G Model

JINJ 7315 No. of Pages 6

Injury, Int. J. Care Injured xxx (2017) xxxxxx

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

A double-plating approach to distal femur fracture: A clinical study

Ely L. Steinberg* , Jacov Elis, Yohai Steinberg, Moshe Salai, Tomer Ben-Tov
Orthopaedic Division, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel

A R T I C L E I N F O A B S T R A C T

Background: Locked plating is one of the latest innovative options for treating supracondylar femur
Keywords: fractures with relatively low failure rates. Single lateral plating was often found to have a relative higher
Distal femur fracture
failure rate. No clinical studies of double-plating distal femur xation have thus far been reported. The
Fracture stabilization
Double-plating
aim of this study is to present our clinical experience with this surgical approach.
Patients and methods: Thirty-two patients (26 females and 6 males, mean age 76 years, range 44101)
were included in the study. Eight of them patients had a periprosthetic stable implant fracture and two
patients were treated for a nonunion.
Results: All fractures, excluding one that needed bone grafting and one refracture, healed within 12
weeks. One patient needed bone grafting for delayed union and one patient needed xation exchange
due to femur re-fracture at the site of the most proximal screw. Two patients developed supercial
wound infection and one patient required medial plate removal after union due to deep infection.
Conclusions: Based on these promising results, we propose that the double-plating technique should be
considered in the surgeons armamentarium for the treatment of supracondylar femur fractures,
particularly in patients with poor bone quality, comminuted fractures and very low periprosthetic
fractures.
2017 Elsevier Ltd. All rights reserved.

Introduction 14]. New retrograde nails were eventually developed to increase

Supracondylar femur fractures are frequently associated with
severe comminution and substantial soft tissue injury. Peripros-
thetic fractures following total knee arthroplasty reportedly have
the same fracture rate as simple fractures, ranging between 0.4% to
2.5% [14]. Most of these fractures are complicated by poor bone
quality (severe osteoporosis), a distal segment that is too short for
adequate xation, blood loss, malunion and nonunion, and
increased mortality in the elderly [5,6].
Supracondylar femur fractures were historically treated with
condylar buttress plates [7]. Fixed-angle implants, angle-blade
plates, intramedullary retrograde nails and dynamic supra-
condylar screws were found to have a superior biomechanical
design for decreasing varus collapse events compared to condylar
buttress plates [8,9]. Locking plates have increased biomechanical
resistance with the possibility of greater numbers of xation
screws in the distal femur metaphysis [10,11]. Locking plates were
found to provide increased stability and resistance to failure
compared to retrograde nails in elderly with poor bone stock [12
* Corresponding author at: Orthopadic Division, Tel-Aviv Sourasky Medical
Center, 6 Weizmann St., Tel-Aviv, 6423906, Israel.
E-mail address: steinberge@tlvmc.gov.il (E.L. Steinberg).
stability, and biomechanical cadaveric studies showed that they
even had a better performance than locking plates in terms of
fatigue resistance [15]. The perioperative complications associat-
ed with supracondylar femur fractures, whatever the choice of
xation, include delayed union or nonunion that requires
reoperation, deep infection, proximal implant failure and mal-
union [5,16,17].
Fracture type, muscle forces acting on the distal part of the
femur, the weight of the lower extremity and natural gravity of
the entire limb may increase lever arm and affect fracture
stabilization and warrant load neutralization. Numerous bio-
mechanical studies have been performed in the past and many
others are currently ongoing with the aim of achieving an optimal
stable construct. Most of them tested fracture stability in
cadaveric bones by comparing locking plates with retrograde
nails [12,14,15,18,19].
We faced some hardware failures in elderly patients who
had been initially treated by a single-side plate and screws and
then needed reoperations. One example of a second surgery
included double plating for preserving the joint (Fig. 1), while a
megaprosthesis was needed for other patient due to screw
penetration into the joint due to poor bone quality (Fig. 2). Based
on the failed cases encountered by our team and those reported in

http://dx.doi.org/10.1016/j.injury.2017.07.025
0020-1383/ 2017 Elsevier Ltd. All rights reserved.

