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Received 6 March 2021; Accepted 25 March 2021.

Femoral Alignment Outcome of Distal Femoral Fracture Fixation with Retrograde Nailing versus Plating

Tarek AbdElsamadElHewala, Alaa Ahmed Elngehy, Mohamed Khaled Engim, and Osam Mohamed Metwally

Department of Orthopedic surgery, Faculty of Medicine, Zagazig University

Abstract:

Background:Distal femoral fractures are serious injuries and represent a real challenge as regards their management. Treatment of such fractures has been controversial as various treatment modalities are available.The aim of this study was to compare the results of retrograde Nailing versus Plating technique in distal femoral fractures regarding alignment both radiologically and clinically.Patients and methods: we enrolled 18 patients with distal femoral fractures divided into two groups; Group a treated by RGN and group B treated by Plating technique. Clinical and radiological measurements of limb alignment, MAD,mLFDA, MPTA, pain, evidence of infection, deformities, and decrease of knee motion were performed to evaluate the outcomes after surgery in both techniques. Results:In group (A) there were six males and three females while in group (B) there were four males and five females. The age of the included patients in group (A) was with a mean of 32.55±8.14 while the mean of age in group (B) was with a mean of 36.44±8.42.The clinical measurements in normal limp was 4.66±1.32 in retrograde nail group while it was 4.88±1.58 in plating group, the MAD in fractured limp clinically was 5.38±1.89 in retrograde nail group while it was 6.48±2.31 in plating group.Medial Proximal Tibial Angle (MPTA) in normal limp radiologically was 88.00±2.12 in retrograde nail group while it was 87.11±2.97 in plating group (P=0.498), the MPTA in fractured limp radiologically was 87.77±1.85 in retrograde nail group while it was 87.88±3.48 in plating group (P =0.663) with no significant difference between groups and no significant between fracture and normal in both groups.In our study the complication including infection were in two patients in group (A) and four patients in group (B).Knee pain in six patients of group (A) and three patients in group (B).Reduction range of motion was found in three patients in group (A) and seven patients in group (B).While delayed of union was one patient in group (B). The only significant difference was found is reduction range of motion which is in group (B), while there were no significant difference regarding the other complications between the two groups.Conclusions:In our study, functional results trended toward better outcomes in distal femoral nails group than plates in terms of knee flexion, early weight bearing, but incidence of knee pain is higher in nailing group as compare to plating group. Therefore, Nailing technique is a better fixation system for distal femurfracture.

Keywords: Nailing; mLFDA; MPTA; femur fracture; PDFA

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INTRODUCTION

The treatment of fractures of the distal femur usually represents a challenge with significant difficulties that affect the end result. These difficulties are due to the inherit instability of the fracture due to the muscle action on the fracture site. Also the small size of the distal fragment with a wide medullary canal, thin cortex and osteoporotic bone in elderly patients added to the complexity of the treatment (1).Operative treatment is indicated for all patients with distal fractures other than for those situations outlined earlier in the non-operative section. As with many articular fractures, the strategy with articular fractures of thedistal femur is to get an anatomic reconstruction of the joint surface, provisional stabilization with Kirschner wires (K-wires) and then definitive fixation with inter-fragmentary compression screws (2).

In fractures of the distal femur should be deal with it and operated as soon as possible either definitively or temporary as in case of open fractures with significant contamination, severe soft tissue swelling, significant patient co-morbidities, unavailability of proper implants and/or surgical personnel, surgery may be delayed (3).Retrograde femoral nailing through the inter-condylar notch has become a popular method for treating AO type A supracondylar fracture. It is preferable to antegrade nailing in certain situations. They are technically easier to antegrade nailing in obese patients. Also, they can be used with distal femoral fractures below hip implants or above total knee implants with an open notch design. Additionally they can be used to stabilize distal femoral fractures with ipsilateral hip fractures (4).

Plates with locking screws have a biological advantage by functioning as internal fixators.

The plate is not compressed against the cortex like any of the previous plates and therefore periosteal blood supply is preserved as much as possible (5,6). Furthermore the use of these plates eliminates the need for exact contouring of the plate to the bone which simplifies the technique of its application, saves time and decreases the chances for loss of reduction making it much easier to apply compared to other fixed angle devices(7).

The aim of this study was to compare the results of retrograde Nailing versus Plating technique in distal femoral fractures regarding alignment both radiologically and clinically.

