Reverse distal femoral locking compression plate a salvage option in nonunion of proximal femoral fractures

Abstract

Background: When primary fixation of proximal femoral fractures with implants fails, revision osteosynthesis may be challenging. Tracts of previous implants and remaining insufficient bone stock in the proximal femur pose unique problems for the treatment. Intramedullary implants like proximal femoral nail (PFN) or surface implants like Dynamic Condylar Screw (DCS) are few of the described implants for revision surgery. There is no evidence in the literature to choose one implant over the other. We used the reverse distal femur locking compression plate (LCP) of the contralateral side in such cases undergoing revision surgery. This implant has multiple options of fixation in proximal femur and its curvature along the length matches the anterior bow of the femur. We aimed to evaluate the efficacy of this implant in salvage situations.

Materials and methods: Twenty patients of failed primary proximal femoral fractures who underwent revision surgery with reverse distal femoral locking plate from February 2009 to November 2012 were included in this retrospective study. There were 18 subtrochanteric fractures and two ipsilateral femoral neck and shaft fractures, which exhibited delayed union or nonunion. The study included 14 males and six females. The mean patient age was 43.6 years (range 22-65 years) and mean followup period was 52.1 months (range 27-72 months). Delayed union was considered when clinical and radiological signs of union failed to progress at the end of four months from initial surgery.

Results: All fractures exhibited union without any complications. Union was assessed clinically and radiologically. One case of ipsilateral femoral neck and shaft fracture required bone grafting at the second stage for delayed union of the femoral shaft fracture.

Conclusions: Reverse distal femoral LCP of the contralateral side can be used as a salvage option for failed fixation of proximal femoral fractures exhibiting nonunion.

Keywords: Osteosysthesis; Reverse distal femur locking compression plate; bone plates; ipsilateral femoral neck and shaft fracture; nonunion fracture proximal femur; orthopedic equipment; proximal femur fracture; subtrochanteric fractures.

Figure 1

(a) X-ray left hip joint with thigh anteroposterior view showing comminuted subtrochanteric fracture femur (b) long proximal femoral nail with nonunion at 9 months after primary fixation. (c) The implant was removed and revision fixation was performed in the compression mode with reverse distal femoral locking compression plate. The radiographs show union at the 4-month followup

Figure 2

Lateral radiograph of the femur with hip joint showing the anterior curvature of the distal femoral locking compression plate, which matched the anterior bow of the femur

Figure 3

Clinical photograph showing primary fixation performed via a minimally invasive surgical approach. An elastic titanium nail with a diameter of 3 mm was used for reduction, and the plate was passed in minimally invasive manner

Figure 4

(a) Anteroposterior and lateral radiographs of a 22-year-old man showing nonunion of ipsilateral femoral neck and shaft fracture following four previous surgeries using a dynamic hip screw and a long proximal femoral nail. Due to repeated surgeries, the proximal femoral bone stock was inadequate. (b) After removal of the implant, autologous fibula bone grafting was performed in the femoral neck, followed by fixation with a reverse distal femoral locking compression plate. Radiographs at the 4-month followup show the union of the femoral neck fracture. However, the femoral shaft fracture shows delayed union. (c) Radiographs demonstrating union of the femoral shaft fracture at 3 months after bone grafting