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Distal femoral fractures
Injury, Int. J. Care Injured 46 (2015) 1084–1088
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Distal femoral fractures The need to review the standard of care James R.A. Smith a,*, Ruth Halliday a, Alexander L. Aquilina b, Rory J.M. Morrison c, Grace C.K. Yip d, John McArthur b, Peter Hull d, Andrew Gray c, Michael B. Kelly a Collaborative - Orthopaedic Trauma Society (OTS) a
Department of Orthopaedics, Southmead Hospital, Southmead Road, Bristol BS10 5NB, United Kingdom Department of Orthopaedics, University Hospital, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom Department of Orthopaedics, Royal Victoria Infirmary, Queen Victoria Rd, Newcastle upon Tyne NE1 4LP, United Kingdom d Department of Orthopaedics, Addenbrooks Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, United Kingdom b c
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 19 February 2015
Background: Hip fracture care has evolved, largely due to standardisation of practice, measurement of outcomes and the introduction of the Best Practice Tariff, leading to the sustained improvements documented by the National Hip Fracture Database (NHFD). The treatment of distal femoral fractures in this population has not had the same emphasis. This study defines the epidemiology, current practice and outcomes of distal femoral fractures in four English centres. Patients and methods: 105 patients aged 50 years or greater with a distal femoral fracture, presenting to four UK major trauma centres between October 2010 and September 2011 were identified. Data was collected using an adapted NHFD data collection tool via retrospective case note and radiograph review. Local ethics approval was obtained. Results: Mean age was 77 years (range 50–99), with 86% female. 95% of injuries were sustained from a low energy mechanism, and 72% were classified as either 33-A1 or 33-C1. The mean Parker mobility score and Barthel Independence Index were 5.37 (0–9) and 75.5 (0–100) respectively. Operative management was performed in 84%, and 86% had their surgery within 36 h. Three quarters were fixed with a peri-articuar locking plate. There was no consensus on post operative rehabilitation, but no excess of complications in the centres where weight bearing as tolerated was the standard. 45% were seen by an orthogeriatrician during their admission. Mean length of stay was 29 days. Mortality at 30 days, 6 months, and 1 year was 7%, 16% and 18% respectively. Discussion: This study demonstrates that the distal femoral and hip fracture populations are similar, and highlights the current disparity in their management. The metrics and standards of care currently applied to hip fractures should be applied to the treatment of distal femoral fractures. Optimal operative treatment and rehabilitation remains unclear, and is in need of further research. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Distal femoral Fracture Femur Supracondylar
Introduction Fractures of the distal part of the femur account for 3–6% of all femoral fractures [1–3]. There is a small incidence following high energy trauma in the younger population, but this is predominately a low energy fracture in the elderly, commonly sustained after a fall from standing height [2,4]. With the elderly cohort
* Corresponding author. E-mail address: [email protected] (James R.A. Smith). http://dx.doi.org/10.1016/j.injury.2015.02.016 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
frequently having multiple comorbidities [5] this low energy fracture can result in multiple complications. Mortality at 30 days, six months and one year have been reported previously as 6%, 17– 18%, and 18–30% respectively, with five year mortality as high as 48% [6–9]. These figures are similar to published mortality rates for proximal femoral fractures [10,11]. The management of proximal femoral fractures in England has hugely evolved in recent years, with the introduction of the National Hip Fracture Database [12] and the Best Practice Tariff. This has resulted in standardised and enhanced quality of care throughout the country, leading to an improved patient
J.R.A. Smith et al. / Injury, Int. J. Care Injured 46 (2015) 1084–1088
experience, and lower morbidity and mortality rates [12]. These benefits however have not yet been extended to patients with a fracture of the distal part of the femur. The main focus of the current literature for distal femoral fractures is on biomechanics of fixation methods, surgical technique and new implant technology. Peri-articular anatomical locking plates are becoming the accepted standard in the treatment of these fractures, with retrograde intramedullary nailing (rIMN) and distal femoral replacement used for some fracture configurations. At present there is no consensus on how to treat these difficult injuries, or how to manage these patients postoperatively. The current approach towards weight-bearing and patient follow-up also remains largely unknown. This multi-centre paper aimed to define the population, current management and outcomes of the treatment of distal femoral fractures in patients aged over 50 years in England.
Patients and methods Patients who presented to each of four major trauma centres (Frenchay Hospital, Bristol (FH); Addenbrooke’s Hospital, Cambridge (AD); Royal Victoria Infirmary, Newcastle (RVI); University Hospital, Coventry (UHC)) with a fracture of the distal femur between October 2010 and September 2011 inclusive were identified. Plain anteroposterior and lateral radiographs from admission were assessed by a senior orthopaedic surgeon at each centre, and classified using the AO-OTA system [13]. Fracture pattern types 33-A,B and C were included in the study. Patients aged less than 50 years of age were excluded. A retrospective review of operative records, inpatient hospital notes, and outpatient appointment letters was performed for each patient at their study centre. Data was collected on a standardised spreadsheet adapted from the National Hip Fracture Database Audit Tool [14]. Pre-morbid mobility was assessed using the Parker and Palmer Mobility Score [15], and Barthel Index [16]. Patient mortality was recorded at 30 days, four months, six months and one year. Data was collated and analysed using descriptive statistics by the lead investigators.
