This document discusses evidence-based medicine (EBM) and summarizes several studies comparing different treatment methods for distal femur fractures. EBM aims to optimize patient care by emphasizing evidence from well-designed research. Several articles compare outcomes of internal fixation with intramedullary nails versus locking plates. In general, nails provide better callus formation, stiffness, and less micromotion at the fracture site, while plates have higher nonunion rates and require more secondary procedures. Retrograde nailing appears to have advantages for distal femur fractures, including improved alignment and reduced complications.

1. EVIDENCE BASED MEDICINE
Presenter: Dr. Saumya Agarwal
Dept of Orthopaedics, JNMC, KLE’S Dr. Prabhakar Kore
Hospital, Belagavi

3.  Evidence based medicine (EBM)
was originally defined as the
conscientious, explicit, and
judicious use of current
best evidence in making decisions
about the care of individual patients.

4. Evidence-based medicine (EBM) is an
approach to medical practice intended to
optimize decision-making by emphasizing the
use of evidence from well designed and
conducted research.
Evidence-based medicine (EBM) is the
process of
• Systematically reviewing,
• appraising and using clinical research
findings to
• aid the delivery of optimum clinical care to
patients.

6. History
Name :- XYZ
Age :- 30
Sex :- Male
Address :- Belagavi
Occupation :- electrician

7. Chief Complaints
 Pain on right lower thigh
 Swelling on right lower thigh

8. History of Presenting
Illness
H/O road traffic accident with a 4 wheeler and
patient was on 2 wheeler, sustained injury
over right lower thigh. After the fall, patient
was conscious but unable to bend the right
knee.
No h/o- loc/vomiting/ENT bleed

9. Personal history
 Diet : Mixed
 Appetite : Normal
 Sleep : Undisturbed
 Bowel & Bladder : Normal and regular
 Habbit : no addiction

10. Past history
• No h/o – DM2/HTN/Asthma/TB
Family history
• Not significant
Vitals
◦ BP: 130/80 mm Hg
◦ Pulse: 90 /min
◦ Respiratory rate: 26 cycles/min
◦ SpO2: 100%

11. Examination
Inspection
 7 x1 cm CLW present over right distal thigh
 Swelling and deformity seen over right distal thigh
 No muscle wasting
 No visible scars or sinuses
Palpation
 All inspectory findings were confirmed
 No local rise of temperature
 Tenderness and bony deformity present
 7 x1 cm CLW present over right distal thigh
 Restricted movements at right knee joint

12. ◦ Pelvic compression test was negative
◦ Chest compression test was negative
◦ B/L Toe movements +
◦ Distal pulses were b/l and equally felt
◦ Motor and sensory examination was
within normal limits

13. Pre-op x-rays AP and lateral
view

14. CT- Scan

15. 3-D Reconstruction CT

16. DIAGNOSIS
 Right supracondylar femur
fracture with intra-articular
extension

17. CLASSIFICATION

18. CLASSIFICATION
 Neer and associates
 Stewart and coworkers
 Schatzker andTile
 Seinsheimer
 AO classification

19. AO/OTA Classification of distal
Femur

20. AO/OTA 33C2

22. Internal Fixation
Devices
 Condylar Buttress Plate
 Condylar Locking Compression Plate
 Less Invasive Stabilization System(LISS)
 Angled Blade plate and lag screws
 Retrograde Nailing
 Ilizarov fixator with minimal internal fixation

23. EVIDENCE 1
 Option 1 : Small fragment fixation of articular
surface+ IM nailing- Useful if the bones are
osteoporotic.
 Option 2: Small fragment fixation followed by
Locking Compression plate. PREFERRED
METHOD
 Option 3: Condylar butress plate; but there is
high incidence of varus collapse; hence not

24. Current AO Recommendation

25. Choice of Implant

26. Article 1
“Stabilization of Distal Femur Fractures with
Intramedullary Nails and Locking Plates:
Differences in Callus Formation”
J. 2010; 30: 61–68.

27.  Analysed 174 distal femur fractures and
cases were then individually matched
between IMIL group and Locking plate.
 The peripheral callus was measured on
lateral and antero-posterior radiographs at
12 weeks in all fractures using validated
software.

28. Callus was
measured in
anterior,
posterior,
medial and
lateral
location

29.  The NAIL group had 2.4 times more
callus area than the PLATE group.
 Compared to the PLATE group, the
NAIL group had 3.4 times more callus
anteriorly, 2.6 times more callus
posteriorly, and 2.3 times more callus
medially.

30.  Significantly less periosteal callus
formed in fractures stabilized with
locking plates than with IM nails.
 High stiffness achieved with locking
plates may limit the amount of callus,
resulting in delayed healing or
nonunion.

