Outcome of retrograde intramedullary nailing and locking compression plating of distal femoral fractures in adults

Abstract Introduction In recent years, the treatment of distal femoral fractures has evolved although these fractures remain complex to treat and carry an inconsistent prognosis. Debate continues around choice of implant for fixation of metaphyseal–diaphyseal fractures. In this retrospective study, we evaluated and compared clinical and radiological outcomes of distal femur fracture stabilisation using retrograde nailing and locking compression plate constructs. Materials and Methods Between 2008 and 2013, 103 patients with distal femoral fracture who had been treated by retrograde intramedullary interlocking (IMIL) nailing (n = 57) and locking compression plating (LCP) (n = 46) were evaluated in this study at our centre. Results Clinical and radiographic evaluation demonstrated osseous healing within 6 months following retrograde nail and LCP plating in over 75% of patients. Average time of union in LCP group was 6.8 months and in retrograde nailing group was about 7.4 months. In the retrograde nail group, 5 out of 57 patients (9%) developed nonunion as no bony consolidation of the femoral fracture was observed 9 months after fixation. In the LCP group, nonunion was observed in 2 out of 46 patients (4%). Conclusion Outcome of retrograde intramedullary nailing and locking compression plating of distal femoral fractures in adults


Introduction
Distal femur fractures account for approximately 7% of fractures in the adults. They have bimodal age distribution; young patients as a result of high-energy injuries like road traffic accidents and elderly patients after simple falls [1] . Fractures in the elderly are often challenging due to osteoporotic bone and co-morbidities and long term disability can occur. Surgery is the standard mode of treatment and hence a quick surgical treatment for early weight bearing and mobilization is required in order to prevent long term complications due to prolonged bed rest [2] . Our study aims to compare the outcomes of DFLCP and retrograde nailing in the management of distal femur fractures. We also aim to compare the functional outcome in the groups using NEER et al. criteria.

Methodology
This study was performed at Hassan Institute of Medical Sciences, Hassan, Karnataka (India) from Jan 2017 to Dec 2019 for a period of 3 years. A total of 40 patients were included with predetermined inclusion and exclusion criteria in this study and were broadly divided into two groups, one treated with DFLCP and one treated with retrograde nailing. All patients were documented prospectively, complete demographic details and clinical history was obtained. Clinical and radiographic evaluation was done in all the patients. Informed consent was taken and all patients were treated with DFLCP and retrograde nailing randomly. Duration of hospitalization was documented and follow up was done for 2 years. Inclusion ccriteria were closed distal femur fractures A1, A2, A3, B3, C1, C2, C3 types of Orthopaedic Trauma Association (AO/OTA) classification, patients of age 18 yrs and above both males and females and patients with comorbid diseases like controlled diabetes mellitus, hypertension, asthma, epilepsy and other medical conditions with closed distal femoral fractures.
Exclusion criteria were Compound fractures of distal femur, Closed distal femur fractures B1, B2 types of Orthopaedic Trauma Association (AO/OTA) classification, Pathological fractures, Pregnancy, Peri-prosthetic fractures, Patients of age group < 18 years and Patients unfit for surgery. We defined fracture union as no abnormal mobility in frontal and coronal planes with no pain, without increase in temperature at the fracture site or discomfort on bearing weight and radiologically union was demonstrated by traberculae crossing at the fracture site with continuity of the cortex atleast in two veiws. Functional and radiological outcomes were assessed with NEER'S criteria. The final outcome was compared with the results available from the latest literature. All the results were analysed by SPSS software. Chi-square test, student test and Mann-Whitney u test were used for assessment of level of significance.        Excellent  9  45  8  40  Satisfactory  7  35  9  45  Unsatisfactory  3  15  2  10  Failure  1  05  1  05  Total  20  100

Discussion
In this study, mean fracture union time was 19…weeks and 14…weeks in DFLCP and nailing group respectively which is similar to Shyam et al.  [1] . Ramanand M et al.
showed that LCP plating proved to be the better choice than DFN for treating distil femur fracture with respect to surgical duration, mobilization, fracture union, weight bearing, range of motion and complications [9] . Kumar SK et al. concluded that distal femoral locking plate in the treatment of choice in the management of comminuted distal femoral fractures especially type A fractures where they had found higher Neer score [10] .
Our study showed no significant difference in the outcomes of two surgeries, although the fracture union time was faster in retrograde nailing. Similar results were proposed by Shyam et al. [1] .

Conclusion
We conclude that both DFLCP and retrograde nailing are equally effective surgical treatment options for distal femur fractures in adults and have comparable outcomes. However, fracture union time is comparatively faster in retrograde nailing than in DFLCP.