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Table 1 Patient demographics. 105 77 50–99
Number Mean age (yrs) Age range (yrs) Gender
Male Female Unknown
11 (14%) 65 (86%) 29
Side of injury
Left Right Bilateral
52 (50%) 48 (46%) 5 (4%)
Open fracture?
Yes No
4 (4%) 101 (96%)
Table 2 Pre-morbid ambulatory ability. Pre-morbid ambulatory ability
Regularly walked without aids Regularly walked with one aid Regularly walked with two aids or frame Wheelchair or bed bound
46% 13% 28% 13%
Treatment
Results
Seventy-two percent of the total distal femoral fractures were 33-A1 or 33-C1 type (Fig. 1). Two-thirds (69%) of the patients were admitted directly to an orthopaedic ward from Accident and Emergency, and 6% were not admitted to an orthopaedic ward during their inpatient episode. The initial treatment plan was operative in 82% of cases, occurring at an average of 2 days post admission (mode 1 day, range 0–18), with 86% having their surgery within 36 h. Reasons for delay are detailed in Table 3. A further two cases required operative intervention after failed conservative management. Seventy-one percent of operative procedures involved an open reduction and internal fixation using a plate and screws, though the mode in which the plate was used varied (Fig. 2). Intraoperative complications occurred in three patients. These comprised two myocardial infarctions (one fatal), and a distal tibial flap required following intra-operative traction. There were 20 known postoperative complications (Table 4).
Patient demographics
Rehabilitation
A total of 105 patients were identified (FH 26, AD 28, RVI 22, UHC 29). This comprises 6% of femoral fractures, when the total number of proximal femoral fractures entered to the NHFD is considered (may represent a very small overestimate as no data is available for diaphysial injuries). Eighty-six percent of the patients were female and the mean age was 77 years (median 80 years, range 50–99) (Table 1). Ninety-five percent of injuries occurred due to a low energy mechanism, and 96% were closed. Periprosthetic fractures occurred in 34% of cases, and 6% were considered to have a pathological aetiology other than osteoporosis. The majority of patients were admitted from their own home, or sheltered housing. 10% were admitted from either a nursing or residential home, 4% from a rehabilitation unit, and 7% sustained their injury whilst already in hospital. Forty-six percent of patients walked regularly without aids (Table 2). The Parker Mobility Score and The Barthel Index were only ascertainable in 57% and 52% of cases respectively. Patients had a mean Parker Mobility Score of 5.37 (range 0–9), and a mean Barthel Index of 75.5 (range 0–100). Mean abbreviated mental test score (AMTS) [17] on admission was 6.75, but only performed on 19% of patients.
The majority of patients were mobilised non-weight-bearing (51%), with 18% touch-weight-bearing, 17% partial weight-bearing and 14% full weight-bearing. Of note, there was no excess of complications of fixation associated with less restrictive practices in terms of permitting weight-bearing. Physiotherapy and occupational therapy were provided in 78% of patients, and 45% were seen by an orthogeriatrician during their admission. It was not possible from the case notes to accurately determine the number of patients who received a specialist falls assessment or reviewed for suitability of bone protection medication. No patient had a post operative Abbreviated Mental Test Score documented. The assumption is that these factors were not a priority in their management Discharge and mortality Mean length of stay was 29 days (range 0–137 days). Seventy percent of patients were seen following discharge in fracture clinic (range 55–82%). Discharge destination is shown in Table 5. Thirty day, 6 month, and 1 year mortality rate was 7%, 16% and 18% respectively (Table 6).
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Fig. 1. AO/OTA fracture classification.
Table 3 Delay to surgery. No delay (surgery within 36 h) Medically unfit – awaiting orthopaedic investigation/review Medically unfit – awaiting medical investigation/review No theatre space Problem with theatre staff cover Other Unknown
52 2 2 1 1 4 26
Discussion This cohort of patients was similar across the centres and shared similar demographics to previous distal femoral fracture studies [2,8,9,18], including fracture type. AO-OTA 33-A1 and 33C1 type accounted for 72% of the fractures seen. There was an intraarticular involvement in 36% of fractures, echoing the findings of a recent French cohort [18], but lower than the 55% suggested by
Court Brown et al. [2]. This discrepancy may reflect error in the use of the classification system, differential use of computer tomography to define fractures, or an actual difference in the types of fracture affecting populations from different geographical locations. When compared to data on fractures of the proximal femur using a National dataset [19], the patients studied in this cohort are very similar (Table 7). Injuries were sustained more frequently in females (86% compared to 73% in the NHFD). 46% of subjects walked unaided prior to their injury in both cohorts, and 79% were admitted from their own home or sheltered accommodation compared with 75% in the proximal femoral group. There was a younger mean age in the distal femur cohort, with nearly half of all proximal femur patients being in their eighties. This could be explained by the inclusion criteria being patients aged 50 years or greater. Fifty years was deemed appropriate as women and men of this age are at a greater risk of a fragility fracture, as outlined by the National Osteoporosis Guideline Group [NOGG] [20]. The NHFD
Fig. 2. Operations performed.
