INTRODUCTION

Background

Intra-articular fractures of the distal femur are devastating injuries because they involve the largest joint in the human body. These fractures are characterized by fragmentation of the weight-bearing surface of the joint, particularly in AO/OTA type C fractures, which shatter the proximal bone of the knee joint. The medial metaphyseal area of the distal femur is also affected [1].

Distal femur fractures account for approximately 4% to 6% of all femoral fractures and less than 1% of all fractures overall. Despite their relatively low frequency, these injuries are often associated with considerable morbidity and mortality [2]. In younger populations, distal femur fractures typically result from high-energy trauma, whereas in elderly individuals, they more commonly arise from low-energy mechanisms such as simple falls or minor trauma [3].

Historically, management of these fractures involved the use of a retrograde femoral nail and a dynamic condylar screw with a side plate. However, a new standard has emerged in the form of an anatomically contoured locked plate [4].

A nail can stabilize a distal femur fracture with metaphyseal comminution to achieve indirect reduction and bridging. Notably, however, this device cannot provide stability for articular multifragmentary fractures due to its limited number of fixation anchors [5]. To address this limitation, surface implants are a superior choice, with the anatomically contoured distal femoral lateral locked plate (DFLLP) being the most popular option for such fractures. This implant enables direct reduction and rigid fixation of the fracture, avoiding the secondary loss of anatomical reduction seen with traditional compression plates [6,7].

Nevertheless, the use of a locked plate on the lateral aspect alone is associated with complications, including varus deformity of the limb with medial collapse, nonunion, and fixation failure. Several studies have reported nonunion and fixation failure rates as high as 20% to 25% [8–10].

Due to the eccentric placement of the plate on the lateral surface, distal femur fractures with medial comminution at the metaphysis may result in deformity. Fractures around the joints, particularly intra-articular fractures, should heal via primary bone healing without callus formation. Articular fragment reduction and rigid fixation are the established principles for periarticular fracture management. Without robust support and rigid fixation, periarticular/intra-articular fractures may deform, resulting in nonunion. Inadequate medial buttressing of fractures with medial comminution and an articular multifragmentary nature can contribute to nonunion and implant dislodgement. This can further precipitate deformation of the bone-implant construct in any plane, leading to a slower healing process, implant loosening, nonunion, and compromised limb function [11].

Objectives

The purpose of this study was to assess the effectiveness of the dual plate concept in failed cases of distal femur fractures that were previously managed with a lateral locked plate alone. Clinical, functional, and radiological outcomes were evaluated following revision surgery.

METHODS

Ethics statement

The study was approved by the Institutional Ethics Committee of All India Institute of Medical Sciences, Jodhpur (No. AIIMS/IEC/2021/3670). Written informed consent for publication of the research details and clinical images was obtained from all participants in the study.

Study design and patients

This study was conducted as a prospective case series after obtaining ethics approval. A cohort of patients with nonunion of distal femur fractures after failed previous surgery presented to us intermittently for subsequent management. All patients had undergone primary surgery at other healthcare centers in the form of open reduction and internal fixation with DFLLP application. These cases of nonunion were scheduled for revision surgery.

Patients with nonunion of distal femur fractures following initial management with a single DFLLP were included in the study. Patients with bilateral lower limb injuries, neurovascular injuries to the limbs, any concomitant fractures of the pelvis or spine, fractures in the same limb other than distal femur fractures, pathological fractures, or previous head injuries were excluded. Patients who did not complete at least 1 year of follow-up after the last surgical procedure were also excluded from the analysis.

Nonunion was defined as the presence of pain at the fracture site, difficulty walking, or inability to bear weight on the affected limb, accompanied by radiographic evidence of a lack of bridging bone across at least 50% of the bone diameter at the fracture site in two orthogonal views.

Before revision surgery, patients were assessed regarding their surgical history, duration of injury (time from injury to revision surgery), and current functional status of the limb. Previous radiographs were obtained, and each fracture was classified using the AO/OTA classification of long bone fractures (Table 1).

Preoperative evaluation included the use of the limb visual analog scale (VAS) and the Tegner Lysholm Knee Scoring Scale (LKS) [12], along with clinical examination of the limb. Radiological assessments, including x-rays and noncontrast computed tomography scans, were performed to evaluate the presence of nonunion, limb deformity, and implant integrity (Fig. 1A–D).

