implant and use one which allows to achieve this. Though the biomechanical advantages of retro nail, the small amount of blood loss and the sort operating time at the end of learning curve makes retro nail an implant of first choice in the treatment of distal femoral fractures

Aims

Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections.

Purpose of study:. Up to 30% of distal femur fractures treated with a locked plate have problems with union. Distal femur locked plates have become a very popular means of internal fixation because of their ability to provide stable distal peri-articular fixation. In spite of this enthusiasm however several studies have reported significant problems with healing. In the distal femur it is recognized that locked plate fixation may be too rigid if used in certain configurations preventing the essential micro movement required for biological healing. Implant failure may arise from rigid configurations that cause excessive hardware stress concentrations. In an attempt to address these problems longer plates and an increased working length have been proposed to reduce construct rigidity. The purpose of our study is to investigate whether an increased working length translates into improved healing. Description of method:. We undertook a retrospective review of 92 consecutive cases performed at our institution from 2007–2010. Case notes and X-rays were reviewed. Working length, plate to fracture zone ratios and working length to fracture zone ratios were calculated. Union was assessed radiographically and clinically. Covariates of smoking, age, sex and fracture severity were included. Outcomes considered were union or established non-union. Delayed union was defined as union after 20 weeks. Summary of results:. Median time to union was 16.9 weeks. 11 delayed unions (23.4%, 95%CI(10.8–36.0%)), 3 non-unions (6.4% 95%CI(0.0–13.6%)) and no implant failures were recorded. Our data are consistent with the previously reported proportion of distal femur fractures treated with a locked plate that have problems with union. Although trends were present, no significant associations between impaired healing and exposure variables were found. Conclusion:. While biomechanical studies have demonstrated increased flexibility of longer plates with an increased working length, clinically this did not translate into significantly improved fracture healing in our study

Aims

The aim of this systematic review and meta-analysis was to gather epidemiological information on selected musculoskeletal injuries and to provide pooled injury-specific incidence rates.

The distal femur fracture is a difficult injury that affects young men andelderly women. The tissue stripping that occurs with the traditional approach has been a factor in the development of complications like infection and nonunion. This study addresses the issue of minimally invasive approach. Does the LISS system really improve the results of such fracture?. Fifty-two patients were included in the trial from six academic trauma centres. Twenty-eight fractures had been randomised to be fixed with the LISS device, while twenty-four had the DCS implant. Type C3 fractures were excluded as they were not amenable for fixation with DCS system. All procedures were performed via minimally invasive technique. The LISS system had the targeter that helped with plate insertion and distal diaphyseal screws placement. Radiography was utilised in the case of the DCS distal screws insertion. All fractures went onto union, except two participants in LISS group who had to be revised due to loss of reduction, in the early post-operative peroid. There were three nonunions in the same group. These required a re-operation. Further more, a LISS participant who had re-injured his distal femur (unrelated to LISS plate), was fixed with different implant. There was a single nonunion with the DCS group that needed revision surgery. There was one participant from each group who had drifted into varus. Neither required a re-operation. This translated into a 21% re-operation rate in the LISS system compared to 4% with the DCS device. Our data supports the use of the DCS system in the fixation of distal femur fractures (except Type C3} via a minimally invasive approach. The LISS implant seems to be technique dependent. In our centre, the LISS plate had been discontinued in favour of the DCP and LCP systems

Aims

Despite multiple trials and case series on hip hemiarthroplasty designs, guidance is still lacking on which implant to use. One particularly deficient area is long-term outcomes. We present over 1,000 consecutive cemented Thompson’s hemiarthroplasties over a ten-year period, recording all accessible patient and implant outcomes.

Introduction: Surgical fixation of intra-articular distal femoral fractures has been associated with nonunion & varus collapse. The soft tissuestripping associated with this fracture andthe surgical exposure have been factors associated with delayed union & infection. The limited soft tissue exposure has been lauded the as a solution to this fracture. However, it has occurred with the new fixation as well.(Locked Plate). Aims: This study is an attempt to look at the fixation. Does the LISS system improve the results of this difficult fracture? Is there truly a difference in the outcome of this fracture utilizing the Locked plate system or is the percieved difference due to the surgical mini invasive approach. Patients & Methods: One hunderd & forty patients were screened, only 53 were randomized and fixed in six academic centers over 5 years. All C3 fractures were excluded as they were felt not to be treatable by the DCS device, but they were treated appropiately. 35 females and 18 males were included in the study and randomized appropiatley. Results: Fifty-three patients were randomized, 28 had the LISS implant and 25 had the DCS utilized. There were 3 nonunions in the LISS group plus two patients with early loss of reduction that required reoperation in the early post operative period. One patient developed arthrofibrosis requiring arthroscopic release and subsequently the implant failed necessitating refixation. In the DCS group, only one nonunion reported & required second surgery. This translated to a reoperation rate of 21% in the LISS group compared to 4% with DCS. Conclusion: This prospective randomized multicentre trial showed a difference when comparing the LISS to the DCS in the supracondylar distal femur fractures

