Full text of DOI:10.1016/S0020-1383(99)00275-2

Injury, Int. J. Care Injured 31 (2000) 169±173
www.elsevier.com/locate/injury
Management of distal femoral fractures in elderly patients using
retrograde titanium supracondylar nails
A. Kumar*, V. Jasani, M.S. Butt
Department of Trauma & Orthopaedics, Russells Hall Hospital, Dudley, West Midlands, UK
Accepted 18 October 1999
Abstract
We present our experience with a retrograde supracondylar nail used for the management of fractures of the distal femur in
elderly patients. Eighteen fractures of the distal femur in 18 patients were treated with AIM titanium supracondylar nails.
Sixteen patients with a median age of 83 years (62±100 years) were ®nally available for review. All 16 fractures were classi®ed as
extra-articular type A according to the AO classi®cation. The average operative time was 58 min. Follow up ranged between 4
and 35 months (average 20.4 months). Fifteen fractures (93.7%) united in an average duration of 3.6 months. The average range
of motion achieved at the knee was 100.68. There were no implant failures, knee sepsis or wound healing problems. One non-
union and two stress fractures of the femur above the nail were the main complications in this series.
We concluded that the AIM titanium supracondylar nail is a useful alternative implant for the management of the
osteoporotic fractures of the distal femur particularly the extra-articular AO type A fracture in the elderly population. # 2000
Elsevier Science Ltd. All rights reserved.
1. Introduction
ity in the management of these fractures for distinct
advantages of preservation of the fracture haematoma,
decreased blood loss, minimal soft tissue dissection,
less operative time and reduced rate of infection [8±
12]. Satisfactory results have been reported in elderly
patients after using an interlocking retrograde supra-
condylar nail [10±12] and Zickel supracondylar nail
[13] for distal femoral fractures. We present our results
of using the AIM titanium supracondylar nail in the
management of distal femoral fractures in elderly
patients.
Fractures of the distal femur in the elderly popu-
lation are dicult to treat because of osteopenia and
preexisting hip and knee disabilities which can also
predispose to these fractures [1]. Stewart et al. and
Neer et al. recommended conservative management
because of the possibility of infection and inadequate
®xation [2,3]. However, with improvement in tech-
niques and instrumentation, surgical treatment has
been recommended to reduce the period of immobilis-
ation and morbidity [4]. Rigid internal ®xation of
osteoporotic fractures in elderly patients is dicult
because of degree of comminution and poor bone
stock [5±7]. The antegrade nailing can be technically
dicult in an arthritic and sti€ hip and can not be
used in the presence of other implants in the proximal
femur. Recently retrograde nailing has gained popular-
2. Materials and methods
Eighteen fractures of the distal femur in 18 patients
were treated with the AIM titanium supracondylar
nail (DePuy ACE) between July 1995 and April 1998.
One patient died due to medical reasons before ade-
quate post-operative follow up was completed; another
patient failed to attend the clinic for ®nal assessment
being asymptomatic, leaving 16 patients for ®nal
* Corresponding author. 51, Heberdeen Park, London N5 2AZ,
UK. Tel.: +44-1902-307-999; fax: +44-1902-642-833.
0020-1383/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved.
PII: S0020-1383(99)00275-2

170
A. Kumar et al. / Injury, Int. J. Care Injured 31 (2000) 169±173
Table 1
Summary of fracture type, associated disabilities and results
SN
Sex
Age
AO
Preexisting disabilities
Union time (months)
ROM Knee
Complications
1
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
85
86
68
62
81
100
82
92
84
88
82
74
92
87
66
82
A2
A2
A2
A1
A2
A3
A1
A2
A1
A1
A2
A2
A2
A2
A2
A2
3 months old ipsilateral # tibia & ®bula
B/L THR
7
0±90
2
3
30±90
5±120
0±120
0±130
10±100
5±90
stress fracture
±
3
±
4.5
3
4
±
±
non-union
5
±
OA knees
±
6
3.5
7
±
stress fracture
7
ipsilateral THR, B/L leg ulcers
ipsilateral hemiarthroplasty
8
4
10±110
10±110
10±80
0±90
±
±
±
±
±
±
±
±
±
9
±
severe OA and B/L genu valgus
3
10
11
12
13
14
15
16
2
OA knees
±
2
4
0±130
10±90
10±120
0±130
10±120
ipsilateral TKR
Alzeihmer's disease
±
4
3
2
OA knee
3
review. Two patients died 6 months after the operation
due to unrelated causes but since the fractures had uni-
ted, they were included in this study. All 16 patients
were females with a median age of 83 years (62±100
years). Low velocity trauma by minor fall was the
cause of the fracture in all patients. Nine fractures
involved the left leg and seven involved the right side.