After completing all necessary assessments and obtaining written informed consent, all patients underwent revision surgical intervention to address the bony nonunion using a dual plating approach. A new 5.0-mm DFLLP was applied in conjunction with a 4.5-mm T-plate on the medial side.

Revision surgery

Twenty-four aseptic nonunions of the distal femur with DFLLP in situ were accessed via a lateral parapatellar approach under spinal anesthesia by a team of three to five orthopedic surgeons, and the loosened implant was extracted (Fig. 1E, F). Marginal freshening of the nonunited fracture was performed, and any fibrous tissue was removed. After correcting the misalignment of the limb, a new 5.0-mm DFLLP was applied. To support the medial column, a 4.5-mm T-buttress plate was fixed on the medial side through a separate incision in the knee, passing medial to the vastus medialis muscle. The nonunion site was filled with an autologous cancellous graft obtained from the iliac crest, along with morselized fresh frozen allograft. The allograft was liberally used to fill the bone gap at the nonunion site after excision of all fibrous tissue, while the autologous cancellous bone provided osteogenic activity. For three cases in which the original lateral locking plate was unbroken and unbent, the plate was retained by placing new cancellous locking screws in new trajectories after shifting the plate anteriorly or posteriorly to achieve purchase in new cancellous bone in the femoral condyle, along with the addition of a supplementary medial T-plate (Figs. 2, 3).

Re-revision surgery

After revision surgery, cases showing delayed union and poor or nonhealing of bone on follow-up radiographs were considered for additional procedures. These procedures involved repeat placement of an autologous cancellous bone graft from the iliac crest at the nonunion site.

Two-stage surgery for infected nonunions

Infected nonunions, which presented with local discharge and sinuses, were managed in a staged manner. In the first stage, the infected area was debrided along with the application of antibiotic-impregnated bone cement combined with dual plating. All patients in this group tested positive for methicillin-resistant Staphylococcus aureus and received our standard antibiotic protocol of intravenous linezolid 600 mg twice a day for 6 weeks, followed by oral linezolid at the same dose and frequency for an additional 6 weeks. In the second stage, at around 10 to 12 weeks, when the patient exhibited no signs of infection and all sinuses had healed, the infection was considered resolved, and re-revision surgery was performed to remove the bone cement and perform bone grafting.

Follow-up after surgery

Regular follow-up appointments were scheduled for all patients at 6 weeks, 3 months, and every 6 months thereafter. At each visit, physiotherapy—including range-of-motion exercises and isometric knee exercises—was encouraged. Serial radiographs of the knees were obtained during each visit to evaluate bony union, implant positioning, and limb alignment. After 1 year following the last surgical procedure, a functional assessment of the limb was conducted using the LKS, and pain was evaluated using the VAS score. Additionally, the limbs were assessed for any residual deformities, limb length discrepancy, and range of motion.

LKS score was used to assess all patients. The scale ranges from 0 to 100 and is based on eight domains: pain, support needs, instability, locking, swelling, limping, stair climbing ability, and squatting ability. A score of ≥75 indicated a good outcome, a score of ≥70 to <75 was considered fair, and a score of <70 was classified as poor. Limb pain was evaluated on a VAS score from 0 to 10.

Statistical analysis

Data were collected before revision surgery and after at least 1 year of follow-up following the last surgical procedure. The paired t-test was used to analyze data on deformities, while the Wilcoxon signed rank test was employed to evaluate functional scores and limb VAS scores. A P-value of less than 0.05 was considered to indicate statistical significance at a 95% confidence level. Statistical analyses were conducted using SPSS ver. 15.0 (SPSS Inc).

RESULTS

Assessment of patients before revision surgery

Initially, this study included 31 patients (25 men and 6 women) consecutively presenting to our outpatient clinic with nonunion of distal femur fractures with a lateral locked plate in situ. Four patients were excluded from the final evaluation due to insufficient follow-up (less than 1 year), leaving 27 patients (22 men and 5 women) for outcome assessment following revision surgery with dual plates. Most patients (81.5%) were between 25 and 50 years old, with a mean age of 38.6 years. Approximately 96% of the nonunion fractures were originally classified as AO/OTA type 33C2 or 33C3; these involved multifragmentary components and were therefore categorized as complex fractures (Table 1).

In most cases, a bone gap was observed at the anterior and medial aspects of the metaphyseal area following the index procedure. In 19 cases (70.4%), callus formation was absent, indicating atrophic nonunion; the remaining 8 cases (29.6%) exhibited oligotrophic nonunion.