Fractures of lower limb treated with Open Reduction and Internal Fixation (O.R.I.F.) are frequently complicated in the postoperative period. Minimal Invasive Plate Osteosynthesis (MIPO) is developing for subcutaneous plating. The purpose of this study is to demonstrate the improvement in dropping the risks of complications following internal fixation using MIPO. From January 1998 to May 1999 we collected 32 cases of lower limb fractures treated with O.R.I.F (Group I). From June 1999 we started to perform MIPO in closed fractures of lower limb with conventional and new devices with angular stability that offer more mechanical stability (Group II 90 cases). In Group I we got 2 infections in pilon fractures, 3 delayed union in distal tibial fractures, 1 non-union in distal femoral fracture, 1 varus deformity in distal femoral fracture and 2 DVT. In Group II we had only 4 cases of varus deformity and 1 DVT. The findings of this study justify the effort to follow this procedure also because the new devices available improved mechanical stability. MIPO is a demanding technique with undoubted advantages: it respects the biology of callus and soft tissues, it reduces the necessity of bone graft and is particularly indicated in polytrauma patients

Aims

The purpose of this study was to determine the weightbearing practice of operatively managed fragility fractures in the setting of publically funded health services in the UK and Ireland.

We prospectively studied 29 patients with distal femoral fractures stabilised using the less invasive stabilisation system [LISS]. Four patients were excluded from the final follow up [3 deaths and 1 case of quadriplegia]. The mean age of the remaining 25 patients [9 males] was 60.9 years and the mean follow up 18 months [12–24]. Eleven patients were tertiary referrals from other hospitals [7 cases were referred due to failure of primary fixation]. Overall, there were 12 cases of high-energy trauma [7 open fractures]. According to the AO classification there were 5 Type 33A, 2 Type 33B and 12 Type 33C fractures and 4 Type 32A, 1 Type 32B, 1 Type 32C fractures. Functional assessment was performed using the Modified HSS and the Schatzker and Lambert scores. The average time to union in 22 cases was 3.5 months [range, 2–5]. None of the acute cases required bone grafting with a 100% union rate. There were 3/7 cases of non-union in the salvage group still undergoing treatment. The overall results in the acute cases were good and in the salvage cases fair. While this is a small series of patients, our preliminary data indicate favourable results using the LISS in stabilizing acute distal femoral fractures. However, when the LISS is used as a revision tool despite the concept of preserving the bone biology, the results seem to be less satisfactory. The system appears to be user friendly and no technical difficulties were encountered

Purpose: We evaluate the results of treatment of A.O. type C distal femoral fractures with 3 methods of internal fixation (condylar plate, 95° condylar blade plate, D.C.S.). Material-Methods: From 1988–2003, 108 patients (59 male, 49 female), aging 19 to 84 years (aver. 46 years), with 116 fractures A.O. /C were treated. 108 were closed and 8 open, Gustillo type II. We used condylar plate in 38 patients (group A), 95° condylar blade plate in 24 (group B) and D.C.S. in 54 (group C). Results: Postoperative follow-up ranged from 1 to 15 years. An early mobilization programme was initiated. The results were evaluated using the Schatzker-Lambert criteria. Pseudarthrosis was found in 4 cases in group A, 6 in B and 3 in C. Varous deformity was present in 10 cases in group A, 6 in B and 2 in C. Severe knee stiffness was present in 2 patients of group A, 2 of B and none of group C. Conclusion: The Dynamic Condylar Screw – D.C.S. seems to have an advantage compared to the other 2 methods of internal fixation regarding the treatment of A.O. /C distal femoral fractures offering stability, anatomical reduction, and early mobilization with a good functional outcome

The purpose of this study was to evaluate the results of LISS fixation of distal femur fractures. This is a single-centre review of 64 consecutive LISS plates used for distal femoral fractures over 5.5 years. No patients were excluded and all were followed for a minimum of one year (mean 37 months). Primary outcomes were time to union, knee ROM, Knee Outcome Survey Activities of Daily Living Scale and SF-36 scores. Secondary outcomes were fracture alignment, additional surgery and complications. Sixty-four fractures were followed in 62 patients with a bimodal distribution of age (mean 66 yrs, 14–98 years). Two major subgroups were young patients (55 and under) with high-energy fractures, most common in men (12:4) and elderly patients with insufficiency or peri-prosthetic fractures, more common in women (11:35). Twenty-two patients died prior to clinical follow-up in the study, but only eight of these died prior to radiological and clinical bony union. No other patients were lost to follow-up. Ninety-four percent of patients achieved within 10 degrees of full knee extension (mean 1.4 degrees), whilst 74% achieved knee flexion > 100 degrees and all achieved 90 degrees. Mean union time was 6.8 months and there was one infected non-union. There were 28 re-operations in 17 patients. Ten were for removal of metal-ware, four required bone grafting and two had revision of fixation. LISS fixation is a reproducible technique, producing reliable union, low re-operation rates (other than metal-ware removal) and good restoration of knee function. LISS is good for both high and low energy injury patterns and works well in the presence of both knee and hip replacements. We recommend bi-cortical proximal fixation in osteoporotic bone

