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Retrograde nailing versus fixed-angle blade plating for supracondylar femoral fractures: A randomized controlled trial
Abstract and Figures
A variety of devices have been used in the treatment of supracondylar femoral fractures. The condylar blade plate relies on the principles of open reduction, absolute stability and interfragmentary compression to achieve union. The technique of retrograde nailing uses indirect reduction of the metaphyseal fracture component, offering relative stability and a less invasive approach. Randomized comparison of these common methods of fixation has not been reported.
Twenty-two patients with 23 supracondylar femur fractures were recruited from two regional trauma centres over a 26-month period and randomized to receive either a retrograde intramedullary nail fixation (IM group, 12 fractures) or a fixed-angle blade plate fixation (BP group, 11 fractures). The groups were followed for 12-36 months. The primary outcome measures were revision surgery and general health.
Three patients in the IM group required revision surgery for the removal of implant components. No reoperations occurred in the BP group. There was a trend towards greater pain in the IM group, although there was no statistically significant difference in the scores for any of the SF-36 domains.
Both distal femoral nailing and blade plating give good outcomes. There is a trend for patients undergoing retrograde nailing to complain of more pain and to require revision surgery for removal of implants.
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... All 18 studies received a one-point deduction due to the lack of a double-blind evaluation of participant endpoints and lack of prospective sample size calculation [3, 23- [34,42]. The randomization processes were specified and adequate in five studies [35,47,[49][50][51]. Two studies specified the randomization processes but were inadequate because patients were allocated to two groups one after the other, which also Content courtesy of Springer Nature, terms of use apply. ...
... One study was double-blinded and, therefore, free of performance and detection biases [31]. Two other studies were free of detection bias [35,50]. One study was considered to have a high risk of attrition bias due to the loss of participants during follow-up ( Fig. 2a and b) [35]. ...
... Two other studies were free of detection bias [35,50]. One study was considered to have a high risk of attrition bias due to the loss of participants during follow-up ( Fig. 2a and b) [35]. ...
Purpose
The distal femur comprises a wide intramedullary cavity and thin cortical bone. Firm internal fixation of comminuted fractures with displacement is challenging. Although many comparative studies have reported retrograde intramedullary nailing (RIN) and distal femoral plating (DFP) as the usual fixation methods for distal femoral fractures, no clear conclusion has been reached. Therefore, a meta-analysis and systematic review of the clinical and radiological results were conducted to determine the appropriate treatment method for distal femoral fractures.
Methods
A systematic search of the PubMed, Embase, Scopus, and Cochrane Library databases from their inception to December 19, 2022, was performed using predefined criteria. Studies comparing the effects of RIN and DFP were considered. The analyzed outcome measures included duration of surgery, blood loss, time to union, delayed union, nonunion, malalignment, implant failure, infection, reoperation, limb length discrepancy, range of motion, persistent anterior knee pain, knee stiffness, and functional scores. Meta-analysis of pooled data was conducted using a random-effects model to determine the standard mean difference (SMD) or odds ratio (OR) with 95% confidence intervals (CIs).
Results
Thirty-three studies with 2,432 patients were included. Compared to DFP, RIN was associated with a shorter time to fracture union (SMD, 1.83 months; 95% CI − 2.76 to − 0.90; P < 0.001) and a lower incidence of postoperative infection (OR 0.54; 95% CI 0.31–0.94; P = 0.03). Pooled analysis revealed no significant differences in other outcome measures between the two treatment modalities.
Conclusion
In distal femoral fractures, RIN had a shorter bone union time and was more resistant to infection than DFP. However, there were no significant differences in the other clinical parameters. Therefore, the characteristics, strengths, and weaknesses of RIN and DFP should be carefully identified, and appropriate treatment should be provided based on the patient’s medical condition and fracture pattern.
... Early definitive fixation is the preferred treatment for haemodynamically stable patients. Depending on the type of fracture, both intra-articular fractures and non-intra-articular fractures of the distal femur can be managed with open or closed reduction and fixation with a plate (less invasive stabilisation system [LISS], angled plate, etc.) or a retrograde nail [78][79][80][81][82][83][84]. Joint-spanning external fixation can be used temporarily in haemodynamically unstable patients or in a damage control situation. ...
Purpose
Our aim was to develop new evidence-based and consensus-based recommendations for the initial inhospital management of lower-extremity injuries in patients with multiple and/or severe trauma. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with multiple and/or severe Injuries.
