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Chinese Journal of Traumatology 18 (2015) 279e283

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Chinese Journal of Traumatology

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Original article

Contralateral reversed distal femoral locking plate for fixation ofsubtrochanteric femoral fractures

Paritosh Gogna, Reetadyuti Mukhopadhyay*, Amanpreet Singh, Ashish Devgan,Sahil Arora, Amit Batra, Sushil Kumar YadavDepartment of Orthopaedics and Rehabilitation, Pt BD Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India

a r t i c l e i n f o

Article history:Received 15 December 2014Received in revised form12 March 2015Accepted 24 March 2015Available online 14 November 2015

Keywords:Femoral fracturesBone platesFracture fixation

* Corresponding author. Tel.: þ91 9818875814.E-mail addresses: reetya_m@hotmail.com,

(R. Mukhopadhyay).Peer review under responsibility of Daping Hospi

of Surgery of the Third Military Medical University.

http://dx.doi.org/10.1016/j.cjtee.2015.11.0021008-1275/© 2015 The Authors. Production and hostUniversity. This is an open access article under the CC

a b s t r a c t

Purpose: Subtrochanteric fractures of the femur are being managed successfully with various intra-medullary and extramedulary implants with reasonable success. However, these implants require preciseplacement under image intensifier guidance, which exposes the surgeon to substantial amount of ra-diation. It also restricts the management of these fractures at peripheral centers where facility of imageintensifiers is not available. Keeping this in mind we designed this study to identify if contralateralreversed distal femoral locking plate can be used successfully without the use of image intensifier.Methods: Twenty-four consecutive patients (18 men and 6 women) with a mean age of 28 years (range19e47 years) suffering subtrochanteric fractures of the femur underwent open reduction and internalfixation with reversed contralateral distal femoral locking plate. The outcome was assessed at the meanfollow-up period of 3.2 years (range 2e4.6 years) using the Harris hip score.Results: Twenty-one fractures united with the primary procedure, with a mean time of consolidationbeing 11 weeks (range, 9e16 weeks). One patient developed superficial suture line infection, whichresolved with oral antibiotics. Another patient had a fall 3 weeks after surgery and broke the plate.Repeat surgery with reversed distal femoral locking compression plate was performed along with bonegrafting and the fracture united. Two cases had nonunion, which went in for union after bone grafting.The mean Harris hip score at the time of final follow-up was 90.63 (range 82e97).Conclusion: The reversed contralateral distal femoral plate is a biomechanically sound implant, whichwhen used for fixation of the subtrochanteric fractures with minimal soft tissue stripping shows resultscomparable to those achieved by using other extramedullary implants as well as intramedullary devices.The added advantage of this implant is its usability in the absence of an image intensifier.

© 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Daping Hospital and theResearch Institute of Surgery of the Third Military Medical University. This is an open access article under

the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

The Subtrochanteric region of the femur is a high stress zonemaking treatment of fractures in this area a challenging job.1 Highenergy trauma is the major culprit causing subtrochanteric frac-tures in young adults. The fixation demands an implant that pro-vides a suitable environment for fracture healing, in addition toproviding stability.2,3 The tug of war between intramedullary and

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extramedullary devices seem never ending. Although the intra-medullary fixation seems to be the current treatment of choice, it isnot without pitfalls.4 It does provide a good bending stiffness,however the torsional control that it provides is poor; thus not anideal implant for the spiral fractures that are often seen in thisregion.5 Patients with an intramedullary device also complain ofsignificant insertion site pain. They also have abductor weaknessand impingement to a certain extent.6 The endosteal blood supplyis also hampered to a great extent.7 The use of an intramedullarydevice is further challenged by a fracture extending to the inter-trochanteric region. In addition, intramedullary fixation is a moretasking surgery, demanding greater amount of skill as compared toextra-medullary stabilization.8

Various extramedullary devices have also been developed andused over time for fixing subtrochanteric fractures. The angled

aping Hospital and the Research Institute of Surgery of the Third Military Medicalcommons.org/licenses/by-nc-nd/4.0/).

Table 1Clinical details of patients.

Case Sex Age Classification Follow-up(year) Full weight bearing(week) Harris hip score Complication Secondary procedure

1 M 19 A1 2 12 912 M 33 B2 2.1 13 953 F 28 B3 2.2 11 894 M 45 C1 2.4 16 945 M 24 B2 2.4 91 Nonunion Grafting at 1 year6 M 25 A3 2.5 90 Nonunion Grafting at 1 year 3 months7 M 27 C1 2.6 12 868 F 35 B3 2.7 16 979 M 24 A1 2.7 12 9310 M 26 A3 2.8 15 9211 M 33 B3 3 14 9312 F 20 B1 3.2 9 9013 M 27 B2 3.2 95 Implant breakage Refixation along with grafting14 M 29 C1 3.4 10 94 Superficial infection15 M 26 B3 3.4 9 9716 F 19 B1 3.7 10 9017 M 20 B3 3.8 12 8318 F 21 A3 3.8 14 9219 M 27 B3 3.9 13 8920 M 27 C2 3.9 9 8221 M 42 A3 4 10 8422 F 24 B3 4.3 11 8623 M 47 A3 4.4 12 8824 M 23 C2 4.6 12 94 1 cm shorteningMean 28 12 90.625