J.R.A. Smith et al. / Injury, Int. J. Care Injured 46 (2015) 1084–1088 Table 4 Post operative complications. Primary operation Hardware failure Deep wound infection Superficial wound infection Non-union Bleeding Malunion Thromboembolic Prominent metalwork Peri-prosthetic fracture Other
4 3 3 2 1 1 1 1 1 3
3 ORIF, 1 Unknown 3 ORIF 2 ORIF, 1 IM nail 2 ORIF Unknown Unknown Unknown ORIF rIMN 3 Unknown
Table 5 Discharge destination from Trust. Another acute hospital Nursing care Residential care Rehabilitation unit Own home/sheltered accommodation Died Other Unknown
1 10 3 9 41 6 2 33
(1%) (10%) (3%) (9%) (39%) (6%) (2%) (31%)
Table 6 Mortality. 30 days 6 months 1 year
7 (7%) 16 (16%) 18 (18%)
Table 7 Patient demographic compared with NHFD 2013. Distal femur
NHFD 2013
Age
Mean 77 yrs
Sex Admitted from home/ sheltered housing Walking without aids AMT score
86% female 79%
22% 70–79 years 48% 80–89 years 74% female 75%
46% Mean 6.75
46% 58% 7–10, 30% 0–6, 12% unknown
however provides data on patients from 65 years. The mean age of the current cohort increases to 82 years when patients aged between 50 and 65 are excluded. The majority of patients with a distal femoral fracture in this cohort were treated operatively (82%), reflecting the recommendations of Butt et al. [6], who report significantly improved outcomes and fewer complications associated with operative treatment of distal femoral fractures when compared with conservative management. This is lower than the 97.6% of patients who are treated operatively following proximal femoral fractures [19]. Fracture fixation was predominantly with anatomical periarticular locking plates, and a smaller number of retrograde intramedullary nails. Whilst this reflects the current literature, with the role of locking plates expanding as the technology evolves [21], studies supporting both methods of fixation have been published [22–32]. However there still remains a paucity of longterm functional and radiological follow-up. Only two patients in this cohort received a femoral replacement (one total knee). The outcome of knee replacement remains largely unknown, with varying results published in small cohorts. There is some suggestion that prosthetic replacement survival at five years
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may be satisfactory, and in fact sufficient to out survive the patient [33]. However, high morbidity, mortality and complication is been reported [33–35]. The current study was not designed to detect differences between implants, or recommend best treatment modality, but to serve as an accurate demographic appraisal of the current population and their management. A current limitation in the treatment of distal femoral fractures is the reluctance to weight bear patients early. Whilst maintaining the reduction is paramount to healing, restoration of mobility is important in the prevention of complications. Accepted practice has been to not weight-bear patients, but this recommendation is based on a small patient cohort [36]. Attitudes to weight-bearing appear to be changing, and this is perhaps as a result of the experience gained in treating proximal femoral fractures. However, this remains centre specific, and the majority (51%) of patients are still rehabilitated non weight-bearing. Ehlinger et al. [29] have outlined criteria for extra-articular fractures treated with a fully locked plate under which they will fully weight-bear a patient post-operatively, however they emphasise in their review article [21] that the quality of surgical technique is the primary factor and only guarantee of obtaining good radiological and clinical results. The optimal weight-bearing strategy is still not clear but it is likely to be independent of the fixation method as borne out by the fact that increasing weight-bearing tolerance in this study was not associated with increased construct failures requiring revision. This study has several limitations, which may be eliminated with a prospective observational trial. Retrospective data collection from patient notes results in missing data, thereby reducing the total number for analysis for some areas of the study. Whilst using multi-centre methodology allowed a large volume of data capture in a short time period, the data was open to collection bias at the different centres. A standardised data collection proforma was used to minimise this, however some aspects may still have been open to interpretation. This paper demonstrates the similarity between the populations who sustain a fracture of the distal and proximal end of the femur. It was not our aim to provide recommendation on best practice when treating distal femoral fractures, but to highlight the large disparity, and lack of consensus currently in their management when compared with neck of femur fractures. This inequality in treatment of the two cohorts is perhaps not universally acknowledged. The introduction of the National Hip Fracture Database and Best Practice Tariff has helped to improve care for proximal femur fractures, partly by incentivising, and encouraging standardised care based on the best available evidence. As a result there has been substantial improvements in the care of these patients, and 30-day mortality has been reduced to 8.2% [19]. At present, this standard of care has not been extended to the estimated 7000 fractures per annum of the distal femur in England [2,4] who have a similar demographic and share a similar mortality rate. The principles of early surgery and universal orthogeriatric involvement can easily be applied to the distal femoral cohort, and it is likely that this is already happening as the evolution of fragility fracture continues. However, there are still two main questions that remain unanswered; firstly how to best fix each fracture configuration (and indeed whether it is best to replace rather that reconstruct in some circumstances), and secondly, is it possible to safely weight bear these patients early in order to reduce post operative morbidity and mortality, and increase the proportion of patients returning to their index place of residence. Only prospective, specifically designed studies will be able to address these issues. In conclusion, patients who fracture their distal femur are of the same demographic as those who fracture the proximal part. Whilst there remain unanswered questions regarding best operative treatment, the overriding principles of management should be
