Geriatric Distal Femur Fracture Management Protocols: A Review and Evidence-based Template

Authors

  • Anthony Gavalas Texas Tech University Health Science Center, El Paso, TX https://orcid.org/0000-0002-1351-5842
  • Cody Perry Texas Tech University Health Science Center, Lubbock, TX https://orcid.org/0000-0002-7064-9783
  • Mikel Tihista Texas Tech University Health Science Center, El Paso, TX
  • Adam Adler Texas Tech University Health Science Center, El Paso, TX
  • Richard Purcell Texas Tech University Health Science Center, El Paso, TX
  • Michael Polmear Texas Tech University Health Science Center, El Paso, TX https://orcid.org/0000-0002-6986-8436

DOI:

https://doi.org/10.55576/job.v2i4.25

Keywords:

Code Femur, Geriatrics, pos-operative mortality, co-morbidity, distal femur fracture

Abstract

Objectives: Provide a framework for the development of a “Code Femur” protocol for geriatric distal femur fractures.

Design: Literature Review and Evidence Based Note Templates

Intervention: Distal Femur Fracture Fixation and Medical Management

Main Outcome Measurement: Post operative Mortality

Results: Geriatric distal femur fractures are rising in number among osteoporotic fractures in the growing elderly population. Current hip fracture literature recommends fixation of proximal femur fractures in 24-48 hours to reduce mortality and the literature surrounding distal femur fractures in this population in trending in this direction as well. The goals of distal femur fracture surgery are early mobilization and fracture stabilization in addition to managing the multiple medical co-morbidities that these patients may have. This review discusses the treatment options available for geriatric distal femur fractures that allow for early mobilization and examines the benefits of early operative care.

Conclusion: Geriatric Distal Femur Fractures present similar challenges to management as the geriatric hip fracture and a proper understanding of medical co-management and early appropriate surgery through the development of a distal femur fracture program similar to hip benefits warrants consideration.

Level of Evidence: Level IV, Systematic Review

Keywords: Code Femur, Geriatric, Distal Femur Fracture, Post-operative Mortality, Co-Morbidity

References

Zlowodzki M, Bhandari M, Marek DJ, Cole PA, Kregor PJ. Operative treatment of acute distal femur fractures: systematic review of 2 comparative studies and 45 case series (1989 to 2005). J Orthop Trauma. May 2006;20(5):366-71. doi:10.1097/00005131-200605000-00013

Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. Aug 2006;37(8):691-7. doi:10.1016/j.injury.2006.04.130

Martinet O, Cordey J, Harder Y, Maier A, Buhler M, Barraud GE. The epidemiology of fractures of the distal femur. Injury. Sep 2000;31 Suppl 3:C62-3. doi:10.1016/s0020-1383(00)80034-0

Kammerlander C, Gosch M, Kammerlander-Knauer U, Luger TJ, Blauth M, Roth T. Long-term functional outcome in geriatric hip fracture patients. Arch Orthop Trauma Surg. Oct 2011;131(10):1435-44. doi:10.1007/s00402-011-1313-6

Kammerlander C, Riedmüller P, Gosch M, et al. Functional outcome and mortality in geriatric distal femoral fractures. Injury. Jul 2012;43(7):1096-101. doi:10.1016/j.injury.2012.02.014

Canton G, Giraldi G, Dussi M, Ratti C, Murena L. Osteoporotic distal femur fractures in the elderly: peculiarities and treatment strategies. Acta Biomed. Dec 5 2019;90(12-s):25-32. doi:10.23750/abm.v90i12-S.8958

Streubel PN, Ricci WM, Wong A, Gardner MJ. Mortality after distal femur fractures in elderly patients. Clin Orthop Relat Res. Apr 2011;469(4):1188-96. doi:10.1007/s11999-010-1530-2

Gwathmey FW, Jr., Jones-Quaidoo SM, Kahler D, Hurwitz S, Cui Q. Distal femoral fractures: current concepts. J Am Acad Orthop Surg. Oct 2010;18(10):597-607. doi:10.5435/00124635-201010000-00003

Cass J, Sems SA. Operative versus nonoperative management of distal femur fracture in myelopathic, nonambulatory patients. Orthopedics. Nov 2008;31(11):1091.

