Distal Femoral Fractures: the Need to Review the Standard of Care

Home , Femoral fracture

Injury, Int. J. Care Injured 46 (2015) 1084–1088

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Injury

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Distal femoral fractures

The need to review the standard of care

a, a b c

James R.A. Smith *, Ruth Halliday , Alexander L. Aquilina , Rory J.M. Morrison ,

d b d c

Grace C.K. Yip , John McArthur , Peter Hull , Andrew Gray ,

Michael B. Kelly Collaborative - Orthopaedic Trauma Society (OTS)

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

Department of Orthopaedics, Addenbrooks Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road,

Cambridge CB2 0QQ, United Kingdom

A R T I C L E I N F O A B S T R A C T

Article history: Background: Hip fracture care has evolved, largely due to standardisation of practice, measurement of

Accepted 19 February 2015

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

Keywords: this population has not had the same emphasis. This study deﬁnes the epidemiology, current practice

Distal femoral

and outcomes of distal femoral fractures in four English centres.

Fracture

Patients and methods: 105 patients aged 50 years or greater with a distal femoral fracture, presenting to

Femur

four UK major trauma centres between October 2010 and September 2011 were identiﬁed. Data was

Supracondylar

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.

Introduction frequently having multiple comorbidities [5] this low energy

fracture can result in multiple complications. Mortality at 30 days,

Fractures of the distal part of the femur account for 3–6% of all six months and one year have been reported previously as 6%, 17–

femoral fractures [1–3]. There is a small incidence following high 18%, and 18–30% respectively, with ﬁve year mortality as high as

energy trauma in the younger population, but this is predomi- 48% [6–9]. These ﬁgures are similar to published mortality rates for

nately a low energy fracture in the elderly, commonly sustained proximal femoral fractures [10,11].

after a fall from standing height [2,4]. With the elderly cohort 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

* Corresponding author.

E-mail address: [email protected] (James R.A. Smith). throughout the country, leading to an improved patient

http://dx.doi.org/10.1016/j.injury.2015.02.016

J.R.A. Smith et al. / Injury, Int. J. Care Injured 46 (2015) 1084–1088 1085

Table 1

experience, and lower morbidity and mortality rates [12]. These

Patient demographics.

beneﬁts however have not yet been extended to patients with a

Number 105

fracture of the distal part of the femur.

Mean age (yrs) 77

The main focus of the current literature for distal femoral

Age range (yrs) 50–99

fractures is on biomechanics of ﬁxation methods, surgical

Gender Male 11 (14%)

technique and new implant technology. Peri-articular anatomical

Female 65 (86%)

locking plates are becoming the accepted standard in the

Unknown 29

treatment of these fractures, with retrograde intramedullary

Side of injury Left 52 (50%)

nailing (rIMN) and distal femoral replacement used for some

Right 48 (46%)

fracture conﬁgurations. At present there is no consensus on how to

Bilateral 5 (4%)

treat these difﬁcult injuries, or how to manage these patients post-

Open fracture? Yes 4 (4%)

operatively. The current approach towards weight-bearing and

No 101 (96%)

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

Table 2

fractures in patients aged over 50 years in England.

Pre-morbid ambulatory ability.

Pre-morbid ambulatory Regularly walked without aids 46%

ability Regularly walked with one aid 13%

Patients and methods

Regularly walked with two aids or frame 28%

Wheelchair or bed bound 13%

Patients who presented to each of four major trauma centres

(Frenchay Hospital, Bristol (FH); Addenbrooke’s Hospital, Cam-

bridge (AD); Royal Victoria Inﬁrmary, Newcastle (RVI); University

Hospital, Coventry (UHC)) with a fracture of the distal femur Treatment

between October 2010 and September 2011 inclusive were

identiﬁed. Plain anteroposterior and lateral radiographs from Seventy-two percent of the total distal femoral fractures were

admission were assessed by a senior orthopaedic surgeon at each 33-A1 or 33-C1 type (Fig. 1). Two-thirds (69%) of the patients were

centre, and classiﬁed using the AO-OTA system [13]. Fracture admitted directly to an orthopaedic ward from Accident and

pattern types 33-A,B and C were included in the study. Patients Emergency, and 6% were not admitted to an orthopaedic ward

aged less than 50 years of age were excluded. A retrospective during their inpatient episode. The initial treatment plan was

review of operative records, inpatient hospital notes, and operative in 82% of cases, occurring at an average of 2 days post

outpatient appointment letters was performed for each patient admission (mode 1 day, range 0–18), with 86% having their surgery

at their study centre. Data was collected on a standardised within 36 h. Reasons for delay are detailed in Table 3. A further two

spreadsheet adapted from the National Hip Fracture Database cases required operative intervention after failed conservative

Audit Tool [14]. Pre-morbid mobility was assessed using the Parker management.

and Palmer Mobility Score [15], and Barthel Index [16]. Patient Seventy-one percent of operative procedures involved an open

mortality was recorded at 30 days, four months, six months and reduction and internal ﬁxation using a plate and screws, though

one year. Data was collated and analysed using descriptive the mode in which the plate was used varied (Fig. 2). Intraoperative

statistics by the lead investigators. 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 post-

Results operative complications (Table 4).