PATIENTS AND METHODS

This study was conducted to detect by clinical and radiological assessment, Abnormalities in the lower limp alignment after treatment of distal femoral fracture in eighteen patients, the patients were either treated by retrograde femoral nail or plating technique of distal femur and

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Received 6 March 2021; Accepted 25 March 2021.

they were collected from registry of Zagazig University Hospital and Al Khadra Hospital, Libya from March 2020 till March 2021.Full counseling of participants and informed consent was obtained with full privacy of participants and confidentiality of the data.

Inclusion and Exclusion Criteria:

Patients with extra-articular distal femoral fracture with intra-articular extension (open fractures grade I& II). Patients who are medically fit for surgery with age between (20-50) years.

While, patients with intra-articular distal femoral fracture only, pathological fracture, fracture in children (immature skeleton), and open fracture grade III and patients who are medically unfit for surgery were excluded.

Eighteen patients were included in this study after subjecting to the inclusion and exclusion criteria and were divided in two matched groups (nine patients in each group) were evaluated carefully through clinical and radiological measurements.

Clinical and Radiologicalassessment:

All Patients were conducted to the clinical measurements of the coronal plane measurement used to identify the hip, knee and ankle centers and a long arm goniometer was used to measure the coronal lower limb alignment either varus/valgus deviation using these surface landmarks(8).

We collected all data and complications that happened to the patients from the patient history and hospital registry, including pain and its relationship to walking, as well as joint stiffness, swelling, stair climbing, running, jumping, use of walking aids and ability to return to work using Modified Olerud Scale score to assess the final outcomeA score of 90 to 100 is considered Excellent; 70 to 89 - Good; 50 to 69 points - Fair and less than 50 is considered Poor(9).

Mechanical Axis of the Lower Limb is determined on the full-length AP standing radiograph using:lateral or medial mechanical axis deviation (MAD) mechanical Lateral Distal Femoral Angle (mLFDA) andMedial Proximal Tibial Angle (MPTA).

Statistical Analysis:

Data were considered using Microsoft Excel software. Data were then imported into Statistical Package for the Social Sciences (SPSS version 20.0). Difference and association of qualitative variable were analyzed by Chi square test (X2). Differences between quantitative independent groups by unpaired t. P value was set at <0.05 for significant results &<0.001 for high significant result.

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RESULTS

The present study showed in group (A) the mean age of patients was 32.55 years. Sex patients were males (66.7%) and 3 patients were females (33.3%). nine patients (100%) had their fractures due to severe trauma (RTA or FFH). In group (B)the mean age of patients was 36.44 years.4 patients were males (44.4%) and 5 patients (55.6%) were females. Eight patients (90%) had their fractures due to severe trauma and 1 patient (10%) due to mild to moderate trauma. However, there were no significant difference between the mean age in both groups (P = 0.334) as well as no significant between percentage of male and female distribution (P = 0.343)(Table 1).

This study showed that the right side injuries in group A (retrograde nail) was five patients (55.6%) and four patients (44.4%) in left side, while in group B (plating technique) it was two patients (22.2%) in the right side and seven patients (77.8%) in left side and according to the mechanism of injuries, the current study showed that in retrograde nail group were two patients (22.2%) due to stairs F/D and seven patients (77.8%) due to Road traffic accident (RTA), while in group B (plating technique) it was one patient (11.1%) simple F/D injury, three patients (33.3%) due to stairs F/D and five patients (55.6 %) due to RTA(Table 2).

In retrograde nail group the AO classification was A2 in six patients (66.7%), A3 in two patients (22.2%) and B2 in one patient (11.1%), while in plating group B it was A2 in five patients (55.6%), A3 in three patients (33.3%) and B1 in one patient (11.1%), with no significant difference between groups (P = 0.51) regard AO classification and the majority was A2 (Table 3).

The clinical measurements in normal limp was 4.66±1.32 in retrograde nail group while it was 4.88±1.58 in plating group (P = 0.812), the MAD in fractured limp clinically was 5.38±1.89 in retrograde nail group while it was 6.48±2.31 in plating group (P = 0.277) with no significant difference between studied groups (Figure 1). There was a significant difference between the normal and operated side (P = 0.017 and 0.00 respectively) regarding the radiological MAD in the normal side and the operated side in both groups.However, there was no significant difference between the two groups (Table 4).

