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Early versus delayed weight bearing after surgical fixation of distal femur fractures: a non-randomized comparative study

  • Paolo ConsigliereEmail author
  • Efthymios Iliopoulos
  • Tamer Ads
  • Alex Trompeter
Original Article • LOWER LIMB - FRACTURES

Abstract

Distal femur fractures are rare injuries with a bimodal distribution (high-energy injury in young males and low-energy fragility fractures in old females). Their management can be challenging: open reduction and internal fixation (ORIF) with distal femur locking plates is a commonly performed procedure especially in comminuted fractures with articular involvement. Anxiety regarding the stability of the fixation, especially in osteoporotic bone, leads to post-operative restrictive instructions with limitations regarding the weight-bearing status. Early weight bearing (EWB), however, was shown to enhance bone healing and was not correlated with an increased risk of fracture displacement or implant failure in previous published studies, which reported the results of proximal femur, tibia and ankle fractures surgical treatment. The current study analysed the results of a series of distal femur fractures (51 patients, mean age 64.3 ± 20.7) all treated with ORIF in a level-I major trauma centre, but differently rehabilitated. Group A was, in fact, instructed not to weight bear or to touch weight bear, while group B started to weight bear soon after surgery without specific restrictions. The objective was to compare the outcome and the complication rate in the two groups at 6 and 12 weeks after surgery. The results showed no statistically significant differences in the two groups and no post-operative complications in the EWB group. Six complications were observed in the non-weight-bearing group (four fractures displacement and two implants failure at 12-week follow-up). Distal femur fractures treated with locking plates can be rehabilitated with EWB to allow early return to function. There is no evidence that EWB increases the risk of fracture displacement or implant failure in distal femur fractures treated with distal locking plates. Instead, it is possible that post-operative non-weight-bearing status delays the fracture-healing process increasing the risk of failure of the fixation.

Keywords

Fracture healing Femur fracture Callus Weight bearing Rehabilitation 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