Purpose: Blocking screws placed adjacent to intramedullary nails supplement fixation in long bone fractures with a short proximal or distal segment. Clinically, blocking screws are placed using fluoroscopy, resulting in variability in screw placement. The clinical significance of the accuracy of screw placement is unknown. Recently, a targeted blocking screw device was developed, enabling precise placement of screws adjacent to the nail. The purpose of this study was to evaluate the mechanical effects of locking screws (LS) and targeted (TBS) and non-targeted blocking screws (NBS) in distal femur fractures. Method: Sawbone. ®. femurs were used to create a fracture model. Femoral sawbone specimens were osteotomized eight cm proximal to the knee joint and a two cm gap was created. Intramedullary nails were used for stabilization, including one proximal locking screw and varying the distal screw configuration for study purposes. Targeted blocking screws were inserted directly adjacent to the intramedullary device using the commercially-available targeting device. Non-targeted screws were inserted one screw diameter medial or lateral to the “ideal” position. Four study groups were created; group one consisted of TBS and two distal LS. Group two had TBS and one LS. Group three had NBS and two LS, and group four consisted of NBS and one LS. Specimens were subjected to a cyclic compression protocol along the mechanical axis of the femur. Applied load varied from 100 to 700 N in 100 N incremental staircase loading protocol. Load-displacement curves recorded construct stiffness. Fracture gap motion was measured with electronic calipers. Results: Targeted constructs were stiffer at all load levels, and 10% stiffer overall. Differences were statistically significant at moderate load levels (Group one vs three, 400N and 500N, p< 0.05). Conclusion: Targeted constructs were stiffer at all load levels despite Sawbones. ®. undergoing significant deformation at the proximal femur, masking the relatively smaller differences in motion at the fracture site. A difference in sagittal motion was found between groups with one and two LS, independent of the position of blocking screws. In conclusion, targeted blocking screw constructs were stiffer at all load levels compared to non-targeted constructs. The number of LS was a factor in sagittal plane stability. This study suggests that using targeted blocking screws in distal femur fractures may reduce fracture motion and decrease post operative malalignment

We report the experience of a Grade 1 Trauma Centre in treating distal femoral and tibial fractures with the Less Invasive Stabilisation System (LISS). Medium term outcomes are presented with a discussion of clinical indications. We conducted retrospective study of patients presenting to St James University Hospital with distal femoral and proximal tibial fractures. Case notes were reviewed for demographics, mode and severity of injury, clinical time to union and complications. AO fracture classification and radiological time to union were assessed. 24 patients (10 males, 14 females) underwent LISS fixation. Average age was 69.7 years (range 31–95 years). Mean injury severity score was 14 (Range 9–36). Overall, there were five patients with isolated proximal tibial fractures, seventeen with isolated femoral fractures and two with fractures of both the distal femur and proximal tibia. Two of the distal femoral fractures were open (Gustillo type IIb). According to the AO classification, the distal femoral fractures were sub-divided into 4 Type 33A fractures, 5 Type 33B fractures, 6 Type 33C fractures, 2 Type 32B fractures and 2 Type 32C fractures. The proximal tibial fractures comprised 3 Type 41-A2, 2 Type 41-C1 and 2 Type 41-C2 fractures. HSS scores for the 24 acute cases were 8 excellent, 8 good, 6 fair and 2 poor results. Average HSS score was 78.8 points. Time to union was determined clinically and radiologically. Bony union was achieved in 23 cases (95.8%). Mean time to radiological union was 3.9 months (range 2–5 months), and clinical union at a mean of 4.46 months (range 3–6 months). We illustrate that the LISS is a useful technique for treating distal femoral and proximal tibial fractures which are often a complex management problem in the elderly population. With increasing incidence of fragility fractures we suggest that this may be an underused treatment option

The principle of open reduction and internal fixation developed during the last few decades provides satisfactory alignment and articular function. The disadvantages of this technique are a large area of surgical exposure with risk of bone avascular necrosis, non-union, infection and stiffness. With LISS (Less Invasive Stabilisation System) the percentage of these problems can be reduced. Over the period January 2003–March 2004, at the Orthopaedics and Traumatology Operative Unit of Maggiore Hospital in Bologna, Italy, 15 patients with distal femur fractures were treated by the use of LISS. Two of them were excluded at the time of follow-up: they died 2 and 12 months after the operation. Thus, we studied outcome in the remaining 13 patients. The average age was 49.7 years (range 18 to 88). According to the AO classification system we had four type 33.A1 fractures, six type 33.A3 fractures, two type 33.C2 fractures, one type 33.C3 fracture and one type 32.A3 open fracture. The mean follow-up was 9.8 months (range 3 to 17 months). Clinical and radiographic assessment was performed using the Neer-Grantham-Shelton score. The mean final score was 70.9/100. The average time of bony union was 12 weeks. We had three complications. In one patient there was a proximal pull out a few days after surgery; however, a satisfactory bony union was obtained with a second operation by a new LISS and a bone graft performed 1 month after the first operation. In the other two patients we had to remove the LISS because of pain at 2 and 14 months after surgery. These complications can be easily explained by the lack of experience in applying this kind of implant and the peculiarity of the cases. We conclude that LISS is an effective system for healing distal femur fractures, with no direct surgical exposure of the fracture site, little bleeding, and early mobilisation and union