According to the AO classi®cation [14], four fractures
were classi®ed as type A1, 11 as type A2 and one as
type A3 fracture. There were no open fractures. No
neuro vascular injury was noted in this series. A high
prevalence of preexisting disabilities was noted in this
series. Four patients already had an implant in the
femur on the ipsilateral side (Table 1).
The AIM titanium supracondylar nail is available in
two diameters of 10 and 12 mm and four lengths of
150, 200, 250 and 300 mm. Unlike other designs this
nail has only two holes at each end for interlocking.
Both proximal and distal interlocking can be carried
out using a single jig, except for the longest nail where
free hand technique is used for proximal interlocking.
canal was reamed only distally so as to accommodate
the broad distal end of the nail. In all patients a nail
of the thickest diameter (12 mm) was used to obtain a
better alignment and stability. The nail was counter
sunk 3±5 mm below the articular surface to avoid
impingement during knee ¯exion. After interlocking
the nail distally, the reduction and the alignment were
checked again under an image intensi®er and if
required ®nal adjustments were carried out. The re-
duction was maintained by ®rmly holding the jig till
the nail was locked proximally. Distal screws were
applied ®rmly but not tightly and advanced by an ad-
ditional 5 mm for better purchase in the cortex. None
of the patients underwent primary bone grafting. The
average operative time was 58 min.
4. Post-operative management
All patients received three doses of intravenous anti-
biotic. Physiotherapy for the knee was commenced
from the ®rst post-operative day. Partial weightbearing
was started as soon as the patient's general condition
permitted. Eight patients with severe osteoporosis and
those that found partial weightbearing dicult, were
initially mobilised in a hinged cast brace for 2±4
months. Depending upon clinical and radiological pro-
gress, mobilisation was gradually progressed to full
weightbearing, usually possible in 6±8 weeks. A frac-
ture was considered united if there was no pain at the
fracture site, the patient was able to full weightbear
and the anteroposterior and lateral radiographs
showed a four-quadrant bridging callus across the
fracture site. If there was no callus and the fracture
line was still visible at 6 months, it was regarded as
non-union. The average follow up was 20.4 months
3. Operative technique
The patient is positioned supine with the knee on
the a€ected side ¯exed to 45±608 across a thigh sup-
port on a radiolucent table. A midline skin incision
with medial parapatellar approach was used. The frac-
ture was aligned anatomically by closed reduction and
the fragments were allowed to impact into each other.
An entry point was made in the intercondylar notch
just anterior to the attachment of the posterior cruciate
ligament. Under radiographic control, a guide wire
was passed in the centre of the medullary canal to pre-
vent angulation at the fracture site. The medullary

A. Kumar et al. / Injury, Int. J. Care Injured 31 (2000) 169±173
171
Fig. 1. AP and oblique view: a long spiral fracture of the distal femur in a 82 year old lady (top). AP and oblique view: 5 months post-operative
showing complete union (bottom).

172
A. Kumar et al. / Injury, Int. J. Care Injured 31 (2000) 169±173
with a range of 4±35 months. On ®nal examination all
fractures had either progressed to union or were
declared as ununited.
tolerate prolonged immobilisation and operative inter-
vention is associated with risk of anaesthetic and surgi-
cal complications. The main objective of surgery in
elderly patients is early ambulation and achieving a
stable painless weightbearing limb with preservation of
knee function [1]. Rigid internal ®xation is often di-
cult in an osteoporotic bone and some studies have
shown less satisfactory results with stable internal ®x-
ation in elderly patients [5±7]. Schatzker and Lambert
suggested closed reduction and early cast bracing to
treat distal femoral fractures in elderly patients [5].