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blade plate and the dynamic condylar screw being the ones thathave been most widely used in this area.3 These extramedullarydevices when used through a minimally invasive technique, put inthe submuscular zone; preserve both the periosteal and endostealblood supply in addition to providing stability and an environmentapt for fracture healing.9 We intend to present a reversed contra-lateral distal femoral locking compression plate (DFLCP) as anbiomechanically sound alternative extramedullary devise for

Fig. 1. (a) Preoperative radiographs of a 24 years old male with type A1 subtrochanteric fracfinal follow-up showing consolidation of the fracture.

fixation of subtrochanteric fractures in adults at centers where animage intensifier is not available at the facility.

2. Material and methods

We treated 24 consecutive patients (18men and 6women), withsubtrochanteric fractures of the femur at our center using reversedDFLCP. The mean age of the patients was 28 years (range 19e47

ture of the femur. (b) Postoperative radiographs of the same patient. (c) Radiographs at

P. Gogna et al. / Chinese Journal of Traumatology 18 (2015) 279e283 281

years) and the mean follow-up period was 3.2 years (range 2e4.6years, Table 1). Exclusion criteria were patients with open injuries,pathological fractures, ipsilateral distal femoral fractures, ipsilateralneck or inter-trochanteric fractures and associated pelvic injury. Allpatients were put on skeletal traction till surgery. The mean timebetween presentation and surgery was 1.2 days (range 0e3 days).According to AO classification, 6 fractures were type A (two A1, andfour A3), 12 were type B (two B1, three B2, and seven B3), and fivewere type C (three C1 and two C2). All fractures were open reduced,with care to minimally damage the soft tissue cover. Skin incisionwas made beginning at the greater trochanter and extending alongthe shaft. Fascia was incised along the skin incision. The fracturewas exposed and reduced under vision, and a plate of appropriatelength was placed with its proximal end at the trochanteric ridge.Post fixation alignment was acceptable as the cases were reducedunder direct vision taking care about the length and rotation. Wedid not denude the bone; only the fracture site was exposed toattain direct anatomical reduction. Being a locking plate, it did notrequire any periosteal stripping. For the purpose of fixation in theproximal femur, the target was to drive long screws up to thefemoral calcar in two rows of locking screws through the proximalexpanded part of the locking plate and 6e8 cortices purchased inthe distal fracture fragment. In 14 patients, in view of the spiralconfiguration of the fracture, it was fixed with inter-fragmentaryscrews and neutralized with a plate. After fixation, we moved the

Fig. 2. (a) Preoperative radiographs of a 27 years old male with type C1 subtrochanteric frDFLCP was applied as a neutralization plate.

hip joint through the complete range of motion and checked thestability. All wounds were closed over drain, which was removed24 h after surgery. Physiotherapy in the form of static quadricepsexercises, ankle pump and active toe movements were encouragedimmediately after operation. Supervised physiotherapy in the formof knee bending and nonweight-bearing walking was initiated assoon as the pain subsided, usually on the third postoperative day.Patients were reviewed at 2 weeks for suture removal, thereafterfortnightly for 2 months, and then at monthly interval for 6 monthsfor clinic-radiological evaluation and complications if any; there-after, clinical assessment was made at 6 monthly intervals. Func-tional outcome was assessed using the Harris hip score. Union wasdefined as bridging of three of the four cortices and disappearanceof fracture line on the plain radiographs for a patient who was ableto bear full weight. Nonunionwas defined as a fracture that did notheal within 9 months.

3. Results

We were able to attain a union rate of 87.5% with the primaryprocedure (Figs. 1e3), with a mean time to full weight bearingbeing 12 weeks (range 9e16 weeks). The average operative timewas 45 min with just one incidence of postoperative infection.There was a single case of limb length discrepancy of 1 cm, whichwas well compensated by the patient. One patient had superficial

acture of the femur. (b) Fracture was reduced and fixed using Lag screws, and reverse

Fig. 3. (a) Preoperative radiographs of a 26 years old male with type A3 subtrochanteric fracture of the femur. (b) Postoperative radiographs of the same patient showing optimalreduction using reverse DFLCP. (c) Radiographs at final follow-up.

P. Gogna et al. / Chinese Journal of Traumatology 18 (2015) 279e283282

suture line infection, which resolved with a ten-day course of anoral antibiotic. We did not observe any implant back out thoughone patient presented with a broken plate due to domestic fallthree weeks after surgery. Repeat surgery with reversed DFLCP wasperformed along with bone grafting and the fracture united. In therest of the 2 cases, bone grafting of the fracture site was performedwith cortico-cancellous graft harvested from ipsilateral iliac crest at1 year and 1 year 3 months respectively, which resulted in union.The functional outcome of the patients was evaluated as per Harriship score. The mean Harris hip score at one-year follow-up was90.63 (range 82e97).