Regarding mLFDA in normal limp radiologically was 88.0±2.17 in retrograde nail group while it was 88.77±2.53 in plating group (P =0.498), the mLFDA in fractured limp radiologically was 88.66±2.54 in retrograde nail group while it was 89.33±3.67 in plating group (P=0.663) with no significant difference between studied groups (Figure 2).

Medial Proximal Tibial Angle (MPTA) in normal limp radiologically was 88.00±2.12 in

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Received 6 March 2021; Accepted 25 March 2021.

retrograde nail group while it was 87.11±2.97 in plating group (P=0.498), the MPTA in fractured limp radiologically was 87.77±1.85 in retrograde nail group while it was 87.88±3.48 in plating group (P =0.663) with no significant difference between groups and no significant between fracture and normal in both groups (Figure 3).

In our study the complication including infection were in two patients in group (A) and four patients in group (B).Knee pain in six patients of group (A) and three patients in group

(B).Reduction range of motion was found in three patients in group (A) and seven patients in group (B).While delayed of union was one patient in group (B). The only significant difference was found is reduction range of motion which is in group (B), while there were no significant difference regarding the other complications between the two groups (Table 5).

Table (1): Age and sex distribution between studied groups

Group A Group B t/ X2 P

Age 32.55±8.14 36.44±8.42 0.996 0.334

Male N 6 4

% 66.7% 44.4%

Sex

Female N 3 5 0.90 0.343

% 33.3% 55.6%

Total N 9 9

% 100.0% 100.0%

Table (2): Injuries characters distribution between studied groups

Group

X2 P

Group A Group B

Right N 5 2

% 55.6% 22.2%

Side

N 4 7 2.10 0.14

Left % 44.4% 77.8%

Simple N 0 1

% 0.0% 11.1%

Mechanism Stairs N 2 3 1.53 0.46

% 22.2% 33.3%

RTA N 7 5

% 77.8% 55.6%

Total N 9 9

% 100.0% 100.0%

Table (3): AO classification distribution between studied groups

Group

X2 P

Group A Group B

AO A2 N 6 5

% 66.7% 55.6%

classification

A3 N 2 3

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% 22.2% 33.3%

B1 N 0 1 2.290.51

% 0.0% 11.1%

B2 N 1 0

% 11.1% 0.0%

Total N 9 9

% 100.0% 100.0%

Figure(1): The clinical measurements of MAD assessment bar chart between the two groups, normal and operated sides

Table (4): Radiological MAD distribution between studied groups at normal and operated sides

Group A Group B Unpaired t P MAD normal Radiological 3.45±1.18 3.22±1.09 0.502 0.623 MAD Fracture Radiological 4.17±1.36 4.48±1.42 0.493 0.629

Paired t 2.689 3.987

P 0.017* 0.00**

Figure (2): Radiological mLDFA assessment chart between the two groups, normal and operated sides

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Received 6 March 2021; Accepted 25 March 2021.

Figure (3): Radiological MPTA assessment bar chart between the two groups, normal and operated sides

Table (5): Complication distribution between studied groups

Group

X2 P

Group A Group B

-VE N 7 5

% 77.8% 55.6%

Infection

N 2 4 1.21 0.317

+VE % 22.2% 44.4%

-VE N 3 6

% 33.3% 66.7%

Knee Pain

N 6 3 2.01 0.15

+VE % 66.7% 33.3%

-VE N 6 2

Reduction % 66.7% 22.2%

ROM +VE N 3 7 3.66 0.058

% 33.3% 77.8%

-VE N 9 8

Delayed % 100.0% 88.9%

union

+VE N 0 1 1.05 0.303

% 0.0% 11.1%

Total N 9 9

% 100.0% 100.0%

DISCUSSION

Distal femur fractures occur following high-energy impact in young patients often resulting in comminuted and open fractures, whereas low-energy injury is sufficient to cause distal femoral fractures in elderly patients with osteopenic or osteoporotic bone.

For the treatment of distal femoral fractures, two major therapeutic principles can be employed: retrograde IM nailing or plating technique. Both operative stabilizing systems follow the principle of biological osteosynthesis. Protection of soft-tissue envelope due to the minimally invasive approach and closed reduction techniques is better realized using IM. nailing.

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The current study showed that the mean age was 32.55±8.14 for group A (retrograde nail) and 36.44±8.42 group B (plating technique) with no significant difference between both groups (P

= 0.334) regarding age, and regarding sex group A included 6 (66.7%) males and 3 (33.3%) females while in group B included 4 (44.4%) males and 5 (55.6%) females with no significant difference between both groups (P = 0.343).

