Comparison of retrograde intramedullary nailing, antegrade intramedullary nailing and distal femur locked plating methods in the treatment of extra-articular distal femur fractures: A retrospective analysis: Treatment of extraarticular distal femur fractures

Nevzat Gönder; Volkan  Özel; Oğuz  Kaya; İbrahim Halil  Demir

doi:10.5281/zenodo.10034822

Authors

Nevzat Gönder Gaziantep Islam Science and Technology University Faculty of Medicine, Department of Orthopedics and Traumatology, Gaziantep, Turkey https://orcid.org/0000-0003-0691-1289
Volkan Özel Şehitkamil State Hospital, Department of Orthopedics and Traumatology, Gaziantep, Turkey https://orcid.org/0000-0003-0163-987X
Oğuz Kaya Elazığ Fethi Sekin City Hospital, Department of Orthopedics and Traumatology, Elazığ, Turkey https://orcid.org/0000-0002-6076-7057
İbrahim Halil Demir Şehitkamil State Hospital, Department of Orthopedics and Traumatology, Gaziantep, Turkey https://orcid.org/0000-0002-7572-7285

DOI:

https://doi.org/10.5281/zenodo.10034822

Keywords:

Antegraded intramedullary nail, distal femur locking plate, Femur distal fracture, retrograd intramedullary nail, orthopedics

Abstract

Objective: Extra-articular distal femoral fractures account for 3% of femoral fractures, while they occur at a rate of 0.4% among all fractures. Although the basic treatment principles have not changed, the development of new implant designs for the biological fixation of this fracture is still ongoing. Among the treatment alternatives, internal fixation with anatomical plates and intramedullary nails are the most frequently utilized methods. Our objective in this research is to compare retrograde intramedullary nailing (RIMN), antegrade intramedullary nailing (AIMN) and distal femur locked plating (DFLP) methods in the treatment of extra-articular distal femoral fractures.

Methods: The study retrospectively examined the data of 48 patients who underwent locked plating for extra-articular distal femoral fracture, 40 patients who underwent retrograde intramedullary nailing, and 36 patients who underwent antegrade intramedullary nailing between 2016 and 2021. Patients who had pathological fracture, periprosthetic fracture, ipsilateral tibial fracture and fracture-associated ligament and neurovascular injury and open fracture were excluded from the study. Fractures were classified based on the classification of Arbeitsgemeinschaft für Osteosynthesefragen Foundation/Orthopedic Trauma Association (AO/OTA) for distal femoral fractures. Functional findings were assessed with respect to the criteria determined by Sanders et al. and Lysholm knee score criteria.

Results: The DFLP group included 48 patients (25 males and 23 females, aged 48.29±18.08 years), the RIMN group included 40 patients (19 males and 21 females, aged 49.93±18.31 years), and the AIMN group included 36 patients (15 males and 19 females, aged 46.22±18.6 years). There was no statistically significant difference between the groups in terms of age (p=0.727). The mean follow-up period was 26.04 months in the DFLP group, 25.9 months in the RIMN group, and 26.61 months in the AIMN group. The functional outcomes of the AIMN group were better than those of the other two groups based on the Sanders and Lysholm knee score criteria (p=0.001).

Conclusion: The results of our current study revealed that all three methods yielded good results. Nevertheless, better functional outcomes were obtained in patients who underwent intramedullary fixation compared to the DFLP group. We suggest AIMN as a reliable method in the treatment of extra-articular distal femoral fractures due to preferable knee joint functions, low bleeding rate and low complication rates compared to other fixation methods.

References

Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006;37:691-7.

Martinet O, Cordey J, Harder Y, Maier A, Bühler M, Barraud GE. The epidemiology of fractures of the distal femur. Injury. 2000;31:C62-C63.

Smith JR, Halliday R, Aquilina AL, Morrison R J, Yip GC, McArthur J, et al. Distal femoral fractures: The need to review the standard of care. Injury. 2015;46:1084-8.

Handolin L, Pajarinen J, Lindahl J, Hirvensalo E. Retrograde intramedullary nailing in distal femoral fractures--results in a series of 46 consecutive operations. Injury. 2004;35:517-22.

Pingsmann A, Lederer M, Wüllenweber C, Lichtinger TK. Early patellofemoral osteoarthritis caused by an osteochondral defect after retrograde solid nailing of the femur in sheep. J Trauma. 2005;58:1024-28.

Seifert J, Stengel D, Matthes G, Hinz P, Ekkernkamp A, Ostermann PA. Retrograde fixation of distal femoral fractures: results using a new nail system. J Orthop Trauma. 2003;17:488-95.

Kubiak EN, Fulkerson E, Strauss E, Egol KA. The evolution of locked plates. J Bone Joint Surg Am. 2006;88:189-200.

