Archives of Orthopaedic and Trauma Surgery

, Volume 139, Issue 8, pp 1057–1068 | Cite as

A surgical algorithm for the management of recalcitrant distal femur nonunions based on distal femoral bone stock, fracture alignment, medial void, and stability of fixation

  • Raja Bhaskara RajasekaranEmail author
  • Dheenadhayalan Jayaramaraju
  • Dhanasekara Raja Palanisami
  • Devendra Agraharam
  • Ramesh Perumal
  • Arun Kamal
  • Shanmuganathan Rajasekaran
Trauma Surgery



Recalcitrant distal femur nonunions (RDFN) are a challenge in management due to factors including poor bone stock, multiple surgeries, metaphyseal bone loss, and joint contractures. There are no specific guidelines in the management of cases of RDFN. Based on our experience, we devised an algorithm and we present the results of 62 cases of RDFN managed following it.

Materials and methods

Our algorithm was formulated after analyzing 34 cases of RDFN and it involved four factors which were hypothesized to influence outcomes namely: distal femoral bone stock, extent of medial void, alignment of the fracture, and stability of fixation. Each factor was addressed specifically to achieve a good outcome. Between 2012 and 2015, 62 patients with RDFN at a mean age of 47.4 years (26–73) and 2.3 prior surgeries (2–6) were managed following the algorithm.


58 patients required revision osteosynthesis to improve alignment and achieve a stable fixation. 4 elderly patients with poor bone stock were managed with arthroplasty. Extent of medial void was found to significantly influence surgical decision making. Five patients without medial void required only cancellous autograft bone grafting, 47 patients with < 2 cm void were treated with an allograft fibular strut inserted in the metaphysis and 6 patients with a void > 2 cm were managed with medial plating.

Outcomes and results

57 patients treated with osteosynthesis achieved union at an average of 7.4 months (6–11) and the 4 patients managed with arthroplasty also had a favourable outcome. One patient who was managed with revision osteosynthesis had a nonunion with an implant failure and needed an arthroplasty procedure. The average LEFS (lower extremity functional score) of all our patients was 67 (51–76) at an average follow-up of 18.2 months (12–33).


Our stepwise surgical algorithm would help surgeons to identify the factors that need to be addressed and guide them towards the interventions that are necessary to achieve a successful outcome while managing cases of RDFN.

Level of evidence


Level of clinical care

Level I Tertiary trauma centre.


Recalcitrant Distal femur nonunions Medial void Bone stock Alignment 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical standards

The study was performed in accordance with the ethical standards in the 1964 Declaration of Helsinki.