Despite advances in Locking Plate (LP) design, distal femoral fractures remain challenging injuries to treat especially in the elderly where approximately 15–30% develop nonunions secondary to failure of fixation. Aim: To establish the mechanisms of nonunion in our patient population using two different LP systems. Methods: Between December 2002-May 2008, we prospectively collected data on all 67 patients with distal femoral fractures who were treated using a suitable distal femoral LP (LISS, 35 cases, or Periloc, 32 cases). 72% of the patients were female; ages ranged from 25–94 years (ave. 67 years). Many of our patients had a number of significant co-morbidities. Results: The presence of significant co-morbities e.g. Rheumatoid arthritis, long term systemic steroid use, cerebrovascular accidents resulting in ambulatory problems, previous major joint arthroplasty including ipsilateral knee replacements, paralysis, and severe dementia, did not appear to influence fracture union significantly. However, old age was strongly correlated with nonunion with all failed cases (7 patients - 10% of the study group) presenting with failure of fixation. 2 of the LP system failures resulted in malunion and the 5 other cases required revision surgery. Of note, all 7 patients were elderly, 6 being over 80 years of age. The mechanism of fixation failure was specific to each of the LP systems. All 4 of the failures treated with LISS, resulted from poor proximal stability as a consequence of unicortical screw fixation. Two patients required to have the proximal fixation revised through the insertion of bicortical screws which subsequently resulted in successful union. The other two patients were treated in long leg casts as the varus deformities were considered acceptable given each patient’s needs. All 3 of the failures who had been treated with a Periloc LP, resulted from fracturing of the plate at the metaphyseo-diaphyseal junction at the level of the main extra-articular component of the fracture. The plates all fractured through the unfilled screw holes, and all 3 patients required revision of fixation to bring about union. Discussion: The LISS failures can all be attributed to poor proximal fixation that is associated with the use of unicortical screws in osteoporotic bone and confirms the need for bicortical screw fixation. However, modern LP systems manufactured from stainless steel offer increased implant stability that may in turn stress any fracture bridging segments of the LP. Conclusion: Although we are aware of the importance of bicortical screws in osteoporotic patients, it is also seems likely that excessive plate rigidity should be avoided, by using long plates with well spaced out screws

The treatment of joint-fractures is a common task in orthopaedic surgery causing considerable health costs and patient disabilities. Percutaneous techniques have been developed to mitigate the problems related to open surgery (e.g. soft tissue damage), although their application to joint-fractures is limited by the sub-optimal intra-operative imaging (2D- fluoroscopy) and by the high forces involved. Our earlier research toward improving percutaneous reduction of intra-articular fractures has resulted in the creation of a robotic system prototype, i.e. RAFS (Robot-Assisted Fracture Surgery) system. We propose a robot-bone attachment device for percutaneous bone manipulation, which can be anchored to the bone fragment through one small incision, ensuring the required stability and reducing the “biological cost” of the procedure. It consists of a custom-designed orthopaedic pin, an anchoring system (AS secures the pin to the bone), and a gripping system (GS connects the pin and the robot). This configuration ensures that the force/torque applied by the robot is fully transferred to the bone fragment to achieve the desired anatomical reduction. The device has been evaluated through the reduction of 9 distal femur fractures on human cadavers using the RAFS system. The devices allowed the reduction of 7 fractures with clinical acceptable accuracy. 2 fractures were not reduced: in one case the GS failed and was not able to keep the pin stationary inside the robot (pin rotates inside the GS). The other fracture was too dislocated (beyond the operational workspace capability of the robot). A more stable GS will be designed to avoid displacements between the pin and the robot

Aims: Loss of distal þxation occurs with this the blade plate, especially in the setting of a very distal femur fracture and/or in osteoporotic bone. The LISS (Less Invasive Stabilization System) provides a þxation construct for supracondylar/intracondylar distal femoral fractures, with features including submuscular þxation and percutaneous placement of self-drilling unicortical þxed angled screws. The purpose of this study was to evaluate the biomechanical characteristics of the LISS versus the angled blade plate in an osteoporotic human cadaveric femoral model. Methods: Twenty-four matched pairs of fresh frozen human femora were utilized. Three groups of eight pairs each were tested to failure in one-time axial loading, one-time torsional loading and cyclical axial loading. A fracture model was created to simulate an AO 33–A3 fracture. Results: The average axial load to failure was 34% higher for the LISS compared with the blade plate (p = 0.03). All 8 LISS constructs failed by plastic deformation of the implant only, while 3/8 blade plates failed by loss of distal þxation. The blade plate had a 47% higher torsional moment to failure (p= 0.05). Permanent deformation after cyclical axial loading was signiþcantly lower for the LISS (p = 0.01). Conclusions: Of signiþcant interest is potential loss of þxation in catastrophic loading of a supracondylar femoral fracture þxation construct. In conclusion, biomechanical testing of the LISS demonstrates in comparison to the blade plate: (1) superior þxation of the distal femoral Ç block È in axial loading, (2) lower torsional strength, and (3) less permanent deformation in cyclical axial loading. The results further indicate that one-time axial loading of the LISS þxation construct will ultimately result in þxator plastic deformation, rather than screw pullout

