Hoffmann et al.

Journal of Orthopaedic Surgery and Research 2013, 8:43

http://www.josr-online.com/content/8/1/43

RESEARCH ARTICLE Open Access

Clinical outcomes of locked plating of distal

femoral fractures in a retrospective cohort
Martin F Hoffmann1,2, Clifford B Jones3*, Debra L Sietsema3, Paul Tornetta III4 and Scott J Koenig4

Abstract
Purpose: Locked plating (LP) of distal femoral fractures has become very popular. Despite technique suggestions
from anecdotal and some early reports, knowledge about risk factors for failure, nonunion (NU), and revision is
limited. The purpose of this study was to analyze the complications and clinical outcomes of LP treatment for distal
femoral fractures.
Materials and methods: From two trauma centers, 243 consecutive surgically treated distal femoral fractures
(AO/OTA 33) were retrospectively identified. Of these, 111 fractures in 106 patients (53.8% female) underwent
locked plate fixation. They had an average age of 54 years (range 18 to 95 years): 34.2% were obese, 18.9% were
smokers, and 18.9% were diabetic. Open fractures were present in 40.5% with 79.5% Gustilo type III. Fixation
constructs for plate length, working length, and screw concentration were delineated. Nonunion and/or infection,
and implant failure were used as outcome complication variables. Outcome was based on surgical method and
addressed according to Pritchett for reduction, range of motion, and pain.
Results: Eighty-three (74.8%) of the fractures healed after the index procedure. Twenty (18.0%) of the patients
developed a NU. Four of 20 (20%) resulted in a recalcitrant NU. Length of comminution did not correlate to NU
(p = 0.180). Closed injuries had a higher tendency to heal after the index procedure than open injuries (p = 0.057).
Closed and minimally open (Gustilo/Anderson types I and II) fractures healed at a significantly higher rate after the
index procedure compared to type III open fractures (80.0% versus 61.3%, p = 0.041). Eleven fractures (9.9%)
developed hardware failure. Fewer nonunions were found in the submuscular group (10.7%) compared to open
reduction (32.0%) (p = 0.023). Fractures above total knee arthroplasties had a significantly greater rate of failed
hardware (p = 0.040) and worse clinical outcome according to Pritchett (p = 0.040). Loss of fixation was related to
pain (F = 3.19, p = 0.046) and a tendency to worse outcome (F = 2.43, p = 0.071). No relationship was found between
nonunion and working length.
Conclusion: Despite modern fixation techniques, distal femoral fractures often result in persistent disability and
worse clinical outcomes. Soft tissue management seems to be important. Submuscular plate insertion reduced the
nonunion rate. Preexisting total knee arthroplasty increased the risk of hardware failure. Further studies determining
factors that improve outcome are warranted.
Keywords: Femur, Fracture, Supracondylar, Locked plating, Outcome

* Correspondence: Clifford.Jones@oamichigan.com
3
Michigan State University/Orthopaedic Associates of Michigan, 230
Michigan St. NE, Grand Rapids MI 49503, USA
Full list of author information is available at the end of the article

© 2013 Hoffmann et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
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Background surgical treatment for distal femoral fractures from

Distal femoral fractures reportedly account for less than March 2002 through June 2009 at two Level I trauma
1% of all fractures and comprise between 4%–6% of all centers. The involved patients were collected from the
femoral fractures [1-3]. Supracondylar femoral fractures clinical database based on a computer query of Current
occur commonly among two populations, young patients Procedural Terminology (CPT) codes for supracondylar
involved in high-energy accidents (including motor ve- fractures. All patients with supracondylar femoral frac-
hicle and motorcycle accidents and sports trauma) and ture treated with locked plate fixation and age equal to
older patients, often osteoporotic, sustaining low-energy or older than 18 years were included in this study. Pa-
fall fractures. Jahangir additionally described an increase tients with intramedullary fixation, metastatic disease,
of periprosthetic fractures of the distal femur in patients impaired lower extremity motor or nerve function prior
with previous total knee arthroplasty or distal to a total to injury, and supplemental methods for bone healing
hip arthroplasty as the third common population [4]. were excluded.