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consistent. We feel therefore it is appropriate that patients suffering a distal femur fracture should be accorded the same metrics and standards of care that have been applied to fractures of the proximal femur. Conflict of interest None. Acknowledgement We would like to thank Mr T. Chesser for assistance in editing the final manuscript. References [1] Martinet O, Cordey J, Harder Y, Maier A, Buhler M, Barraud GE. The epidemiology of fractures of the distal femur. Injury 2000;31(Suppl. 3):C62–3. [2] Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury 2006;37(8):691–7. [3] Wahnert D, Hoffmeier K, Frober R, Hofmann GO, Muckley T. Distal femur fractures of the elderly—different treatment options in a biomechanical comparison. Injury 2011;42(7):655–9. [4] Gwathmey Jr FW, Jones-Quaidoo SM, Kahler D, Hurwitz S, Cui Q. Distal femoral fractures: current concepts. The Journal of the American Academy of Orthopaedic Surgeons 2010;18(10):597–607. [5] Nieves JW, Bilezikian JP, Lane JM, Einhorn TA, Wang Y, Steinbuch M, et al. Fragility fractures of the hip and femur: incidence and patient characteristics. Osteoporosis International: A Journal Established as Result of Cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA 2010;21(3):399–408. [6] Butt MS, Krikler SJ, Ali MS. Displaced fractures of the distal femur in elderly patients. Operative versus non-operative treatment. The Journal of Bone and Joint Surgery British Volume 1996;78(1):110–4. [7] Dunlop DG, Brenkel IJ. The supracondylar intramedullary nail in elderly patients with distal femoral fractures. Injury 1999;30(7):475–84. [8] Streubel PN, Ricci WM, Wong A, Gardner MJ. Mortality after distal femur fractures in elderly patients. Clinical Orthopaedics and Related Research 2011;469(4):1188–96. [9] Kammerlander C, Riedmuller P, Gosch M, Zegg M, Kammerlander-Knauer U, Schmid R, et al. Functional outcome and mortality in geriatric distal femoral fractures. Injury 2012;43(7):1096–101. [10] Haleem S, Lutchman L, Mayahi R, Grice JE, Parker MJ. Mortality following hip fracture: trends and geographical variations over the last 40 years. Injury 2008;39(10):1157–63. [11] National Hip Fracture Database; 2013. Available from: www.nhfd.co.uk. [12] National Hip Fracture Database; 2013. [13] Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, et al. Fracture and dislocation classification compendium – 2007: orthopaedic Trauma Association classification, database and outcomes committee. Journal of Orthopaedic Trauma 2007;21(10 Suppl.):S1–33. [14] National Hip Fracture Database – Audit Tool v7. Available from: www.nhfd.co. uk/20/hipfractureR. . ./NHFD%20Audit%20Tool%20v7.doc. [15] Parker MJ, Palmer CR. A new mobility score for predicting mortality after hip fracture. The Journal of Bone and Joint Surgery British Volume 1993;75(5): 797–8. [16] Mahoney FI, Barthel DW. Functional evaluation: The Barthel Index. Maryland State Medical Journal 1965;14:61–5.
[17] Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age and Ageing 1972;1(4):233–8. [18] Pietu G, Lebaron M, Flecher X, Hulet C, Vandenbussche E, SOFCOT. Epidemiology of distal femur fractures in France in 2011–12. Orthopaedics & Traumatology Surgery & Research: OTSR 2014;100(5):545–8. [19] National Hip Fracture Database [Internet]. 2013. Available from: www.nhfd. co.uk. [20] Group NOG. Guideline for the diagnosis and management of osteoporosis; 2014. [21] Ehlinger M, Ducrot G, Adam P, Bonnomet F. Distal femur fractures. Surgical techniques and a review of the literature. Orthopaedics & Traumatology Surgery & Research: OTSR 2013;99(3):353–60. [22] Markmiller M, Konrad G, Sudkamp N. Femur-LISS and distal femoral nail for fixation of distal femoral fractures: are there differences in outcome and complications? Clinical Orthopaedics and Related Research 2004;426:252–7. [23] Acharya KN, Rao MR. Retrograde nailing for distal third femoral shaft fractures: a prospective study. Journal of Orthopaedic Surgery 2006;14(3):253–8. [24] 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). Journal of Orthopaedic Trauma 2006;20(5):366–71. [25] Dougherty PJ, Kim DG, Meisterling S, Wybo C, Yeni Y. Biomechanical comparison of bicortical versus unicortical screw placement of proximal tibia locking plates: a cadaveric model. Journal of Orthopaedic Trauma 2008;22(6):399–403. [26] Kolb W, Guhlmann H, Windisch C, Marx F, Kolb K, Koller H. Fixation of distal femoral fractures with the Less Invasive Stabilization System: a minimally invasive treatment with locked fixed-angle screws. The Journal of Trauma 2008;65(6):1425–34. [27] Thomson AB, Driver R, Kregor PJ, Obremskey WT. Long-term functional outcomes after intra-articular distal femur fractures: ORIF versus retrograde intramedullary nailing. Orthopedics 2008;31(8):748–50. [28] Henderson CE, Lujan T, Bottlang M, Fitzpatrick DC, Madey SM, Marsh JL. Stabilization of distal femur fractures with intramedullary nails and locking plates: differences in callus formation. The Iowa Orthopaedic Journal 2010;30: 61–8. [29] Ehlinger M, Adam P, Abane L, Arlettaz Y, Bonnomet F. Minimally-invasive internal fixation of extra-articular distal femur fractures using a locking plate: tricks of the trade. Orthopaedics & Traumatology Surgery & Research: OTSR 2011;97(2):201–5. [30] Ehlinger M, Adam P, Arlettaz Y, Moor BK, DiMarco A, Brinkert D, et al. Minimally-invasive fixation of distal extra-articular femur fractures with locking plates: limitations and failures. Orthopaedics & Traumatology Surgery & Research: OTSR 2011;97(6):668–74. [31] Henderson CE, Lujan TJ, Kuhl LL, Bottlang M, Fitzpatrick DC, Marsh JL. 2010 mid-America Orthopaedic Association Physician in Training Award: healing complications are common after locked plating for distal femur fractures. Clinical Orthopaedics and Related Research 