Patient demographics Rehabilitation

A total of 105 patients were identiﬁed (FH 26, AD 28, RVI 22, The majority of patients were mobilised non-weight-bearing

UHC 29). This comprises 6% of femoral fractures, when the total (51%), with 18% touch-weight-bearing, 17% partial weight-bearing

number of proximal femoral fractures entered to the NHFD is and 14% full weight-bearing. Of note, there was no excess of

considered (may represent a very small overestimate as no data is complications of ﬁxation associated with less restrictive practices

available for diaphysial injuries). Eighty-six percent of the in terms of permitting weight-bearing. Physiotherapy and

patients were female and the mean age was 77 years (median occupational therapy were provided in 78% of patients, and 45%

80 years, range 50–99) (Table 1). Ninety-ﬁve percent of injuries were seen by an orthogeriatrician during their admission. It was

occurred due to a low energy mechanism, and 96% were closed. not possible from the case notes to accurately determine the

Periprosthetic fractures occurred in 34% of cases, and 6% were number of patients who received a specialist falls assessment or

considered to have a pathological aetiology other than osteopo- reviewed for suitability of bone protection medication. No patient

rosis. The majority of patients were admitted from their own had a post operative Abbreviated Mental Test Score documented.

home, or sheltered housing. 10% were admitted from either a The assumption is that these factors were not a priority in their

nursing or residential home, 4% from a rehabilitation unit, and 7% management

sustained their injury whilst already in hospital. Forty-six percent

of patients walked regularly without aids (Table 2). The Parker Discharge and mortality

Mobility Score and The Barthel Index were only ascertainable in

57% and 52% of cases respectively. Patients had a mean Parker Mean length of stay was 29 days (range 0–137 days). Seventy

Mobility Score of 5.37 (range 0–9), and a mean Barthel Index of percent of patients were seen following discharge in fracture clinic

75.5 (range 0–100). Mean abbreviated mental test score (AMTS) (range 55–82%). Discharge destination is shown in Table 5. Thirty

[17] on admission was 6.75, but only performed on 19% of day, 6 month, and 1 year mortality rate was 7%, 16% and 18% patients. respectively (Table 6).

1086 J.R.A. Smith et al. / Injury, Int. J. Care Injured 46 (2015) 1084–1088

Fig. 1. AO/OTA fracture classiﬁcation.

Table 3

Court Brown et al. [2]. This discrepancy may reﬂect error in the use

Delay to surgery.

of the classiﬁcation system, differential use of computer tomogra-

No delay (surgery within 36 h) 52

phy to deﬁne fractures, or an actual difference in the types of

Medically unﬁt – awaiting orthopaedic investigation/review 2

fracture affecting populations from different geographical loca-

Medically unﬁt – awaiting medical investigation/review 2

tions.

No theatre space 1

Problem with theatre staff cover 1 When compared to data on fractures of the proximal femur

Other 4 using a National dataset [19], the patients studied in this cohort are

Unknown 26

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

Discussion admitted from their own home or sheltered accommodation

compared with 75% in the proximal femoral group. There was a

This cohort of patients was similar across the centres and younger mean age in the distal femur cohort, with nearly half of all

shared similar demographics to previous distal femoral fracture proximal femur patients being in their eighties. This could be

studies [2,8,9,18], including fracture type. AO-OTA 33-A1 and 33- explained by the inclusion criteria being patients aged 50 years or

C1 type accounted for 72% of the fractures seen. There was an greater. Fifty years was deemed appropriate as women and men of

intraarticular involvement in 36% of fractures, echoing the ﬁndings this age are at a greater risk of a fragility fracture, as outlined by the

of a recent French cohort [18], but lower than the 55% suggested by 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 1087

Table 4

may be satisfactory, and in fact sufﬁcient to out survive the patient

Post operative complications.

[33]. However, high morbidity, mortality and complication is been

Primary operation reported [33–35]. The current study was not designed to detect

differences between implants, or recommend best treatment

Hardware failure 4 3 ORIF, 1 Unknown

Deep wound infection 3 3 ORIF modality, but to serve as an accurate demographic appraisal of the

Superﬁcial wound infection 3 2 ORIF, 1 IM nail current population and their management.

Non-union 2 2 ORIF

A current limitation in the treatment of distal femoral fractures

Bleeding 1 Unknown

is the reluctance to weight bear patients early. Whilst maintaining

Malunion 1 Unknown

the reduction is paramount to healing, restoration of mobility is

Thromboembolic 1 Unknown

Prominent metalwork 1 ORIF important in the prevention of complications. Accepted practice

Peri-prosthetic fracture 1 rIMN

has been to not weight-bear patients, but this recommendation is

Other 3 3 Unknown

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. Howev-

Table 5

er, this remains centre speciﬁc, and the majority (51%) of patients

Discharge destination from Trust.

are still rehabilitated non weight-bearing. Ehlinger et al. [29] have

Another acute hospital 1 (1%)

outlined criteria for extra-articular fractures treated with a fully

Nursing care 10 (10%)

locked plate under which they will fully weight-bear a patient

Residential care 3 (3%)

post-operatively, however they emphasise in their review article

Rehabilitation unit 9 (9%)

Own home/sheltered accommodation 41 (39%) [21] that the quality of surgical technique is the primary factor and

Died 6 (6%) only guarantee of obtaining good radiological and clinical results.