Except in extreme circumstances, operative treatment Two hundred forty three (243) fractures were surgi-
for supracondylar femoral fractures is the standard, while cally treated for distal femur fractures during the study
nonsurgical treatment has largely fallen out of favor as the period. Sixty-one fractures were excluded because of age
result of further advances in technique and implants [4]. younger than 18 years old (14), open reduction and in-
Surgical fixation has consistently demonstrated better out- ternal fixation other than locked plating or intramedullary
comes than nonsurgical management [5] mainly based on fixation (40), carcinoma with metastasis to the supracon-
fixed angle devices starting with the blade plate, dynamic dylar region (2), paraplegia (3), and implanted bone stimu-
condylar screw [6,7], and nail resulting in the advent of lator (2). Additionally, 71 were lost due to death (1),
locked plating. The current trend is toward periarticular follow-up less than 6 months (62), and incomplete radio-
distal femoral locking plates [8,9], which can be inserted graphic data (8). The death occurred during the initial
submuscularly as a minimally invasive procedure to pre- hospital period and was related to other associated injur-
serve blood supply, fracture hematoma, and avoid exten- ies. A final study group of 111 fractures (67 left, 44 right)
sive soft tissue damage [10-13]. in 106 patients with a mean age of 54 years (range 18–95
Definitive treatment of distal femoral fractures requires years) remained. There were 49 (46.2%) males and 57
maintenance or restoration of distal femoral alignment to (53.8%) females with an average body mass index (BMI) of
preserve the function of the extremity [14]. Additionally, 29.8 kg/m2 (range 17–67). Length of follow-up was 23.3
early knee motion is central to the management of distal months (range 6–72). High-energy injuries were more
femoral fracture. Knee stiffness and loss of range of mo- common and occurred in 64 of 111 patients (57.7%)
tion (ROM) may develop with immobilization [15], and compared to low energy fall in 41 of 111 patients (36.9%)
these often contribute to a poor outcome [10]. Supracon- (Table 1). Patients with high-energy trauma averaged 44
dylar fractures, intraarticular in particular, are difficult to years (range 18–88 years) while patients suffering from a
treat to successful union without complications. Similar low-energy fall averaged 69 years (range 31–95) (t = 8.27,
nonunion rates of 0%–20% for conservative treatment or p < 0.001). These injuries resulted in 72 (64.9%) closed and
internal fixation methods [5,6,16-19] have been described. 39 (35.1%) open fractures. Open fractures were associated
This finding was treatment independent. In addition, dia- with high-energy injury mechanism (p < 0.001). Comor-
betic and obese patients seem to be at high risk for healing bidities and potential contributing factors were recorded
complications, infections, and specifically nonunions [7]. (Table 2). Obesity with BMI ≥ 30 kg/m2 (38/111), previous
Concerns have been voiced that the material of the im- total knee arthroplasty (22/111), smoker (21/111), dia-
plant might be of importance [8]. A significantly higher betes mellitus, and a history of smoking (20/111) were
nonunion rate for stainless steel plate implants compared most common.
to titanium has been reported [8]. Each patient had two initial injury femur views
Understanding characteristics of distal femoral fractures (Figure 1A,B) and additional diagnostics when assumed
as well as the principles and challenges of management is
Table 1 Mechanism of injury
important in optimizing outcomes [14]. Therefore, the
Mechanism of injury Number Percentage (%)
purpose of this study was to analyze the complications
and clinical outcomes of locked plating for supracondylar Low energy fall 41 36.9
femur fractures utilizing Cain's [9], Kristensen's [11], and High energy fall 9 8.1
Pritchett's [12] criterion. Motor vehicle accident 44 39.6
Motor cycle accident 7 6.3
Methods Sport 4 3.6
This study was an Institutional Review Board approved
Unknown 6 5.4
retrospective cohort analysis of patients undergoing LP
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Table 2 Comorbidities and contributing factors necessary for assessing fracture pattern (Figure 2).
