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2010 Mid-America Orthopaedic Association Physician in Training Award: Healing Complications Are Common After Locked Plating for Distal Femur Fractures

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Clinical Orthopaedics and Related Research®

Abstract

Background

Several mechanical studies suggest locking plate constructs may inhibit callus necessary for healing of distal femur fractures. However, the rate of nonunion and factors associated with nonunion are not well established.

Questions/purposes

We (1) determined the healing rate of distal femur fractures treated with locking plates, (2) assessed the effect of patient injury and treatment variables on fracture healing, and (3) compared callus formation in fractures that healed with those that did not heal.

Patients and Methods

We retrospectively reviewed 82 patients treated with 86 distal femur fractures using lateral locking plates. We reviewed all charts and radiographs to determine patient and treatment variables and then determined the effects of these variables on healing. We quantitatively measured callus at 6, 12, and 24 weeks. The minimum time for telephone interviews and SF-36v2TM scores was 1 year (mean, 4.2 years; range, 1–7.2 years).

Results

Fourteen fractures (20%) failed to unite. Demographics and comorbidities were similar in patients who achieved healing compared with those who had nonunions. There were more empty holes in the plate adjacent to fractures that healed; comminuted fractures failed to heal more frequently than less comminuted fractures. Less callus formed in fractures with nonunions and in patients treated with stainless steel plates compared with titanium plates. Complications occurred in 28 of 70 fractures (40%), 19 of which had additional surgery.

Conclusions

We found a high rate of nonunion in distal femur fractures treated with locking plates. Nonunion presented late without hardware failure and with limited callus formation suggesting callus inhibition rather than hardware failure is the primary problem. Mechanical factors may play a role in the high rate of nonunion.

Level of Evidence

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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References

  1. Baker SP, O’Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14:187–196.

    Article  PubMed  CAS  Google Scholar 

  2. Button G, Wolinsky P, Hak D. Failure of less invasive stabilization system plates in the distal femur: a report of four cases. J Orthop Trauma. 2004;18:565–570.

    Article  PubMed  Google Scholar 

  3. Claes LE, Heigele CA, Neidlinger-Wilke C, Kaspar D, Seidl W, Margevicius KJ, Augat P. Effects of mechanical factors on the fracture healing process. Clin Orthop Relat Res. 1998;355(suppl):S132–S147.

    Article  PubMed  Google Scholar 

  4. Corrales LA, Morshed S, Bhandari M, Miclau T 3rd. Variability in the assessment of fracture-healing in orthopaedic trauma studies. J Bone Joint Surg Am. 2008;90:1862–1868.

    Article  PubMed  Google Scholar 

  5. Egol KA, Kubiak EN, Fulkerson E, Kummer FJ, Koval KJ. Biomechanics of locked plates and screws. J Orthop Trauma. 2004;18:488–493.

    Article  PubMed  Google Scholar 

  6. Fankhauser F, Gruber G, Schippinger G, Boldin C, Hofer HP, Grechenig W, Szyszkowitz R. Minimal-invasive treatment of distal femoral fractures with the LISS (Less Invasive Stabilization System): a prospective study of 30 fractures with a follow up of 20 months. Acta Orthop Scand. 2004;75:56–60.

    Article  PubMed  Google Scholar 

  7. Gaines RJ, Sanders R, Sagi HC, Haidukewych GJ. Titanium versus stainless steel locked plates for distal femur fractures: is there any difference? OTA abstract. 2008: Paper Number 55.

  8. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58:453–458.

    PubMed  CAS  Google Scholar 

  9. Henderson CE, Bottlang M, Marsh JL, Fitzpatrick DC, Madey SM. Does locked plating of periprosthetic supracondylar femur fractures promote bone healing by callus formation? Two cases with opposite outcomes. Iowa Orthop J. 2008;28:73–76.

    PubMed  Google Scholar 

  10. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol. 1992;13:606–608.

    Article  PubMed  CAS  Google Scholar 

  11. Kayali C, Agus H, Turgut A. Successful results of minimally invasive surgery for comminuted supracondylar femoral fractures with LISS: comparative study of multiply injured and isolated femoral fractures. J Orthop Sci. 2007;12:458–465.