2011;469(6):1757–65. [32] Nayak RM, Koichade MR, Umre AN, Ingle MV. Minimally invasive plate osteosynthesis using a locking compression plate for distal femoral fractures. Journal of Orthopaedic Surgery 2011;19(2):185–90. [33] Appleton P, Moran M, Houshian S, Robinson CM. Distal femoral fractures treated by hinged total knee replacement in elderly patients. The Journal of Bone and Joint Surgery British Volume 2006;88(8):1065–70. [34] Haidukewych GJ, Springer BD, Jacofsky DJ, Berry DJ. Total knee arthroplasty for salvage of failed internal fixation or nonunion of the distal femur. The Journal of Arthroplasty 2005;20(3):344–9. [35] Vaishya R, Singh AP, Hasija R, Singh AP. Treatment of resistant nonunion of supracondylar fractures femur by megaprosthesis. Knee Surgery Sports Traumatology Arthroscopy: Official Journal of the ESSKA 2011;19(7):1137–40. [36] Vallier HA, Hennessey TA, Sontich JK, Patterson BM. Failure of LCP condylar plate fixation in the distal part of the femur. A report of six cases. The Journal of Bone and Joint Surgery American Volume 2006;88(4):846–53.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Distal femoral fractures The need to review the standard of care James R.A. Smith a,*, Ruth Halliday a, Alexander L. Aquilina b, Rory J.M. Morrison c, Grace C.K. Yip d, John McArthur b, Peter Hull d, Andrew Gray c, Michael B. Kelly a Collaborative - Orthopaedic Trauma Society (OTS) a
Department of Orthopaedics, Southmead Hospital, Southmead Road, Bristol BS10 5NB, United Kingdom Department of Orthopaedics, University Hospital, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom Department of Orthopaedics, Royal Victoria Infirmary, Queen Victoria Rd, Newcastle upon Tyne NE1 4LP, United Kingdom d Department of Orthopaedics, Addenbrooks Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, United Kingdom b c
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 19 February 2015
Background: Hip fracture care has evolved, largely due to standardisation of practice, measurement of outcomes and the introduction of the Best Practice Tariff, leading to the sustained improvements documented by the National Hip Fracture Database (NHFD). The treatment of distal femoral fractures in this population has not had the same emphasis. This study defines the epidemiology, current practice and outcomes of distal femoral fractures in four English centres. Patients and methods: 105 patients aged 50 years or greater with a distal femoral fracture, presenting to four UK major trauma centres between October 2010 and September 2011 were identified. Data was collected using an adapted NHFD data collection tool via retrospective case note and radiograph review. Local ethics approval was obtained. Results: Mean age was 77 years (range 50–99), with 86% female. 95% of injuries were sustained from a low energy mechanism, and 72% were classified as either 33-A1 or 33-C1. The mean Parker mobility score and Barthel Independence Index were 5.37 (0–9) and 75.5 (0–100) respectively. Operative management was performed in 84%, and 86% had their surgery within 36 h. Three quarters were fixed with a peri-articuar locking plate. There was no consensus on post operative rehabilitation, but no excess of complications in the centres where weight bearing as tolerated was the standard. 45% were seen by an orthogeriatrician during their admission. Mean length of stay was 29 days. Mortality at 30 days, 6 months, and 1 year was 7%, 16% and 18% respectively. Discussion: This study demonstrates that the distal femoral and hip fracture populations are similar, and highlights the current disparity in their management. The metrics and standards of care currently applied to hip fractures should be applied to the treatment of distal femoral fractures. Optimal operative treatment and rehabilitation remains unclear, and is in need of further research. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Distal femoral Fracture Femur Supracondylar
Introduction Fractures of the distal part of the femur account for 3–6% of all femoral fractures [1–3]. There is a small incidence following high energy trauma in the younger population, but this is predominately a low energy fracture in the elderly, commonly sustained after a fall from standing height [2,4]. With the elderly cohort
* Corresponding author. E-mail address: [email protected] (James R.A. Smith). http://dx.doi.org/10.1016/j.injury.2015.02.016 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
frequently having multiple comorbidities [5] this low energy fracture can result in multiple complications. Mortality at 30 days, six months and one year have been reported previously as 6%, 17– 18%, and 18–30% respectively, with five year mortality as high as 48% [6–9]. These figures are similar to published mortality rates for proximal femoral fractures [10,11]. The management of proximal femoral fractures in England has hugely evolved in recent years, with the introduction of the National Hip Fracture Database [12] and the Best Practice Tariff. This has resulted in standardised and enhanced quality of care throughout the country, leading to an improved patient
J.R.A. Smith et al. / Injury, Int. J. Care Injured 46 (2015) 1084–1088
experience, and lower morbidity and mortality rates [12]. These benefits however have not yet been extended to patients with a fracture of the distal part of the femur. The main focus of the current literature for distal femoral fractures is on biomechanics of fixation methods, surgical technique and new implant technology. Peri-articular anatomical locking plates are becoming the accepted standard in the treatment of these fractures, with retrograde intramedullary nailing (rIMN) and distal femoral replacement used for some fracture configurations. At present there is no consensus on how to treat these difficult injuries, or how to manage these patients postoperatively. The current approach towards weight-bearing and patient follow-up also remains largely unknown. This multi-centre paper aimed to define the population, current management and outcomes of the treatment of distal femoral fractures in patients aged over 50 years in England.