Comorbidities and contributing Number Percentage (%) Fractures were classified according to the AO/OTA
factors (may have more than 1) (Arbeitsgemeinschaft Osteosynthese/Orthopaedic Trauma
Diabetes 21 18.9 Association) system in 44 A-type, 4 B-type, and 63 C-type
Current smoker 21 18.9 fractures [13] (Table 3). Twenty-two patients suffered
Past smoker 20 18.0 from a fracture proximal to a total knee replacement
(TKR). Periprosthetic fractures were additionally classified
Previous total knee replacement 22 19.8
according to Lewis and Rorabeck [20].
Obesity (body mass index ≥ 30 kg/m2) 38 34.2
Open or closed reduction and internal fixation of the
supracondylar femoral fracture was performed with the
patient in the supine position on a radiolucent table with
fluoroscopic assistance. The operative approaches to the
distal femur were tailored to each patient based on the
particular pattern of the injury, location of the fracture,

Figure 1 Treatment and follow-up of a distal femoral fracture. (A) Preoperative radiographic AP view of a distal femur fracture with external
fixation. (B) The lateral view shows the sagittal alignment of the fragments. (C,D) Postoperative radiographs confirm reduction quality and
implant position. (E,F) Callus formation and cortical continuity demonstrate ongoing fracture healing.
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Figure 2 CT-scans provide additional information concerning articular involvement. (A) Coronal image of a Hoffa's fracture. (B) CT
reconstruction of a Hoffa's fracture.

associated injuries, and soft tissue involvement. Internal strengthening, dynamic lumbar stabilization, range of mo-
fixation of the metaphyseal part of the fracture was either tion, strengthening, and conditioning.
performed open (36) or submuscular (75). Six trauma fel- Patients were followed in the office on a regular basis
lowship trained orthopedic surgeons performed the surger- at intervals of 2 weeks, 6 weeks, 12 weeks, 6 months, 1
ies at two trauma centers. All patients had postoperative year, and 2 years. Complaints of pain were assessed with
radiographs (AP, LAT) imaging to confirm reduction qual- a visual analog scale (VAS), and problems with ambula-
ity and implant position (Figure 1C,D). tion (limp and required aides) were recorded. Clinical
Postoperatively, patients had antibiotic and deep vein examination of incisional healing, motor exam, sensory
thrombosis prophylaxis. Open fractures were either treated exam, knee stability, range of motion (ROM), and ambu-
with primary closure or returned for delayed primary clos- lation was performed. Radiographs consisting of AP and
ure. Antibiotics were continued and readministered based LAT views of the distal femur were obtained and evalu-
upon wound severity and surgeon preference. Patients ated by the orthopedic surgeons during office follow-up
were mobilized based upon the constellation of injuries at each interval. Additionally, all radiographs were exam-
and femur fracture pattern. In general, weight bearing on ined digitally by two authors (MFH, SJK) utilizing a
the distal femoral fracture was delayed until signs of heal- picture archiving and communication system (PACS,
ing with callus formation or resolution of fracture lines. Kodak Carestream PACS 2006, Eastman Kodak Com-
Formal physical therapy was instituted working on core pany, Rochester, NY, USA) and Horizon Rad Station
(McKesson, Medical Imaging, San Francisco, CA, USA).
Bridging of the fracture site at three cortices by callus or
Table 3 AO/OTA classification cortical continuity as well as obliteration of the fracture
AO/OTA classification Number Percentage (%) line were defined as radiographic union (Figure 1E,F)
33 A1 17 15.3 [21]. Missing radiographic evidence of fracture union
33 A2 5 4.5
with continued progress toward healing at the 6-month
time point was defined as delayed union [22]. Malunion
33 A3 22 19.8
was defined as varus angulation >10° at fracture healing.