Other 2 (2%)

The optimal weight-bearing strategy is still not clear but it is likely

Unknown 33 (31%)

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.

Table 6

This study has several limitations, which may be eliminated

Mortality.

with a prospective observational trial. Retrospective data collec-

30 days 7 (7%)

tion from patient notes results in missing data, thereby reducing

6 months 16 (16%)

the total number for analysis for some areas of the study. Whilst

1 year 18 (18%)

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

Table 7

was used to minimise this, however some aspects may still have

Patient demographic compared with NHFD 2013.

been open to interpretation.

Distal femur NHFD 2013 This paper demonstrates the similarity between the popula-

tions who sustain a fracture of the distal and proximal end of the

Age Mean 77 yrs 22% 70–79 years

48% 80–89 years femur. It was not our aim to provide recommendation on best

Sex 86% female 74% female practice when treating distal femoral fractures, but to highlight the

Admitted from home/ 79% 75%

large disparity, and lack of consensus currently in their manage-

sheltered housing

ment when compared with neck of femur fractures. This inequality

Walking without aids 46% 46%

in treatment of the two cohorts is perhaps not universally

AMT score Mean 6.75 58% 7–10, 30% 0–6,

12% unknown 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

however provides data on patients from 65 years. The mean age of there has been substantial improvements in the care of these

the current cohort increases to 82 years when patients aged patients, and 30-day mortality has been reduced to 8.2% [19]. At

between 50 and 65 are excluded. present, this standard of care has not been extended to the

The majority of patients with a distal femoral fracture in this estimated 7000 fractures per annum of the distal femur in England

cohort were treated operatively (82%), reﬂecting the recommen- [2,4] who have a similar demographic and share a similar mortality

dations of Butt et al. [6], who report signiﬁcantly improved rate. The principles of early surgery and universal orthogeriatric

outcomes and fewer complications associated with operative involvement can easily be applied to the distal femoral cohort, and

treatment of distal femoral fractures when compared with it is likely that this is already happening as the evolution of fragility

conservative management. This is lower than the 97.6% of patients fracture continues. However, there are still two main questions

who are treated operatively following proximal femoral fractures that remain unanswered; ﬁrstly how to best ﬁx each fracture

[19]. Fracture ﬁxation was predominantly with anatomical peri- conﬁguration (and indeed whether it is best to replace rather that

articular locking plates, and a smaller number of retrograde reconstruct in some circumstances), and secondly, is it possible to

intramedullary nails. Whilst this reﬂects the current literature, safely weight bear these patients early in order to reduce post

with the role of locking plates expanding as the technology evolves operative morbidity and mortality, and increase the proportion of

[21], studies supporting both methods of ﬁxation have been patients returning to their index place of residence. Only

published [22–32]. However there still remains a paucity of long- prospective, speciﬁcally designed studies will be able to address

term functional and radiological follow-up. Only two patients in these issues.

this cohort received a femoral replacement (one total knee). The In conclusion, patients who fracture their distal femur are of the

outcome of knee replacement remains largely unknown, with same demographic as those who fracture the proximal part. Whilst

varying results published in small cohorts. There is some there remain unanswered questions regarding best operative

suggestion that prosthetic replacement survival at ﬁve years treatment, the overriding principles of management should be

1088 J.R.A. Smith et al. / Injury, Int. J. Care Injured 46 (2015) 1084–1088

[17] Hodkinson HM. Evaluation of a mental test score for assessment of mental

consistent. We feel therefore it is appropriate that patients

impairment in the elderly. Age and Ageing 1972;1(4):233–8.

suffering a distal femur fracture should be accorded the same

[18] Pietu G, Lebaron M, Flecher X, Hulet C, Vandenbussche E, SOFCOT. Epidemiol-

metrics and standards of care that have been applied to fractures of ogy of distal femur fractures in France in 2011–12. Orthopaedics & Trauma-

tology Surgery & Research: OTSR 2014;100(5):545–8.

the proximal femur.

[19] National Hip Fracture Database [Internet]. 2013. Available from: www.nhfd.

co.uk.

Conﬂict of interest [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

None.

techniques and a review of the literature. Orthopaedics & Traumatology

Surgery & Research: OTSR 2013;99(3):353–60.

Acknowledgement [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.

We would like to thank Mr T. Chesser for assistance in editing [23] Acharya KN, Rao MR. Retrograde nailing for distal third femoral shaft frac-

tures: a prospective study. Journal of Orthopaedic Surgery 2006;14(3):253–8.

the ﬁnal manuscript.

[24] Zlowodzki M, Bhandari M, Marek DJ, Cole PA, Kregor PJ. Operative treatment

of acute distal femur fractures: systematic review of 2 comparative studies

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