Evaluating a Nail-Plate Combination Implant in Treatment of Distal Femoral Fractures: A Case Series

Distal femur fractures are severe injuries that have varying management among orthopedic surgeons. These fractures are thought to be caused by high-energy trauma in younger patients and low-energy injuries in older patients. These fractures account for approximately 6 to 7% of all fractures and the gender distribution is estimated to be 33.4% male and 66.6% female. Additionally, there is increase in distal femoral fracture incidence after the age of 60 in both genders. Therefore, these fractures require optimal treatment to prevent disability and improve patient quality of life.

Current treatment for distal femur fractures can vary broadly but in this study, we focus on intramedullary nailing and plating. Intramedullary nailing has been championed as less invasive as it offers minimal disruption of soft tissues and endosteal arterial supply. Nailing of extremely distal periarticular fractures is becoming more common because of better load sharing and minimal soft tissue stripping compared to plating. In comparison, submuscular locking plates have become standard in these fractures and offer several advantages. These include more flexibility in periprosthetic fractures, preservation of blood supply to the periosteum, decreased time under anesthesia, and lower blood loss. The purpose of this case series is to qualitatively examine the outcomes of patients who received a nail-plate combination for their distal femoral fracture.

A chart review of 10 patients who received a nail and side plate combination at JPS Hospital was conducted. These patients underwent surgery from August 2021 to May 2022. They consisted of 4 males and 6 females with a mean age of 63 years (range of 36 to 89 years). For each patient, an outcome of union or nonunion was recorded along with time since surgery. The nailing system used was the Synthes Retrograde Femoral Nailing System.

When examining results, only 6 patients had follow up visits. 4 of the 6 patients achieved union at times of 3, 4, 6, and 8 months since date of surgery. Meanwhile, the remaining 2 patients had nonunion. One of these nonunion patients required hardware removal and has not achieved union at 5 months. The other nonunion patient has yet to achieve union at 7 months.

When compared to current literature, two studies have shown promising results with the nail-plate combination. The first had 8 patients with 100% union rate while the second had 15 patients with 93% union rate. The union rate in this study is relatively lower at 66%. However, this can be attributed to variables such as severity of initial injury, patient compliance, comorbidities affecting healing, and implant manufacturer. The rationale behind the combination technique is creating a stable and balanced fixation that allows for immediate weight bearing and mobilization post-surgery. While it shows promising results, more research in larger cohorts need to be done before the nail-plate combination can be evaluated against traditional methods.