33 B1 3 2.7 Complications were recorded concerning healing, hard-
33 B2 1 0.9 ware loosening, hardware failure, and revision surgery.
33 B3 0 0.0 Infection was defined as either deep or superficial. Deep
33 C1 6 5.4 infections were defined as those that required operative
33 C2 38 34.2
treatment. Superficial infections were defined as those that
were treated only with local antibiotics and wound care,
33 C3 19 17.1
and no operative treatment for the infection. Complaints
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of leg length discrepancy, instability, and knee stiffness healed after the index procedure. No difference was found
were recorded. for healing after the index procedure when comparing
Data was analyzed using PASW® 18 (IBM, Armonk, NY, titanium (7/8, 87.5%) to stainless steel (76/103, 73.8%),
USA). Descriptive statistics including percentage, standard (p = 0.677). Comparing open and closed fractures, we
deviation, mean, and range were completed. Chi square found a greater percentage of healed fractures after the
and t tests were used to compare those that developed index procedure for closed injuries (80.6% versus 64.1%,
complications versus those that did not, based on demo- p = 0.057). This finding becomes significant comparing
graphic data, contributing factors, empty holes adjacent to closed and minimally open (Gustilo/Anderson types I
the fracture, numbers of screws, and femoral-tibial align- and II) fractures to type III open fractures (80.0% versus
ment. When an unequal variance of means was present, a 61.3%, p = 0.042). Fifty-two fractures (46.9%) underwent
Wilcoxon two-sample test was used to determine differ- additional surgical procedures including hardware re-
ences in analysis such as proximal screw concentration in moval after fracture healing in 10 patients (9.0%) who
implant failure and length of comminution and nonunion. complained of prominent medial screws. The final heal-
An analysis of variance (ANOVA) was used to determine ing status of the patients is listed in Table 5.
a difference in categorical groups including AO/OTA clas- Surgical complications were found in 14 treated frac-
sification grouped by A, B, and C, pain levels, range of tures (12.6%). Heterotopic ossifications were removed in
motion, and outcomes categorized by the Pritchett [12] five patients (4.5%) and one patient developed a superfi-
criteria. Significance was set at <0.05. cial infection, which resolved under local wound therapy
and oral antibiotics. Eight patients underwent irrigation
Results and debridement for deep infection (7.2%). Infection
Twenty-nine fractures (26.1%) were initially stabilized was related to open fracture (7/39, 18.0%, p = 0.003) and
using a temporary spanning external fixator. Initial tem- current smokers had a higher infection rate than non-
porary external fixation was commonly used with open smokers (3/21, 14.3% versus 1/51, 1.9%; p = 0.010), but
fractures (15/39 versus 14/72, p = 0.029). Eight fractures no relationship to diabetes, implant material, or initial
of 111 (7.2%) received titanium implants while 103 frac- treatment with external fixation was found (p = 0.361,
tures of 111 (92.8%) were stabilized with stainless steel im- p = 0.670, and p = 0.203, respectively).
plants. Seventy-five fractures of 111 (67.6%) were treated Of the 111 fractures, 20 (18.0%) developed a nonunion
utilizing a minimal invasive submuscular approach. The or delayed union with 11 fractures (9.9%) leading to
implant types used are listed in Table 4. hardware failure. Hardware failure occurred proximally
According to the different fracture patterns, plate length in six cases, three plates fractured in the area of the
varied from 6–18 holes with holes proximal to the fracture working length and two plates loosened distally. Postop-
varying from 2 to 13. The number of proximal screws var- erative staged bone grafting was performed in 19 pa-
ied from 1 to 9. Three to five proximal screws were most tients. Four fractures underwent planned staged bone
common (82.9%). An average of 52% of the proximal holes grafting with one fracture requiring an additional second
were filled with screws. No difference in the proximal bone grafting. A significant reduction of nonunion for-
screw concentration for implant failure was found (Z = mation was found in the submuscular minimal invasive
0.4947, p = 0.621). Fixation of the condyles was performed group (10.7%) compared to the open reduction group
with 4 to 6 screws in 90.1% of the fractures. In 33 of 111 (32.0%) (p = 0.024). Length of comminution did not in-
fractures (29.7%), additional interfragmentary fixation util- fluence nonunion rate (Z = 1.3406, p = 0.180). No differ-
izing lag screws was performed. ence in working length was found in fractures resulting
One hundred and one fractures (91.0%) finally healed in nonunions compared to fractures with primary heal-
including three malunions. Thereof, 83 fractures (74.8%) ing (p = 0.784). Additional lag screws did not influence
nonunion rate (p = 0.590).