Seifert J, Stengel D, Matthes G, Hinz P, Ekkernkamp A, Ostermann PA. Retrograde fixation of distal femoral fractures: results using a new nail system. J Orthop Trauma. Aug 2003;17(7):488-95. doi:10.1097/00005131-200308000-00003

Papadokostakis G, Papakostidis C, Dimitriou R, Giannoudis PV. The role and efficacy of retrograding nailing for the treatment of diaphyseal and distal femoral fractures: a systematic review of the literature. Injury. Jul 2005;36(7):813-22. doi:10.1016/j.injury.2004.11.029

Investigators HA. Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial. Lancet. Feb 29 2020;395(10225):698-708. doi:10.1016/S0140-6736(20)30058-1

Perry C, Rossettie, S, Hayward, D, Folsom, A, Jacobson, A, Adler, A, Polmear, M Medical Management of Common Comorbidities in Elderly Patients with Proximal Femur Fractures. Journal of Orthopedic Business. 2022;2(2):19-36. doi:https://doi.org/10.55576/job.v2i2.17

Link BC, Babst R. Current concepts in fractures of the distal femur. Acta Chir Orthop Traumatol Cech. 2012;79(1):11-20.

Stover M. Distal femoral fractures: current treatment, results and problems. Injury. Dec 2001;32 Suppl 3:SC3-13. doi:10.1016/s0020-1383(01)00179-6

Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and Dislocation Classification Compendium-2018. J Orthop Trauma. Jan 2018;32 Suppl 1:S1-S170. doi:10.1097/BOT.0000000000001063

Dugan TR, Hubert MG, Siska PA, Pape HC, Tarkin IS. Open supracondylar femur fractures with bone loss in the polytraumatized patient - Timing is everything! Injury. Dec 2013;44(12):1826-31. doi:10.1016/j.injury.2013.03.018

Gangavalli AK, Nwachuku CO. Management of Distal Femur Fractures in Adults: An Overview of Options. Orthop Clin North Am. Jan 2016;47(1):85-96. doi:10.1016/j.ocl.2015.08.011

Boyce RH, Singh K, Obremskey WT. Acute Management of Traumatic Knee Dislocations for the Generalist. J Am Acad Orthop Surg. Dec 2015;23(12):761-8. doi:10.5435/JAAOS-D-14-00349

Nork SE, Segina DN, Aflatoon K, et al. The association between supracondylar-intercondylar distal femoral fractures and coronal plane fractures. J Bone Joint Surg Am. Mar 2005;87(3):564-9. doi:10.2106/JBJS.D.01751

Richards JA, Berkay FB, Davis CM, Zamora RA. Intra-articular Fracture Pattern in Intercondylar Distal Femur Fractures: An Analysis of Frequency and Major Fracture Fragments. Injury. Apr 2021;52(4):967-970. doi:10.1016/j.injury.2020.11.061

Khan TH, Farooqui FA, Niazi K. Critical review of the ankle brachial index. Curr Cardiol Rev. May 2008;4(2):101-6. doi:10.2174/157340308784245810

Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma. Jun 2004;56(6):1261-5. doi:10.1097/01.ta.0000068995.63201.0b

Kanis JA, Oden A, Johnell O, Jonsson B, de Laet C, Dawson A. The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporos Int. 2001;12(5):417-27. doi:10.1007/s001980170112

Hernlund E, Svedbom A, Ivergard M, et al. Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos. 2013;8:136. doi:10.1007/s11657-013-0136-1

Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA. Oct 14 2009;302(14):1573-9. doi:10.1001/jama.2009.1462

Nellans KW, Kowalski E, Chung KC. The epidemiology of distal radius fractures. Hand Clin. May 2012;28(2):113-25. doi:10.1016/j.hcl.2012.02.001

Schousboe JT. Epidemiology of Vertebral Fractures. J Clin Densitom. Jan-Mar 2016;19(1):8-22. doi:10.1016/j.jocd.2015.08.004

Elsoe R, Larsen P, Nielsen NP, Swenne J, Rasmussen S, Ostgaard SE. Population-Based Epidemiology of Tibial Plateau Fractures. Orthopedics. Sep 2015;38(9):e780-6. doi:10.3928/01477447-20150902-55

Elsoe R, Ceccotti AA, Larsen P. Population-based epidemiology and incidence of distal femur fractures. Int Orthop. Jan 2018;42(1):191-196. doi:10.1007/s00264-017-3665-1