Please cite this article in press as: E.L. Steinberg, et al., A double-plating approach to distal femur fracture: A clinical study, Injury (2017), http://
dx.doi.org/10.1016/j.injury.2017.07.025
G Model
JINJ 7315 No. of Pages 6

2 E.L. Steinberg et al. / Injury, Int. J. Care Injured xxx (2017) xxxxxx

Fig. 1. A 92-year-old female with a Type 33-A3 supracondylar femur fracture (a)
initially treated by a lateral locking plate. Hardware breakage and nonunion were
detected 5 months following surgery (b). A double-plating procedure was
performed, and good radiographic healing of the fracture was observed 2 years
following the injury (c).

the literature, we decided to increase the support of distal femur

fracture stabilization. We chose to use the double-plating
technique for the distal femur, similar to the treatment for other
two-column fracture types, such as, acetabulum, tibial plateau and
distal humerus.
The purpose of this study was to evaluate our experience with
the use of double plating technique for the treatment of unstable
supracondylar femur comminuted fractures with poor bone
quality.

Patients and methods

We used a double plating approach in patients with supra-
condylar femur fractures that fulll the following criteria: non-
union, non-union following hardware failure, poor bone quality,
Type A3, C3, according to AO/OTA classication and very low
supracondylar and periprosthetic fractures. The clinical course of
all the study patients was prospectively documented. The recorded
data included the patients clinical and radiographic healing time,
Fig. 2. A 90-years-old female with a Type 33-A3 supracondylar femur fracture
treated by a lateral locking plate (a). Fracture displacement and joint penetration
were detected 2 months following surgery (b).
hospitalization time, reoperations, infection and other local and
systemic complications. After receiving institutional ethics com-
mittee approval, all data were analyzed in a retrospective manner.

Please cite this article in press as: E.L. Steinberg, et al., A double-plating approach to distal femur fracture: A clinical study, Injury (2017), http://
dx.doi.org/10.1016/j.injury.2017.07.025
G Model
JINJ 7315 No. of Pages 6
E.L. Steinberg et al. / Injury, Int. J. Care Injured xxx (2017) xxxxxx
Fig. 3. A 45-year-old male who suffered a gunshot injury to his right thigh. Initial
treatment by a ring external xator failed to heal the supracondylar femur fracture
(a). The frame was removed and the leg was xed in a plaster cast for 4 weeks for
soft tissue healing (b). A double-plating procedure was performed, and good
fracture healing was observed at 1 year after surgery (c).
The surgery was performed using a two-incision (lateral and
medial) approach. The medial incision was located proximal to the
medial femoral condyle. A relatively small (810 holes) medial
Please cite this article in press as: E.L. Steinberg, et al., A double-plating approach to distal femur fracture: A clinical study, Injury (2017), http://
dx.doi.org/10.1016/j.injury.2017.07.025
3
plate was used. Two proximal and 23 distal screws were inserted
bypassing the comminuted area.
All fractures were classied according to the AO/OTA system
[20], the periprosthetic fractures according to Rorabeck-Taylor
classication [21], and the injuries as either closed or open
according to the Gustilo-Andersen classication [22]. Three
patients had non-unions, one of them after a gunshot injury.
Patients with pathological fractures were excluded.
Postoperative treatment included early mobilization in a
protected hinged knee brace. Weight bearing was permitted
according to the ndings of radiographic and clinical examina-
tions at the 7-week follow-up. Radiographic healing was
established when 3 cortices of the bone were united on the
anteroposterior (AP) and lateral views of the bone. Clinical
healing was established by absence of pain either with weight
bearing or with applied stress over the injured area on
examination. We assessed malrotation clinically by comparing
the injured side to the normal side. Follow-up continued up to
fracture healing and full weight-bearing or up to one year
following surgery.
Results
Thirty-two patients (26 females and 6 males, mean age 76 years,
range, 44101 years) were operated with the double-plating
technique between November 2011 and September 2016. Surgery
was performed within a mean of 3.8 days (range, 011 days) from
injury.
Twenty-four of the 32 patients were classied according to
AO/OTA classication as follows: A2 = 1, A2 = 2, A3 = 7, C1 = 4,
C2 = 7, and C3 = 3. The other 8 patients had periprosthetic
fractures: 7 had Type 2 and one had Type 1 according to the
Rorabeck-Taylor classication. Only one patient had an open
fracture (caused by a gunshot injury). Two study patients
presented with nonunions. The rst nonunion involved a 92-
years-old female with a Type 33-A3 supracondylar femur fracture
that had been initially treated by a lateral locking plate. The
hardware breakage and nonunion were observed 5 months
following surgery that required a double-plating reoperation
approach, as seen in Fig. 1. Fig. 3 illustrates the second nonunion
involved a 45-year-old male whose gunshot injury to his right
thigh had initially been treated by a ring external xation that
failed to heal. The external xation was removed and a double-
plating procedure was performed after one month of soft-tissue
healing time.
The mean hospitalization time of the study group was
11.6 days (range, 523 days). Followup continued until fracture
healing or for a minimum of 1 year (average 12, range 8 to 20
months) following surgery. All fractures, excluding one that
needed bone grafting and one refracture, healed radiographically
within a mean of 12 weeks (range, 6 to 21 weeks) and clinically
within 11 weeks (range, 617 weeks). Axial alignment was good
in all cases, but one fracture had a valgus of 8 . The range of
motion was between 0 and 20  for extension and 85120  for
exion.
Five patients had surgery-related complications. One patient
with delayed union needed bone grafting without hardware
exchange and one patient that had a shaft fracture adjacent to the
most proximal screw was treated by exchange of the lateral plate to
a longer one. Both cases healed uneventfully within 12 weeks
following re-operation. Two patients had supercial wound
infections that were treated by irrigation and debridement. A
medial plate was removed in one drug-addicted patient who
developed a local deep infection after union. No hardware
loosening or joint penetration was observed during the follow-up.
G Model
JINJ 7315 No. of Pages 6