Table 4 Implant types and manufacturer

Implant type (manufacturer) Frequency Material Percentage Table 5 Healing status after distal femur fracture
(%)
Final healing status Number Percentage (%)
Periarticular distal lateral 57 Stainless steel 51.4
Healed 101 91.0
femoral locking plate
(Zimmer) Nonunion 4 3.6
Periloc (Smith and Nephew) 25 Stainless steel 22.5 Total knee replacement 4 3.6
Locked compression plate 21 Stainless steel 18.9 Antibiotic spacer after infected 1 0.9
(Synthes) total knee replacement
LISS (Synthes) 8 Titanium 7.2 Below knee amputation 1 0.9
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Hardware failure was related to nonunion (p < 0.001). Table 7 The Pritchett rating system for supracondylar
Fractures proximal to total knee arthroplasties had a sig- femoral fractures
nificantly greater rate of failed hardware (p = 0.040). No Result Criteria
difference in hardware failure was found comparing ti- Excellent Full extension; flexion >110°; no deformity or joint
tanium and stainless steel (p = 0.948). Additional lag incongruity
screws did not influence hardware failure (p = 0.731). Good Full extension; flexion >90°; <5° of varus or valgus;
Alignment was restored to an average of 7.4° of valgus loss of length <1.5 cm, minimal pain
(range −4.4° to 16.3°) and 87.8° of extension (range 71°– Fair Flexion of 75°–90°; varus, valgus, or angular deformity
118°). The loss of fixation was an average 0.97° (range 0° of 5°–10°; mild or moderate pain
to 14°). No significant difference was found in loss of fix- Poor Flexion <75°; valgus, varus, or angular deformity >10°;
articulate incongruity; frequent pain requiring analgesics
ation for patients with lag screws compared to patients
without lag screws (Z = 0.1039, p = 0.917).
At the last follow-up, 47.8% of the patients did not
complain of any pain (VAS 0). Thirty-seven percent had than patients with excellent outcome (F = 4.17, p = 0.008).
mild (VAS 1–3), 10.8% had moderate (VAS 4–6), and Comparing AO/OTA classification to outcome did not re-
1.8% (2 patients) had severe (VAS 7–10) pain. No rela- veal any difference (p = 0.420). A significantly worse out-
tionship between open fractures and persistent pain was come was found for patients with periprosthetic fractures
found (p = 0.178). Pain was not related to healing status (p = 0.040). Patients with varus malalignment did not have
(p = 0.698), valgus alignment (p = 0.759), or range of mo- a different outcome (F = 1.39, p = 0.250), but greater loss
tion (p = 0.214). Patients with increased loss of fixation of fixation seems to trend toward a worse outcome
had higher pain levels (F = 3.19, p = 0.046). (F = 2.43, p = 0.071). No difference was found comparing
Patients had reduced range of motion resulting mostly the outcome of submuscular procedures to open reduc-
from loss of flexion. Extension was restored to a mean tion (p = 0.899).
