Distal femur fractures are about 4-6% of all femoral fractures.1, 2These fractures are frequent in healthy, active elderly population accounting for more than 50% of these injuries.3, These fractures tend to show a bimodal distribution in age groups, with high-energy trauma causing fractures in the younger individuals and low-energy trauma causing fractures in the elderly age groups..1These low-energy injuries are becoming more common as the older population becomes healthier, more active, and lives longer.5The morbidity and mortality of these fractures are similar to hip injuries, which necessitates early operative intervention and mobilization.5, Distal femoral fractures can be treated in different ways such as conservative and operative treatments, using 95° angle blade plate internal fixation, C-C screws, dynamic condylar screw plate, condylar buttress plates, nails-plate construct, distal locking plate for femur or antegrade and retrograde intramedullary (IM) nailing7,8. As a rule of thumb, distal femur fractures with inadequate bony stock for a stable nail construct are being treated with plating constructs with partial or restricted weight bearing post-operatively9 Comminuted distal femur fractures pose a unique set of problems due to their participation in the knee joint, the largest joint in the human body meant to bear the weight of an individual. Non-union and varus collapse are common problems in distal femur fractures due to poor bone stock. These fractures also have an added problem of bone loss, wound contamination, adding to the morbidity of these injuries. This makes treating these fractures a formidable challenge to the orthopaedic surgeon. Although distal femoral locking plate system has revealed favorable results in intra-and extraarticular fractures of the distal femur especially in osteoporotic bones10,11 , complex comminuted distal femur fractures poses a challenge of sufficient contact between the main fracture fragments due to metaphyseal comminution. Therefore, the plating techniques have a restrictive prolonged period of non-weight bearing to prevent early construct failure and varus collapse, which would further increase the risk of non-union and patient morbidity. 12–14 To overcome these complications, primary bone grafting with fibular strut and cancellous grafts are advocated. However, this has it’s own set of complications like donor site morbidity, graft resorption, and higher rates of infection. 15–17 The advantages of femur nail system are indirect fracture reduction, in the IM load at 2 weeks postoperative with no-touch weight-bearing, and percutaneous placement, thus avoiding blood supply disruption at the fracture site. However, this becomes technically challenging in cases with articular comminution, severe metaphyseal comminution. Also maintaining limb length and alignment is difficult in severe comminuted fractures.18,19 Hence, the addition of both systems in combination (nail and plate) can minimize the problems inherent with these systems individually and provide added benefits of each system.20–24 In our study, all the cases were managed by nail-plate combination which had the added benefit of providing stable fixation in comminuted fractures as well. This combined approach provides soft tissue-friendly, stable fixation that allows for safe, rapid weight bearing in both native and periprosthetic distal femur fractures. The goals of our treatment are to achieve stable fixation, anatomic reduction, and restoration of limb alignment, length, and rotation, followed by providing early union and mobilization. The aim of our study is to assess the efficacy of nail plate combination (NPC) for distal femoral fractures in both young adults as well as elderly patients, to assess the functional outcome in terms of the patient’s range of motion of the knee and the union of fractures and to assess the radiological outcomes in these cases.

