European Journal of Cardiovascular Medicine

A considerable source of morbidity, distal femur fractures make up about 3-6% of all femoral fractures. These fractures are more common in young people after high-energy trauma and in the elderly from low-energy falls caused by osteoporosis. Complex anatomy, poor bone quality, and the requirement to restore limb alignment while permitting early movement make extra-articular distal femur fractures a unique challenge for orthopedic surgeons [1, 2].

With the goal of achieving secure internal fixation, early rehabilitation, and improved functional results, the care of distal femur fractures has moved from conservative treatment to operative fixation, thanks to advancements in surgical methods and implant design. When it comes to treating distal femur fractures that are located outside of the joint, two surgical procedures that have become widely used are locking compression plate fixation and retrograde intramedullary nailing (RIMN). There are unique biomechanical and biological benefits to each method [3-5].

As a load-sharing device, retrograde intramedullary nailing permits early weight bearing and secure fixation with little damage to soft-tissue. It helps a lot with individuals who have suffered multiple traumas or who have fractures with basic patterns. While locking compression plates may necessitate more extensive removal of soft tissues, they serve as internal fixators that improve fixation in comminuted fractures and osteoporotic bone by providing angular stability [6, 7].

Both approaches are becoming more common, but nobody agrees on how to treat distal femur fractures that occur outside of the joint. There is no clear consensus favoring one approach over the other, and the literature reports differences in fracture union time, functional outcome, complication rates, and rehabilitation regimens [8, 9].

The purpose of this study was to determine which treatment method was more effective for patients with extra-articular distal femur fractures: retrograde intramedullary nailing or locking compression plate fixation, by comparing the functional outcome, fracture union, and complications of the two.

This was a prospective comparison study carried out in the Department of Orthopaedics at a tertiary care teaching hospital. The study comprised 50 patients with extra-articular distal femur fractures, all of whom provided informed permission. This study was conducted at Dr Chandramma Dayananda Sagar Institute of Medical Sciences, Karnataka, From December 2020 to November 2021. Patients with extra-articular distal femur fractures (AO/OTA type 33-A) underwent clinical and radiological evaluation. Eligible patients were assigned to two groups according to the surgical technique employed. Group A (n = 25) had retrograde intramedullary nailing, while Group B (n = 25) underwent locking compression plate fixation. Inclusion Criteria:  Patients aged 18 years and above  Radiologically confirmed extra-articular distal femur fractures  Closed fractures or Gustilo-Anderson type I open fractures  Patients medically fit for surgery  Patients willing to participate and comply with follow-up protocol Exclusion Criteria:  Intra-articular distal femur fractures  Pathological fractures  Polytrauma patients with life-threatening injuries  Open fractures Gustilo-Anderson type II and III  Associated ipsilateral fractures of the hip or tibia Postoperative Protocol and Follow-up: Patients were encouraged to strengthen their quadriceps and increase their knee range of motion after surgery, as they were able to do so safely. Radiographic evidence of callus formation prompted the patient to begin partial weight bearing, which was later increased to full weight bearing following confirmation of fracture union. After surgery, patients were checked again six weeks, three months, and six months later. Outcome Measures: We used Neer's scoring method to evaluate the functional outcome. When a bridge callus was seen over three or more cortices, it was considered a radiological union. Infection, implant failure, delayed union, non-union, malalignment, and knee discomfort were among the complications that were meticulously documented. Statistical Analysis: Data were inputted and analyzed utilizing the Statistical Package for the Social Sciences (SPSS) program. Continuous variables were represented as mean ± standard deviation, whilst categorical variables were displayed as frequencies and percentages. The Student's t-test was employed to compare continuous variables between the two groups, while the Chi-square test or Fisher's exact test was utilized for categorical variables. A p-value less than 0.05 was deemed statistically significant.

Group A consisted of 25 patients treated with retrograde intramedullary nailing (RIMN) and Group B consisted of 25 patients treated with locking compression plate (LCP) fixation; the study included 50 patients with extra-articular distal femur fractures. A minimum of six months of follow-up was required of all patients.

Table 1: Demographic and Injury Characteristics of Patients

Road traffic accidents were the leading cause of fracture in both groups, which were otherwise similar in age, sex distribution, side involved, and mode of injury.

Table 2: Fracture Pattern and Operative Details

The distribution of fracture types was comparable in the two groups. When contrasted with the LCP group, the RIMN group showed reduced intraoperative blood loss and a shorter operating time.