Methods
MEDLINE and Embase were systematically searched to May 2021. Randomised controlled trials, prospective cohort studies, and comparative registry studies were included if they compared interventions for the initial surgical and non-surgical management of fractures, dislocations or vascular injuries of the lower extremities in patients with multiple and/or severe trauma. We considered patient-relevant clinical outcomes such as mortality, complication rates, length of stay, and function. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength.
Results
Eleven studies were identified. They addressed time to definitive fixation (n = 10 studies) and amputation (n = 1). Two new recommendations were developed, one was modified. All recommendations achieved strong consensus.
Conclusion
This systematic literature review and subsequent expert consensus process resulted in the following new key recommendations. It is recommended that isolated and multiple lower-extremity fractures are managed with primary definitive fixation in patients whose condition is stable. Patients condition is not considered stable should be managed with primary temporary fixation. In addition, it is recommended that dislocations of the lower extremities are reduced and immobilised as early as possible.
... They stress that choosing the right implant is less important than using a surgical approach that produces high-quality results. In a randomized study of the management of extraarticular fractures by retrograde intramedullary nailing and blade plate, Hartin et al. 5 found no differences in functional recovery. The sole difference was that the group receiving retrograde nailing experienced more frequent knee pain, resulting in a 25% removal rate of the fixation material. ...
Background: Majority of these fractures are situated in close proximity to neurovascular structures, treating distal femur fractures is often complicated.Surgical methods available for treating distal femoral fractures reflects the difficulties these injuries present. The study compared the functional outcomes of the retrograde supracondylar interlocking nail with the distal femoral locking compression plate for the treatment of extra articular distal femur fractures. Methods: A prospective observational study of 70 Patients with fracture distal femur presenting to the outpatient department and emergency of Mahatma Gandhi Hospital, satisfying the following inclusion & exclusion criteria were included in this study. Initially patient was well educated about the significance of each of the procedure surgery and the detailed surgical procedure. All patients were enrolled in this study and allocated into two groups. Results: Patients who underwent DFLCP in Group A and Patients who underwent Retrograde Nailing in Group B. The mean age is 49.87±12.09. 82% of all the patients affected were males while 12% of the patients affected were females. The right limb was affected more commonly than the left limb. Mostly 49 patients were due to a Road Traffic Accident (RTA).While comparing the outcomes, 29 patients out of 35 had excellent and good outcomes. Conclusion: We therefore draw the conclusion that DLFP and Retrograde intramedullary nail fixation are both successful methods for treating distal femur fractures based on the aforementioned findings. Retrograde nailing, however, resulted in a significantly quicker period for fracture union.
... Thomson et al. 43 reported a better union and lower revision rates with a retrograde IMN. Hartin et al. 44 reported no difference in functional recovery between retrograde IMN and blade plate. ...
Purpose
The fixation method of distal, extra-articular femur fractures is a controversially discussed. To ensure better stability itself, earlier mobilization and to prevent blood loss – all these are justifications for addressing the femur via reamed intramedullary nailing (RIMN). Anatomical reposition of multifragmentary fractures followed by increased risks of non-union are compelling reasons against it. The purpose of this study was to systematically review the literature for rates of non-union and wound infection, as well as blood loss and time of surgery.
Methods
According to the PRISMA guidelines we conducted this systematic review by searching the Cochrane, PubMed, Ovid, MedLine, and Embase databases. Inclusion criteria were the modified Coleman methodology score (mCMS) >60, age >18 years, and extra-articular fractures of the distal femur. Biomechanical and animal studies were excluded. By referring to title and abstract relevant articles were reviewed independently. In the consecutive meta-analysis, we compared 9 studies and 639 patients.
Results
There is no statistically significant difference comparing superficial wound infections when RIMN was performed (OR = 0.50; 95% CI: 0.18 – 1.42; P = 0.19) as well as in deep wound infections (OR = 0.74; 95% CI: 0.19–2.81; P = 0.62). However, these results were not significant. We also calculated for potential differences in the rate of non-unions depending on the surgical treatment applied. Data of 556 patients revealed an overall number of 43 non-unions. There was no significant difference in rate of non-unions between both groups (OR = 0.97; 95% CI: 0.51–1.85; P = 0.92).
Conclusion
No statistical difference was found in our study among RIMN and plate fixation in the treatment of distal femoral fractures with regard to the incidence of non-union and wound infections. Therefore, the indication for RIMN or plating should be made individually and based on the surgeon’s experience.