A majority (22 patients, 81.5%) sought medical intervention within 12 months following index surgery, with a mean nonunion duration of 8.9 months since injury. Additionally, seven patients (25.9%) were active smokers, and four patients (14.8%) were diagnosed with diabetes.

Most fractures (23 of 27, 85.2%) were classified as closed injuries at the time of primary injury, while a minority (4 of 27, 14.8%) had a history of open injury. Retrospective analysis of previous surgical interventions and patient medical histories revealed that five patients (18.5%) experienced infections following primary surgery; however, as of the current assessment, only three patients (11.1%) exhibited active infections.

In 24 cases (88.9%), breakage or bending of the original implant was observed, while the remaining 3 (11.1%) displayed loosening at plate-screw and screw-bone interfaces (Table 2). All patients exhibited varus deformity of the knees, with measurements of 5° in 3 cases, 6°–10° in 6 cases, 11°–15° in 10 cases, and greater than 15° in 8 cases compared to the contralateral side. Functional assessment revealed that all patients had LKS scores below 70 (median, 30; range, 12–67), with a median limb VAS score of 6 (range, 4–8).

Assessment of patients after revision surgery

The final follow-up period had a mean duration of 15 months (range, 12–18 months) after the last surgical procedure. Following revision surgery, bony union was achieved in 20 of 24 aseptic nonunions (83.3%), with a mean healing time of 22.5 weeks (range, 15–27 weeks). The remaining four (16.7%) showed a poor bone healing response on radiographs, with no initiation of callus formation observed on any plane even 4 to 5 months after revision surgery; these cases were considered revision failures. All of these patients subsequently underwent repeat cancellous autografting at the nonunion site, after which bony healing was achieved with a mean healing time of 30.25 weeks (range, 27–32 weeks).

The three infected nonunions (11.1%) were treated with two-stage management. In the first stage, debridement, fracture stabilization, and application of antibiotic-impregnated bone cement were performed. After 8 to 10 weeks, once the infection had resolved, bone cement was removed, and bone grafting was conducted. Bony union was achieved in all these cases, with a mean fracture healing time of 33.6 weeks following first-stage surgery.

Overall, bony union was successfully achieved in all patients (after re-revision and second-stage surgery), with substantial graft consolidation observed at the fracture site (Fig. 4). At final follow-up, the integrity of the implant assembly remained intact, with no new deformities or infections.

In this series, 6 of 27 cases (22.2%) ultimately exhibited limb shortening, predominantly ranging from 1 to 4 cm, with an average shortening of 2.3±1.0 cm. Knee varus deformity of ≤5° was observed in 7 patients (25.9%) and of 5°–8° in 12 patients (44.5%), while no coronal plane deformity was noted in the remaining 8 patients (29.6%). Correction of varus deformity yielded a statistically significant difference (P<0.001), as shown in Table 3.

At final assessment, all patients were ambulatory, with an average knee range of motion of 80° (range, 40°–120°). The LKS score outcomes were favorable in 20 cases (74.1%), fair in 5 cases (18.5%), and poor in 2 cases (7.4%). The improvement in the LKS score after revision surgery was highly significant (P<0.001). The mean VAS score was 3 (range, 1–6), and its improvement was also statistically significant (P<0.001), as shown in Table 3.

DISCUSSION

This study highlights the issues of failure and nonunion in distal femur fractures with intra-articular involvement, specifically AO/OTA type C fractures treated solely with a lateral locking plate. It also emphasizes the successful repair of these nonunions using a dual plate approach. Like fracture repair of the distal humerus and proximal tibia, for which dedicated dual anatomical locked plates are standard, distal femur fracture nonunions can be effectively managed using a dual plate (medial and lateral) approach. However, unlike other sites, distal femur fractures generally lack dedicated medial plates. Thus, in this study, the combination of a DFLLP and a supplementary medial T-plate was used to stabilize the nonunion by securing the fracture from the medial and lateral sides.

Fractures classified as AO/OTA type C involve extensive articular surfaces, which are critical for transmitting body weight through the knee joint. The degree of bony comminution in these fractures may vary, affecting the articular region, the metaphyseal region, or both, depending on the nature of the injury [13].

