WIROC 2025 : Salvaging Distal Femur Failures- Dr Chetan Pradhan.

[00:00:06]Thank [music] you, Sangeet.

[00:00:08]Thank [clears throat] you, office bearers of BOS for giving me this opportunity yet again. And I'm going to talk about salvaging distal femur failures.

[00:00:19]So, failure rates across the literature, if you see, are quite significantly high in this fracture, and the revision rates are almost up to 30%.

[00:00:30]If you see the causes, most of them are surgeon dependent.

[00:00:35]And there are three main identified causes which lead to failure which we all as surgeons should be careful about.

[00:00:44]First is the length of your implant.

[00:00:47]Second, of course, the most important is your reduction. And the third very frequent cause is what we just saw, medial defect which is not addressed.

[00:00:59]Now, this was a very landmark paper by Wong et al. 2019 injury, which is level one evidence. It's a systematic review which has analyzed multiple papers across the literature and come up with these recommendations.

[00:01:15]So, if you have more metaphyseal combination, more are the chances of non-unions.

[00:01:21]Especially the last two points, if you see, short plates and medial cortical combination which is more than 2 cm, which is not really addressed.

[00:01:34]So, how do you salvage them?

[00:01:36]These are my strategies to salvage distal fail. So, first thing is correct choice of implant, correct length of the implant, addressing medial wall defects, and then augmenting your fixation with either a bicondylar plating or a nail plate combination.

[00:01:53]And uh quite an impracticable or a costly solution, and that is distal femur replacement, but it can be useful when you cannot reconstruct the articular surface.

[00:02:05]Choice of implant. Now, this was a young dentist treated by her boyfriend who was an orthopedic surgeon.

[00:02:12]Needless to say that they did not end up together.

[00:02:17]I had to revise it with a plate.

[00:02:22]Yes.

[00:02:25]But, to revise her not for anything else, but I revised it with a plate and it healed very well.

[00:02:34]So, today we have a plethora of nails, but if you see this paper, it's about 48, that is 50% malalignment in type C fractures or C type fractures, and mainly it is malrotation, angulation, or shortening because it's difficult to control the small distal fragment, especially in combination. So, choose the right implant. Today, we have all companies providing with multi lock nails with multipolar locking and the locking bolts which lock into the nails.

[00:03:07]Or augments like this along with the nail, which are very much available and therefore make your life easier. Reduction tips, every trick in your textbook or on in the trade.

[00:03:23]Reduce these fractures not in traction or in extension, but in flexion because of the special biomechanics, or use a chance screw or a joystick or bone hooks or whatever you want.

[00:03:36]Assess rotation and length correctly like Sangeet showed in his first case, draping both the limbs together.

[00:03:43]>> [snorts] >> Now, what is the correct nail length? My take on that is chase choose as long as possible. Increase the working length as long as possible. Short nails is equal to failure.

[00:03:56]Also equally important is the distal length of the nail.

[00:03:59]So if you have a fracture like this, it's tempting to put a small nail because you can lock easily proximally, but then longer the better.

[00:04:08]Especially in periprosthetic fractures because you need to span the entire length of the plate the bone. See what happens when you use a short nail. Now let's see these few examples. This was a 1-year-old post-op x-ray patient came unable to walk and he was not willing for another nail. I just told him that we need to use a longer nail and bone graft, but he was not willing for nail because this had failed. So I had to use a plate and a long plate that too and it healed in 1 year.

[00:04:41]Very interesting case.

[00:04:43]4 months after he was operated by the index surgeon, he came with a huge swelling in the mid-thigh, severe pain, unable to bear weight, no infection, all parameters were normal. What do you think this is?

[00:04:58]Sangeet The swelling was here.

[00:05:04]>> Instability, a short nail.

[00:05:06]Uh it is not crossing the isthmus.

[00:05:09]It's a >> No, no, what could be the swelling? We were dumbfounded with that swelling.

[00:05:16]It was a vascular aneurysm, probably iatrogenic. Had to be clipped first and then I revised it with a long plate and bone grafting and it healed.

[00:05:29]What should be the length of the plate?

[00:05:31]Always avoid the short plate syndrome.

[00:05:33]This is the commonest cause of failure in distal femur, especially comminuted ones. Should be minimum nine holes and four bicortical screws, not all locked.

[00:05:44]When you have a comminution like this, textbook mentions that it the plate should be three times the combination.

[00:05:49]So, ideally it should extend here. So, even if you are doing a MIPO, this was a MIPO done and this healed predictably well in 6 months. That's the function.

