TRAUMA

‘Modern’ distal femoral locking plates allow

safe, early weight-bearing with a high rate of
union and low rate of failure
FIVE-YEAR EXPERIENCE FROM A UNITED KINGDOM MAJOR
W. E. C. Poole, TRAUMA CENTRE
D. G. G. Wilson, Aims
H. C. Guthrie, Fractures of the distal femur can be challenging to manage and are on the increase in the
S. F. Bellringer, elderly osteoporotic population. Management with casting or bracing can unacceptably
R. Freeman, limit a patient’s ability to bear weight, but historically, operative fixation has been
E. Guryel, associated with a high rate of re-operation. In this study, we describe the outcomes of
S. G. Nicol fixation using modern implants within a strategy of early return to function.
Patients and Methods
From Royal Sussex All patients treated at our centre with lateral distal femoral locking plates (LDFLP) between
County Hospital, 2009 and 2014 were identified. Fracture classification and operative information including
Brighton, United weight-bearing status, rates of union, re-operation, failure of implants and mortality rate,
Kingdom were recorded.
W. E. C. Poole, MBBS, BSc,
MRCS, Trauma and Results
Orthopaedic Registrar
D. G. G. Wilson, MBBS, BSc, A total of 127 fractures were identified in 122 patients. The mean age was 72.8 years (16 to
MRCS, Trauma and 101) and 92 of the patients (75%) were female. A consultant performed the operation in 85 of
Orthopaedic Registrar
S. F. Bellringer, MBBS, BSc, the cases, (67%) with the remainder performed under direct consultant supervision. In total
MRCS, Trauma and 107 patients (84%) were allowed to bear full weight immediately. The rate of clinical and
Orthopaedic Registrar
R. Freeman, MBBS, MSc, radiological union was 81/85 (95%) and only four fractures of 127 (3%) fractures required re-
FRCS (Tr & Orth), Consultant operation for failure of surgery. The 30-day, three- and 12-month mortality rates were 6 (5%),
Trauma and Orthopaedic
Surgeon 17 (15%) and 25 (22%), respectively.
E. Guryel, BSc, FRCS (Tr &
Orth), Consultant Trauma and Conclusion
Orthopaedic Surgeon Our study suggests an exponential increase in the incidence of a fracture of the distal femur
Royal Sussex County Hospital,
Eastern Road, Brighton BN2 with age, analogous to the population suffering from a proximal femoral fracture. Allowing
5BE, UK. immediate unrestricted weight-bearing after LDFLP fixation in these elderly patients was
H. C. Guthrie, MBE, MBCHB, not associated with failure of fixation. There was a high rate of union and low rate of re-
FRCS (Tr&Orth), Consultant
Trauma and Orthopaedic operation.
Surgeon, Defence Medical
Group South-East Cite this article: Bone Joint J 2017;99-B:951–7.
St George’s University
Hospitals NHS Foundation Non-operative treatment of fractures of the dis- demographic parallels between the two. Both
Trust, Blackshaw Road, Tooting,
London, UK.
tal femur often results in inadequate reduction groups have high rates of intercurrent health
S. G. Nicol, MBCHB, FRCS
of the injury and loss of weight-bearing capacity problems, and it has been suggested that frac-
(Tr&Orth), Consultant Trauma and mobility, while surgical treatment has been tures of the distal femur should be treated to
and Orthopaedic Surgeon
The Townsville Hospital, 100
associated with high rates of re-operation for similar standards of care as proximal frac-
Angus Smith Drive, Douglas, failure of fixation and nonunion.1-3 tures.7,8
Queensland 4814, Australia.
Fractures of the distal femur (Arbeitsge- While these fractures are most commonly
Correspondence should be sent meinschaft für Osteosynthesefragen (AO) surgically treated by plate osteosynthesis or
to W. E. C. Poole; email:
[email protected] type-33)4 accounted for 0.4% of fractures intramedullary nailing (IMN), other reconstruc-
occurring each year in a United Kingdom tive options include complex primary arthro-
©2017 The British Editorial
Society of Bone & Joint cohort study.5 A bimodal distribution has been plasty and external fixation. Plating techniques
Surgery reported,6 but increasingly this is as an osteo- have evolved from blade and dynamic condylar
doi:10.1302/0301-620X.99B7.
BJJ-2016-0585.R1 $2.00 porotic fracture occurring most commonly in plates to pre-contoured locking plates, with
elderly women.7 Although distal femoral frac- designs refined over several generations.9 Such
Bone Joint J
2017;99-B:951–7. tures are much less common than their proxi- plates have been in use in our major trauma cen-
Received 29 June 2016; mal counterparts, accounting for just 3% to tre for more than five years, as part of a treat-
Accepted after revision 07
February 2017 6% of all femoral fractures,5,6 there are ment strategy driven by early weight-bearing