Since the introduction of locking plate technology, the management of intra-articular and periarticular fractures has significantly improved in terms of restoring limb function. Although not always required, anatomically contoured locked plates are available for various anatomical locations. The locking design operates on the principle of angular stability at the screw-plate interface, as opposed to the traditional method of compressing the plate against the bone [14]. The lateral locking plate for distal femur fractures is a fixation construct with angular stability that can secure most fracture fragments at the lower end of the femur. However, as a surface implant placed eccentrically on the bone, this device is limited in its capacity to address medial metaphyseal and/or epiphyseal comminution. This limitation has been associated with fixation failure and nonunion with subsequent deformities, as reported in several studies with nonunion rates as high as 30% [15–17].

Research has identified various factors contributing to fixation failure in AO/OTA type C fractures managed with a DFLLP. These include open fracture, diabetes mellitus, smoking, elevated body mass index, fragility fracture, and shorter plate length [9,18]. Other studies have suggested that fixation failure is primarily attributable to intra-articular fractures with a sagittal oblique orientation, Hoffa fractures, and malreduction in the coronal plane [19].

Revision surgery is the most frequently recommended procedure for treating distal femur nonunions following primary management. Techniques used during revision surgery include revision of the lateral locking plates, debridement of the surgical site, decortication, additional bone grafting, and/or the application of biological materials. Some studies have also explored the use of allogenic bone pegs on the medial side of the distal femur to reinforce the medial pillar of the bone. These revision procedures have demonstrated varying outcomes, with union rates ranging from 57% to 100% across multiple reports (Table 4) [20–30].

Double implant placement, especially in the setting of periprosthetic distal femoral fractures and fragility fractures, has been reported in multiple notable studies. Saxena et al. [26] described successful bony union in 10 distal femur nonunions using a nail-plate construct in revision surgery, achieving union in a mean time of 10.3 months; these cases had previously been managed with either nails or plates using a single implant.

Passias et al. [31] managed 97 cases of distal femoral fractures using a nail-plate combination in eight cases, lateral plating in 67 cases, and retrograde intramedullary nailing in 22 cases, reporting a 100% union rate in the double implant group compared to only 69% in the standalone device group. In another study, fixation using a nail-plate combination (27 cases) was compared with a standalone lateral plate group (40 cases), and the union rate was reported as 100% in the nail-plate group versus 72.5% (29 of 40) in the standalone group. The latter group experienced a nonunion rate of 27.5% (11 of 40), with hardware failure in 17.5% (7 of 40) [32].

In contrast to the nail-plate combination, the literature on the use of double or dual plating for managing distal femoral nonunions is sparse, with only a few reports. One study investigated the treatment of 20 cases of aseptic nonunions of distal femur fractures, including 18 atrophic and 2 oligotrophic nonunions; most (78%) were classified as AO/OTA type A fractures. Patients were treated with medial augmentation plating and bone grafting, resulting in a union rate of 90% [27]. Similarly, Lee et al. [28] utilized medial supplementation with a T-plate in 15 cases and reported a union rate of 93% with one case of persistent nonunion.

Fragility fractures in the elderly population pose challenges for fixation due to compromised bone quality, often contributing to construct failure and subsequent bone nonunion. Repeated surgical interventions further exacerbate bone stock depletion. In cases with nonrepairable and nonsalvageable distal femur fractures, prosthetic solutions have shown promising results. Haidukewych et al. [29] reported outcomes for 17 patients with distal femur nonunion who were managed using total knee arthroplasty (modular hinged distal femoral arthroplasty), with a revision-free survival rate of 91% at 5 years and substantial improvement in Knee Society pain scores. Similarly, Vaishya et al. [30] described favorable outcomes in eight cases of resistant nonunion in elderly patients treated with mega-prostheses, with significant functional improvement and survival of all prostheses over 4 years.

The intra-articular nature of distal femur type AO/OTA 33C fractures typically precludes callus formation, necessitating absolute reduction and rigid fixation for optimal healing. In contrast, metaphyseal regions should exhibit significant callus formation. The excessive flexibility of the implant-bone construct in highly unstable intra-articular fractures may lead to implant loosening, fixation failure, and fibrotic tissue formation in the fracture gap.

In the present study, revision surgery involved excision of nonvascularized and fibrotic tissue, filling of the bone void with autograft and allograft, and fixation of the fracture using dual plates as a double implant. A bone gap or void at the metaphyseal level with varus collapse of the construct was consistent across all cases. Contrary to previous research [18], we did not encounter any nonunion due to fixation failure in the proximal fragment of the femur; therefore, the length of the plate appeared to be of less value for these fractures.