These results are in agreementwith Singh et al. (12) who reported the mean age of plating group was 48.00±15.65 years, while the mean age of retrograde nail group was 40.43±14.39 years.

The female – male ratio was 21.9: 78.1% and for the two groups it was matched with no significant difference between studied groups (p=.075). Similar preoperative demographic data were noticed by Hefny et al. (13) with no significant difference reported that Age in group A (retrograde nail) ranged 28-60 with mean value 40.90 ± 11.28 and in group B (plating) ranged 24-52 with mean value 41.70 ± 9.72. Males in group A were 8(80%) and females were 2(20%) while in group B, males were 7(70%) and females were 3(30%).

The current study showed that the right side injuries in group A (retrograde nail) was 5 patients (55.6%) and 4 patients (44.4%) in left side, while in group B (plating technique) it was 2 patients (22.2%) in the right side and 7 patients (77.8%) in left side, with no significant statistical difference between both groups (P = 0.14). these results wasin agreement with the study of Ajith et al. (14) who found that Right side involvement occurred in 53.33 percent of the patients of the plating group and 60 percent of the patients of the retrograde nailing group respectively with no significant statistical difference between both groups (P => 0.05).

According to the mechanism of injuries, the current study showed that in retrograde nail group 2 patients (22.2%) due to stairs and 7 patients (77.8%) due to Road traffic accident (RTA), it was while in group B (plating technique) it was 1 patient (11.1%) simple injury, 3 patients (33.3%) due to stairs and 5 patients (55.6 %) due to RTA with no significant statistical difference between both groups (P = 0.46), which in agreement with the study of Singh et al. (12) who reported that majority of cases mechanism of inquiries was road traffic accident (RTA) which was found to be 72.2%

cases in group I (plating) and was 78.6% for group II (retrograde nail). The left and right side of fracture in both the groups was found to be approximately in same proportion (55.6:44.4, 64.3:35.7 respectively) with no significant statistical difference between both groups regarding side and mechanism of injury. Also, Agarwal et al., (15) concluded a similar results were in both groups majority of cases mechanism of inquiries was RTAwhich was found in 17 patients (95%) in group I (plating) and was 85% for group II (nailing) with no significant statistical difference between both groups regarding mechanism of injury (P = 0.6).

The AO classification is a good comprehensive way of identifying the fracture type and

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Received 6 March 2021; Accepted 25 March 2021.

severity, where the increase in the numbering indicates more severe and comminuted fracture. In the whole study type A2 was the major fracture type (11/18) patients. When comparing both groups according to the AO classification, no significant difference was found between the groups.Six types A2 patients (66.7%) were found in retrograde nail group while the plating group included 5 patients only (55.6%) (P = 0.51).These in agree with Gupta et al. (16) who found that according to AO classification, there were 65 type A fractures (retrograde nailing 41, plating 24) and 38 type C fractures (retrograde nailing 16, plating 22). A total of 21% (n = 12) and 16% (n =

7) were open fractures in the retrograde nailing and plating group, respectively with no significant difference between groups (P > 0.05).

Concerning the mechanical axis measurements of the lower limb, our results are in agreement with the study of Choudhary et al. (17) who concluded that there was no significant difference between studied groups regarding mLDFA and MPTA .

The current study showed that infection and decrease range of motion in the nail group was lower than that of the plating group. Knee pain in nail group was higher than that of the plating group, with no difference regard delay union. These is agree with Jillala et al. (18) whoreported that pain was found in 1 patient (3.7 %) in Nailing group and in plating group patient 1 (3.4 %), Superficial Infection was found in 1 patient (3.7 %) in Nailing group while no infection recorded in plating, Knee Stiffness was recorded only in plating group in 4 patients (13.6%), Local Symptoms At Distal Screw was recorded only in Nailing group in 3 patients (11.1%) with no significant difference between both group.

CONCLUSIONS

In our study, functional results trended toward better outcomes in distal femoral nails group than plates in terms of knee flexion, early weight bearing, but incidence of knee pain is higher in nailing group as compare to plating group. Therefore, Nailing technique is a better fixation system for distal femur fracture.

No Conflict of Interest.