During the years 1966 to 1972, the Toronto group of surgeons obtained 75% good to excellent results in the treatment of the supracondylar fracture by rigid internal fixation. The present review of 49 fractures is a continuation of the same study. Internal fixation was performed using implants and instruments developed by the Swiss Association for the study of internal fixation. Fixation. In many cases the requirements for accurate reduction and absolute rigid fixation had not been met. This group was classified as 'the others', and was contrasted with those patients in whom rigid fixation has been successfully achieved. Rigid internal fixation led to 71% of good to excellent results whereas only 21% of good to excellent results were obtained in patients in whom the fixation was not absolutely rigid. Rigid fixation is difficult to achieve with osteoporotic bone because of the degree of comminution and the poor holding power of the bone. The mere use of the appropriate implant does not assure rigid fixation. Failure to meticulously observe all details of the method of rigid fixation resulted in a high complication rate with failures. These factors must be considered in evaluating criteria for surgical treatment.
Fractures of the distal femur are often complex injuries presenting numerous potential complications. The surgical management of these difficult injuries is based on classification, patient selection, and preoperative planning. The surgical approach and modified extensile approach include four fixation devices. The results with 63 patients and 68 injuries reviewed over a ten-year period consisted of 76% good to excellent results, five malunions, and a 4.4% infection rate.
The records on fifty-two supracondylar-intercondylar fractures of the femur were reviewed twenty to 120 months after injury. More than one-third of the fractures had been open. All of the fractures were treated in a single trauma center, using: (1) a single lateral incision, (2) internal fixation with ASIF interfragmentary screws and plates, (3) bone-grafting of comminuted metaphyseal segments, (4) impaction of comminuted metaphyseal segments in osteoporotic elderly patients, and (5) repair of any associated torn ligaments and patellar fractures. Postoperatively, early active motion of the knee was encouraged, and for selected patients a brace was used only to protect the repair of associated disruptions of ligaments or of the extensor mechanism. The fractures were classified by the ASIF system, with C1 being a simple Y pattern, C2 having additional supracondylar comminution, and C3 having intra-articular comminution. The final results were rated using the system that was described by Neer et al. for fractures of the distal end of the femur. The average time between the operation and full weight-bearing (healing) was 13.6 weeks and ranged from 12.3 weeks for C1 fractures (as graded using the ASIF classification) to 15.4 weeks for C3 fractures. The average final arc of motion of the knee was 107 degrees, ranging from 113 degrees for C1 fractures to 99 degrees for C3 fractures. C1 fractures had a better outcome (92 per cent excellent and good results) than did C2 and C3 fractures (77 per cent excellent and good results). Two amputations and one arthrodesis were done to treat infection, and infection accounted for three of the four poor results. Age did not influence the final results, although elderly patients had a longer period of hospitalization. Supracondylar-intercondylar fractures of the femur should be analyzed separately from other fractures of the distal end of the femur because of their intra-articular involvement and associated ligamentous injuries and patellar fractures. Rigid internal fixation permits early functional rehabilitation of the patient and decreases the incidence of malunion, non-union, and loss of fixation.
Surgical treatment of supracondylar fractures of the femur has become commonplace. A variety of surgical implants are available. In carefully chosen patients treated with appropriate surgical technique, early motion and good knee function can be obtained with open reduction and internal fixation. However, the morbidity (and mortality) are substantial following complications of open reduction and internal fixation of supracondylar fractures of the femur. We present a series of 30 consecutive patients referred to Rancho Los Amigos Medical Center for complications following open reduction and internal fixation of supracondylar femur fractures. Three patients with septic pseudarthrosis underwent above-knee amputations. Two of these three patients died of systemic sepsis. Fourteen additional patients were treated for nonunions, with 13 patients achieving union at an average time of 36.5 months from the date of injury. Six patients underwent quadricepsplasties for residual knee stiffness. Only 16 patients were returned to their preinjury ambulatory status.
Sixteen patients with supracondylar-condylar fractures of the femur were treated by the technique developed by the Swiss AO group. The end results were analyzed in fifteen of these patients who were available for follow-up.
Two patients had a Group-I fracture and five, a Group-II fracture. Nine patients had Group-III fractures of which three were open and six needed cancellous bone grafts to fill bone defects present after anatomical reduction.
All fractures united although one had a pseudarthrosis and required further stabilization and bone grafting before it healed.
Three patients had infections but only one had severe symptoms and marked limitation of the knee joint motion as a consequence.
Follow-up study revealed very good and satisfactory results in fourteen patients and a poor result in one.