This study was conducted in patients aged >18 yrs with distal femoral fractures who came to DR.B.R.Ambedkar Medical College and Hospital Department of Orthopaedics from July 2023 to June 2025. With the due consent of the patient, Thirty patients were included in our study, with informed consent sought, of whom 18 were males and 12 were females. The patients were serially followed up at 6 weeks, 12 weeks, 6 months and 1 year. They were observed for a median duration of 12- to 24-months (mean follow-up time- 18 months). The Inclusion Criteria for our study were age of the patient being 18 years and more, all closed fractures and patients with extraarticular and Gustilo-Anderson type I and II open fractures. And patients with extraarticular and intra articular distal femur fractures with metaphyseal comminution with or without articular comminution. Pathological fractures of the distal femur, Gustilo Anderson type III open fractures, patients with associated vascular injury, associated ipsilateral proximal tibia fracture (Floating knee), patients not willing to give consent for surgery and patients who were medically unfit for surgery were excluded from our study. PRE-OPERATIVE PLANNING AND WORK UP: All patients underwent thorough assessment including a detailed history, physical examination, pre-anaesthesia workup, and patient workup. Radiographic evaluation included AP, lateral, and oblique radiographs of the knee with the thigh. In selected cases, where intra-articular extension of fracture was suspected, a computed tomography (CT) scan was also done to confirm the same and complete the radiographic assessment of the injury. Patients who had sustained high-energy trauma also underwent evaluation of the ipsilateral hip region, pelvis, and spine by clinical examination and screening radiographs of the lumbosacral spine and pelvis.10Attention was also given to look out for a possible Hoffa’s fragment (intra-articular fracture in the coronal plane of the condyle).11 SURGICAL TECHNIQUE: The patient was positioned supine on the radiolucent table and fluoroscopy was performed from the contralateral side of the table. A small pad was positioned under the ipsilateral buttock in order to medially rotate the patella. A radiolucent triangle would then have been placed under the injured distal thigh with knee flexion to about 30 degrees. The contralateral uninjured knee and femur radiographs were obtained as a reference for alignment and rotation. The apex posterior deformity was reduced by traction and the radiolucent triangle. Once the femur length. Alignment and rotation were restored, a single midline incision of 10 to 15cm curving laterally proximally (Fig.1) Lateral patellar arthrotomy was performed, extending the incision over the Iliotibial band. The vastus lateralis was then lifted off the intermuscular septum, to expose the underlying fracture site. Articular fragments were reduced and stabilized with the help of cannulated cancellous screws. After achieving reduction of the articular fragments, an entry into the distal femur was made, the entry being placed in line with the medullary canal of the femur at the intercondylar notch. A distal femur nail of appropriate size was inserted to ensure adequate working length. Once the nail is inserted, a plate that is typically longer than the nail in length is taken and fixed through lateral parapatellar arthrotomy and separate lateral incision proximally. We tried to insert at least one screw proximally and distally through the nail's empty locking holes during locking screw insertion of the plates, so that they function as a single unit. Fixation was completed with adequate number of screws in the plate. After fixation, a thorough wound wash was given. Wound closure was achieved in layers using vicryl and skin monofilament sutures. In 8 cases where the patient had a compound fracture, the wounds were secondarily closed after 3–5 days and vacuum-assisted closure was also performed to prevent infection. POST-OPERATIVE CARE: After surgery, strict limb elevation was given to reduce the limb edema. Intravenous antibiotics and subcutaneous enoxaparin were administered up to 5 days post-operatively. Check dressing was done after 48 h and isometric quadriceps exercise and ROM exercise was initiated from post-op day 1 as tolerated. Post procedure from 1st day non weight bearing mobilisation with walker was begun. Suture removal was performed at the first follow-up, which was between post-op days 12 and 14. Toe touch and walker-assisted partial weight-bearing were permitted after the first follow-up. Full weight bearing was postponed for roughly 12 to 16 weeks post-op, or until radiographical and clinical evidence of fracture healing was noted. They were followed-up at 4 weeks, 12 weeks, and then at 24 weeks, and then at 6m post-op and subsequently thereafter every six-months to evaluate them clinically and radiologically.

Out of the total sample of patients (n = 30), 12 were female and the rest (n=18) were male, with a mean age at recruitment in the study being 59.22 years (maximum age- 90 years and minimum age -30 years). The mechanism of injury was high-energy trauma in 20 patients and the other 10 patients had sustained the injury with low-energy trauma. Various data, such as valgus/varus tilt, anterior/posterior tilt, rotational mal-alignment, time of union, and implant loosening and failure, were recorded during the radiological evaluation on follow up. The average length of a union was 14.80 weeks, with 14 patients(46.67%) showing radiological union at 14 weeks and 10 patients (33.33%) showing union at 16 weeks postoperatively. In 23 cases, regular surgical wound healing was noted, while 7 cases showed postoperative infection at the wound site. These patients were treated with culture-specific antibiotics. Two of these patients who required treatment with wound debridement and antibiotics based on culture and sensitivity showed delayed union (radiological union time- 20 weeks). Even though no axial malalignment was found, four cases showed slight rotational malalignment (~5°). There were no implant failures in any of the cases. In our Nail Plate Combination (NPC) construct study functional assessment was determined by the Neer's scoring system. According to this scoring system, 17 patients demonstrated ‘excellent’ results (56.67%), 10 patients showed ‘good’ results (33.33%), 2 patients demonstrated ‘fair’ results (6.67%), and 1 patient met the criteria for ‘poor’ performance (3.33%) When using NPC, 6 patients (20%) of cases had knee flexion greater than 110 degrees, 20 patients (66.67%) had knee flexion between 91 and 109 degrees, and 4 patients (13.34%) less than 90 degrees at the end of six months. The mean grade of knee flexion was 114°. KNEE FLEXION 6 week 3months 6months >110 degree 0 4 6 90 – 110 degree 6 22 20 75 -90 degree 21 4 4 <75 degree 3 0 0 Time of radiological union (weeks) Number of patients Percentage 12 4 13.4% 14 14 46.67% 16 10 33.33% 20 2 6.67% Mode of Injury Number of patients, n Percentage 1. High Energy Trauma 20 66.67% Motor vehicle Accidents 16 Fall from height 4 2. Low Energy Trauma (slip and fall) 10 33.33% NEER’S SCORE Number of Patients Percentage EXCELLENT 17 56.66% GOOD 10 33.33% FAIR 2 6.66% POOR 1 3.33%