4. Discussion

The DFLCP has long been used in distal fractures of the femurwith good long-term results.10 It is a biomechanically soundimplant to be used in the subtrochanteric region as well. The shapeof a reversed contralateral distal femoral plate fits well with thecontour of the greater trochanter and the shaft of the plate fits wellwith the anterolateral curve of the femur. The use of locking screwsfurther leaves a gap between the bone and the implant thus pre-serving the periosteal bold supply of the bone.3 The placement ofthe proximal end of the plate at the trochanteric ridge ensures atleast one row of screws in the femoral calcar. Also, it was observedeven if the most proximal screw went into the neck. It, being of alocking nature ensured sufficient hold. We achieved a union rate of87.5% in our study group further confirming the bio-mechanicallysound principle of this technique. Our union rate was comparableto that achieved by Siebenrock et al.11

Pakuts12 compared intramedullary devices with extramedullaryimplants for fixation of unstable intertrochanteric fractures. Heobserved that the mean time to union was 10 weeks when he usedan intramedullary device (Gamma nail) as against 15 weeks in thegroup of patients treated with dynamic condylar screw. Theyconcluded that extramedulary devices result in early ambulation;however wewere able to achieve union in a mean time period of 11

weeks, which is comparable to the Gamma Nail group in their se-ries. Use of locking plate as an internal fixator reduces the platecontact area thus preserving the vascularity and enhances healing;the chances of osteoporosis at the plate bone interface is alsoreduced.13 Thus, using an extra-medullary implant with minimalsoft tissue stripping we can achieve a quick callus formation andgood union rate thus allowing our patients an early rehabilitationand weight bearing comparable to that by an intramedullaryfixation.14

Of the various extramedullary devices available for fixation of afracture in this region, the angled blade plate and the dynamiccondylar screw are the ones most widely used.3 Although theangled blade achieves good results particularly in comminutedfractures, its use is technically demanding requiring a tri-planarorientation.15 The use of the dynamic condylar screw also re-quires significant level of skill and an image intensifier.7

Rohilla et al16 using a mini incision technique of dynamiccondylar screw fixation achieved results comparable to ours. Theyshowed union at a mean interval of 16 weeks post surgery with fullweight bearing at a mean of 11 weeks post surgery. AlthoughRantanen et al17 reported higher complication rates with the use ofintra-medullary devices and higher rates of refracture and fixationfailure put against extramedullary devices, intramedullary devicesseem to be the implant of choice at most centers for sub-trochanteric fracture fixation today, with reports suggesting betterpostoperative restoration of walking ability. The recovery afterintramedullary nailing may be faster and better with less compli-cation because of its biomechanical benefit with central buttressand a shortened lever arm.18

The use of the reversed contralateral distal femoral plate ishowever a good option by surgeons working at centers withoutaccess to an image intensifier; with results comparable to thatachieved by other modes of fixation, be it intramedullary orextramedullary. Ouyang et al19 using the reverse less invasive sta-bilization system plates showed complete union in all his 26 elderlypatients with subtrochanteric femur fractures. He also observed

P. Gogna et al. / Chinese Journal of Traumatology 18 (2015) 279e283 283

that his results were comparable to those attained by intra-medullary fixation. Gogna et al20 have used proximal humeruslocking plate for fixation of paediatric subtrochanteric fractures andattained a 100% union rate at a mean of 8.75 weeks (range 6e14weeks) thus, supporting the fact that locking periarticular platesare a viable option for fixation of subtrochanteric fractures.

Using this method, one needs to reduce the fracture undervision, ensuring that the distal expanded part of the plate falls justshort of the trochanteric tip, as the target is no longer to insert a hipscrew, visualization with an image intensifier in not required. Thereason why we chose DFLCP rather than any other plates in ourseries is that it is readily available and familiar, provides multipleoptions for screw fixation in the proximal part of the fracture, itadheres closely to the anatomy of the proximal femur and theimplant is cheaper compared with the LISS. With contralateralreversed DFLCP, the surgeon is able to insert at least two rows oflong screws up to the femoral calcar providing enough stability. Theinitial mid-term result of our series is quite encouraging.

Our study has its own set of limitations. It is a small series withdifferent configurations of subtrochanteric fractures. The follow-upperiod is short and there is lack of a control group. However, thestrength of the study is that it is a single institutional study withcases treated by the same team of surgeons. The findings of ourstudy show that reversed contralateral DFLCP, when used for fixa-tion of the subtrochanteric fractures shows results comparable tothose achieved by using other extra-medullary implants as well asintramedullary devices. The added advantages of this implant areits familiarity by the surgeons and usability in the absence of animage intensifier.

References

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