References

  1. 1.
    Gwathmey FWJ, Jones-Quaidoo SM, Kahler D et al (2010) Distal femoral fractures: current concepts. J Am Acad Orthop Surg 18:597–607.  https://doi.org/10.1007/s00113-012-2218-8 CrossRefPubMedGoogle Scholar
  2. 2.
    Stover M (2001) Distal femoral fractures: current treatment, results and problems. Injury 32(Suppl 3):SC3-C13.  https://doi.org/10.1016/S0020-1383(01)00179-6 CrossRefGoogle Scholar
  3. 3.
    Rodriguez EK, Boulton C, Weaver MJ et al (2014) Predictive factors of distal femoral fracture nonunion after lateral locked plating: a retrospective multicenter case-control study of 283 fractures. Injury 45:554–559.  https://doi.org/10.1016/j.injury.2013.10.042 CrossRefPubMedGoogle Scholar
  4. 4.
    Giannoudis PV (2006) Principles of fixation of osteoporotic fractures. J Bone Jt Surg Br 88-B:1272–1278.  https://doi.org/10.1302/0301-620x.88b10.17683 CrossRefGoogle Scholar
  5. 5.
    Seebeck J, Goldhahn J, Morlock MM, Schneider E (2005) Mechanical behavior of screws in normal and osteoporotic bone. Osteoporos Int 16:S107–S111.  https://doi.org/10.1007/s00198-004-1777-0 CrossRefPubMedGoogle Scholar
  6. 6.
    Henderson CE, Kuhl LL, Fitzpatrick DC, Marsh JL (2011) Locking plates for distal femur fractures: is there a problem with fracture healing? J Orthop Trauma 25(Suppl 1):S8–S14.  https://doi.org/10.1097/BOT.0b013e3182070127 CrossRefPubMedGoogle Scholar
  7. 7.
    Kregor PJ, Stannard JA, Zlowodzki M, Cole PA (2004) Treatment of distal femur fractures using the Less Invasive Stabilization System: surgical experience and early clinical results in 103 fractures. J Orthop Trauma 18:509–520.  https://doi.org/10.1097/00005131-200409000-00006 CrossRefPubMedGoogle Scholar
  8. 8.
    Huang HT, Huang PJ, Su JY, Lin SY (2003) Indirect reduction and bridge plating of supracondylar fractures of the femur. Injury 34:135–140.  https://doi.org/10.1016/S0020-1383(02)00213-9 CrossRefPubMedGoogle Scholar
  9. 9.
    Başcı O, Karakaşlı A, Kumtepe E et al (2015) Combination of anatomical locking plate and retrograde intramedullary nail in distal femoral fractures: comparison of mechanical stability. Eklem Hastalik Cerrahisi 26:21–26.  https://doi.org/10.5606/ehc.2015.06 CrossRefPubMedGoogle Scholar
  10. 10.
    Yoo JH, Kim SW, Kwak YH, Kim HJ (2015) Overlapping intramedullary nailing after failed minimally invasive locked plating for osteoporotic distal femur fractures—report of 2 cases. Injury 46:1174–1177.  https://doi.org/10.1016/j.injury.2015.01.011 CrossRefPubMedGoogle Scholar
  11. 11.
    Goodship AE, Kenwright J (1985) The influence of induced micromovement upon the healing of experimental tibial fractures. J Bone Joint Surg Br 67(4):650–655CrossRefGoogle Scholar
  12. 12.
    Perren SM (1979) Physical and biological aspects of fracture healing with special reference to internal fixation. Clin Orthop Relat Res (138):175–196Google Scholar
  13. 13.
    Elliott DS, Newman KJH, Forward DP et al (2016) A unified theory of bone healing and nonunion: BHN theory. Bone Joint J 98-B:884–891.  https://doi.org/10.1302/0301-620x.98b7.36061 CrossRefPubMedGoogle Scholar
  14. 14.
    Kubiak EN, Beebe MJ, North K et al (2013) Early weight bearing after lower extremity fractures in adults. J Am Acad Orthop Surg 21:727–738.  https://doi.org/10.5435/JAAOS-21-12-727 CrossRefPubMedGoogle Scholar
  15. 15.
    Bailón-Plaza A, Van Der Meulen MCH (2003) Beneficial effects of moderate, early loading and adverse effects of delayed or excessive loading on bone healing. J Biomech 36:1069–1077.  https://doi.org/10.1016/S0021-9290(03)00117-9 CrossRefPubMedGoogle Scholar
  16. 16.
    Smith JRA, Halliday R, Aquilina AL et al (2015) Distal femoral fractures: the need to review the standard of care. Injury 46:1084–1088.  https://doi.org/10.1016/j.injury.2015.02.016 CrossRefPubMedGoogle Scholar
  17. 17.
    Williamson M, Iliopoulos E, Jain A et al (2018) Immediate weight bearing after plate fixation of fractures of the tibial plateau. Injury 49:1886–1890.  https://doi.org/10.1016/j.injury.2018.06.039 CrossRefPubMedGoogle Scholar
  18. 18.
    Wolff P, Maquet PFR (1986) The law of bone remodelling. Springer, BerlinCrossRefGoogle Scholar
  19. 19.
    El Haj AJ, Thomas G (1994) Cellular modelling of mechanical interactions with the skeleton. In: Lyall F, El Haj AJ (eds) Biomechanics and cells. Cambridge University Press, Cambridge, pp 147–163CrossRefGoogle Scholar
  20. 20.