Hake ME, Davis ME, Perdue AM, Goulet JA. Modern Implant Options for the Treatment of Distal Femur Fractures. J Am Acad Orthop Surg. Oct 1 2019;27(19):e867-e875. doi:10.5435/JAAOS-D-17-00706

Wahnert D, Hoffmeier K, Frober R, Hofmann GO, Muckley T. Distal femur fractures of the elderly--different treatment options in a biomechanical comparison. Injury. Jul 2011;42(7):655-9. doi:10.1016/j.injury.2010.09.009

von Keudell A, Shoji K, Nasr M, Lucas R, Dolan R, Weaver MJ. Treatment Options for Distal Femur Fractures. J Orthop Trauma. Aug 2016;30 Suppl 2:S25-7. doi:10.1097/BOT.0000000000000621

Merino-Rueda LR, Rubio-Saez I, Mills S, Rubio-Suarez JC. Mortality after distal femur fractures in the elderly. Injury. Jul 2021;52 Suppl 4:S71-S75. doi:10.1016/j.injury.2021.03.066

Neer CS, 2nd, Grantham SA, Shelton ML. Supracondylar fracture of the adult femur. A study of one hundred and ten cases. J Bone Joint Surg Am. Jun 1967;49(4):591-613.

Jennison T, Divekar M. Geriatric distal femoral fractures: A retrospective study of 30 day mortality. Injury. Feb 2019;50(2):444-447. doi:10.1016/j.injury.2018.10.035

Myers P, Laboe P, Johnson KJ, et al. Patient Mortality in Geriatric Distal Femur Fractures. J Orthop Trauma. Mar 2018;32(3):111-115. doi:10.1097/BOT.0000000000001078

Langford J, Burgess A. Nailing of proximal and distal fractures of the femur: limitations and techniques. J Orthop Trauma. May-Jun 2009;23(5 Suppl):S22-5. doi:10.1097/BOT.0b013e31819f2797

Shah JK, Szukics P, Gianakos AL, Liporace FA, Yoon RS. Equivalent union rates between intramedullary nail and locked plate fixation for distal femur periprosthetic fractures - a systematic review. Injury. Apr 2020;51(4):1062-1068. doi:10.1016/j.injury.2020.02.043

Koso RE, Terhoeve C, Steen RG, Zura R. Healing, nonunion, and re-operation after internal fixation of diaphyseal and distal femoral fractures: a systematic review and meta-analysis. Int Orthop. Nov 2018;42(11):2675-2683. doi:10.1007/s00264-018-3864-4

Nino S, Parry JA, Avilucea FR, Haidukewych GJ, Langford JR. Retrograde intramedullary nailing of comminuted intra-articular distal femur fractures results in high union rate. Eur J Orthop Surg Traumatol. Oct 8 2021;doi:10.1007/s00590-021-03140-8

Pekmezci M, McDonald E, Buckley J, Kandemir U. Retrograde intramedullary nails with distal screws locked to the nail have higher fatigue strength than locking plates in the treatment of supracondylar femoral fractures: A cadaver-based laboratory investigation. Bone Joint J. Jan 2014;96-B(1):114-21. doi:10.1302/0301-620X.96B1.31135

Schutz M, Muller M, Krettek C, et al. Minimally invasive fracture stabilization of distal femoral fractures with the LISS: a prospective multicenter study. Results of a clinical study with special emphasis on difficult cases. Injury. Dec 2001;32 Suppl 3:SC48-54. doi:10.1016/s0020-1383(01)00183-8

Krettek C, Muller M, Miclau T. Evolution of minimally invasive plate osteosynthesis (MIPO) in the femur. Injury. Dec 2001;32 Suppl 3:SC14-23. doi:10.1016/s0020-1383(01)00180-2

Ricci WM, Streubel PN, Morshed S, Collinge CA, Nork SE, Gardner MJ. Risk factors for failure of locked plate fixation of distal femur fractures: an analysis of 335 cases. J Orthop Trauma. Feb 2014;28(2):83-9. doi:10.1097/BOT.0b013e31829e6dd0

Bliemel C, Buecking B, Mueller T, et al. Distal femoral fractures in the elderly: biomechanical analysis of a polyaxial angle-stable locking plate versus a retrograde intramedullary nail in a human cadaveric bone model. Arch Orthop Trauma Surg. Jan 2015;135(1):49-58. doi:10.1007/s00402-014-2111-8

