Which fixation produces the best outcome for distal femoral fractures? Meta-analysis and systematic review of retrograde nailing versus distal femoral plating in 2432 patients and 33 studies

Han Soul Kim; Yong-Cheol Yoon; Sang-Jin Lee; Jae Ang Sim

doi:10.1007/s00068-023-02393-8

Which fixation produces the best outcome for distal femoral fractures? Meta-analysis and systematic review of retrograde nailing versus distal femoral plating in 2432 patients and 33 studies

Eur J Trauma Emerg Surg. 2023 Dec 7. doi: 10.1007/s00068-023-02393-8. Online ahead of print.

Authors

Han Soul Kim¹, Yong-Cheol Yoon², Sang-Jin Lee¹, Jae Ang Sim¹

Affiliations

¹ Department of Orthopedic Surgery, Gachon University College of Medicine, Namdong-Gu, Incheon, Republic of Korea.
² Orthopedic Trauma Division, Trauma Center, Gachon University College of Medicine, 21, Namdong-Daero 774 Beon-Gil, Namdong-Gu, Incheon, 21565, Republic of Korea. dryoonyc@gmail.com.

PMID: 38057606
DOI: 10.1007/s00068-023-02393-8

Abstract

Purpose: The distal femur comprises a wide intramedullary cavity and thin cortical bone. Firm internal fixation of comminuted fractures with displacement is challenging. Although many comparative studies have reported retrograde intramedullary nailing (RIN) and distal femoral plating (DFP) as the usual fixation methods for distal femoral fractures, no clear conclusion has been reached. Therefore, a meta-analysis and systematic review of the clinical and radiological results were conducted to determine the appropriate treatment method for distal femoral fractures.

Methods: A systematic search of the PubMed, Embase, Scopus, and Cochrane Library databases from their inception to December 19, 2022, was performed using predefined criteria. Studies comparing the effects of RIN and DFP were considered. The analyzed outcome measures included duration of surgery, blood loss, time to union, delayed union, nonunion, malalignment, implant failure, infection, reoperation, limb length discrepancy, range of motion, persistent anterior knee pain, knee stiffness, and functional scores. Meta-analysis of pooled data was conducted using a random-effects model to determine the standard mean difference (SMD) or odds ratio (OR) with 95% confidence intervals (CIs).

Results: Thirty-three studies with 2,432 patients were included. Compared to DFP, RIN was associated with a shorter time to fracture union (SMD, 1.83 months; 95% CI - 2.76 to - 0.90; P < 0.001) and a lower incidence of postoperative infection (OR 0.54; 95% CI 0.31-0.94; P = 0.03). Pooled analysis revealed no significant differences in other outcome measures between the two treatment modalities.

Conclusion: In distal femoral fractures, RIN had a shorter bone union time and was more resistant to infection than DFP. However, there were no significant differences in the other clinical parameters. Therefore, the characteristics, strengths, and weaknesses of RIN and DFP should be carefully identified, and appropriate treatment should be provided based on the patient's medical condition and fracture pattern.

Keywords: Distal femoral fracture; Distal femoral plating; Meta-analysis; Retrograde intramedullary nailing; Systemic review.

Publication types

Review