4 E.L. Steinberg et al. / Injury, Int. J. Care Injured xxx (2017) xxxxxx

Fig. 4. Computerized tomographic angiography of the lower limb. The medial superior genicular artery is shown in the 3D image as having a postero-superior to antero-
inferior trajectory. It is clearly seen that the artery is not adjacent to bone and that the medial aspect of the lower femur is free from massive vascularity.

Discussion and a periprosthetic fracture that needed lateral plate exchange to

Supracondylar femur fracture treatment is challenging for the
orthopaedic surgeon. Many factors that may affect patient
outcome need to be considered, such as articular involvement
and extension into the shaft, comminution and short fragments,
bone quality, the patients age, the extent of soft tissue injury and
the type of instrumentation to be used. Devices that were
designed to increase stability and decrease motion at the fracture
site include side plates and intramedullary nails with or without
locking screws. Despite the continuous development of products
for treating difcult fractures, there are still many failures related
to poor bone quality and to the increased load applied on this
distal part of the lower limb. We may assume that the increased
interaction between limb weight and the hardware (plate or nail)
has a sizeable effect upon the loosening and failure of the xation.
Given the increasing incidences of hardware failure and varus
collapse, we decided to evaluate a double-plating technique for
the treatment of supracondylar femoral fractures. We assumed
that double plating might decrease the lever arm that acts on the
femoral axis and thereby decrease the load applied on the
fracture site. This approach increases fracture stabilization, and
none of our patients sustained loosening of the implant. The
quality of reduction was preserved even in the two cases of
complications (a delayed union that needed only bone grafting
a longer one). No re-reduction was required, and all reoperations
were considered as being short procedures.
Our clinical study showed that the fractures became united
within 12 weeks. Three patients with wound complication needed
reoperation, irrigation and debridement, and only one patient, a
heavy smoker and a drug addict, needed medial plate removal. Two
other patients needed reoperation due to delayed union and shaft
fracture at the proximal end of the xation. In the latter patient,
both proximal ends of the plates were seen to be located on the
same level. We recommend using a lateral plate longer than the
medial one by at least two cortexes.
Most of the published studies on lateral locking plates reported
a union rate ranging between 81%-95% [5,11,16,17,23,24]. The union
rate for patients treated by retrograde nails was reported to be 91%
[5], although Large et al. reported a 100% malunion or nonunion
using a retrograde nail in a small patient cohort [17]. Complications
related to the implants, such as loosening, breakage, and rotational
malposition, were reported as being between 5% to 7%, with a
revision rate ranging between 19% to 23% [16,23,24]. Other
potential complications, such as hardware malposition and plate
located too ventral, too proximal or too short for adequate xation
[16,23], may weaken mechanical stability of the implant followed
by early loosening and failure. The double-plating technique may
overcome these complications by its properties that provide