Bologna MG, Claudio MG, Shields KJ, Katz C, Salopek T, Westrick ER. Dual plate fixation results in improved union rates in comminuted distal femur fractures compared to single plate fixation. J Orthop. Mar-Apr 2020;18:76-79. doi:10.1016/j.jor.2019.09.022

Rodriguez EK, Zurakowski D, Herder L, et al. Mechanical Construct Characteristics Predisposing to Non-union After Locked Lateral Plating of Distal Femur Fractures. J Orthop Trauma. Aug 2016;30(8):403-8. doi:10.1097/BOT.0000000000000593

Medda S, Kessler RB, Halvorson JJ, Pilson HT, Babcock S, Carroll EA. Technical Trick: Dual Plate Fixation of Periprosthetic Distal Femur Fractures. J Orthop Trauma. Apr 1 2021;35(4):e148-e152. doi:10.1097/BOT.0000000000001869

Liporace FA, Yoon RS. Nail Plate Combination Technique for Native and Periprosthetic Distal Femur Fractures. J Orthop Trauma. Feb 2019;33(2):e64-e68. doi:10.1097/BOT.0000000000001332

Passias BJ, Emmer TC, Sullivan BD, et al. Treatment of Distal Femur Fractures with a Combined Nail-Plate Construct: Techniques and Outcomes. J Long Term Eff Med Implants. 2021;31(3):15-26. doi:10.1615/JLongTermEffMedImplants.2021038016

Park KH, Oh CW, Park IH, Kim JW, Lee JH, Kim HJ. Additional fixation of medial plate over the unstable lateral locked plating of distal femur fractures: A biomechanical study. Injury. Oct 2019;50(10):1593-1598. doi:10.1016/j.injury.2019.06.032

Liporace FA, Aneja A, Carroll EA, Yoon RS. Maintaining the Neutral Axis in the Treatment of Distal Femur Fractures Via Dual Plate or Nail Plate Combination Technique: When and How? J Orthop Trauma. Oct 1 2021;35(Suppl 5):S38-S40. doi:10.1097/BOT.0000000000002235

Wyles CC, Tibbo ME, Yuan BJ, Trousdale RT, Berry DJ, Abdel MP. Long-Term Results of Total Knee Arthroplasty with Contemporary Distal Femoral Replacement. J Bone Joint Surg Am. Jan 2 2020;102(1):45-51. doi:10.2106/JBJS.19.00489

Chen F, Li R, Lall A, Schwechter EM. Primary Total Knee Arthroplasty for Distal Femur Fractures: A Systematic Review of Indications, Implants, Techniques, and Results. Am J Orthop (Belle Mead NJ). May/Jun 2017;46(3):E163-e171.

Hart GP, Kneisl JS, Springer BD, Patt JC, Karunakar MA. Open Reduction vs Distal Femoral Replacement Arthroplasty for Comminuted Distal Femur Fractures in the Patients 70 Years and Older. J Arthroplasty. Jan 2017;32(1):202-206. doi:10.1016/j.arth.2016.06.006

Salazar BP, Babian AR, DeBaun MR, et al. Distal Femur Replacement Versus Surgical Fixation for the Treatment of Geriatric Distal Femur Fractures: A Systematic Review. J Orthop Trauma. Jan 1 2021;35(1):2-9. doi:10.1097/BOT.0000000000001867

Wadhwa H, Salazar BP, Goodnough LH, et al. Distal Femur Replacement Versus Open Reduction and Internal Fixation for Treatment of Periprosthetic Distal Femur Fractures: A Systematic Review and Meta-Analysis. J Orthop Trauma. Jan 1 2022;36(1):1-6. doi:10.1097/BOT.0000000000002141

Rubinger L, Khalik HA, Gazendam A, et al. Very Distal Femoral Periprosthetic Fractures: Replacement Versus Fixation: A Systematic Review. J Orthop Trauma. Nov 1 2021;35(11):573-583. doi:10.1097/BOT.0000000000002080

Rosen AL, Strauss E. Primary total knee arthroplasty for complex distal femur fractures in elderly patients. Clin Orthop Relat Res. Aug 2004;(425):101-5. doi:10.1097/01.blo.0000132466.65220.62