Objectives: The comminuted supracondylar femur fractures are resulted from high energy trauma. Infection and union problems are common complications. LISS is a new generation implant leading to decrease these complications. The aim of this prospective study is to compare the outcomes of distal femoral fractures treated by LISS (Less Invasive Stabilization System) of the multiple injured and isolated fractured cases. Patients and Methods: This prospective study comprised of twentysix patients, sixteen men and ten women, who had 27 distal femoral fractures. Patients were divided as having multiple injury (group I) or isolated femur distal fractures (group II). There were fourteen supracondylar (AO type A) and thirteen intercondylar (AO type C) fractures. The average Injury Severity Scores (ISS) of group I and II were 26.7 and 9 respectively. Operations were performed according to biological fixation principles by means of submuscular manner. No grafting was performed to enhance the healing. The cases were evaluated based on the criteria of Schatzker–Lambert and modified Hospital for Special Surgery (HSS) scoring system. Results: The mean hospitalization time was 16 days (range 13–46) in GI mainly depended on the presence of concomitant injuries and 8 days (range 6–12) in GII. The mean age of the patients was 49 years (range 26–80) (51.6 in GI and 45.6 in GII). The mean follow up period was 25.8 months. Union was achieved in all cases. Two cases required debridement procedures due to deep infection in group I. One of them healed completely but the other not resulted in chronic ostemyelitis. Revision surgery was carried out in one case due to screw pull out at second weeks postoperatively. The average range of knee motion of the group I and II at the last control were 112.8°, 121.8 respectively. The mean modified HSSs were 73.9 and 79.9 respectively. There was no significant difference for HSS scores and range of knee motion (p> 0.05). Based on the criteria described by Schatzker and Lambert, the outcomes were assessed as excellent in 3 cases, good in 8, fair in 3, and poor in 2 in GI and as excellent in 3, good in 7 and fair in 1 in GII. Poor results of GI were because of osteomyelitis in one case and 15° varus deformity in another. The full weight bearing time was longer in group II depending on the concomitant injuries. Conclusion: We concluded that LISS is effective method to yield satisfactory results for comminuted supracondylar fractures with multi trauma, even if their final results seem to be lower in comparison to isolated femur fractures

Aims

This prospective study reports longitudinal, within-patient, patient-reported outcome measures (PROMs) over a 15-year period following cemented single radius total knee arthroplasty (TKA). Secondary aims included reporting PROMs trajectory, 15-year implant survival, and patient attrition from follow-up.

Background. Treating fractures is expensive and includes a long post-operative care. Intra-articular fractures are often treated with open surgery that require massive soft tissue incisions, long healing time and are often accompanied by deep wound infections. Minimally invasive surgery (MIS) is an alternative to this but when performed by surgeons and supported by X-rays does not achieve the required accuracy of surgical treatment. Methods. Functional and non-functional requirements of the system were established by conducting interviews with orthopaedic surgeons and attending fracture surgeries at Bristol Royal Infirmary to gain first-hand experience of the complexities involved. A robot-assisted fracture system (RAFS) has been designed and built for a distal femur fracture but can generally serve as a platform for other fracture types. Results. The RAFS system has been tested in BRL and the individual robots can achieve the required level of reduction positional accuracy (less than 1mm translational and 5 degrees of rotational accuracy). The system can simultaneously move two fragments. The positioning tests have been made on Sawbones. Conclusions. The proposed approach is providing an optimal solution by merging the fracture reduction knowledge of the orthopaedic surgeon and the robotic system's precision in 3D. Level of Evidence. The current level of evidence is limited and based on the Sawbones testing. Acknowledgement. This is a summary of independent research funded by the NIHR's i4i Programme. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health