Please cite this article in press as: E.L. Steinberg, et al., A double-plating approach to distal femur fracture: A clinical study, Injury (2017), http://
dx.doi.org/10.1016/j.injury.2017.07.025
G Model
JINJ 7315 No. of Pages 6
E.L. Steinberg et al. / Injury, Int. J. Care Injured xxx (2017) xxxxxx
Fig. 5. Computerized tomographic angiography of the lower limb. The third perforating artery to the vastus medialis muscle is shown in the 3D image as having a postero-
anterior trajectory.
increased stability by compensating for some of the intraoperative
technical errors to permit complete healing.
Several studies reported that double plating is an advantageous
solution for Type C3 distal femoral fractures [2527]. Sanders et al.
[25] used a non-locking condylar buttress plate on the lateral side
and a medial plate with bone graft. Healing was completed in all 9
patients within 6.7 months. Ziran et al. [26] used a longitudinal
anterior incision to minimize stripping of the medial femur side,
and two plates were placed orthogonally oriented. They also used a
lateral condylar or a buttress plate and an anterior reconstruction
or dynamic compression plate and reported uneventful healing
within 16 weeks in 24 out of 36 reported patients. Khalil and Ayoub
[27] used a double-plating technique through a modied Olerud
extensile approach in 25 patients, placing the plates laterally and
medially. The mean radiologic healing time was reported to be 18.3
weeks.
A potential vascular injury to the distal part of the medial thigh
and femur aspects may be expected during the procedure.
Computerized tomographic angiography studies demonstrated
that this area is supplied by two vessels, the medial superior
genicular artery and the third perforating artery to the vastus
medialis muscle. However, neither artery is adjacent to the bone,
so vessel injury can be prevented by meticulous dissection (Figs. 4
and 5). We recommend initiating the medial incision on the top of
Please cite this article in press as: E.L. Steinberg, et al., A double-plating approach to distal femur fracture: A clinical study, Injury (2017), http://
dx.doi.org/10.1016/j.injury.2017.07.025
5
the medial condyle and proceeding proximally for about 57 cm.
Two proximal screws should be inserted into the shaft and the two
distal screws into the condyles.
Limitations of this study include its retrospective nature, and
the relative small group of patients studied. The treatment of all
patients by senior surgeons and in one institution represents
strengths of this work. We welcome further larger-scale studies to
further investigate this type of xation, concentrating on bone
fragility and the nature of the supracondylar femur fractures.
Conclusion
We recommend that the double-plating technique for supra-
condylar femur fractures should be considered in cases of poor
bone quality, for very low periprosthetic and comminuted
fractures.
References
[1] Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury
2006;37:6917.
[2] Meling T, Harboe K, Soreide K. Incidence of traumatic long-bone fractures
requiring in-hospital management: a prospective age- and gender-specic
analysis of 4890 fractures. Injury 2009;40:12129.
[3] Merkel KD, Johnson EW. Supracondylar fracture of the knee after total knee
arthroplasty. J Bone Joint Surg Am 1986;68:2943.
G Model
JINJ 7315 No. of Pages 6
6 E.L. Steinberg et al. / Injury, Int. J. Care Injured xxx (2017) xxxxxx
[4] Delport PH, Audekercke R, Martens M, Mulier JC. Conservative treatment of
ipsilateral supracondylar femoral fracture after total knee arthroplasty. J
Trauma 1984;24:8469.
[5] Meneghini RM, Keyes BJ, Reddy KK, Maar DC. Modern retrograde
intramedullary nails versus periarticular locked plates for supracondylar
femur fractures after total knee arthroplasty. J Arthroplasty 2014;29:15036.
[6] Streubel PN, Ricci WM, Wong A, Gardner MJ. Mortality after distal femur
fractures in elderly patients. Clin Orthop Relat Res 2011;469:118896.
[7] Davison BL. Varus collapse of comminuted distal femur fractures after: open
reduction and internal xation with a lateral condylar buttress plate. Am J
Orthop 2003;32:2730.
[8] Christodoulou A, Terzidis I, Ploumis A, Metsovitis S, Koukoulidis A, Toptsis C.
Supracondylar femoral fractures in elderly patients treated with the dynamic