During revision surgery for such nonunions, the distal fragment typically exhibits poor bone stock due to deformity, bone gap, disuse osteopenia, and preexisting hardware. Achieving robust fixation is quite challenging. In such cases, the dual plate concept provides a salvage procedure that accomplishes sturdy fixation and facilitates subsequent fracture repair (Fig. 5). Moreover, this revision procedure enables correction of the limb deformity at the nonunion site. In the present study, achieving union (done in 20 of 24 aseptic nonunions, 83.3%) and correcting the deformity resulted in significant improvement in functional outcomes, as evidenced by statistically significant improvements in LKS and VAS scores. However, despite the application of this principle, some candidates required additional surgery to stimulate the bone healing process. Although these outcomes are slightly inferior to those reported in separate studies by Lotzien et al. [27] and Lee et al. [28], the difference in successful outcomes is minimal. This study also involved AO/OTA type C fracture nonunions with poor bone stock in the anterior and medial metaphyseal regions, which required a large amount of allograft to provide an osteoconductive environment. Moreover, some participants were smokers, and smoking abstinence could not be ascertained. The study also included some cases of infected nonunions, which required additional surgical interventions to achieve bony union.

Infected nonunions require a staged surgical approach, beginning with initial debridement, fracture stabilization, and the application of antibiotic-laden bone cement to eradicate infection. The creation of a stable fracture environment, combined with prolonged local antibiotic delivery, facilitates the resolution of the bone infection, even if bony union is not immediately achieved. The second stage of surgery aims to promote bone healing by introducing osteoconductive and osteoinductive materials into the fracture site, thereby enhancing the biological environment for bone regeneration.

This study highlights the effectiveness of a DFLLP combined with a T-plate on the medial side as a dual plate concept for managing distal femoral nonunions. Distal femur fractures that failed when treated with a lateral locking device alone can be successfully managed through revision and addition of a supplementary T-plate for medial augmentation. The addition of allografts and autografts further enhances stability, improves fracture biology, and promotes bone union while restoring limb function. Furthermore, the study demonstrates that distal femoral fractures classified as AO/OTA type C, particularly those with medial metaphyseal comminution/bone gap, are inherently unstable and have a higher risk of fixation failure when managed with a lateral surface implant alone. To ensure optimal stability and successful outcomes, these fractures should ideally be treated during the initial procedure using dual plating with medial augmentation.

Limitations

This study has several limitations, including a small sample size and the absence of a control group. Furthermore, the heterogeneity of nonunion cases necessitates caution in interpreting the findings. Future research involving larger, more homogeneous cohorts and controlled studies is essential to establish more definitive conclusions.

Conclusions

Dual plate application effectively addresses fixation failure and nonunion in complex distal femoral fractures with intra-articular extension. In some cases, additional surgical intervention involving repeated bone grafting may be necessary to expedite fracture repair.

ARTICLE INFORMATION

Author contributions

Conceptualization: NB, AE; Data curation NB, GG, AE; Formal analysis: GG, SB, NG; Investigation, Methodology: NB; Project administration: NB, NG; Visualization: AR; Resources: AR; Software: AR; Writing–original draft: NB; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data analyzed in this study are available from the corresponding author upon reasonable request.

Fig. 1.

Preoperative imaging and intraoperative picture of distal femur nonunion and broken lateral locked plate. (A–D) Radiograph and computed tomography scan of distal femur nonunion with lateral locked plate in situ. The arrows point toward bone gaps in the coronal and sagittal sections. (E, F) Broken distal femur lateral locked plate (arrow) with intraoperative picture.

Fig. 2.

Intraoperative image while applying lateral 5.0 mm distal femoral lateral locked plate and a supplementary 4.5-mm T-plate on the medial side (yellow arrow) with plenty of morselized allograft and autograft placement (white arrow) in the fracture gap in a case of distal femur nonunion.

Fig. 3.

Intraoperative image while applying a supplementary medial T-plate (arrow) in a case of distal femur nonunion.

Fig. 4.

Distal femur x-ray showing the full union of the distal femur fracture with restoration of normal bone anatomy following a dual plating approach. (A) Anteroposterior view. (B) Lateral view.

Fig. 5.

Radiograph images of a revision surgery case. (A, B) Radiograph of a distal femur fracture showing fixation failure, implant breakage, fracture deformation, and subsequent nonunion following a single lateral locked plate. (C, D) Immediate postoperative radiographs following a revision surgery with dual plating and bone grafting. (E, F) The radiograph shows a complete bony union without deformity after the final follow-up.

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Figure & Data

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