    Article  PubMed  Google Scholar 

  12. Keating JF, O’Brien PJ, Blachut PA, Meek RN, Broekhuyse HM. Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft: a prospective, randomized study. J Bone Joint Surg Am. 1997;79:334–341.

    PubMed  CAS  Google Scholar 

  13. Kenwright J, Richardson JB, Goodship AE, Evans M, Kelly DJ, Spriggins AJ, Newman JH, Burrough SJ, Harris JD, Rowley DI. Effect of controlled axial micromovement on healing of tibial fractures. Lancet. 1986;2:1185–1187.

    Article  PubMed  CAS  Google Scholar 

  14. Kregor PJ, Hughes JL, Cole PA. Fixation of distal femoral fractures above total knee arthroplasty utilizing the Less Invasive Stabilization System (L.I.S.S). Injury. 2001;32(suppl 3):SC64–SC75.

    PubMed  Google Scholar 

  15. Kregor PJ, Stannard J, Zlowodzki M, Alonso J. Distal femoral fracture fixation utilizing the Less Invasive Stabilization System (L.I.S.S.): the technique and early results. Injury. 2001;32(suppl 3):SC32–SC47.

    PubMed  Google Scholar 

  16. Kregor PJ, Stannard JA, Zlowodzki M, Cole PA. Treatment of distal femur fractures using the less invasive stabilization system: surgical experience and early clinical results in 103 fractures. J Orthop Trauma. 2004;18:509–520.

    Article  PubMed  Google Scholar 

  17. Kubiak EN, Fulkerson E, Strauss E, Egol KA. The evolution of locked plates. J Bone Joint Surg Am. 2006;88(suppl 4):189–200.

    Article  PubMed  Google Scholar 

  18. Lujan TJ, Henderson CE, Madey SM, Fitzpatrick DC, Marsh JL, Bottlang M. Locked plating of distal femur fractures leads to inconsistent and asymmetrical callus formation. J Orthop Trauma. 2010;24:156–162.

    Article  PubMed  Google Scholar 

  19. Lujan TJ, Madey SM, Fitzpatrick DC, Byrd GD, Sanderson JM, Bottlang M. A computational technique to measure fracture callus in radiographs. J Biomech. 2010;43:792–795.

    Article  PubMed  Google Scholar 

  20. Markmiller M, Konrad G, Sudkamp N. Femur-LISS and distal femoral nail for fixation of distal femoral fractures: are there differences in outcome and complications? Clin Orthop Relat Res. 2004;426:252–257.

    Article  PubMed  Google Scholar 

  21. Marti A, Fankhauser C, Frenk A, Cordey J, Gasser B. Biomechanical evaluation of the less invasive stabilization system for the internal fixation of distal femur fractures. J Orthop Trauma. 2001;15:482–487.

    Article  PubMed  CAS  Google Scholar 

  22. Moed BR, Watson JT, Goldschmidt P, van Holsbeeck M. Ultrasound for the early diagnosis of fracture healing after interlocking nailing of the tibia without reaming. Clin Orthop Relat Res. 1995;310:137–144.

    PubMed  Google Scholar 

  23. Morshed S, Corrales L, Genant H, Miclau T 3rd. Outcome assessment in clinical trials of fracture-healing. J Bone Joint Surg Am. 2008;90(suppl 1):62–67.

    Article  PubMed  Google Scholar 

  24. Orthopaedic Trauma Association Committee for Coding and Classification. Fracture and dislocation compendium. J Orthop Trauma. 1996;10(suppl 1):v–ix, 1–154.

    Google Scholar 

  25. Paley D. Principles of Deformity Correction. Berlin, Germany: Springer-Verlag; 2002.

    Google Scholar 

  26. Rorabeck CH, Taylor JW. Periprosthetic fractures of the femur complicating total knee arthroplasty. Orthop Clin North Am. 1999;30:209–214.

    Article  PubMed  CAS  Google Scholar 

  27. Schandelmaier P, Partenheimer A, Koenemann B, Grun OA, Krettek C. Distal femoral fractures and LISS stabilization. Injury. 2001;32(suppl 3):SC55–SC63.