Introduction. Although total knee arthroplasty (TKA) in end-stage hemophilic arthropathy can reduce the severe joint pain and improve the functional disability, it is technically demanding. In addition, it has generally reported a high rate of complication including periprosthetic joint infection (PJI) and component loosening up to 20%. Although the Knee Society classification system of TKA complication was introduced, the complications of TKA in hemophilic arthropathy has not stratified using this classification system in previous articles to the best of our knowledge. The purpose of this study was to evaluate the mid-term outcomes and complications of TKA in hemophilic arthropathy. Methods. The study retrospectively reviewed 131 consecutive primary TKAs (102 patients) in single institute. The mean patient age was 41.0 years and mean follow-up time was 6.4 years. The clinical and radiographic results were evaluated. The complications were categorized according to the classification system of the Knee Society for TKA complications. Results. The average WOMAC score improved from 66.0 to 24.2. The average flexion contracture significantly decreased from 17.3° to 4.7°, but the average pre and postoperative maximum flexion did not differ (80.9 ° vs. 85.6°). The average mechanical axis was varus 5.2° preoperatively and valgus 0.3° postoperatively. The coronal position of femoral and tibial components and sagittal position of those components were within ±3° in 83.2%, 89.3%, 63.4%, and 73.3%. The complications occurred in 17 knees (13.0%). There were 7 bleeding and hemarthrosis. Five knees were treated with increased amounts of coagulation factor concentrate and two knees were treated with incision and drainage of hematoma. One medial collateral ligament injury of grade 2 required change of postoperative rehabilitation protocol and bracing. Two stiffness of grade 3 required unplanned admission and manipulation under anesthesia. Three deep PJI were treated with 2 stage revision TKA. There were 4 periprosthetic fractures. Three distal femur fractures were treated with open reduction and internal fixation for 3 knees. One patellar fracture was healed with conservative treatment. Conclusions. The mid-term results of TKA in end-stage hemophilic arthropathy were satisfactory with obtaining pain relief, improving function, and decreasing flexion contracture. Bleeding and PJI continues to be a major concern for TKA in patients with hemophilic arthropathy, and risk of periprosthetic fracture has to be taken into account for patient education and appropriate prevention. Level of evidence. Level IV

Object: We performed retrograde nailing of type C fractures and periprothetic percondylar fractures of the distal femur using a new dedicated femoral implant (T2 Supra-Condylar Nail). Herewith a powerful tool for the treatment of complex very distal femoral fractures was created. This nail has four distal locking holes placed from 6 to 32 mm at the end of the nail for a 3 plane fixation. We present the new implant and the preliminary clinical outcome in 25 cases. Methods: A consecutive series of 24 patients with 25 fractures of the distal femur (6 fractures AO type A, 1 type B, 12 type C fractures and 6 periprothetic fractures) was operated between January 2003 and September 2004. The epidemiology was typical for trauma patients with 18 male and 6 female patients. The mean age was 50.8 years (range 21–92 ys). The bone stock was osteopenic in 9 cases and regular in 16 cases. There were 6 patients who sustained polytrauma, 5 paraplegic patients fell out of their wheelchair. The remaining 13 patients suffered isolated injuries. The patients were followed up clinically and radiographically. Results: Seven patients were stabilized intramedullary at the day of the accident, 11 patients in the next 5 days. The remaining 6 fractures were initially stabilized with an external fixator in case of multiple injury. 7 percondylar fractures were stabilized with a short nail of 200 mm in cases of implants in the proximal femur (hip prosthesis: 3, DHS: 2, gamma nail: 2). Mean duration of operation was 106 minutes. The retrograde nailing using the T2 implant is a good suitable method performing a correct reposition of the fragments with high primary stability. There were no problems in woundhealing at all. Postoperatively a wheightbearing mobilisation with 20kg was possible and range of motion was unlimited. Radiographs showed better ossification compared with plate osteosynthesis. Only one nail is broken out and needed a corrective operation with a plate. We saw no greater X- or O-deformity or rotation divergence. Only in 3 cases of delayed union, a spongioaplasty was indicated. Conclusions: The retrograd nailing of distal femoral fractures type A is well accepted. After changing a C fracture in A fracture, it is also possible to stabilize complex intraarticular fractures intramedullarly. If a stabile metaphyseal block of minimal 3,5 centimeter is present after anatomical reconstruction of the joint, even in cases of osteoporotic bone stock, a intramedullary nailing is possible. Also in cases of periprothetic fractures with a short metaphyseal block of the distal femur, the T 2 supracondylar nail with its 4 locking screws at the end of the nail can stabilize this block in a 3 plane fixation

Total knee arthroplasty using navigation system is known to be more effective than conventional methods in achieving more accurate bone resection and neutral alignment. Mobile bearing is also known to reduce wear and automatically correct rotational mal-alignment of the tibia but the long-term follow-up results of more than 10 years are extremely rare. The purpose of this study is to investigate the results of clinical and radiologic long-term follow-up and complications of total knee arthroplasty using navigation and multi-directional mobile bearing. From 2003 to 2006, a total of 111 navigation TKAs using multi-directional mobile bearing design were carried out and reviewed retrospectively. TKAs were performed by two experienced surgeons at one institute. Of the 111 patients, 102 were women and 9 were men. The mean duration of follow-up was 11.4 ± 1.0 years (range, 10.1 to 14.08 years). Clinical outcomes were evaluated in terms of Knee Society Score, Hospital for Special Surgery score, Western Ontario and McMaster University (WOMAC) score, range of motion and complications. Long-term radiological outcomes and survival rates were evaluated at least 10 years. Average preoperative HSS score was 66.5 ± 9.8 and KSS pain and function score were 25.0 ± 11.8 and 44.5 ± 12.3, respectively. Scores improved to 94.1 ± 8.2, 46.6 ± 11.6 and 88.2 ± 14.6 at the last follow up, respectively. Mean preoperative WOMAC scores of 75.8 ± 16.5 improved to 13.8 ± 16.0 at last follow-up. Five knees required re-operation, two for liner breakage for liner wear, one for distal femoral fracture and one for infection. The estimated 10-year prosthesis survival rates for any reason and for prosthesis-related problems were 95.5% and 97.4%, respectively. TKAs using each techniques resulted in similar good clinical outcomes and post-operative leg alignments. Robotic and navigation TKA appeared to reduce the number of postoperative leg alignment outliers and revision rate compared to conventional TKA