Patients and methods Patients who presented to each of four major trauma centres (Frenchay Hospital, Bristol (FH); Addenbrooke’s Hospital, Cambridge (AD); Royal Victoria Infirmary, Newcastle (RVI); University Hospital, Coventry (UHC)) with a fracture of the distal femur between October 2010 and September 2011 inclusive were identified. Plain anteroposterior and lateral radiographs from admission were assessed by a senior orthopaedic surgeon at each centre, and classified using the AO-OTA system [13]. Fracture pattern types 33-A,B and C were included in the study. Patients aged less than 50 years of age were excluded. A retrospective review of operative records, inpatient hospital notes, and outpatient appointment letters was performed for each patient at their study centre. Data was collected on a standardised spreadsheet adapted from the National Hip Fracture Database Audit Tool [14]. Pre-morbid mobility was assessed using the Parker and Palmer Mobility Score [15], and Barthel Index [16]. Patient mortality was recorded at 30 days, four months, six months and one year. Data was collated and analysed using descriptive statistics by the lead investigators.
1085
Table 1 Patient demographics. 105 77 50–99
Number Mean age (yrs) Age range (yrs) Gender
Male Female Unknown
11 (14%) 65 (86%) 29
Side of injury
Left Right Bilateral
52 (50%) 48 (46%) 5 (4%)
Open fracture?
Yes No
4 (4%) 101 (96%)
Table 2 Pre-morbid ambulatory ability. Pre-morbid ambulatory ability
Regularly walked without aids Regularly walked with one aid Regularly walked with two aids or frame Wheelchair or bed bound
46% 13% 28% 13%
Treatment
Results
Seventy-two percent of the total distal femoral fractures were 33-A1 or 33-C1 type (Fig. 1). Two-thirds (69%) of the patients were admitted directly to an orthopaedic ward from Accident and Emergency, and 6% were not admitted to an orthopaedic ward during their inpatient episode. The initial treatment plan was operative in 82% of cases, occurring at an average of 2 days post admission (mode 1 day, range 0–18), with 86% having their surgery within 36 h. Reasons for delay are detailed in Table 3. A further two cases required operative intervention after failed conservative management. Seventy-one percent of operative procedures involved an open reduction and internal fixation using a plate and screws, though the mode in which the plate was used varied (Fig. 2). Intraoperative complications occurred in three patients. These comprised two myocardial infarctions (one fatal), and a distal tibial flap required following intra-operative traction. There were 20 known postoperative complications (Table 4).
Patient demographics
Rehabilitation
A total of 105 patients were identified (FH 26, AD 28, RVI 22, UHC 29). This comprises 6% of femoral fractures, when the total number of proximal femoral fractures entered to the NHFD is considered (may represent a very small overestimate as no data is available for diaphysial injuries). Eighty-six percent of the patients were female and the mean age was 77 years (median 80 years, range 50–99) (Table 1). Ninety-five percent of injuries occurred due to a low energy mechanism, and 96% were closed. Periprosthetic fractures occurred in 34% of cases, and 6% were considered to have a pathological aetiology other than osteoporosis. The majority of patients were admitted from their own home, or sheltered housing. 10% were admitted from either a nursing or residential home, 4% from a rehabilitation unit, and 7% sustained their injury whilst already in hospital. Forty-six percent of patients walked regularly without aids (Table 2). The Parker Mobility Score and The Barthel Index were only ascertainable in 57% and 52% of cases respectively. Patients had a mean Parker Mobility Score of 5.37 (range 0–9), and a mean Barthel Index of 75.5 (range 0–100). Mean abbreviated mental test score (AMTS) [17] on admission was 6.75, but only performed on 19% of patients.