REFERENCES

1. Giusti, A., Hamdy, N. A., Dekkers, O. M., Ramautar, S. R., Dijkstra, S., & Papapoulos, S. E.

(2011). Atypical fractures and bisphosphonate therapy: a cohort study of patients with femoral fracture with radiographic adjudication of fracture site and features. Bone, 48(5), 966-971.

2. Griffin XL, Parsons N, Zbaeda MM, McArthur J.(2015). Interventions for treating fractures of the distal femur in adults. Cochrane Database Syst Rev 2015(8):Cd010606.

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3. Massoud EI.(2015). Fixation of distal femoral fractures: Restoration of the knee motion.

Ulus Travma Acil Cerrahi Derg 2015;21(3):197-203.

4. Zhao Z, Li Y, Ullah K, Sapkota B, Bi H, Wang Y.(2018). The antegrade angle-stable locking intramedullary nail for type-C distal femoral fractures: a thirty four case experience. Int Orthop 2018;42(3):659-65.

5. Sekel R, Newman AS.(1994). Supracondylar fractures above a total knee arthroplasty: A novel use of the Huckstepp nail. The Journal of arthroplasty 1994;9(4):445-7.

6. Heckman JD, McQueen MM, Ricci WM, Tornetta P, McKee MD.(2015). Rockwood and Green's fractures in adults: Wolters Kluwer Health; 2015.

7. Du YR, Ma JX, Wang S, Sun L, Wang Y, Lu B, et al.(2019). Comparison of Less Invasive Stabilization System Plate and Retrograde Intramedullary Nail in the Fixation of Femoral Supracondylar Fractures in the Elderly: A Biomechanical Study. Orthop Surg 2019;11(2):311-7.

8. Deep K, Nunag P, Willcox N, Deakin AH, Picard F (2016).A Comparison of Three Different Methods of Measurement of Knee Deformity in Osteoarthritis. J Orth Rhe Sp Med 1(1): 107.

9. Olerud S. (1972). Operative treatment of supracondylar-condylar fractures of the femur:

technique and results in fifteen cases. JBJS 1972;54(5):1015-32.

10. Krettek C, Müller M, Miclau T.(2019). Evolution of minimally invasive plate osteosynthesis (MIPO) in the femur. Injury 2001;32:14-23.

11. Rafalla AAA; MD, Abdullah EA; MD. (2020). Locked plate fixation of the distal femoral fractures by using the less invasive stabilization system (LISS). The Egyptian Orthopedic Journal; 2020 supplement (1), June, 55: 81-87.

12. Singh, S., Baghel, P. K., Rastogi, D., Shantanu, K., & Sharma, V. (2018).Distal femoral locked plating versus retrograde nailing for extra articular distal femur fractures: A comparative study. International Journal of Orthopaedics, 4(4), 702-705.

13. Hefny, A. M., Khira, Y. M., Mohamed, A. A., & Mousa, M. N. M. (2020). Treatment of Distal Femoral Fractures by Retrograde Nail Versus Minimally Invasive Percutaneous Plate Osteosynthesis: A Comparative Study. The Egyptian Journal of Hospital Medicine, 78(1), 28-33.

14. Ajith Kumar, K. S., Mohsin, S., &Sreeranga, N. (2020). Comparative study of outcome of retrograde intramedullary nailing and locking compression plating of distal femoral fractures in adults. International Journal of Orthopaedics, 6(3), 765-768.

15. Agarwal, S., Udapudi, S., & Gupta, S. (2018). To Assess Functional Outcome for Intra- Articular and Extra-Articular Distal Femur Fracture in Patients using Retrograde Nailing or Locked Compression Plating. Journal of Clinical & Diagnostic Research, 12(3).

16. Gupta, S.K.V., Govindappa, C. V. S., &Yalamanchili, R. K. (2013). Outcome of retrograde

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Received 6 March 2021; Accepted 25 March 2021.

intramedullary nailing and locking compression plating of distal femoral fractures in adults.

OA Orthopaedics, 1(3), 23.

17. Choudhary S., Nishant K Gaonkar., Amit B Garud., Gaurav Sahu. (2019). A study of the functional outcome of different operativemodalities of treatment for distal femur fractures. Int J Orthop Sci2019;5(2):911-922.

18. Jillala, S.R., Ahmed, S.W., Shruthi, A., Gajul, R., et al. (2017). A Comparative Study of Supracondylar Nail versus Locking Compression Plate in Distal Femur Fractures. Annals of International Medical and Dental Research, 3(4), 35-41.

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