Abstract. A number of postoperative complications of navigated total knee arthroplasty have been discussed in the literature, including tracker pin site infection and fracture. In this paper we discuss the low postoperative complication rate in a series of 3100 navigated total knee arthroplasties and the overall complication rate in a systematic analysis of the literature. Methods. 3100 consecutive patients with navigated total knee arthroplasties from 2001 to 2016 were retrospectively evaluated for complications specific to navigation. We discuss the two cases of postoperative fracture through tracker pin sites that we experienced and compare this systematically to the literature. Results. Postoperatively, our 3100 patient cohort experienced a total of two fractures through pin sites for an incidence of 0.065%. One was a distal femoral fracture which was treated surgically, and the other was a proximal tibial fracture treated nonoperatively. Due to our incorporation of the tracker sites within our operative incision, there were no identifiable pin site infections which others have noted. Our 0.065% fracture rate compares favorably with the 0.16% rate of fracture published in the literature. We had no separate pin site infections in comparison to the 0.47% incidence of separate pin site infection reported by those who use seperate percutaneous incisions for tracker placement. Conclusion. There is an extremely low risk of perioperative complications due to the instrumentation used in navigated total knee arthroplasty when utilizing the Stryker Navigation System and 4.0 mm anchoring pins placed within the surgical incision. Our experience has demonstrated that careful placement of the bicortical anchoring pin is important

The technique involves impaction of cancellous bone into a cavitary femur. If segmental defects are present, the defects can be closed with stainless steel mesh. The technique requires retrograde fill of the femoral cavity with cancellous chips of appropriate size to create a new endomedullary canal. By using a set of trial impactors that are slightly larger than the real implants the cancellous bone is impacted into the tube. Subsequent proximal impaction of bone is performed with square tip or half moon impactors. A key part of the technique is to impact the bone tightly into the tube especially around the calcar to provide optimal stability. Finally a polished tapered stem is cemented using almost liquid cement in order to achieve interdigitation of the implant to the cancellous bone. The technique as described is rarely performed today in many centers around the world. In the US, the technique lost its interest because of the lengthy operative times, unacceptable rate of peri-operative and post-operative fractures and most importantly, owing to the success of tapered fluted modular stems. In centers such as Exeter where the technique was popularised, it is rarely performed today as well, as the primary cemented stems used there, rarely require revision. There is ample experience from around the globe, however, with the technique. Much has been learned about the best size and choice of cancellous graft, force of impaction, surface finish of the cemented stem, importance of stem length, and the limitations and complications of the technique. There are also good histology data that demonstrate successful vascularization and incorporation of the impacted cancellous bone chips and host bone. Our experience at the clinic was excellent with the technique as reported in CORR in 2003 by M Cabanela. The results at mid-term demonstrated minimal subsidence and good graft incorporation. Six of 54 hips, however, had a post-operative distal femoral fracture requiring ORIF. The use of longer cemented stems may decrease the risk of distal fracture and was subsequently reported by the author after reviewing a case series from Exeter. Today, I perform this technique once or twice per year. It is an option in the younger patient, where bone restoration is desired. Usually in a Paprosky Type IV femur, where a closed tube can be recreated and the proximal bone is reasonable. If the proximal bone is of poor quality, then I prefer to perform a transfemoral osteotomy, and perform an allograft prosthetic composite instead of impaction grafting, and wrap the proximal bone around the structural allograft. I prefer this technique as I can maintain the soft tissues over the bone and avoid the stripping that would be required to reinforce the bone with struts or mesh. Another indication for its use in the primary setting is in the patient with fibrous dysplasia

Aims

There are concerns regarding nail/medullary canal mismatch and initial stability after cephalomedullary nailing in unstable pertrochanteric fractures. This study aimed to investigate the effect of an additional anteroposterior blocking screw on fixation stability in unstable pertrochanteric fracture models with a nail/medullary canal mismatch after short cephalomedullary nail (CMN) fixation.