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952 W. E. C. POOLE, D. G. G. WILSON, H. C. GUTHRIE, S. F. BELLRINGER, R. FREEMAN, E. GURYEL, S. G. NICOL

Table I. Subgroup analysis of fracture characteristics by age

Fracture characteristics by patient age Age group (yrs)

Under 50 Over 50 Total
Number of fractures (%) 14 (11) 113 (89) 127 (100)
Open fractures (%) 6 (42) 5 (4) 11 (9)
Intra-articular (%) 7 (50) 13 (12) 20 (16)
Periprosthetic (%) 0 (0) 71 (63) 71 (56)
American Society of Anaesthesiologists grade III or IV (%) 2 (14) 72 (64) 74 (61)

and mobility. In this retrospective analysis, we describe imaging, a telephone consultation was performed to assess
the population and clinical and radiological outcomes of functional status and identify complications or re-
surgery. operations. Patients and carers were asked if any wound-
healing problems had occurred, had required any re-opera-
Patients and Methods tions for any reason, and whether they could bear weight
The project was registered locally as a service evaluation on the limb without discomfort or deformity.
and required no further institutional review. Our clinical We identified 105 AO type-33 fractures recorded on our
database (Bluespier, Droitwich, United Kingdom), contain- system, and a further 22 type-32 distal diaphyseal femoral
ing details of all patients referred to the on-call orthopaedic fractures treated by the same strategy. All fractures were
team, was examined to identify all patients undergoing fixed with either the 4.5 mm Variable angle locking com-
fracture fixation with lateral distal femoral locking plates pression plate (VA-LCP) Curved Condylar Plating System
(LDFLP) between November 2009 and November 2014. (Synthes, West Chester, Pennsylvania) or the 4.5 mm Peri-
Within this system, electronically recorded operation notes Loc Distal Femur Locking Plate System (Smith & Nephew,
were reviewed and patient demographics and details of sur- Andover, Massachusetts). In all, ten patients managed by
gery recorded. Skeletally immature patients and those retrograde intramedullary nailing (RIMN) were excluded.
undergoing treatment for complications of primary surgery As all patients admitted with these fractures are discussed
undertaken elsewhere were excluded. at our trauma review, no patients would have been omitted
Using a Picture Archiving and Communication System from the database or treated non-operatively.
(Phillips IntelliSpace PACS, Guildford, United Kingdom), The mean age of our patients was 72.8 years (16 to 101),
intra-operative fluoroscopy and pre- and post-operative with just 14 fractures (11%) occurring in patients under the
radiographs were reviewed to determine fracture pattern age of 50 years. The latter group appeared to represent a
and plate and screw configuration. Each radiograph was separate fracture population with approximately ten times
assessed by consensus including at least two senior trainees the rate of open fracture and four times the rate of intra-
(WECP, DGGW, HCG, SFB, RF). Where disagreement articular fracture compared with patients aged 50 years and
occurred, a third opinion was sought from a senior author over (Table I).
(EG, SGN). The final outcome was determined to be one of A total of 97 fractures (75%) occurred in female
radiographic union (cortical bridging callus on three of four patients. Most patients had significant medical comorbid-
cortices on orthogonal radiographs), death of the patient, or ity, with 74 (61%) recorded as American Society of Anaes-
failure of surgery, defined as loss of reduction, implant fail- thesiologists (ASA) grade III or above (ASA I, 11 (9%);
ure or nonunion requiring revision surgery. Re-operations ASA II, 37 (30%); ASA III, 66 (54%); ASA IV, 8 (7%)).10
for any other reason were also noted. Statistical analysis. Age-adjusted relative incidence was
Older patients were not routinely followed up, mirroring estimated using local population demographics.11
the departmental policy on fragility fractures of the proxi-
mal femur, itself driven by the relatively low rates of com- Results
plication, high rates of cognitive impairment and common The age distribution of our patients appeared to be bimodal
logistical difficulties associated with outpatient attendance. with a smaller distinct group of young patients contrasting
Surgeons may specify additional follow-up if they perceive with a much larger older group. Only 14 fractures occurred
additional risk of failure and if the patient is concerned or in patients under 50 years old. However, among the
has a high functional demand. Where fracture union was younger group the incidence of intra-articular fractures was
not seen on the last available radiograph, surviving patients four times higher and the incidence of open fracture was ten
were invited back for further radiographs. When union was times as frequent. The age-related relative risk for this frac-
confirmed only on these late review radiographs, their time ture is shown in Figure 1.
to union was excluded from the dataset. Where the patient Of the 127 fractures, 11 were open with primary closure
was too frail or unable to attend hospital for further possible in nine, and two required delayed closure with a