    PubMed  Google Scholar 

  28. Schutz M, Muller M, Krettek C, Hontzsch D, Regazzoni P, Ganz R, Hass N. Minimally invasive fracture stabilization of distal femoral fractures with the LISS: a prospective multicenter study. Results of a clinical study with special emphasis on difficult cases. Injury. 2001;32(suppl 3):SC48–SC54.

    PubMed  Google Scholar 

  29. Schutz M, Muller M, Regazzoni P, Hontzsh D, Krettek C, Van der Werken C, Hass N. Use of the less invasive stabilization system (LISS) in patients with distal femoral (AO33) fractures: a prospective multicenter study. Arch Orthop Trauma Surg. 2005;125:102–108.

    Article  PubMed  Google Scholar 

  30. Stoffel K, Dieter U, Stachowiak G, Gachter A, Kuster MS. Biomechanical testing of the LCP: how can stability in locked internal fixators be controlled? Injury. 2003;34(suppl 2):B11–B19.

    Article  PubMed  Google Scholar 

  31. Syed AA, Agarwal M, Giannoudis PV, Matthews SJ, Smith RM. Distal femoral fractures: long-term outcome following stabilisation with the LISS. Injury. 2004;35:599–607.

    Article  PubMed  CAS  Google Scholar 

  32. Vallier HA, Hennessey TA, Sontich JK, Patterson BM. Failure of LCP condylar plate fixation in the distal part of the femur: a report of 6 cases. J Bone Joint Surg Am. 2006;88:846–853.

    Article  PubMed  Google Scholar 

  33. Ware JE, Kosinski M, Dewey JE. How to Score Version 2 of the SF-36 Health Survey. Lincoln, RI: QualityMetric Inc; 2000.

    Google Scholar 

  34. Weight M, Collinge C. Early results of the less invasive stabilization system for mechanically unstable fractures of the distal femur (AO/OTA types A2, A3, C2, and C3). J Orthop Trauma. 2004;18:503–508.

    Article  PubMed  Google Scholar 

  35. Whelan DB, Bhandari M, McKee MD, Guyatt GH, Kreder HJ, Stephen D, Schemitsch EH. Interobserver and intraobserver variation in the assessment of the healing of tibial fractures after intramedullary fixation. J Bone Joint Surg Br. 2002;84:15–18.

    Article  PubMed  CAS  Google Scholar 

  36. Wong MK, Leung F, Chow SP. Treatment of distal femoral fractures in the elderly using a less-invasive plating technique. Int Orthop. 2005;29:117–120.

    Article  PubMed  Google Scholar 

  37. 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;20:366–371.

    Article  PubMed  Google Scholar 

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Acknowledgments

We thank Todd O. Mckinley for his contribution to this study.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA

    Christopher E. Henderson MD, Lori L. Kuhl & John L. Marsh MD

  2. Biomechanics Laboratory, Legacy Research and Technology Center, Portland, OR, USA

    Trevor J. Lujan PhD & Michael Bottlang PhD

  3. Slocum Center for Orthopaedics, Eugene, OR, USA

    Daniel C. Fitzpatrick MD

Authors
  1. Christopher E. Henderson MD
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  2. Trevor J. Lujan PhD
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  3. Lori L. Kuhl
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  4. Michael Bottlang PhD
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  5. Daniel C. Fitzpatrick MD
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  6. John L. Marsh MD
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Corresponding author

Correspondence to Christopher E. Henderson MD.

Additional information

One or more of the Authors (MB, DF) have a commercial association with a company (Zimmer) that introduced MotionLoc technology.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at University of Iowa Hospitals and Clinics and the Slocum Center for Orthopaedics.

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Henderson, C.E., Lujan, T.J., Kuhl, L.L. et al. 2010 Mid-America Orthopaedic Association Physician in Training Award: Healing Complications Are Common After Locked Plating for Distal Femur Fractures. Clin Orthop Relat Res 469, 1757–1765 (2011). https://doi.org/10.1007/s11999-011-1870-6

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  • DOI: https://doi.org/10.1007/s11999-011-1870-6

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