condylar screw and the retrograde intramedullary nail: a comparative study of
the two methods. Arch Orthop Trauma Surg 2005;125:739.
[9] Hartin NL, Harris I, Hazratwala K. Retrograde nailing versus xed-angle blade
plating for supracondylar femoral fractures: a randomized controlled trial.
ANZ J Surg 2006;76:2904.
[10] Frigg R, Appenzeller A, Christense R, Frenkl A, Gilbertz S, Schavanl R. The
development of the distal femur less invasive stabilization system (LISS).
Injury 200132: S-C24-31.
[11] Kregor PJ, Stannard J, Zlowodzki M, Cole PA, Alonso J. Distal femoral fracture
xation utilizing the Less Invasive Stabilization System (L.I.S.S.): the technique
and early results. Injury 200132: S-C32-41.
[12] Assari S, Kaufmann A, Darvish K, Park J, Hawb J, Safadi F, et al. Biomechanical
comparison of locked plating and spiral blade retrograde nailing of
supracondylar femur fractures. Injury 2013;44:13405.
[13] Salas C, Mercer D, DeCoster TA, Taha MMR. Experimental and probabilistic
analysis of distal femoral periprosthetic fracture: a comparison of locking plate
and intramedullary nail xation. Part A: experimental investigation. Comput
Methods Biomech Biomed Eng 2011;14:15764.
[14] Salas C, Mercer D, DeCoster TA, Taha MMR. Experimental and probabilistic
analysis of distal femoral periprosthetic fracture: a comparison of locking plate
and intramedullary nail xation. Part B: probabilistic investigation. Comput
Methods Biomech Biomed Eng 2011;14:17582.
[15] Pekmezci M, McDonald E, Buckley J, Kandemir U. Retrograde intramedullary
nails with distal screws locked to the nail have higher fatigue strength than
locking plates in the treatment of supracondylar femoral fractures. Bone Joint J
2014;96:11421.
Please cite this article in press as: E.L. Steinberg, et al., A double-plating approach to distal femur fracture: A clinical study, Injury (2017), http://
dx.doi.org/10.1016/j.injury.2017.07.025
[16] Ricci WM, Streubel PN, Morshed S, Collinge CA, Nork SE, Gardner MJ. Risk
factors for failure of locked plate xation of distal. femur fractures: an analysis
of 335 Cases. J Orthop Trauma 2014;28:839.
[17] Large TM, Kellam JF, Bosse MJ, Sims SH, Althausen P, Masonis JL. Locked plating
of supracondylar periprosthetic femur fractures. J Arthroplasty 2008;23(6
Suppl 1):11520.
[18] Cui S, Bledsoe JG, Israel H, Watson JT, Cannada LK. Locked plating of
comminuted distal femur fractures: does unlocked screw placement affect
stability and failure? J Orthop Trauma 2014;28:906.
[19] Paller DJ, Frenzen SW, Bartlett CS, Beardsley CL, Beynnon BD. A three-
dimensional comparison of intramedullary nail constructs for osteopenic
supracondylar femur fractures. J Orthop Trauma 2013;27:939.
[20] Mller ME, Nazarian S, Koch P, Schatzker J. The Comprehensive Classication
of Fractures of Long Bones. Berlin, Heidelberg, New-York: Springer-Verlag;
1990.
[21] Rorabeck CH, Taylor JW. Classication of periprosthetic fractures complicating
total knee arthroplasty. Orthop Clin North Am 1999;30:20914.
[22] Gustilo RN, Andersen JT. Prevention of infection in the treatment of one
thousand and twenty-ve open fractures of long bones: retrospective and
prospective analyses. J Bone Joint Surg 1976;58:4538.
[23] Schtz M, Mller M, Krettek C, Hntzsch D, Ragazzoni P, Ganz R, et al.
Minimally invasive fracture stabilization of distal femoral fractures with the
LISS: a prospective multicenter study. Results of a clinical study with special
emphasis on difcult cases. Injury 2001;32:SC4852.
[24] Rodriguez EK, Boulton C, Weaver MJ, Herder LM, Morgan JH, Chacko AT, et al.
Predictive factors of distal femoral fracture nonunion after lateral locked
plating: a retrospective multicenter case-control study of 283 fractures. Injury
2014;45:5549.
[25] Sanders R, Swiontkowski M, Rosen H, Helfet D. Double-plating of comminuted,
unstable fracture of the distal part of the femur. J Bone Joint Surg 1991;73:341
6.
[26] Ziran BH, Rohde RH, Wharton AR. Lateral and anterior plating of intra-articular
distal femoral fractures treated via an anterior approach. Int Ortho
2002;26:3703.
[27] Khalil Ael S, Ayoub MA. Highly unstable complex C3-type distal femur
fracture: can double plating via a modied Olerud extensile approach be a
standby solution. J Orthop Traumatol 2012;13:17988.