    Augat P, Simon U, Liedert A, Claes L (2005) Mechanics and mechano-biology of fracture healing in normal and osteoporotic bone. Osteoporos Int 16:S36.  https://doi.org/10.1007/s00198-004-1728-9 CrossRefPubMedGoogle Scholar
  21. 21.
    Carlin L, Sibley K, Jenkinson R et al (2018) Exploring Canadian surgeons’ decisions about postoperative weight bearing for their hip fracture patients. J Eval Clin Pract 24:42–47.  https://doi.org/10.1111/jep.12645 CrossRefPubMedGoogle Scholar
  22. 22.
    Garden RS, Preston E (1961) Low angle fixation in fractures of the femoral neck. Surger 101:647.  https://doi.org/10.1302/0301-620X.43B4.647 CrossRefGoogle Scholar
  23. 23.
    Graham J (1968) Early or delayed weight-bearing after internal fixation of transcervical fracture of the femur: a clinical trial. Bone Jt Surg Br 3:562–569CrossRefGoogle Scholar
  24. 24.
    Koval KJ, Friend KD, Aharonoff GB, Zuckerman JD (1996) Weight bearing after hip fracture: a prospective series of 596 geriatric hip fracture patients. J Orthop Trauma 10:526–530.  https://doi.org/10.1097/00005131-199611000-00003 CrossRefPubMedGoogle Scholar
  25. 25.
    Conn KS, Parker MJ (2004) Undisplaced intracapsular hip fractures: results of internal fixation in 375 patients. Clin Orthop Relat Res 421:249–254.  https://doi.org/10.1097/01.blo.0000119459.00792.c1 CrossRefGoogle Scholar
  26. 26.
    Khan AM, Tang QO, Spicer D (2017) The epidemiology of adult distal femoral shaft fractures in a central London major trauma centre over five years. Open Orthop J 11:1277–1291.  https://doi.org/10.2174/1874325001711011277 CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Haak KT, Palm H, Holck K, Krasheninnikoff M, Gebuhr P, Troelsen A (2012) Immediate weight-bearing after osteosynthesis of proximal tibial fractures may be allowed. Dan Med J 59(10):A4515PubMedGoogle Scholar
  28. 28.
    Thewlis D, Fraysse F, Callary SA et al (2017) Postoperative weight bearing and patient reported outcomes at one year following tibial plateau fractures. Injury 48:1650–1656.  https://doi.org/10.1016/j.injury.2017.05.024 CrossRefPubMedGoogle Scholar
  29. 29.
    Solomon LB, Callary SA, Stevenson AW et al (2011) Weight-bearing-induced displacement and migration over time of fracture fragments following split depression fractures of the lateral tibial plateau: a case series with radiostereometric analysis. Bone Joint J 93-B:817–823.  https://doi.org/10.1302/0301-620x.93b6.26122 CrossRefGoogle Scholar
  30. 30.
    Eggli S, Hartel MJ, Kohl S et al (2008) Unstable bicondylar tibial plateau fractures: a clinical investigation. J Orthop Trauma 22:673–679.  https://doi.org/10.1097/BOT.0b013e31818b1452 CrossRefPubMedGoogle Scholar
  31. 31.
    Lin C-WC, Donkers NAJ, Refshauge KM et al (2012) Rehabilitation for ankle fractures in adults. Cochrane database Syst Rev 11:CD005595.  https://doi.org/10.1002/14651858.cd005595.pub3 CrossRefPubMedGoogle Scholar
  32. 32.
    Van Laarhoven CJ, Meeuwis JD, van der Werken C (1996) Postoperative treatment of internally fixed ankle fractures: a prospective randomised study. J Bone Joint Surg Br 78:395–399CrossRefGoogle Scholar
  33. 33.
    Dehghan N, McKee MD, Jenkinson RJ et al (2016) Early weightbearing and range of motion versus non-weightbearing and immobilization after open reduction and internal fixation of unstable ankle fractures: a randomized controlled trial. Int J Orthop Trauma 30:345–352CrossRefGoogle Scholar
  34. 34.
    Simanski CJP, Maegele MG, Lefering R et al (2006) Functional treatment and early weightbearing after an ankle fracture. J Orthop Trauma 20:108–114.  https://doi.org/10.1097/01.bot.0000197701.96954.8c CrossRefPubMedGoogle Scholar
  35. 35.
    Gul A, Batra S, Mehmood S, Gillham N (2007) Immediate unprotected weight-bearing of operatively treated ankle fractures. Acta Orthop Belg 73:360–365PubMedGoogle Scholar
  36. 36.
    Kortebein P, Symons TB, Ferrando A et al (2008) Functional impact of 10 days of bed rest in healthy older adults. J Gerontol A Biol Sci Med Sci 63:1076–1081.  https://doi.org/10.1093/gerona/63.10.1076 CrossRefPubMedGoogle Scholar
  37. 37.
    Clement ND, Aitken SA, Duckworth AD et al (2011) The outcome of fractures in very elderly patients. J Bone Joint Surg Br 93:806–810.  https://doi.org/10.1302/0301-620X.93B6.25596 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2019

Authors and Affiliations

  1. 1.St George’s University Hospital NHS Foundation TrustLondonUK

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