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 ’MODERN’ DISTAL FEMORAL LOCKING PLATES ALLOW SAFE, EARLY WEIGHT-BEARING 953

1.4

1.2

Relative risk
0.8

0.6
Relative risk
0.4

0.2

0
15 20 30 40 50 60 70 80 > 90
to to to to to to to to
19 29 39 49 59 69 79 89
Age (yrs)
Fig. 1

Graph showing relative incidence of fractures of the distal femur,

adjusted for age demographics of the local population.

Table II. Fracture characteristics

Fracture characteristics n (%) n (%)

Diaphyseal (AO type-32) 22 (17) Periprosthetic 18 (14)
No prosthesis 4 (3)
Extra-articular distal metaphyseal 85 (67) Periprosthetic 52 (41)
No prosthesis 33 (26)
Intra-articular distal metaphyseal 20 (16) AO type-33B 4 (3)
AO type-33C 16 (12)
Total 127 (100)
Periprosthetic fractures 71 (56) Below THA 15 (12)
Below short IMN 3 (2)
Below DHS 2 (1)
Above TKA 36 (28)
Interprosthetic 15 (12)
Open fractures – Gustilo Grade 11 (9) Grade I* 4 (3)
Grade II 0 (0)
Grade IIIa 5 (4)
Grade IIIb 1 (1)
Grade IIIc 1 (1)
*Gustilo open fracture classification12
AO, Arbeitsgemeinschaft für Osteosynthesefragen; THA, total hip arthroplasty; DHS, dynamic hip screw; TKA,
total knee arthroplasty; IMN, intramedullary nailing

local flap. Three open fractures were temporarily stabilised supplemented with either cerclage cables, a periprosthetic
with external fixators and definitively fixed with LDFLP. locking attachment plate or both.
Table II12 further demonstrates the fracture characteristics. In 107 of 127 fractures (84%), patients were permitted
A consultant performed the operation in 85 of 127 of the to bear full weight as tolerated immediately. No patients
cases (67%). The remainder were supervised by a consult- had primary bone grafting or cement augmentation or
ant or performed by a senior trauma fellow. underwent dual plating in their primary fixation.
The most commonly used plate length was 14 holes, with Outcomes. Four fractures (3%) required re-operation for
a median of six locking screws distal to the fracture (4 to 9). loss of fixation prior to union.
The average working length (the distance between closest Two further fractures (2%) underwent re-operation for
screw above and below the fracture) was five screw holes. infection but revision fixation was not required. The metal-
In seven fractures (6%), the proximal fixation was work was retained until union in both cases but