The majority of patients were mobilised non-weight-bearing (51%), with 18% touch-weight-bearing, 17% partial weight-bearing and 14% full weight-bearing. Of note, there was no excess of complications of fixation associated with less restrictive practices in terms of permitting weight-bearing. Physiotherapy and occupational therapy were provided in 78% of patients, and 45% were seen by an orthogeriatrician during their admission. It was not possible from the case notes to accurately determine the number of patients who received a specialist falls assessment or reviewed for suitability of bone protection medication. No patient had a post operative Abbreviated Mental Test Score documented. The assumption is that these factors were not a priority in their management Discharge and mortality Mean length of stay was 29 days (range 0–137 days). Seventy percent of patients were seen following discharge in fracture clinic (range 55–82%). Discharge destination is shown in Table 5. Thirty day, 6 month, and 1 year mortality rate was 7%, 16% and 18% respectively (Table 6).
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Fig. 1. AO/OTA fracture classification.
Table 3 Delay to surgery. No delay (surgery within 36 h) Medically unfit – awaiting orthopaedic investigation/review Medically unfit – awaiting medical investigation/review No theatre space Problem with theatre staff cover Other Unknown
52 2 2 1 1 4 26
Discussion This cohort of patients was similar across the centres and shared similar demographics to previous distal femoral fracture studies [2,8,9,18], including fracture type. AO-OTA 33-A1 and 33C1 type accounted for 72% of the fractures seen. There was an intraarticular involvement in 36% of fractures, echoing the findings of a recent French cohort [18], but lower than the 55% suggested by
Court Brown et al. [2]. This discrepancy may reflect error in the use of the classification system, differential use of computer tomography to define fractures, or an actual difference in the types of fracture affecting populations from different geographical locations. When compared to data on fractures of the proximal femur using a National dataset [19], the patients studied in this cohort are very similar (Table 7). Injuries were sustained more frequently in females (86% compared to 73% in the NHFD). 46% of subjects walked unaided prior to their injury in both cohorts, and 79% were admitted from their own home or sheltered accommodation compared with 75% in the proximal femoral group. There was a younger mean age in the distal femur cohort, with nearly half of all proximal femur patients being in their eighties. This could be explained by the inclusion criteria being patients aged 50 years or greater. Fifty years was deemed appropriate as women and men of this age are at a greater risk of a fragility fracture, as outlined by the National Osteoporosis Guideline Group [NOGG] [20]. The NHFD
Fig. 2. Operations performed.
J.R.A. Smith et al. / Injury, Int. J. Care Injured 46 (2015) 1084–1088 Table 4 Post operative complications. Primary operation Hardware failure Deep wound infection Superficial wound infection Non-union Bleeding Malunion Thromboembolic Prominent metalwork Peri-prosthetic fracture Other
4 3 3 2 1 1 1 1 1 3
3 ORIF, 1 Unknown 3 ORIF 2 ORIF, 1 IM nail 2 ORIF Unknown Unknown Unknown ORIF rIMN 3 Unknown
Table 5 Discharge destination from Trust. Another acute hospital Nursing care Residential care Rehabilitation unit Own home/sheltered accommodation Died Other Unknown
1 10 3 9 41 6 2 33
(1%) (10%) (3%) (9%) (39%) (6%) (2%) (31%)
Table 6 Mortality. 30 days 6 months 1 year
7 (7%) 16 (16%) 18 (18%)
Table 7 Patient demographic compared with NHFD 2013. Distal femur
NHFD 2013
Age
Mean 77 yrs
Sex Admitted from home/ sheltered housing Walking without aids AMT score
86% female 79%
22% 70–79 years 48% 80–89 years 74% female 75%
46% Mean 6.75
46% 58% 7–10, 30% 0–6, 12% unknown
however provides data on patients from 65 years. The mean age of the current cohort increases to 82 years when patients aged between 50 and 65 are excluded. The majority of patients with a distal femoral fracture in this cohort were treated operatively (82%), reflecting the recommendations of Butt et al. [6], who report significantly improved outcomes and fewer complications associated with operative treatment of distal femoral fractures when compared with conservative management. This is lower than the 97.6% of patients who are treated operatively following proximal femoral fractures [19]. Fracture fixation was predominantly with anatomical periarticular locking plates, and a smaller number of retrograde intramedullary nails. Whilst this reflects the current literature, with the role of locking plates expanding as the technology evolves [21], studies supporting both methods of fixation have been published [22–32]. However there still remains a paucity of longterm functional and radiological follow-up. Only two patients in this cohort received a femoral replacement (one total knee). The outcome of knee replacement remains largely unknown, with varying results published in small cohorts. There is some suggestion that prosthetic replacement survival at five years
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may be satisfactory, and in fact sufficient to out survive the patient [33]. However, high morbidity, mortality and complication is been reported [33–35]. The current study was not designed to detect differences between implants, or recommend best treatment modality, but to serve as an accurate demographic appraisal of the current population and their management. A current limitation in the treatment of distal femoral fractures is the reluctance to weight bear patients early. Whilst maintaining the reduction is paramount to healing, restoration of mobility is important in the prevention of complications. Accepted practice has been to not weight-bear patients, but this recommendation is based on a small patient cohort [36]. Attitudes to weight-bearing appear to be changing, and this is perhaps as a result of the experience gained in treating proximal femoral fractures. However, this remains centre specific, and the majority (51%) of patients are still rehabilitated non