loss of 1.4°. Seventeen knees (15.3%) had an extension
deficit of 5° or more. Flexion ranged from 0° in the Discussion
patient with explanted TKR to 150° with a mean flexion Controversy still exists regarding the surgical treatment
of 114°. One hundred three knees (92.8%) were able to method of distal femoral fractures. Internal fixation proce-
flex to 90° according to Cain's criteria [9]. Additionally, dures are dependent on fracture type and the surgeon's
flexion has been divided into four groups (<60, 60–94, preference. While intramedullary nails have comparable
95–104, >104) according to Kristensen [11] (Table 6). advantages as locking plates such as percutaneous place-
Utilizing Kristensen's criteria, 75.7% of the patients had ment, indirect fracture reduction, soft tissue protection,
acceptable flexion. This was not influenced by AO/OTA success in osteoporotic bone, and high healing rates [23],
classification (F = 1.05, p = 0.354) or AP alignment (t = 0.12, locking plates have become the most commonly used
p = 0.905). Reduced flexion was found in patients with method to stabilize fractures of the distal femur [24]. Ad-
advanced age and periprosthetic fractures (t = −3.32, vanced age of the patient population might be a reason.
p = 0.001, Z = −2.366, p = 0.018, respectively). Improved distal fixation for locked plates compared to
Combining the results of pain, deformity, and range of blade plate and retrograde nailing has been demonstrated
motion for outcome using the rating system of Pritchett in osteoporotic bone [25]. Although locking plates have
[12] (Table 7), we had 22 excellent (20.8%), 29 good provided a valuable additional option for treatment of
(27.4%), 48 fair (45.3%), and 7 poor (6.6%) results. Five distal femoral fractures, the use of locked plates has ex-
patients were not classifiable due to TKR and antibiotic panded and the numbers of fractures fixed with these
spacer. Age or mechanism of injury did not influence the plates have increased, complications related to slow heal-
outcome (F = 1.03, p = 0.382; p = 0.341, respectively), but ing including nonunion, delayed union, and implant fail-
patients with poor outcome had a significantly higher BMI ure are not infrequent and are ongoing problems in
managing these fractures [17,24].
Earlier studies have shown reduced nonunion rates
for locked plating of distal femoral fractures compared
Table 6 Clinical outcome (range of motion) according to
Kristensen [11] to non-locking plates [5,26], but more recent studies
found nonunion rates up to 20% [17-19]. In the current
Range of motion
study, 18% of the fractures showed signs of delayed or
<60° 60–94° 95–104° >104° Unknown or
not applicable non-union. Multiple reasons influence union rates.
Number of patients 3 19 11 73 5
Higher stiffness of locking plates has been related to
suppressing interfragmentary movement and callus for-
Percentage (%) 2.7 17.1 9.9 65.8 4.5
mation [17,27]. But in a systematic review by Zlowodski
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[28] comparing traditional plating, intramedullary nails, plane alignment has been shown to be the most difficult
and locking plates, no observed differences were found factor to control and the most crucial to overall outcome
between implants regarding the rate of nonunion, infec- [37]. Malalignment in the axial and sagittal planes also
tion, fixation failure, or revision surgery [23]. Titanium affects knee kinematics and range of motion [14]. When
has been noted to have superior biocompatibility with comminution is present, supracondylar femoral fractures
an elasticity modulus more similar to bone than stain- are especially prone to varus collapse [38]. The current
less steel [29]. Therefore, increased stiffness of stainless study supports the reduced rate of fixation loss due to the
steel implants was related to higher nonunion rates [8]. utilization of locked plating and shows that additional lag
Yet, this was based on unpublished data. Additionally, screws do not influence varus collapse. Patients with
no significant difference for closed fractures was found. greater loss of fixation tend to have a worse outcome.
The significance was based on open fractures. On the We found more than 40% open fractures in our study
contrary, biomechanical testing demonstrated only a population. Previous studies stated that open fractures
significantly greater stiffness for torsion in stainless steel are common in the setting of distal femur fractures
plates (LISS) [29]. A different study by Henderson found (19%–54%) [17]. Open fractures were related to high-
no significant difference between non-union rates for energy injury mechanism and a greater prevalence of
stainless steel or titanium (p = 0.71) [18]. The current infection. Therefore, the outcome of distal femoral frac-
study did not discover any difference for nonunion rates tures, similar to other major injuries, not only depends
or hardware failure between titanium and stainless steel. on bony reconstruction but also on soft tissue manage-
Conclusions are not definitive due to insufficient sample ment. Henderson states, ‘The diversity of injury patterns
size. A power analysis considering significance of 0.05 and bone quality and the complex mechanical and bio-
and power of 0.80 requires a sample of 642 fractures logical interplay in each individual case make it difficult
equally distributed between hardware metal based on to separately assess and study potentially important vari-
Henderson's data. ables’ [17]. The importance of soft tissue preservation
Axial stiffness and torsional rigidity of internal fixation for fracture healing has been previously described. We
is mainly influenced by working length [30]. There is a confirmed that submuscular plate insertion reduces non-
fine line between flexible fixation, which enhances callus union formation significantly.