Hoskins W, Sheehy R, Edwards ER, Hau RC, Bucknill A, Parsons N, et al. Nails or plates for fracture of the distal femur? data from the Victoria Orthopaedic Trauma Outcomes Registry. Bone Joint J. 2016;98-B:846-50.

Henderson CE, Lujan T, Bottlang M, Fitzpatrick DC, Madey SM, Marsh JL. Stabilization of distal femur fractures with intramedullary nails and locking plates: differences in callus formation. Iowa Orthop J. 2010;30:61-8.

Gill S, Mittal A, Raj M, Singh P, Singh J, Kumar S. Extra Articular Supracondylar Femur Fractures Managed with Locked Distal Femoral Plate or Supracondylar Nailing: A Comparative Outcome Study. J Clin Diagn Res. 2017;11:RC19-RC23.

Zlowodzki M, Bhandari M, Marek DJ, Cole PA, Kregor PJ. Operative treatment of acute distal femur fractures: systematic review of 2 comparative studies and 45 case series (1989 to 2005). J Orthop Trauma. 2006;20:366-71.

Salem KH, Maier D, Keppler P, Kinzl L, Gebhard F. Limb malalignment and functional outcome after antegrade versus retrograde intramedullary nailing in distal femoral fractures. J Trauma. 2006;61:375-81.

Hierholzer C, von Rüden C, Pötzel T, Woltmann A, Bühren V. Outcome analysis of retrograde nailing and less invasive stabilization system in distal femoral fractures: A retrospective analysis. Indian J Orthop. 2011;45:243-50.

Ocalan E, Ustun CC, Aktuglu K. Locking plate fixation versus antegrade intramedullary nailing for the treatment of extra-articular distal femoral fractures. Injury. 2019;50:55-62.

Ziranu A, Noia G, Cipolloni V, Coviello M, Maccagnano G, Liuzza F, et al. Revision Surgery Using Retrograde Nail versus Replating in Nonunion Distal Femur Fracture Treated with Plate. Adv Orthop. 2022;2022:5742743.

Dunbar RP, Egol KA, Jones CB, Ertl JP, Mullis B, Perez E, et al. Locked Lateral Plating Versus Retrograde Nailing for Distal Femur Fractures: A Multicenter Randomized Trial. J Orthop Trauma. 2023;37:70-6.

Redondo-Trasobares B, Sarasa-Roca M, Rosell-Pradas J, Calvo-Tapies J, Gracia-Villa L, Albareda-Albareda J. Comparative clinical and biomechanical study of different types of osteosynthesis in the treatment of distal femur fractures. Rev Esp Cir Ortop Traumatol. 2023;67:216-25.

Collinge CA, Reeb AF, Rodriguez-Buitrago AF, Archdeacon MT, Beltran MJ, Gardner MJ, et al. Analysis of 101 Mechanical Failures in Distal Femur Fractures Treated with 3 Generations of Precontoured Locking Plates. J Orthop Trauma. 2023;37:8-13.

Siddiqui YS, Mohd J, Abbas M, Gupta K, Khan MJ, Istiyak M. Technical difficulties and mechanical failure of distal femoral locking compression plate (DFLCP) in management of unstable distal femoral fractures. Int J Burns Trauma. 2021;11:9-19.

Hsu CL, Yang JJ, Yeh TT, Shen HC, Pan RY, Wu CC. Early fixation failure of locked plating in complex distal femoral fractures: Root causes analysis. J Formos Med Assoc. 2021;120:395-403.

Gao K, Gao W, Huang J, Li H, Li F, Tao J, et al. Retrograde nailing versus locked plating of extra-articular distal femoral fractures: comparison of 36 cases. Med Princ Pract. 2013;22:161-6.

Demirtaş A, Azboy I, Özkul E, Gem M, Alemdar C. Comparison of retrograde intramedullary nailing and bridge plating in the treatment of extra-articular fractures of the distal femur. Acta Orthop Traumatol Turc. 2014;48:521-6.

Nester M, Borrelli J Jr. Distal femur fractures management and evolution in the last century. Int Orthop. 2023;47:2125-35.

Von Rehlingen-Prinz F, Eggeling L, Dehoust J, Huppke C, Strahl A, Neumann-Langen M V, et al. Current standard of care for distal femur fractures in Germany and Switzerland. Injury. 2023;54:110936.

Aggarwal S, Rajnish RK, Kumar P, Srivastava A, Rathor K, Haq RU. Comparison of outcomes of retrograde intramedullary nailing versus locking plate fixation in distal femur fractures: A Systematic Review and Meta-analysis of 936 patients in 16 studies. J Orthop. 2022;36:36-48.