The good end results were attributed to the stable osteosynthesis which permitted early postoperative function.
Two common types of internal fixations for the supracondylar femur fractures--the retrograde intramedullary nail and the 95 degrees sideplate and screw--were mechanically tested in synthetic composite femur bones to determine the quantitative differences in their inherent rigidity. The medial and lateral femoral condyles were separated by a sagittal osteotomy, and a standardized medial segmental shaft defect was created at the distal shaft. The osteotomized specimens were stabilized using one of the two implants and were tested in different modes of loading. The bending stiffness of both constructs were not significantly different in varus compression, medial bending (pure varus), and bending in flexion. The plate and screw implant was three times stiffer in lateral bending (pure valgus) and 1.2 times stiffer in valgus compression than the retrograde supracondylar nail (p < 0.01). The torsional stiffness of the plate and screw implant was significantly higher, 1.6 times that of the nail. Clinically, the most important and common cause of implant failure is varus loadings due to loss of medial cortical contact. Although the retrograde nail was less rigid in other physiologically less critical modes of loading, it had a rigidity comparable to that of the plate in varus loading. Therefore, a supracondylar nail may be considered a mechanically possible alternative to plate fixation.
An 80-year-old man sustained a T-shaped supracondylar fracture of the femur associated with distal one-third shaft comminution. Initial failure of a 95 degrees angle blade plate was followed by insertion of an intraarticular intramedullary nail stabilized with static locking-screw fixation. A second failure of the implant was treated by extraarticular tension band condylar buttress plate osteosynthesis. Severe knee synovial metallosis was found at the time of removal of the intraarticular nail device.
A biomechanical cadaver study was performed to compare the stability of three standard distal femoral fixation techniques. Eighteen mildly osteoporotic femurs were selected, based on a dual-energy x-ray absorption scanning bone density of 0.3-0.5 g/cm2 and a Singh index of III-IV. After initial mechanical characterization of these intact femurs, a distal femoral osteotomy was created, reduced, and stabilized under compression using random assignment to one of three methods of fixation: (a) six-hole 95 degrees supracondylar plate, (b) retrograde inserted statically locked supracondylar intramedullary nail, and (c) antegrade inserted statically locked Russell-Taylor nail. The instrumented femurs were mechanically tested, a 1-cm gap created, and the femurs retested. The specimens were finally loaded to failure in A-P three-point bending. The 95 degrees plate provided significantly stiffer fixation than the supracondylar intramedullary nail or Russell-Taylor nail in both a compressed transverse and gap distal femoral osteotomy model. The Russell-Taylor nail provided the least rigid fixation. The 95 degrees plate and Russell-Taylor nail had statistically significant greater loads to failure than the supracondylar intramedullary nail. These results support the use of a 95 degrees plate when maximum rigidity of fixation or maximum compression is desired.
The results of 57 A-O type A or C supracondylar femur fractures treated by open reduction and internal fixation using indirect reduction techniques are reported. No bone grafting or dual plating was used. All patients were placed in a continuous passive motion (CPM) machine postoperatively. Patients were followed at 4-week intervals until fracture healing had occurred. All patients were followed for at least 1 year after injury. All fractures were treated by a single surgeon. The average time for fracture healing was 10.7 weeks (range 8-16). Hardware failure did not occur in this series. Outcomes were assessed using a modified Schatzker scoring method. Using the scale, there were 84% good to excellent results, 11% fair results, and 5% poor outcomes. Fair and poor results tended to occur in more severe fractures and were primarily due to limited knee motion. Complications included two broken screws, one deep infection, and one malunion. No fractures failed to unite. In conclusion, holding the surgical skill factor constant, it appeared that biologic reduction techniques, although they provided excellent bone healing capability, did not guarantee universally satisfactory outcomes.
From August 1992 to January 1995, 24 patients with 26 supracondylar femoral fractures were treated with a retrograde intramedullary nail. There were 22 patients with 24 nails available for review. Eight fractures were open and 13 were intraarticular fractures. There were a significant number of associated injuries. The average followup interval was 18 months (range, 4-36 months). All fractures healed by 4 months, (average, 3 months). Only 1 patient required bone grafting. There were no implant failures or superficial or deep infections. One malunion occurred. Average knee range of motion was 104 degrees. A previously described rating scale was used to evaluate function. There were 4 excellent, 16 good, 2 fair, and 2 poor results. The supracondylar nail provides rigid internal fixation for rapid healing and comparable functional outcomes to lateral fixation devices with significantly less soft tissue dissection.