formation and improves the healing process, and an un- Outcome has been previously defined by reduction
stable fixation, which leads to nonunion and/or implant quality, range of motion, and pain [9,11,12]. Historically,
failure [30]. Short-spanning segments concentrate the different classification systems have been utilized. Fol-
stress moment and may lead to failure of the construct lowing these, we found 92.8% good flexion according to
[31]. Henderson found no empty holes next to the frac- Cain [9] and 75.7% of the patients had acceptable flexion
ture in 71% of the nonunions [18]. Bottlang reported a following the criteria of Kristensen [11]. Utilizing the
19% nonunion rate in a cohort of 72 patients but found more strict criteria of Pritchett [12], only 45.9% excellent
no significant difference in bridging span in those that or good results were achieved. Multiple factors are re-
healed compared with those that did not heal [32]. The lated to patient outcome. We showed that outcome was
current recommendation for adequate bridge plate fix- associated with obesity and periprosthetic fractures. From
ation is three or four empty holes at the level of the frac- a surgical and a mechanical standpoint, submuscular pro-
ture [33]. We found a shorter working length in patients cedures influence nonunion rate but not the final out-
with nonunions. Additional lag screws did not influence come. Additionally, patients with varus malalignment did
the nonunion rate and did not reduce loss of fixation. not have a different outcome, but greater loss of fixation
The recommended screw ratio is 0.4 to 0.5 for bridg- was related to worse outcome.
ing fixation with three to four screws on either side of The limitations of the study are related to the retro-
the fracture gap [24,30,34]. Ricci recommended at least spective design. Almost 16.5% of the initial patient co-
five screws proximally but required an adequate plate hort was excluded due to operative fixation techniques
length to maintain screw density below 60% [35]. In our other than locked plating which may have created a se-
study, these recommendations were followed. More than lection bias. Furthermore, the majority of fractures in
82% had three to five proximal screws and only 52% of this study were treated utilizing stainless steel plates. No
the proximal holes were filled. This may be the reason comparison between the Pritchett functional outcome and
why we did not see differences in these parameters for subjective outcome scores were performed. The strength
nonunion or hardware failure. of this study is the large number of patients from two
Distal femoral alignment is one of the treatment prior- Level 1 trauma centers treated similarly by fellowship-
ities. The femoral shaft is oriented 7° of valgus in relation trained orthopedic trauma surgeons. In addition, the ma-
to the knee joint [36]. Maintaining this alignment is critical jority of fractures were treated with similar plate lengths,
to the function and durability of the limb [14]. Coronal screw concentration, and working lengths.
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Conclusion 10. Bolhofner BR, Carmen B, Clifford P: The results of open reduction and
Despite modern fixation techniques of locked periarticu- internal fixation of distal femur fractures using a biologic (indirect)
reduction technique. J Orthop Trauma 1996, 10:372–377.
lar plating, distal femoral fractures often still result in 11. Kristensen O, Nafei A, Kjaersgaard-Andersen P, Hvid I, Jensen J: Long-term
persistent disability and poor clinical outcome. Soft tis- results of total condylar knee arthroplasty in rheumatoid arthritis. J Bone
sue management seems to be important. Submuscular Joint Surg Br 1992, 74:803–806.
