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(fracture healing or subsidence) outcome, or infection rate; and (4) the study was primarily based on published or unpublished randomized, controlled trials.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.

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