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954 W. E. C. POOLE, D. G. G. WILSON, H. C. GUTHRIE, S. F. BELLRINGER, R. FREEMAN, E. GURYEL, S. G. NICOL

Fig. 2a Fig. 2b Fig. 2c Fig. 2d

A distal femoral periprosthetic fracture occurring in a patient aged 72 years: a) pre-operative lateral radiograph, b) pre-
operative CT 3D reconstruction, c) pre-operative anteroposterior (AP) radiograph, d) post-operative AP radiograph at nine
months post-operatively demonstrating united fracture.

subsequently removed in one. Table III provides further implies a higher energy transfer, and hence different pattern
information for the cases of failure. of injury to that seen in the older patients who are more
Excluding patients who died (n = 34) during the study likely to suffer from osteoporosis. Although fixation was
period prior to union or who were lost to follow-up (n = 6), equally successful in both younger and older subgroups, the
our rate of clinical and radiographic union was 95% (81 of small number of patients in the younger group means that the
85 fractures). Two of the four fractures which failed to low rates of failure must be interpreted with some caution.
unite after the initial surgery achieved union after revision This estimate of relative incidence assumes that no non-
fixation at between seven and 12 months. One patient died operatively treated fractures were missed and equates our
during follow-up, the other underwent complex knee catchment population to our local population. In fact, our
arthroplasty with a linked prosthesis. catchment population for high-energy fractures in young
A total of 59 fractures (46%) with complete radiographs patients extends beyond our local population of this age
available had radiological union at a mean of seven months group, as we receive direct transfer in our capacity as a
(3 to 14) after primary fixation without re-operation. Fur- major trauma centre. In contrast, older patients with iso-
ther outpatient review was not possible for 22 patients lated low-energy fractures of the distal femur will tend to be
(17%) with fractures. Telephone follow-up at a mean of 31 treated at their local district general hospital. Despite our
months (9 to 45) confirmed satisfactory clinical outcomes. larger catchment population for young high-energy inju-
These fractures were deemed to have united. ries, we observed an apparent exponential increase in rela-
In all, 34 fractures (27%) occurred in 34 patients who tive incidence with age.
subsequently died without radiographic evidence of union. Technical considerations. In patients with a small distal
None of these patients had required re-operation. Satisfac- articular block of bone, pre-operative CT scans were under-
tory reduction and stable fixation was noted on the last taken. Plate fixation was achievable in all cases, with the
radiographs prior to death. design of the plate allowing at least four screws distally in
Six patients (5%) each with unilateral fractures were lost all fracture patterns. It was not necessary to refer any
to follow-up prior to union but have not re-presented to patient for primary arthroplasty and cut-out of screws from
our unit with complications, and had satisfactory fixation the distal articular fragment was not witnessed. In peripros-
and reduction on last available radiographs. Five of these thetic fractures, the intact cement mantle of the knee or hip
patients are known to live abroad, and were repatriated arthroplasty was noted to provide excellent purchase for
after the index procedure. screws (Fig. 2).
After successful union, six patients (5%) had sympto- Fixation constructs with a short working length can
matic metalwork removed. A further three patients (2%) result in excessive stiffness with inadequate strain to allow
underwent re-operation for a fracture above the femoral secondary bone healing, and also results in a concentration
plate, all after successful union of the primary fracture. of strain that can result in breakage of the plate.13,14 Three
Excluding the six patients lost to follow-up, 42 (of 116 of our four surgical failures were seen when a plate with 12
patients, 36%) died within the follow-up period. The or fewer holes was used to fix a fracture with a working
cumulative 30-day, three-month and 12-month rates of length of three or four holes. In contrast, there was only one
mortality were 6 (5%), 17 (15%) and 25 (22%), respec- failure in the 95 fractures where a plate with 13 holes or
tively. more was used. This failure was in a 16-hole VA-Condylar
plate (Synthes, West Chester, Pennsylvania) which was
Discussion inserted with an unusually long working length of eight
Demographics. Our study data suggest an exponential holes. Overall, the small number of failures means that def-
increase in the incidence of distal femoral fractures in the inite conclusions cannot be drawn from these findings.
elderly, echoing recent literature.7 In the 11% of fractures Long plates also reduce the risk of a secondary fracture
occurring in patients under the age of 50 years, there were above them, a complication that occurred in three of our
much higher rates of open and intra-articular fracture. This patients after successful union of the primary fracture.

