Integrated Nail and Plate Fixation with Allograft in the Management of Osteoporotic Intra-articular Distal Femur Fracture – A Case Report (2024)

[1] Department of Orthopaedics, Dr. DY Patil Medical College and Hospital, Mumbai, Maharashtra, India.

Article Received : 2024-04-30,

Article Accepted : 2024-07-18

Introduction: Securing stable internal fixation for fractures in the osteoporotic intra-articular distal femur proves to be a demanding task due to thin cortices, a wide medullary canal, diminished bone stock, and fracture comminution. No singular therapeutic approach has successfully tackled all facets of this injury. Consequently, we now introduce a pioneering fixation method in our report, aiming to offer a holistic solution to the intricate challenges associated with this scenario.

Case Report: A 60-year-old female presented with an intra-articular distal femur fracture, and underwent a combination fixation of distal femur plate and intramedullary interlocking nailing. The patient was rehabilitated with active knee range of motion on post-operative day 7 and has now attained full knee range of motion.

Conclusion: The utilization of anatomical plates with locking mechanisms, in tandem with intramedullary interlocking nailing, holds promise for the secure stabilization and fixation of osteoporotic distal femur fractures, potentially leading to an expedited recovery process.

Keywords: Distal femur fracture, intra-articular fracture, distal femur plating, intramedullary nailing.

Introduction:

Distal femoral fractures account for 3–6% of all femur fractures. Clinically, these fractures are characterized by occurrences within 15 cm from the distal femoral articular surface. The unstable fracture pattern and frequent comminution of these fractures make treatment extremely challenging ^[1]. Historically, the majority of distal femur fractures were managed without surgery until around 1970 [2,3]. However, the drawbacks associated with prolonged bed rest, the risk of knee motion loss, incongruities in the knee joint, and the potential for angular deformities prompted further exploration into more effective treatment strategies. In the past 50 years, substantial progress in surgical techniques and implant technology has transformed the landscape, making internal fixation the primary approach for treating distal femur fractures^[4]. Despite these advancements, achieving stable internal fixation remains a persistent challenge due to factors such as thin cortices, a wide medullary canal, poor bone stock, and fracture comminution ^[5]. It is noteworthy that no single therapeutic approach has emerged as a comprehensive solution capable of addressing all aspects associated with this complex injury [6,7]. Hence, we now report this case and the fixation method we used to treat this intra-articular osteoporotic distal femur fracture ^[4].

Case Report:

Discussion:

In recent times, there has been a growing trend ‘towards’ utilizing in double construct fixation for distal femoral fractures, especially in cases involving more intricate fractures. This approach, involving both nail and plate fixation, is suggested to provide patients with a more resilient construct capable of supporting early weight bearing ^[8]. In scenarios marked by severe articular and metaphyseal comminution, osteoporotic bone, medial cortical defect, and very low distal femur fractures, depending on a solitary lateral plate proves insufficient, lacking the necessary support to resist strain. This deficiency in fixation stability, coupled with the risk of early implant failure, non-union, and the potential for varus or valgus collapse, arises from incapacity to counteract the bending tendency induced by the vertical load. Despite incorporating fixed angles, locking systems, enhanced screw purchase in the distal fragment, and cutting-edge biological fixation-powered locking plates, the presence of a medial cortical defect and extensive comminution, particularly in osteoporotic bones with a low fracture line, poses a formidable challenge by concentrating stress predominantly on the lateral side. A multitude of biomechanical studies conducted over time consistently highlight the insufficiency of relying solely on lateral locking plate fixation. Concerns regarding non-union and the potential for metalwork failure have recently gained attention in the context of standalone lateral plate fixation for distal femoral fractures. An alternative approach for addressing these fractures involves the usage of a retrograde intramedullary nail. Historically, plates have been employed to manage fractures when there is inadequate distal bone stock for nail attachment, despite the fact that retrograde intramedullary nail constructs do not exhibit a significant biomechanical advantage over lateral plate constructs. Furthermore, it is important to note that not all distal femoral fractures treated with nailing are authorized for full weight-bearing [9, 10]. The biomechanical attributes of retrograde intramedullary nailing and lateral plates are synergistically combined in nail plate constructions to create a more sturdy fixation. In this construct, the entire load is borne by the plate, making it the primary load-bearing structure. Conversely, the nail serves as a load sharing mechanism, distributing forces through contact between the nail and the cortex, as well as the surrounding cortex. Notably, in a biomechanical study utilizing a synthetic model of distal femur fracture, the nail plate construct demonstrated superior performance in terms of axial strength and torsional stability compared to solitary nails or plates [11, 12]. To enhance the overall stability of the system, Liporace and Yoon recommended connecting the plate and the nail distally. This connection is established using fluoroscopy and the “perfect circle” approach. In instances of severe osteoporosis, these authors advocate for the use of two interconnected screws and typically spanning the entire femur with plate ^[13].

Conclusion:

Much like fractures in the proximal femur, prompt surgical intervention is crucial for osteoporotic distal femoral fractures, aiming for a secure repair that allows early weight-bearing. Treatment options include distal femur replacement, lateral plate, retrograde intramedullary nail, or a combination of implants such as nail plate. Nail plate constructs, merge the load-sharing features of nailing with the load-bearing characteristics of plating, expediting weight bearing and diminishing the risk of non-union and hardware failure. Employing a dual implant fixation approach may particularly benefit obese, osteoporotic, or elderly patients, minimizing non-union risk and facilitating swift mobilization. Factors contributing to non-union risk encompass periprosthetic fractures, fractures with medial comminution, and metaphyseal engagement ^[14]. While larger randomized controlled trials may eventually establish the superiority of nail and plate fixation, additional research is necessary for definitive conclusions.

Clinical Message:

Treating fractures in treatingosteoporotic distal femur is a challenge due to its weakened bone quality. Combining an intramedullary nail with an anatomically contoured plate offers a strategic solution to enhance stability and support during healing, with the added advantage of earlier mobilization.

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