[00:05:59]Look at this.

[00:06:01]First failure, 6 months post surgery, the plate broke.

[00:06:05]So, the surgeon revised with this plate.

[00:06:07]What will happen to it?

[00:06:10]This broke at 4 and 1/2 months.

[00:06:14]And I had to revise it with a still longer plate and bone graft. And this is 1 year post second revision. It healed.

[00:06:23]Look at this.

[00:06:25]Short plate fixed in varus because of combination.

[00:06:28]It's a too rigid construct. All the proximal screws are locking screws.

[00:06:33]And it predictably failed.

[00:06:35]So, this is when I revised it to another long plate.

[00:06:40]Used two principles here of absolute stability. So, interfragmentary along with a long neutralizing plate and bone grafting. And it heals at 1 year post revision.

[00:06:53]So, in a spiral fracture like this, I would not hesitate to use as long a plate like this along with some interfrags. And it heals very well.

[00:07:02]Now, the medial wall. It is clearly established now that if you have a more than 2 cm defect, you either need to use a fibular strut graft like the Nasser said or a medial plate with a graft or any of the techniques like a cage, allografts, etc. Look at this. 3B open.

[00:07:21]Typically, this is what happens. A telescopic reduction, lateralization of the shaft, and a golf club deformity what Sangeet showed.

[00:07:30]So, again, a 3B open.

[00:07:32]You could use this is a floating knee.

[00:07:36]I used a fibular strut from the same side.

[00:07:39]And it healed well in 1 year.

[00:07:44]But, don't do this. Now, this was a 37-year-old engineer who came to me like this, almost about to fail.

[00:07:51]So, I revised it with a dual plate and a fibula double-barrel fibula.

[00:07:57]And he was quite okay, but at 6 months this was the picture. I was not really happy with it. He was walking with a stick.

[00:08:04]I waited, did nothing. At 1 year, he came back again walking with a limp. He was still okay, but I was not because this was loosening. So, I re-revised it with another medial plate and more bone graft. And this is his picture at 6 months.

[00:08:20]So, when do you do a primary medial fixation when you have a medial defect or very severely low porotic fractures, nonunions, and periprosthetic low fractures? So, if you have a bad bone with so little such a low fracture, do this medial fixation primarily. And it heals well. And it's been very well described through a single incision, you can do this.

[00:08:41]Infected nonunion, implant removed, debrided, stimulan used with cultured antibiotic.

[00:08:49]This is 2 months post-op and a dual plating done with bone graft. So, dual plate is my go-to strategy when uh I'm dealing with revisions. This is 1 year post-op.

[00:09:03]And this is at 2 years post-op.

[00:09:07]Another similar uh infected, debrided, implant removed, dual plating, bone grafting, and result at 1 year.

[00:09:18]Usually does not fail when you plate on both sides and bone grafted. This is 3 months post-op. Anything going wrong there?

[00:09:30]This is what happened at 6 months. All the distal screws failed. 75-year-old porotic lady. I would have used a a very long plate in this case. At 8 months, this was the situation. So, I had to revise again with the same principle, dual plate, bone graft, and healed at 1 year.

[00:09:48]Sometimes, even the dual plate fails.

[00:09:51]Now, this was done uh and it in a trivial fall, this failed.

[00:09:57]I did the same thing again with bone grafts, a lateral longer plate, and it healed in 1 year. This is a combination of allograft with um No, this is only an allograft. No No iliac crest.

[00:10:11]And it worked.

[00:10:13]So, instead, when you can also use a nail plate technique, it has been described by Lipo Rachi and works well when there is not a huge medial defect.

[00:10:27]For example, this was a chain smoker. At 3 months post first revision done elsewhere, he still had pain.

[00:10:35]I told him to wait, do nothing, but at 6 months, he still had a warmth, and now it was infected. CRP 300, HBA1C uncontrolled. So, I did implant removal.

[00:10:46]The patient was not willing for another plate because two previous plates had failed or ring, which was my plan. A ring meaning LRS.

[00:10:55]So, I had to then This was at 2 months. Infection had settled down. Sugars were under control.

[00:11:01]So, I used a long nail with a plate, and it healed. This is at 6 months, and this is at 2 years.

[00:11:09]So, to conclude, to salvage your distal femur failures, use a longer plate, address your medial wall defects, and augment your fixation using either a dual plate or a nail plate.

[00:11:24]Distal femur replacement is an option with a customized implant. Personally, I have No, not much experience in it.

[00:11:33]Thank you.