31. Article 2
RETROGRADE INTRAMEDULLARY NAILING
VERSUS LISS PLATING FOR DISTAL FEMUR
FRACTURES

32. Fracture type LISS Group IM Nailing Group
Type A 5% 11%
Type C 35% 7%
Rate of Non union
FRACTURE
TYPE
LISS
GROUP
IM Nailing
group
Total
Type A 21 31 52
Type C 35 28 63
Fracture Type

33.  Both, retrograde IM nailing and LISS plating are
adequate treatment options for distal femur #
 Locked plating can be utilized for all distal femur #
including complex type C #, periprosthetic # and
osteoporotic #
 IM nailing provides favorable intramedullary stability and
can be successfully implanted in bilateral or
multisegmental # of distal femur as well as in extra-
articular and type C1 to C2 #
CONCLUDED

34. Article 3
J Orthop Trauma Volume 26, No. 6, June
2012
“Comparison of the 95-Degree Angled Blade
Plate and the Locking Condylar Plate for
the Treatment of Distal Femoral Fractures”

35. Conclusion:
 Patients treated with locking plates had more
complications and nonunion, requiring more
secondary procedures to treat complications and
to remove prominent implants
 There has been a dramatic increase in use of
LCPs reasons being ease of application, ability to
gain purchase in a small distal fragment, ability to
apply despite metaphyseal comminution, and
ability to apply with less soft tissue disruption

36. Articles 4 & 5
 Journal of Orthopaedic Trauma
Issue: Volume 25 Supplement 1, February 2011, pp S8-S14
“Locking Plates for Distal Femur Fractures: Is There a Problem
With Fracture Healing?”
 CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Volume 469 (2011), 1757-1765,
“2010 Mid America Orthopaedic Association Physician in training
Award:
 Healing Complications are common after Locked plating for
distal femur fractures.”

37.  Both articles reported that Nonunion presented
late without hardware failure and with limited
callus formation suggesting callus inhibition as
the primary problem. They suggested that
mechanical factors may play a role in the high
rate of nonunion.
 Titanium plates had a nonunion rate of 7%
compared with 23% for the more rigid stainless
steel locking plates . They concluded that the
stiffer nature of the stainless plates may
contribute to the increased nonunion rates
observed.

38. Article 6
“Distal femoral fixation: a biomechanical comparison of
Trigen Retrograde Intramedullary (IM) nail, dynamic
condylar screw (DCS), and locking compression plate
(LCP) condylar plate.”
Journal of trauma 2009 Feb;66(2):443-9. Department of Orthopaedic
Surgery, Promedica Health System, USA

39.  Retrograde intramedullary (IM) nail, dynamic
condylar screw (DCS), and locked condylar
plate (LCP) were tested using 33-cm long
synthetic femurs.
 A standardized supracondylar medial
segmental defect was created in the distal
femur bone models.
 Peak displacements were measured, and
analysis was done to determine construct
stiffness and gap micromotion in axial
loading.

40.  The stiffness of the IM nail, DCS and
LCP were 1,106, 750 and 625 N/mm,
respectively.
 The average total micromotion across
the fracture gap for the IM nail, DCS,
and LCP were 1.96, 10.55, and 17.74
mm, respectively.

41. CONCLUSION:
When considering micromotion and
construct stiffness, the IM nail had
statistically significant higher stiffness and
significantly lower micromotion across the
fracture gap with axial compression.

42. Outcome analysis of retrograde nailing and less
invasive stabilization system in distal femoral
fractures: A retrospective analysis
59 (RN) [28 C2#], 56 (LISS) [31 C2#]
Concluded:
IM nailing may provide favorable IM stability, may promote
formation of circular and stable callus, and may be
successfully implanted in bilateral or multisegmental
fractures of the lower extremity as well as in extra-articular
and type C1& C2 fractures.
Christian Hierholzer et al 2011

43. Parameters Watanabe
et al
Yeap et al Gao K et al Gupta SKV et al Our patient
RN LCP RN LCP RN LCP RN
Average Knee
flexion
115.3⁰ 112.2⁰ 103.4⁰ 98.2⁰ 110.3⁰ 115.4⁰ 115⁰
Average Full
weight bearing
13.8 weeks 14.1 weeks 15.7 weeks 16.8
weeks
15.6 weeks 14.9
weeks
12 weeks
Average
Radiological
union time
15.4 weeks 15.8 weeks 14.8 weeks 16.1
weeks
16.8 weeks 15.2
weeks
14 weeks
Modified Neer’s
Criteria Score
68% 70% 76% 65% 79% 85% 90%

44. What we have done???

45. Post-op X-rays AP and lateral view

46. Post-op x-rays at 6 months
follow-up

47. 6-month follow-
up

48. Benefits of RN VS LCP
RETROGRADE NAILING LOCKED COMPRESSION
PLATING
1. The Intramedullary device aligns
the femoral shaft with condyles
reducing the tendency to place varus
movement at the fracture site.
1.Prompt healing
2.There will be decreased failure of
fixation in osteoporotic bone as the
bending movement of intramedullary
device is substantially reduced.
2.Lower rate of infection
3.Preservation of fracture hematoma 3.Reduced bone resorption
4.Decreased blood loss 4.Creates a fixed angle construct
5.Minimal soft tissue dissection 5.Rigidity of fixation is better in
osteoporotic bone
6.Less operative time 6.Angular as well as axial stability
restored
7.Reduced rate of infection 7. Highly effective in comminuted
and displaced fracture

49. Risks of RN VS
LCPRETROGRADE NAILING LOCKED COMPRESSION
PLATING
1.Distal screw related local
symptoms
1.Does not completely solve the age
old problems of non-union and mal-
union.
2.Shortening 2.Impossible to fix the bone fragment
distant from plate.
3.Angulation disturbance 3.Simple fracture treated with locked
compression plate are prone for non-
union.

50. Take Home Message
 Retrograde nailing is a better fixation
system for intra & extra articular
fractures of distal femur with better
outcome in terms of range of
movements, early radiological union,
early mobilization and less operative
time and blood loss.
 Surgeon preference