weight-bearing. Ehlinger et al. [29] have outlined criteria for extra-articular fractures treated with a fully locked plate under which they will fully weight-bear a patient post-operatively, however they emphasise in their review article [21] that the quality of surgical technique is the primary factor and only guarantee of obtaining good radiological and clinical results. The optimal weight-bearing strategy is still not clear but it is likely to be independent of the fixation method as borne out by the fact that increasing weight-bearing tolerance in this study was not associated with increased construct failures requiring revision. This study has several limitations, which may be eliminated with a prospective observational trial. Retrospective data collection from patient notes results in missing data, thereby reducing the total number for analysis for some areas of the study. Whilst using multi-centre methodology allowed a large volume of data capture in a short time period, the data was open to collection bias at the different centres. A standardised data collection proforma was used to minimise this, however some aspects may still have been open to interpretation. This paper demonstrates the similarity between the populations who sustain a fracture of the distal and proximal end of the femur. It was not our aim to provide recommendation on best practice when treating distal femoral fractures, but to highlight the large disparity, and lack of consensus currently in their management when compared with neck of femur fractures. This inequality in treatment of the two cohorts is perhaps not universally acknowledged. The introduction of the National Hip Fracture Database and Best Practice Tariff has helped to improve care for proximal femur fractures, partly by incentivising, and encouraging standardised care based on the best available evidence. As a result there has been substantial improvements in the care of these patients, and 30-day mortality has been reduced to 8.2% [19]. At present, this standard of care has not been extended to the estimated 7000 fractures per annum of the distal femur in England [2,4] who have a similar demographic and share a similar mortality rate. The principles of early surgery and universal orthogeriatric involvement can easily be applied to the distal femoral cohort, and it is likely that this is already happening as the evolution of fragility fracture continues. However, there are still two main questions that remain unanswered; firstly how to best fix each fracture configuration (and indeed whether it is best to replace rather that reconstruct in some circumstances), and secondly, is it possible to safely weight bear these patients early in order to reduce post operative morbidity and mortality, and increase the proportion of patients returning to their index place of residence. Only prospective, specifically designed studies will be able to address these issues. In conclusion, patients who fracture their distal femur are of the same demographic as those who fracture the proximal part. Whilst there remain unanswered questions regarding best operative treatment, the overriding principles of management should be
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consistent. We feel therefore it is appropriate that patients suffering a distal femur fracture should be accorded the same metrics and standards of care that have been applied to fractures of the proximal femur. Conflict of interest None. Acknowledgement We would like to thank Mr T. Chesser for assistance in editing the final manuscript. References [1] Martinet O, Cordey J, Harder Y, Maier A, Buhler M, Barraud GE. The epidemiology of fractures of the distal femur. Injury 2000;31(Suppl. 3):C62–3. [2] Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury 2006;37(8):691–7. [3] Wahnert D, Hoffmeier K, Frober R, Hofmann GO, Muckley T. Distal femur fractures of the elderly—different treatment options in a biomechanical comparison. Injury 2011;42(7):655–9. [4] Gwathmey Jr FW, Jones-Quaidoo SM, Kahler D, Hurwitz S, Cui Q. Distal femoral fractures: current concepts. The Journal of the American Academy of Orthopaedic Surgeons 2010;18(10):597–607. [5] Nieves JW, Bilezikian JP, Lane JM, Einhorn TA, Wang Y, Steinbuch M, et al. Fragility fractures of the hip and femur: incidence and patient characteristics. Osteoporosis International: A Journal Established as Result of Cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA 2010;21(3):399–408. [6] Butt MS, Krikler SJ, Ali MS. Displaced fractures of the distal femur in elderly patients. Operative versus non-operative treatment. The Journal of Bone and Joint Surgery British Volume 1996;78(1):110–4. [7] Dunlop DG, Brenkel IJ. The supracondylar intramedullary nail in elderly patients with distal femoral fractures. Injury 1999;30(7):475–84. [8] Streubel PN, Ricci WM, Wong A, Gardner MJ. Mortality after distal femur fractures in elderly patients. Clinical Orthopaedics and Related Research 2011;469(4):1188–96. [9] Kammerlander C, Riedmuller P, Gosch M, Zegg M, Kammerlander-Knauer U, Schmid R, et al. Functional outcome and mortality in geriatric distal femoral fractures. Injury 2012;43(7):1096–101. [10] Haleem S, Lutchman L, Mayahi R, Grice JE, Parker MJ. Mortality following hip fracture: trends and geographical variations over the last 40 years. Injury 2008;39(10):1157–63. [11] National Hip Fracture Database; 2013. Available from: www.nhfd.co.uk. [12] National Hip Fracture Database; 2013. [13] Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, et al. Fracture and dislocation classification compendium – 2007: orthopaedic Trauma Association classification, database and outcomes committee. Journal of Orthopaedic Trauma 2007;21(10 Suppl.):S1–33. [14] National Hip Fracture Database – Audit Tool v7. Available from: www.nhfd.co. uk/20/hipfractureR. . ./NHFD%20Audit%20Tool%20v7.doc. [15] Parker MJ, Palmer CR. A new mobility score for predicting mortality after hip fracture. The Journal of Bone and Joint Surgery British Volume 1993;75(5): 797–8. [16] Mahoney FI, Barthel DW. Functional evaluation: The Barthel Index. Maryland State Medical Journal 1965;14:61–5.
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