MarkClatworthyMiddlemoreHospital

AucklandNewZealand

  Incidence0.9%primary,1.7%revision–USdataPersonalseries0/2155

  Riskfactors–age,osteoporosis,steroiduse,neurologicalconditions,RharthritisNotchingfemur??,Navigationpins

  AllfractureideallyrequirestabilizationType1undisplacedfractureinapatientunsuitableforsurgerycantrialtractionorabrace

  CRTKAmaybeamenabletoretrogradeIMnail

  PositioningofthefemoralimplantimportanttodeterminepositioningoftheIMnail

  Anintercondylardistanceof>1mmthenaildiameterisrequired

  LockeddistalplatessuchastheLISSplateareusefulinosteoporoticbone,moredistalfractures,andsituationsinwhichthefemoralcomponentdoesnotallowpassageofanail.

  LateralapproachOpenreductionoffracturePercutaneousproximalscrewplacementunderIIguidance

  BiomechanicalstudyComputMethodsBiomechBiomedEngin.2011TheprobabilisticanalysisfoundthelockingplatefixationtohaveahigherprobabilityoffracturethantheIMnailfixationundertheappliedloadingconditionsLockingplate21.8%versusIMnail0.019%

  HerreraetalActaOrthop2008NonunionrateRIMN1.5%cf5.3%forLPSecondaryprocedure4.6%RIMNgroupcf8.8%LP

  MeneghinietalJArthroplasty2014Nonunionratetobe9%RIMNcf19%LPDespitethisdifference,theRIMNgroupshowedasignificantlyhighermalunionrate(11%vs9%forLP)

  Indicationsare:  Significantcomminutionandorosteoporosis  Fracturetoodistaltousemultiplescrewinsertion  Loosefemoralcomponent  Instability

  Enablesrapidrecoverywithearlymobilizationandweight‐bearing

  Nounionissues

  Primaryversussecondarydistalfemoralarthroplastyfortreatmentoftotalkneearthroplastyperiprostheticfemurfractures.ChenetalJArthroplasty2013

  ThereweresignificantlymoresurgicalproceduresforORIFrevisiontoDFAcomparedtoprimaryDFA

  PrimaryreconstructionviaORIFisbeneficialforpreservingbonestock,butprimaryDFAmaybepreferredinosteopenicpatients,orthoseathighriskfornonunion

  Incidenceof0.4%‐1.7%Personalseries3/2155–0.1%‐Twopinsite#’s

  Aetiology‐usuallytraumaMal‐alignmentcanleadtoastressfracturePinsitefractures

TypeA StableProsthesisTypeB UnstableProsthesis

TypeC IntraoperativeFracture

  Determinedbyimplantloosening

  Iflooserevisewithlongstemdistaltothefracturewithlockedplate

  Ifimplantstable–lockedplate