Background. Constrained condylar knees are used infrequently but are successful for the treatment of the primary or revision knee with ligamentous instability and bony defect. The purpose of the present study is retrospectively analyze clinical and radiological outcome of primary and revision total knee arthroplasty with condylar constrained knee (CCK) prosthesis at a minimum of 5 years. Methods. Fourteen knees underwent total knee arthroplasty with CCK prosthesis, performed between 2003 and 2009. The average age of the patients at the time of the surgery was 71.4 years (range, 47 to 88 years). The reason for the operation was primary (osteoarthritis) in 2, revision due to aseptic loosening in 9 and infection after total knee arthroplasty in 4 knees. NexGen LCCK was used in all cases. The mean follow-up period was 91months (range, 60 to 128 month). Results. The mean Knee Society knee score and Knee Society functional score were 82.8 (range, 60 to 92) and 57.2 (range, 10 to 89) points at the time of the final follow-up. The mean knee extension and flexion angle were −3.3 (−20 to 0) and 99.2 (65 to 135) before the operation, and −1.7 (−5 to 0) and 103.2 (80 to 130) at the latest follow-up evaluation. In radiographic results, the mean of postoperative femorotibial angle (FTA) was 178° (range, 168 to 187). In one case, radiolucent line was present in Zone 1 to 4 of tibial component. There were one distal femur fracture and one dislocation of the femorotibial joint, with a rate of re-operation of 14.3%. In these two cases, the time from total knee arthroplasty to re-operation were 7 years and 2 years. There were no revisions for aseptic loosening, patella problems, or fractures. Kaplan-Meier survivorship analysis, with revision or other re-operation as the end point, revealed that the ten-year rate of survival of the components was 87.3%. Conclusions. Primary and revision total knee arthroplasty with use a constrained condylar knee prosthesis had reproducible clinical success at the mid-term follow-up

Peri-prosthetic distal femoral fractures around total knee replacement is a highly complex reconstructive challenge, particularly in the presence of bone comminution and poor bone quality in elderly patients. With the incidence of peri-prosthetic fractures ranging from 0.3% to 2.5%, this is becoming a common problem. Older patients with concomitant medical issues have a very limited tolerance for prolonged immobilisation. It is the author's practice to revise, rather that attempt to fix, peri-prosthetic fractures of the knee which are very close to the femoral or tibial implants, particularly when associated with osteoporosis and comminution. When compared to fracture fixation, distal femoral replacement has significantly shorter operative time, less blood loss, and shorter hospital stay. Patients have been shown to recover faster, have fewer complications, and left hospital sooner. The general assumption has been that the use of a distal femoral replacement prosthesis is cost prohibitive in revision total knee settings, however, initial differences in the price of the prosthesis are more than offset by a shortened hospital stay and a more rapid return to pre-fracture level of function

Introduction. Distal femur fracture is a critical issue in orthopedic trauma, because it is difficult to manage especially in cases with intra-articular fracture. Osteoporosis may cause instability of implant and increase complications. Few studies investigate on the stability of distal femur osteoporotic fracture and the behaviors under cycling. Our hypothesis was that the stiffness of construct would decrease as cycling in osteoporotic bone. Materials and Methods. Seven cadaver specimens were used in this study. Relative bone density for each specimen was evaluated using CT scanning by three known calibration phantoms scanned simultaneously with the specimen. All cadaver specimens were divided normal (group 1) and osteoporosis (group 2) in accordance with the bone density. The titanium distal femur locking plates with 6 screws placed in distal femur condyle and 4 in shaft. A 10 mm gap with 65 mm proximal to the center of articular surface and a vertical fractural line between intra-articular were created to simulate AO C2 type fracture. Each specimen was cyclically loaded in two-phase at a frequency of 2 Hz. Phase 1 was set at 1000 N for 10000 cycles. In phase 2, the load was set at 2000 N for 10000 cycles. Then, the specimen was loaded up to failure at a rate of 5 mm/min. Stiffness was evaluated from the linear portion of load-displacement curve at 2000 cycle interval. Results and Discussion. Figure 1 showed the stiffness deterioration during cycling. Group 1 expresses the cadaveric specimen with normal bone density, and group 2 expresses osteoporosis. The stiffness of group 1 (with normal bone density) decreased for 26.2 % after 20000 cycles, however, group 2 (osteoporotic bone) revealed 90.3 % decay in stiffness. The stiffness decay observably when the load increased from 0 to 1000 N and from 1000 to 2000 N. The maximum load for group1 and group 2 were 4883±134 N and 2538 N, respectively. It can be found the normal bone density group showed intact circular hole, however, the osteoporotic bone revealed an oval contour. The subsidence of screws increased the risk of screw loosening and instability. It can be concluded that the bone quality and cyclic loading could be the important factors that affect the stability and failure strength of the construct

The use of tourniquets in lower limb trauma surgery to control bleeding and improve the surgical field is a long established practice. In this article, we review the evidence relating to harms and benefits of tourniquet use in lower limb fracture fixation surgery and report the results of a survey on current tourniquet practice among trauma surgeons in the UK.

Aim. A case series with functional and radiographic outcomes, of modular endoprosthetic distal femoral replacement in complex cases of periprosthetic fracture. Method. Sixteen cases were identified of endoprosthetic replacement (EPR) from the bone and soft tissue cancer implant registry. A retrospective review was undertaken. Results. There were 11 periprosthetic fractures of total knee arthroplasty, 3 revision arthroplasty cases, and 3 cases of distal femoral fracture. Of which four were complicated by infection. AKSS scores ranged from 62-100, average 82, with 6 month minimum follow up. There were two post operative infections, both successfully treated. One femoral component required exchange for aseptic loosening at two years. Conclusion. EPR is an effective surgical procedure for complex cases with a demonstrable good functional outcome