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 ’MODERN’ DISTAL FEMORAL LOCKING PLATES ALLOW SAFE, EARLY WEIGHT-BEARING 955

Table III. Failure of surgical cases

Fracture and fixation Time to failure

Age Gender AO classification characteristics (mths) Revision procedure Outcome
38 M 33 type-A3 High energy open fracture 3 First revision to longer plate, Fracture united
broke again at five months
12-hole VA-Condylar plate Second revision to orthogonal
(Synthes, West Chester, plating + limb shortening
Pennsylvania) with short
working length (3 holes)
Plate broke
61 M 33 type-A3 High energy fracture with medial 1 Revised to longer plate with Patient died during
comminution shorter working length (5 holes) follow-up period
16-hole VA-Condylar plate with
long working length (8 holes)
Plate broke
86 F 33 type-A3 Fracture in elderly patient with 5 Revised to hinged TKA Successful
medial comminution arthroplasty
10-hole VA-Condylar plate with
4-hole working length
Plate broke
95 M 33 type-A3 Fracture in elderly patient with 2 Revised to 16-hole Peri-Loc plate Fracture united
medial comminution (Smith & Nephew, Andover,
Massachusetts) with six screws
distal to fracture and 5-hole
working length
12-hole VA-Condylar plate with
four hole working length
AO, Arbeitsgemeinschaft für Osteosynthesefragen; TKA, total knee arthroplasty

Learning from this, we adapted our technique to the use of prosthetic fractures retrograde nailing is not possible due to
a plate extending as far proximally as the greater tro- the geometry of the existing arthroplasty. Compatibility
chanter. The proximal end of the plate can be bent laterally guides are available.18,19 A recent review of 448 peripros-
to accommodate the greater trochanteric flare, allowing thetic fractures of the distal femur after total knee arthro-
locking screws to be directed into the femoral neck and plasty (TKA)20 concluded slightly superior results in lateral
thereby affording whole-bone fixation analogous to a ceph- locked plates to IMN (union rates of 87% and 84%,
alomedullary nail. respectively) with lower complication rates associated with
Most patients were allowed to bear weight as tolerated in use of plates. Further data have recently favoured IMN fix-
the immediate post-operative period, increasingly so that ation compared with LDFLP for short term EuroQol-5D
our confidence in the technique grew, so that none of the scores and reduction in angular deformity. However, the
last 49 fractures in the series were made non-weight bear- matching of the groups is unclear, with A1 to C1 fractures
ing. Not all patients in this population will achieve this, but included but with intra-articular fractures predominantly
it does provide an easier route for rehabilitation. fixed with LDFLP.21
No patient was immobilised in a cast. Some surgeons TKA may be appropriate in multi-fragmentary intra-
employed removable hinge-knee braces, but it was articular fractures in elderly patients, in fractures above
observed that these were often a hindrance to walking in loose implants and in the presence of significant pre-
elderly frail patients, in which case such patients were existing arthritis, particularly if there is associated deform-
allowed to weight-bear without the brace. ity or instability of the knee. Currently, reports on this
Alternative methods of fixation. RIMN has biomechanical approach remain limited to small series.9,22,23
data suggesting that a multi-planar locked retrograde nail External fixation is often applied when temporisation is
has the greatest stability (compared with locking compres- required to manage multiple injuries, when a staged
sion plate and DCS) for type-A fractures of the distal fem- approach to treatment may be preferable. A quadrilateral
oral shaft with statistically higher stiffness and significantly frame construct has been proposed where external fixation
lower micro-motion across the fracture gap with axial com- is required.24
pression.15 However, the same study revealed RIMN had Dynamic condylar screw and blade plates are generally
the lowest resistance to fatigue failure in intra-articular regarded to be unforgiving implants.25 Insertion may dis-
type-C fracture where distal locking screws failed after less rupt the fracture further, requiring removal of bone stock
than 10 000 cycles.16 Although the AO group4 advocate which can complicate revision options. Biomechanically
avoiding IMN in fractures within 6 cm of the joint surface, they are less suitable for osteoporotic bone and type-C frac-
experts can manage these distal fractures with IM17 devices tures than locking plates, due to the relatively poor sagittal
using additional techniques such as inter-fragmentary plane stability they provide. These implants have been
screws to reconstruct the articular block and blocking larger superseded by the Less Invasive Stabilisation System
screws to ensure idea nail placement. In some peri (LISS) plate (Synthes). This allows for locking plate