Comminuted distal femur fractures pose a significant challenge for stable fixation. Intramedullary nailing and extramedullary plating are common modes of treatment. The implant choice may depend on fracture pattern, patient-related and surgeon-related factors. However, single implant fixation has been widely reported to injury-related hardware failure, especially for comminated fractures 12–14,25,26 Intramedullary nailing of such fractures is associated with potential issues of: difficulty in achieving reduction of the comminuted articular fragments, inability to achieve sufficient fixation, with the possibility of iatrogenic comminution that may require plate augmentation.18 Reduced torsional stability in comparison to plating, difficulty in restoration of axial alignment and limb length are additional problems noted in some cases of extensively comminuted injuries.19,27 Pean et al. reported greater rates of thromboembolism and longer operating times in IM nailing patients when compared with the plate fixation group. While these are the problems encountered with nailing, the anatomic design of the LCP plates overcomes many of the problems of IM nailing. However, this robust treatment option does have its own pitfalls. Plate fixation on the lateral side in extensive metaphyseal comminution can lead to initial valgus malalignment during fixation. Later varus collapse as high as 42% is expected due to lack of medial cortical support. Hence fixation failure rates are high. Further, extensive periosteal stripping can lead to devascularisation of the fracture fragments and high rates of non union. Delayed weight bearing further adds to the patient’s morbidity.12–14,26,27 To overcome these problems, surgical techniques that focus on “double fixation constructs” have been developed. In our study, the combined usage of both distal femur nailing and lateral plating has been employed for distal femur fracture fixation. This combination provides an even more stable construction. According to Liporace et al, this nail-plate combination should lead to a more uniform energy distribution between the implant and bone. Furthermore, when the nail and plate are connected with locking screws, this will lead to a better stress distribution between them with an increased rigidity and enabling early mobilisation. 22 In the same way, Kontakis et al reported that NPC provided higher torsional stability and axial strength as well as reduced load to failure than isolated plate or nail. Biomechanical studies demonstrate that immediate post operative weight bearing is associated with increased risk of failure of the implant and malunion in isolated fixation, while NPC allows the same but with decreased likelihood of failure. There are 3 separate studies of NPC which have reported follow up union rates close to 100% 22–24 The biomechanical study by Basci et al20 in the nail plate construct, there was a higher resistance in both axial and torsional modes of load application as well as the maximum number of cycles to failure than in single implant fixation. In another study by Fontenot et al, the NP construct had 1.8 times as many cycles to failure than lateral plating. Several measurement scales have been used by different authors to evaluate functional outcome after surgical management of distal femur fractures. NEER30, HOSPITAL FOR SPECIAL SURGERY SCORE31,32, LYSHOLM GILLQUIST SCORING SYSTEM10, HAMMER SCORE33 are few of the rating scales which is being used frequently. In our study, we used Neer’s scores because it evaluates important outcome variables such as functions related to activities of daily living, pain assessment, return to work, gross anatomic alignment, mechanical alignment, and radiographic evaluation of union.30 The nail/plate construct for the management of distal femur fractures includes the placement of a distal femur nail (DFN) along with a distal lateral plate.33The insertion of the DFN provides an adequate spanning of the distal femur segment and also preliminary stability at the fracture site. 34,35The addition of the distal lateral plate provides added stability and by linking the two implants together, they function as a single unit allowing the weight-bearing forces to be transferred smoothly between the bone and implants. 36 It is believed that by linking the implants together, a more equal distribution of the load between the nail and plate can be achieved, avoiding premature construct failure to one of the devices.34Furthermore, they also tend to function as a single unit, thus providing a scaffold for good callus formation and bone growth. In our series, all distal femur fractures were stabilized with these linked nail- plate constructs using the “perfect circle” technique in which fluoroscope is use to link the two implants. This method afforded sufficient support at the fracture site with minimal risk of failure of the implant, facilitating early weight-bearing ambulation in these patients.

The nail-plate construct provides stable fixation of comminuted distal femur fractures with the advantage early weight-bearing and reduced varus collapse post-operatively. With goals of early mobilization to reduce subsequent complication risk, using the nail plate combination technique can offer stable, balanced fixation allowing for immediate weight bearing and early mobilization. In an elderly population this allows improved mobility post-operatively, which may result in reduced length of hospital stay, decreased morbidity and mortality rates at 1 year. Therefore, we believe that the combined nail plate construct is an effective and safe treatment option in comminuted distal femur fractures.

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