12. Pritchett JW: Supracondylar fractures of the femur. Clin Orthop Relat Res
plate insertion reduces the nonunion rate. Preexisting 1984, 184:173–177.
total knee arthroplasty increases the risk of hardware 13. Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, Prokuski
failure. Further studies determining factors that improve L, Sirkin MS, Ziran B, Henley B, Audige L: Fracture and dislocation
classification compendium - 2007: Orthopaedic Trauma Association clas-
outcome are warranted. sification, database and outcomes committee. J Orthop Trauma 2007,
21:S1–S133.
Competing interests
14. Gwathmey FW Jr, Jones-Quaidoo SM, Kahler D, Hurwitz S, Cui Q: Distal fem-
The authors declare that they have no competing interests.
oral fractures: current concepts. J Am Acad Orthop Surg 2010, 18:597–607.
15. Nasr AM, Mc Leod I, Sabboubeh A, Maffulli N: Conservative or surgical
Authors’ contributions
management of distal femoral fractures. A retrospective study with a
MFH performed the data collection for the first study site, participated in its
minimum five year follow-up. Acta Orthop Belg 2000, 66:477–483.
design, carried out the literature search, performed the data interpretation,
16. Herrera DA, Kregor PJ, Cole PA, Levy BA, Jonsson A, Zlowodzki M:
and drafted the manuscript. DLS performed the statistical analysis and was
Treatment of acute distal femur fractures above a total knee
involved in revising the manuscript. SJK carried out the data collection for
arthroplasty: systematic review of 415 cases (1981–2006). Acta Orthop
the second study site. CBJ and PT3 initiated the study, were involved in
2008, 79:22–27.
revising it critically for important intellectual content, and have given final
17. Henderson CE, Kuhl LL, Fitzpatrick DC, Marsh JL: Locking plates for distal
approval of the version to be published. All authors read and approved the
femur fractures: is there a problem with fracture healing? J Orthop
final manuscript.
Trauma 2011, 25(Suppl 1):S8–S14.
18. Henderson CE, Lujan TJ, Kuhl LL, Bottlang M, Fitzpatrick DC, Marsh JL: Mid-
Acknowledgements
America Orthopaedic Association Physician in Training Award: healing
We thank Benjamin T. Maatman for his help in reviewing charts and
complications are common after locked plating for distal femur
collecting data. The authors did not receive grants or outside funding in
fractures. Clin Orthop Relat Res 2010, 2011(469):1757–1765.
support of their research or preparation of the manuscript. No funding was
received for this work from any of the following organizations: National 19. Markmiller M, Konrad G, Sudkamp N: Femur-LISS and distal femoral nail
Institutes of Health (NIH), Wellcome Trust, and the Howard Hughes Medical for fixation of distal femoral fractures: are there differences in outcome
Institute (HHMI). The paper was presented as Paper #78 at the OTA Annual and complications? Clin Orthop Relat Res 2004, 426:252–257.
Meeting Oct. 12–15, 2011 in San Antonio, TX. 20. Rorabeck CH, Taylor JW: Classification of periprosthetic fractures
complicating total knee arthroplasty. Orthop Clin North Am 1999, 30:209–214.
Author details 21. Corrales LA, Morshed S, Bhandari M, Miclau T 3rd, Morshed S, Corrales L,
1
Grand Rapids Medical Education Partners, 1000 Monroe Ave NW, Grand Genant H, Miclau T 3rd: Variability in the assessment of fracture-healing
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Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany. 3Michigan State 22. Phieffer LS, Goulet JA: Delayed unions of the tibia. J Bone Joint Surg Am
University/Orthopaedic Associates of Michigan, 230 Michigan St. NE, Grand 2006, 88:206–216.
Rapids MI 49503, USA. 4Boston Medical Center, 88 East Newton Street, 23. Henderson CE, Lujan T, Bottlang M, Fitzpatrick DC, Madey SM, Marsh JL:
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doi:10.1186/1749-799X-8-43
Cite this article as: Hoffmann et al.: Clinical outcomes of locked plating
of distal femoral fractures in a retrospective cohort. Journal of
Orthopaedic Surgery and Research 2013 8:43.

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