Medial and lateral dual plating of native distal femur fractures: a systematic literature review

Abstract

Introduction:Lateral locked plating (LLP) development has improved outcomes for distal femur fractures. However, there is still a modest rate of nonunion in fractures treated with LLP alone, with higher nonunion risk in high-energy fractures, intra-articular involvement, poor bone quality, severe comminution, or bone loss. Several recent studies have demonstrated both the safety and the biomechanical advantage of dual medial and lateral plating (DP). The purpose of this study was to evaluate the clinical outcomes of DP for native distal femoral fractures by performing a systematic review of the literature.Methods:Studies reporting clinical outcomes for DP of native distal femur fractures were identified and systematically reviewed. Publications without full-text manuscripts, those solely involving periprosthetic fractures, or fractures other than distal femur fractures were excluded. Fracture type, mean follow-up, open versus closed fracture, number of bone grafting procedures, nonunion, reoperation rates, and complication data were collected. Methodologic study quality was assessed using the Coleman methodology score.Results:The initial electronic review and reverse inclusion protocol identified 1484 publications. After removal of duplicates and abstract review to exclude studies that did not discuss clinical treatment of femur fractures with dual plating, 101 potential manuscripts were identified and manually reviewed. After final review, 12 studies were included in this study. There were 199 fractures with average follow-up time of 13.72 months. Unplanned reoperations and nonunion occurred in 19 (8.5%) and 9 (4.5%) cases, respectively. The most frequently reported complications were superficial infection (n = 6, 3%) and deep infection (n = 5, 2.5%) postoperatively. Other complications included delayed union (n = 6, 3%) not requiring additional surgical treatment and knee stiffness in four patients (2%) necessitating manipulation under anesthesia or lysis of adhesions. The average Coleman score was 50.5 (range 13.5–72), suggesting that included studies were of moderate-to-poor quality.Conclusions:Clinical research interest in DP of distal femoral fractures has markedly increased in the past few decades. The current data suggest that DP of native distal femoral fractures is associated with favorable nonunion and reoperation rates compared with previously published rates associated with LLP alone. In the current review, DP of distal femoral fractures was associated with acceptable rates of complications and generally good functional outcomes. More high-quality, directly comparable research is necessary to validate the conclusions of this review.

Distal femur fractures: basic science and international perspectives

“…A recent systemic review demonstrated acceptable results of dual plating with nonunion rates of less than 5% despite a selection bias for complex, high-risk cases. 37 More recently there has been a trend toward the use of nail-plate combined constructs. 40,41 This technique has been shown to improve biomechanical stability without the need for a second medial approach or additional metaphyseal soft tissue stripping.…”

“…The use of a second plate to augment lateral fixation has been described for decades. 37 Broadly there are 2 distinct techniques. The first is application of a medial plate through a separate approach, most commonly a medial subvastus approach.…”

“…Although this is a very effective method for increasing stability, it may increase periosteal stripping and further disrupt vascular supply at the fracture site. 37 , 38 Percutaneous medial approaches are limited by the crossing of the femoral artery, which is typically 16 to 18 cm proximal to the adductor tubercle. 38 These downsides of the medial plate may be overcome using the endosteal plating technique described by Mast et al 39 In this technique, a plate is inserted through the fracture site into the intramedullary canal using the same lateral approach.…”

“…A recent systemic review demonstrated acceptable results of dual plating with nonunion rates of less than 5% despite a selection bias for complex, high-risk cases. 37 …”

“…Common indications described include acute fractures at high risk for nonunion, such as fractures with extensive comminution, bone loss, or open fractures. 32 , 37 A further argument for dual implant constructs is to allow for early weight-bearing in geriatric patients. 40 Finally, dual implants constructs may have a role in the treatment of nonunions.…”