Moloney GB, Pan T, Van Eck CF, Patel D, Tarkin I. Geriatric distal femur fracture: Are we underestimating the rate of local and systemic complications? Injury. Aug 2016;47(8):1732-6. doi:10.1016/j.injury.2016.05.024

von Rüden C, Augat P. Failure of fracture fixation in osteoporotic bone. Injury. Jun 2016;47 Suppl 2:S3-s10. doi:10.1016/s0020-1383(16)47002-6

Ebraheim NA, Liu J, Hashmi SZ, Sochacki KR, Moral MZ, Hirschfeld AG. High complication rate in locking plate fixation of lower periprosthetic distal femur fractures in patients with total knee arthroplasties. J Arthroplasty. May 2012;27(5):809-13. doi:10.1016/j.arth.2011.08.007

Consigliere P, Iliopoulos E, Ads T, Trompeter A. Early versus delayed weight bearing after surgical fixation of distal femur fractures: a non-randomized comparative study. Eur J Orthop Surg Traumatol. Dec 2019;29(8):1789-1794. doi:10.1007/s00590-019-02486-4

Smith WR, Stoneback JW, Morgan SJ, Stahel PF. Is immediate weight bearing safe for periprosthetic distal femur fractures treated by locked plating? A feasibility study in 52 consecutive patients. Patient Saf Surg. 2016;10:26. doi:10.1186/s13037-016-0114-9

Hussain MS, Dailey SK, Avilucea FR. Stable Fixation and Immediate Weight-Bearing After Combined Retrograde Intramedullary Nailing and Open Reduction Internal Fixation of Noncomminuted Distal Interprosthetic Femur Fractures. J Orthop Trauma. Jun 2018;32(6):e237-e240. doi:10.1097/bot.0000000000001154

Smith TO, Hedges C, MacNair R, Schankat K. Early rehabilitation following less invasive surgical stabilisation plate fixation for distal femoral fractures. Physiotherapy. Jun 2009;95(2):61-75. doi:10.1016/j.physio.2009.02.002

Vestergaard V, Pedersen AB, Tengberg PT, Troelsen A, Schrøder HM. 20-year trends of distal femoral, patellar, and proximal tibial fractures: a Danish nationwide cohort study of 60,823 patients. Acta Orthop. Feb 2020;91(1):109-114. doi:10.1080/17453674.2019.1698148

Delanois RE, Mistry JB, Gwam CU, Mohamed NS, Choksi US, Mont MA. Current Epidemiology of Revision Total Knee Arthroplasty in the United States. J Arthroplasty. Sep 2017;32(9):2663-2668. doi:10.1016/j.arth.2017.03.066

Singleton N, Sahakian V, Muir D. Outcome After Tibial Plateau Fracture: How Important Is Restoration of Articular Congruity? J Orthop Trauma. Mar 2017;31(3):158-163. doi:10.1097/bot.0000000000000762

Pua YH, Poon CL, Seah FJ, et al. Predicting individual knee range of motion, knee pain, and walking limitation outcomes following total knee arthroplasty. Acta Orthop. Apr 2019;90(2):179-186. doi:10.1080/17453674.2018.1560647

Jiwanlal A, Jeray KJ. Outcome of Posterior Tibial Plateau Fixation. J Knee Surg. Jan 2016;29(1):34-9. doi:10.1055/s-0035-1564729

Canton G, Tomic M, Giunta M, Maritan G, Murena L. Distal femur periprosthetic knee fractures in elderly patients: clinical and radiographic outcome after internal fixation. Acta Biomed. Jul 26 2021;92(S3):e2021028. doi:10.23750/abm.v92iS3.11770

Mamczak CN, Gardner MJ, Bolhofner B, Borrelli J, Jr., Streubel PN, Ricci WM. Interprosthetic femoral fractures. J Orthop Trauma. Dec 2010;24(12):740-4. doi:10.1097/BOT.0b013e3181d73508

Published

2022-10-01

How to Cite

Gavalas, A., Perry, C. ., Tihista, M., Adler, A., Purcell, R., & Polmear, M. (2022). Geriatric Distal Femur Fracture Management Protocols: A Review and Evidence-based Template. Journal of Orthopaedic Business, 2(4), 14–23. https://doi.org/10.55576/job.v2i4.25

Issue

Section

Evidence based note templates

Similar Articles

You may also start an advanced similarity search for this article.

Most read articles by the same author(s)

1 2 > >>