  1. 1.
    Kolmert L, Wulff K (1982) Epidemiology and treatment of distal femoral fractures in adults. Acta Orthop Scand 53(6):957–962 (PubMed PMID: 7180408) CrossRefGoogle Scholar
  2. 2.
    Court-Brown CM, Caesar B (2006) Epidemiology of adult fractures: a review. Injury 37(8):691-7 (Epub 2006 Jun 30. Review. PubMed PMID: 16814787) CrossRefGoogle Scholar
  3. 3.
    Schatzker J, Lambert DC (1979) Supracondylar fractures of the femur. Clin Orthop Relat Res 138:77–83 (PubMed PMID: 445921) Google Scholar
  4. 4.
    Neer CS, Grantham SA, Shelton ML (1967) Supracondylar fracture of the adult femur. A study of one hundred and ten cases. J Bone Joint Surg Am 49(4):591–613 (PubMed PMID: 6025996) CrossRefGoogle Scholar
  5. 5.
    Krettek C, Schandelmaier P, Miclau T, Tscherne H (1997) Minimally invasive percutaneous plate osteosynthesis (MIPPO) using the DCS in proximal and distal femoral fractures. Injury 28(Suppl 1):A20–A30 (PubMed PMID: 10897284) CrossRefGoogle Scholar
  6. 6.
    Ricci WM, Streubel PN, Morshed S, Collinge CA, Nork SE, Gardner MJ (2014) Risk factors for failure of locked plate fixation of distal femur fractures: an analysis of 335 cases. J Orthop Trauma 28(2):83–89. (PubMed PMID: 23760176) CrossRefGoogle Scholar
  7. 7.
    Paley D, Tetsworth K (1992) Mechanical axis deviation of the lower limbs. Preoperative planning of uniapical angular deformities of the tibia or femur. Clin Orthop Relat Res 280:48–64 (PubMed PMID: 1611764) Google Scholar
  8. 8.
    Kolodziej P, Lee FS, Patel A, Kassab SS, Shen KL, Yang KH, Mast JW. Biomechanical evaluation of the schuhli nut. Clin Orthop Relat Res. 1998 347:79–85 (PubMed PMID: 9520877) Google Scholar
  9. 9.
    Niemeyer P, Südkamp NP (2006) Principles and clinical application of the locking compression plate (LCP). Acta Chir Orthop Traumatol Cech 73(4):221–228 (review. PubMed PMID: 17026880) Google Scholar
  10. 10.
    Binkley JM, Stratford PW, Lott SA, Riddle DL (1999) The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Phys Ther 79(4):371–383 (PubMed PMID: 10201543) Google Scholar
  11. 11.
    Healy WL, Brooker AF Jr (1983) Distal femoral fractures. Comparison of open and closed methods of treatment. Clin Orthop Relat Res 174:166–171 (PubMed PMID: 6831801) Google Scholar
  12. 12.
    Ebraheim NA, Martin A, Sochacki KR, Liu J (2013) Nonunion of distal femoral fractures: a systematic review. Orthop Surg 5(1):46–50. (review. PubMed PMID: 23420747) CrossRefGoogle Scholar
  13. 13.
    Sanders R, Swiontkowski M, Rosen H, Helfet D (1991) Double-plating of comminuted, unstable fractures of the distal part of the femur. J Bone Joint Surg Am 73(3):341–346 (PubMed PMID: 2002071) CrossRefGoogle Scholar
  14. 14.
    Krettek C, Miclau T, Grün O, Schandelmaier P, Tscherne H (1998) Intraoperative control of axes, rotation and length in femoral and tibial fractures. Tech Note Injury 29(Suppl 3):C29–C39 (PubMed PMID: 10341895) CrossRefGoogle Scholar
  15. 15.
    Holzman MA, Hanus BD, Munz JW, O’Connor DP, Brinker MR. Addition of a Medial Locking Plate to an In Situ Lateral Locking Plate Results in Healing of Distal Femoral Nonunions. Clin Orthop Relat Res. 2016 Jun;474(6):1498–1505. (Epub 2016 Jan 21. PubMed PMID: 26797911; PubMed Central PMCID: PMC4868169)
  16. 16.
    Stoffel K, Dieter U, Stachowiak G, Gächter A, Kuster MS (2003) Biomechanical testing of the LCP—how can stability in locked internal fixators be controlled? Injury 34(Suppl 2):B11-9 (PubMed PMID: 14580982) Google Scholar
  17. 17.
    Wang JW, Weng LH (2003) Treatment of distal femoral nonunion with internal fixation, cortical allograft struts, and autogenous bone-grafting. J Bone Joint Surg Am 85-A(3):436–440 (PubMed PMID: 12637428) Google Scholar
  18. 18.
    Gardner MJ, Toro-Arbelaez JB, Harrison M, Hierholzer C, Lorich DG, Helfet DL (2008) Open reduction and internal fixation of distal femoral nonunions: long-term functional outcomes following a treatment protocol. J Trauma 64(2):434–438. (PubMed PMID: 18301211) CrossRefGoogle Scholar
  19. 19.
    Kanakeshwar RB, Jayaramaraju D, Agraharam D, Rajasekaran S (2017) Management of resistant distal femur non-unions with allograft strut and autografts combined with osteosynthesis in a series of 22 patients. Injury 48(Suppl 2):S14–S17 (PubMed PMID: 28802414)CrossRefGoogle Scholar
  20. 20.
    Attum B, Douleh D, Whiting PS, White-Dzuro GA, Dodd AC, Shen MS, Mir HR, Obremskey WT, Sethi MK (2017) Outcomes of distal femur nonunions treated with a combined nail/plate construct and autogenous bone grafting. J Orthop Trauma 31(9):e301 (e304.PubMed PMID: 28708782) CrossRefGoogle Scholar
  21. 21.
    Singh AK, Rastogi A, Singh V (2013) Biomechanical comparison of dynamic condylar screw and locking compression plate fixation in unstable distal femoral fractures: An in vitro study. Indian J Orthop 47(6):615–620. (PubMed PMID: 24379469; PubMed Central PMCID:PMC3868145) CrossRefGoogle Scholar
  22. 22.
    Heiney JP, Barnett MD, Vrabec GA, Schoenfeld AJ, Baji A, Njus GO (2009) Distal femoral fixation: a biomechanical comparison of trigen retrograde intramedullary(i.m.) nail, dynamic condylar screw (DCS), and locking compression plate (LCP)condylar plate. J Trauma 66(2):443–449. (PubMed PMID: 19204519) CrossRefGoogle Scholar
  23. 23.
    Vaishya R, Singh AP, Hasija R, Singh AP (2011) Treatment of resistant nonunion of supracondylar fractures femur by megaprosthesis. Knee Surg Sports Traumatol Arthrosc 19(7):1137–1140. (Epub 2011 Feb 11. PubMed PMID: 21311865) CrossRefGoogle Scholar
  24. 24.
    Kim JW, Yoon YC, Oh CW, Han SB, Sim JA, Oh JK (2018) Exchange nailing with enhanced distal fixation is effective for the treatment of infraisthmal femoral nonunions. Arch Orthop Trauma Surg 138(1):27–34. (Epub 2017 Sep 27. PubMed PMID: 28956142) CrossRefGoogle Scholar
  25. 25.
    Kim JW, Oh CW, Oh JK, Park KH, Kim HJ, Kim TS, Seo I, Park EK (2018) Treatment of infra-isthmal femoral fracture with an intramedullary nail: Is retrograde nailing a better option than antegrade nailing? Arch Orthop Trauma Surg 138(9):1241–1247. (Epub 2018 May 24. PubMed PMID: 29799078)
  26. 26.
    Ma CH, Chiu YC, Tu YK, Yen CY, Wu CH. Three-stage treatment protocol for recalcitrant distal femoral nonunion. Arch Orthop Trauma Surg. 2017 137(4):489–498. (Epub 2017 Feb 20. PubMed PMID: 28220260)

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Raja Bhaskara Rajasekaran
    • 1
    Email author
  • Dheenadhayalan Jayaramaraju
    • 1
  • Dhanasekara Raja Palanisami
    • 1
  • Devendra Agraharam
    • 1
  • Ramesh Perumal
    • 1
  • Arun Kamal
    • 1
  • Shanmuganathan Rajasekaran
    • 1
  1. 1.Department of Orthopaedics and TraumaGanga Medical Centre and Hospitals Pvt. LtdCoimbatoreIndia

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