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956 W. E. C. POOLE, D. G. G. WILSON, H. C. GUTHRIE, S. F. BELLRINGER, R. FREEMAN, E. GURYEL, S. G. NICOL

technology to be used with a minimally invasive plate sound biomechanical principles to permit unrestricted
osteosynthesis technique, in order to produce a fixed con- weight-bearing.
struct that is essentially an internally positioned external
fixator. However, a meta-analysis of the LISS plate in nearly Take home message:
700 femoral fractures across 21 studies showed up to 19% - Surgeons treating distal femoral fractures with modern gen-
loss of reduction, 6% delayed union/nonunion, and 5% eration distal femoral locking plates should be aware of the
biomechanical principles of using longer plates with the correct working
implant failure.26 Subsequently plating systems offer stain-
length.
less steel pre-contoured design for implantation using a
- Using these can allow early unrestricted weight-bearing with low
soft-tissue sparing technique. The locking screws may be
reported rate of failure.
fixed angle (as in the Peri-Loc plate) or variable angle (as in
the VA-Condylar plate). The rationale for variable angle Author contributions:
W. E. C. Poole: Data collection, Writing and editing the paper.
screws is increased versatility, allowing the surgeon a D. G. G. Wilson: Data collection, Writing and editing the paper.
degree of choice in screw placement (usually a 30° arc), H. C. Guthrie: Concept, Data collection, Writing and editing the paper.
S. F. Bellringer: Data collection, Editing the paper.
which can be useful in engaging in bone and avoiding an R. Freeman: Concept, Data collection, editing.
implant. This theoretical benefit has yet to be reflected in E. Guryel: Concept, Editing the paper.
S. G. Nicol: Concept, Writing and editing the paper.
the literature in improved outcomes. Indeed, a recent study
S. G. Nicol receives funding for teaching on educational courses for Smith &
of 67 patients27 found increased failure rates in the VA- Nephew, no benefits were received relating either directly or indirectly to the
Condylar plate compared with the LISS plate (22% versus subject of this article.

14%). The more complex fracture patterns were fixed with The author or one or more of the authors have received or will receive benefits
for personal or professional use from a commercial party related directly or
the VA device in this series. In our study, all four failures of indirectly to the subject of this article.
surgery were with the VA-Condylar plate, giving a failure
This article was primary edited by P. Page and first proof edited by G. Scott.
rate of 5%. None of the 53 Peri-Loc fixations failed. The
very small number of failures makes it difficult to draw
robust conclusions on the causes of those failures. References
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