Supracondylar Femoral Fractures: Is a Locking Plate or a Nail Better?

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Chapter 63 Supracondylar Femoral Fractures: Is a Locking Plate or a Nail Better?

ROSS K. LEIGHTON, BSc, MD, FRCSC, FACS, KELLY. TRASK, MSc

Supracondylar fractures of the femur have been a controversial topic over the years. As the literature indicates, the first attempt at minimally invasive surgery in this area was the intramedullary (IM) nail, first done antegrade, then later, more successfully, in a retrograde fashion.¹ Although the union rate seemed improved with the IM nail, the number of malunions appeared to increase as the fracture type became more complex. Eventually, the technique for a minimally invasive dynamic condylar screw (DCS)² and the advent of the locked plate with its minimally invasive tools and technique opened the door for biomechanical and prospective clinical studies to evaluate whether the increased cost of the new locked plate was associated with improved outcome.³^–⁷

OPTIONS

Treatment options for fractures of the supracondylar femur in adults include nonoperative treatment and operative treatment. Nonoperative treatment is mainly of historical interest but may still have a role in special circumstances such as nonambulatory patients or those unable to undergo an anesthetic. This chapter focuses on operative treatment alternatives.

Operative management requires anatomic reduction of the articular surface, which is generally achieved with an open reduction and lag screw fixation. Arthroscopically or fluoroscopically assisted percutaneous reduction and fixation may be considered for simple fracture patterns but has not been studied systematically. Attaching the articular surface to the diaphysis can be achieved using IM nailing or plating with fixed-angle plates or regular plates and screws. Plates can be applied using an open technique or using minimally invasive techniques.

EVIDENCE

We identified primary articles with the following features: (1) the target population was skeletally mature patients with a fracture of the femur in the supracondylar region; (2) the intervention was the use of a fixed-angle plate (DCS, blade plate, or locked plate) or an IM nail in the management of these fractures; (3) the outcome measure was either functional (pain or impairment) or radiographic (fracture healing or subsidence) outcome, or infection rate; and (4) the study was primarily based on published or unpublished randomized, controlled trials. However, because of the paucity of this data set, secondary articles were also reviewed.

Are Plates Better Than Nails in Supracondylar Fractures of the Femur?

Christodoulou and colleagues ¹¹ examined the fixation methods of supracondylar fractures before the introduction of the locked plate. The objective of the study was to present the results of surgical management of supracondylar fractures of the femur (types A and C according to the Association for Osteosynthesis/Association for Research and Education Foundation [AO/ASIF] classification) in elderly patients with the use of two different methods of fixation: the mini open DCS fixation and the closed retrograde intramedullary nailing (RIN). Eighty patients with supracondylar fractures of the femur were treated from January 1994 to June 2000, and 72 of them followed up completely. The authors conclude that although the two methods appear to have the same percentage of excellent results and same time to bony union, RIN is preferable to DCS in terms of less blood loss and shorter operating time (Fig. 63-1).

FIGURE 63-1 A retrograde intramedullary nail utilized to stabilize a compound periprosthetic supracondylar fracture of the femur with associated tibial fracture. A–B, Initial radiographs. C–D, Compound tibial wound. E–F, Postoperative radiographs.

Hartin and coauthors ¹² studied the blade plate and the IM nail 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. Twenty-two patients with 23 supracondylar femur fractures were recruited from two regional trauma centers over a 26-month period and randomized to receive either a retrograde IM nail fixation (12 fractures) or a fixed-angle blade plate fixation (11 fractures). Both distal femoral nailing and blade plating gave good outcomes. There was a trend for patients undergoing retrograde nailing to report more pain and to require revision surgery for removal of implants.

Biomechanical Data on Nails versus Plates

Koval and investigators ⁵ performed a biomechanical cadaver study to compare the stability of three standard distal femoral fixation techniques. After initial mechanical characterization of intact femurs, a distal femoral osteotomy was created, reduced, and stabilized under compression using random assignment to one of three methods of fixation: (1) 6-hole 95-degree supracondylar plate; (2) retrograde inserted, statically locked, supracondylar IM nail; and (3) antegrade inserted, statically locked Russell–Taylor nail.

The 95-degree plate and Russell–Taylor nail had statistically significant greater loads to failure than the supracondylar IM nail. These results supported the use of a 95-degree plate when maximum rigidity of fixation or maximum compression is desired.

Koval and investigators ⁴ report on the biomechanical properties of the locked plate compared with the standard condylar buttress plate. The locked buttress plate provided significantly greater fixation stability than the standard plate both before and after cycling in axial loading. The locked buttress plate also proved significantly more stable in axial loading than the blade plate both before and after cycling. The authors conclude that a condylar buttress plate with locked screws improves fixation stability.

Duffy and colleagues ¹³ also studied the biomechanical characteristics of the DCS, standard condylar buttress plate, and the limited invasive stabilization system (LISS). Both of these studies indicate the locked plate (LISS) was indeed stronger than the other two standard devices. Duffy and colleagues’¹³ study used radiostereometric analysis to measure micromotion between bone segments. Permanent deformation was measured after cyclic axial loading, and elastic deformation was measured during a static load. The LISS plate proved to be more flexible and allowed some motion, which may explain the clinical impression of more exuberant callous formation at the fracture site (Figs. 63-2 and 63-3).

FIGURE 63-2 Permanent deformation reported as the mean maximum total point motion (MTPM) of each fracture segment pairing after cyclic loading. CBP, condylar buttress plate; DCS, dynamic condylar screw; LISS, less invasive stabilization system. *P < 0.05.

FIGURE 63-3 Elastic deformation reported as the mean maximum total point motion (MTPM) of each fracture segment pairing under static loading. CBP, condylar buttress plate; DCS, dynamic condylar screw; LISS, less invasive stabilization system. *P < 0.05.

Prospective cohort studies suggest that the biomechanical properties of the locked plate seem to hold up clinically, although there are as yet no published prospective RCTs to compare implants. Fankhauser and coworkers ³ used the LISS to treat 30 distal femoral fractures in 29 patients. They found the LISS to be a safe and effective treatment. Schutz and researchers⁶ managed 112 patients with 116 distal femoral fractures in a prospective multicenter study. All fractures were treated with the LISS plate. The study had a 93% follow-up rate with the follow-up period ranging from 7 to 33 months. The study showed that with a sound knowledge of the operative technique and careful preoperative planning, the LISS represents an excellent, safe procedure for the treatment of almost all distal femoral fracture types including periprosthetic fractures of the distal femur, generally without the need for primary cancellous bone grafting. Locked plates have also demonstrated good results in the treatment of difficult fractures such as AO33 types A and C in patients with multiple trauma injuries with soft-tissue damage⁷ (Fig. 63-4) and periprosthetic supracondylar femur fractures.¹⁴

FIGURE 63-4 Locked plates inserted via a limited invasive approach are utilized to rigidly fix an associated supracondylar femoral fracture and a tibial fracture (floating knee) in a 32-year-old pregnant woman after a motor vehicle crash. A–B, Preoperative radiographs. C–D, Limited invasive approach. E–F, Seven months after surgery.

Ly and coworkers ¹⁵ presented data at the Orthopaedic Trauma Association (OTA) general meeting indicating that, in a review of their last 124 supracondylar fractures treated in a standard nonlocked fashion, 20 were complicated by nonunion and required further surgical intervention to achieve union.

Large and colleagues ¹⁶ also presented at the OTA meeting a study of lateral locked plating versus other operative techniques. The locked plate group had six malunions (24%) and no nonunions. The other group had nine malunions (47%) and three nonunions (16%). Both approached clinical significance but remain underpowered to date.