Review Question - QID 219496

Surgical fixation of extra-articular supracondylar distal femur fractures in elderly patients have shown no difference in functional outcomes when either locked lateral plating or intramedullary nailing are chosen as the primary method of treatment, with immediate weightbearing demonstrating no appreciable negative effect on early clinical, radiographic, or functional outcomes.

Distal femur fractures in elderly patients are typically due to low-energy mechanisms, often falls from standing height, in the setting of osteoporotic bone and often multiple medical comorbidities. Treatment choice is often based on fracture pattern, location, and surgeon preference, with locked lateral plating (Illustration A) and retrograde intramedullary nailing (Illustration B) being the predominant choices for extra-articular fractures in the supracondylar region. Both methods may lead to malunions, particularly in the coronal plane, with varus collapse and loss of fixation if poorly executed, but none of these outcomes have been associated with early weightbearing post-operatively on either construct. Despite not compromising early clinical, radiographic, or functional outcomes in appropriate surgeon-selected elderly extra-articular distal femur fractures, use of a locked lateral plate instead of an intramedullary nail with immediate weightbearing has also not shown statistically significant improvements in function or shorter lengths of hospitalization.

Lieder et al. reviewed whether or not immediate weightbearing was safe after single-implant fixation of elderly distal femur fractures. The authors looked at 135 patients aged 60 or older who underwent surgical fixation of AO 33-A1-3 fractures and found that the rate of early adverse events requiring reoperation was similar between the WBAT group (10.7%) and the TDWB group (19.0%; P= 0.23). They concluded that there was no difference between groups with respect to length of stay, discharge disposition, malunion, and patient-reported outcomes.

Hussain et al. reviewed stable fixation and immediate weightbearing after combined retrograde intramedullary nailing and open reduction internal fixation of non-comminuted distal interprosthetic femur fractures. The authors reviewed 9 patients with non-comminuted, distal femur fractures in which no interfragmentary screws, cables, cerclage wires, or supplemental bone grafts of any type were used and each patient initiated weight-bearing as tolerated after operative intervention. Every fracture healed at an average of 20 weeks, leading them to conclude that a lateral locking plate combined with a retrograde intramedullary nail provides stable fixation for patients with interprosthetic femur fractures to allow for immediate weightbearing.

Figure A is an AP radiograph demonstrating an extra-articular supracondylar distal femur fracture in a patient with poor bone quality. Illustration A is a set of post-operative films demonstrating a locked lateral plate. Illustration B is a set of post-operative films demonstrating a retrograde IMN.

Incorrect Answers:
Answers 1-3 and 5: Early immediate weightbearing after isolated locked, lateral plating for extra-articular, supracondylar distal femur fractures in the elderly has not been associated with increased risk for delayed union, malunion, or early failure, but has also not been shown to result in shorter operative times, shorter lengths of hospitalization, or statistically significantly improved functional status when compared to intramedullary nailing of the same fracture types.