Table 3: Radiological Union and Weight Bearing

While both groups had similar union rates, patients who underwent retrograde nailing instead of LCP healed their fractures faster and were able to advance to full weight bearing sooner.

Table 4: Functional Outcome Based on Neer’s Score

Functional recovery was better in the RIMN group as measured by a higher mean Neer's score and a slightly greater proportion of excellent to good outcomes compared to the LCP group.

Table 5: Complications Observed in Both Groups

There was no statistically significant difference in the number of complications observed in the two groups. Of all the complications, knee stiffness was the most prevalent. The risk of implant-related problems was marginally greater in the LCP group.

Distal femur fractures remain a therapeutic challenge due to their intricate anatomy, inadequate bone quality, and the necessity for stable fixation that allows for early mobilization. This study examined the functional and radiological results of extra-articular distal femur fractures treated with retrograde intramedullary nailing with locking compression plate fixation in 50 patients [10, 11].

This study predominantly involved middle-aged males, with road traffic accidents identified as the primary mechanism of injury. This demographic trend aligns with prior research indicating a greater occurrence of distal femur fractures in younger males resulting from high-energy trauma, whereas elderly individuals generally have similar fractures after low-energy falls [12, 13].

This study found that the operational duration and intraoperative hemorrhage were reduced in the retrograde intramedullary nailing group relative to the locking compression plate group. This finding aligns with prior research that have ascribed shorter operating duration and lower blood loss associated with intramedullary nailing to its minimally invasive characteristics and restricted soft-tissue dissection [14-16].

This study demonstrated that radiological union was attained in most patients across both groups, with the retrograde nailing group exhibiting a somewhat reduced mean time to union [18]. Previous research have revealed analogous findings, indicating that the load-sharing properties of intramedullary nails facilitate advantageous biological repair. Nonetheless, locking compression plates have exhibited consistent union rates, especially in cases of comminuted and osteoporotic fractures [18].

In this study, patients undergoing retrograde intramedullary nailing initiated complete weight bearing sooner than those receiving locking compression plates. This conclusion aligns with prior investigations, which have highlighted that intramedullary implants facilitate earlier mobilization owing to their biomechanical stability and central load transfer [19, 20].

This study revealed that functional outcomes evaluated with Neer’s scoring system indicated a greater percentage of excellent and good results in the retrograde nailing group, but adequate outcomes were noted in both groups. Previous studies have confirmed similar results, suggesting that although both fixation procedures are effective, retrograde nailing may offer enhanced functional recovery for specific fracture types [21, 22].

This study observed problems including knee stiffness, infection, malalignment, and delayed union in both groups, with no statistically significant differences identified between them. Knee stiffness was the predominant consequence, widely documented in prior studies, and is often associated with extended immobilization and deferred rehabilitation. Complications associated with implants were marginally more prevalent in the locking compression plate cohort, a result that corroborates existing research emphasizing the risk of implant failure in osteoporotic bone [23].

This study revealed that locking compression plates offer distinct benefits in the treatment of comminuted fractures and in patients with compromised bone quality, due to their angular stability. This discovery corroborates prior research that endorses the utilization of LCPs as internal fixators in intricate fracture topologies [24].

This study demonstrated that both retrograde intramedullary nailing and locking compression plate fixation yielded satisfactory radiological union and functional outcomes for extra-articular distal femur fractures. The findings align with prior research and indicate that fixing selection should be tailored according to fracture morphology, bone integrity, patient characteristics, and surgeon proficiency [25, 26].

For the treatment of non-articular distal femur fractures, this research found that locking compression plate fixation and retrograde intramedullary nailing both produced good functional and radiological results. Somewhat higher functional outcomes were achieved with retrograde intramedullary nailing due to its shorter operation duration, less blood loss, quicker fracture union, and earlier commencement of full weight bearing. With satisfactory union rates and functional outcomes, locking compression plate fixation offered stable fixation, especially in cases with comminuted fractures and osteoporotic bone. Conclusion: fracture configuration, bone quality, patient characteristics, and surgeon ability should be considered when choosing an implant, as neither approach was proven to be uniformly superior. The functional recovery of patients with distal femur fractures that occur outside of the joint is heavily dependent on early mobilization and proper therapy.

Funding

None

Conflict of Interest:

None

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