Benum suggested the use of bone cement to improve
®xation when using an angled blade plate because of
frequency of pull out [15]. The extensive approach and
prolonged exposure required to ®x these fractures with
lateral devices can lead to increased chances of infec-
tion [16,17], especially in a debilitated elderly patient
with poor resistance to infection [1]. There were no
cases of knee sepsis or wound healing problems in this
series.
In the osteoporotic fractures anatomical reduction
of the fragments is often dicult and can result in
shortening [13,16,17]. We allowed the fracture ends to
impact against each other maintaining the alignment
between two fragments which resulted in an average
shortening of 1.4 cm. Primary bone grafting has been
suggested with extramedullary devices to enhance the
bone union in the osteoporotic fractures [5,16,17].
None of our patients underwent bone grafting and the
morbidity from the bone graft site was avoided. A
union rate of 93.7% achieved in an average period of
3.6 months is comparable to the union rate of 87±
100% reported by other authors using a retrograde
intramedullary nail in the same age group [10±13].
There was one non-union where slight distraction at
the fracture site was noted on the ®rst post-operative
radiograph. This was attributed to a technical error
rather than an implant problem. Good results have
been reported after internal ®xation using an angled
blade plate and dynamic condylar screw [16±18]. The
mean ages in these series were 47, 47.2 and 59 years,
respectively and for this reason comparison of our
results with those reported in these series should be
made with caution.
5. Results
In eight fractures early callus was seen within the
®rst 3±6 weeks after surgery. Fifteen of 16 fractures,
united in an average duration of 3.6 months (2±7
months). None of the patients required any secondary
procedure to achieve union. The average range of
motion at the knee was 100.68, with an average exten-
sor lag of 6.98. None of the fractures united with an
angulation of more than 108 at the fracture site. There
was an average shortening of 1.4 cm. One patient had
a shortening of 4 cm following malunion of a conser-
vatively treated stress fracture of the femur above the
nail, whereas other patients had a shortening in the
range of 0±2.5 cm. There were no implant failures,
knee sepsis or wound healing problems. There was
loosening of a distal screw in one patient 4 weeks after
the operation. The radiographs showed good early cal-
lus and the screw was removed under local anaesthesia
which did not a€ect the ®nal outcome (Fig. 1). One
patient had some tenderness at the site of insertion of
a distal screw.
Immediate post-operative complications included
chest infection in one patient which resolved with
intravenous antibiotics; congestive cardiac failure in
another patient which was also treated successfully.
There was one non-union and two stress fractures of
the femur. The patient with the non-union was mobi-
lising without any pain with a single stick and refused
any surgical intervention. Two patients sustained frac-
ture of the shaft of the femur just above the nail while
the original distal fractures were still uniting. Both
patients had a preexisting ipsilateral total hip replace-
ment. In one patient, the fracture was treated with
open reduction and internal ®xation with plate and
screws. The fracture united in 158 of varus angulation
after the plate showed signs of loosening. The original
supracondylar fracture united in satisfactory alignment
within 3 months of the injury. The second patient had
very restricted mobility because of ischaemic ulcers
over both ankles and a painful hip on the same side.
She was treated conservatively in a hinged cast brace
and the fracture united in 258 of valgus angulation.
The original supracondylar fracture took 7 months to
heal, but again in good alignment.
The retrograde femoral nail has been found to be
mechanically similar to a 958 blade plate in clinically
important loading modes, i.e. varus compression load-
ing in laboratory studies [19]. However, a nail with
multiple holes spaced throughout the length can
undergo fatigue fracture through one of the holes
[8,9,12]. There were no cases of bent or broken nails in
our series. This nail being a titanium nail has the ad-
vantage of better strength, better biocompatability and
high corrosive resistance compared to stainless steel
and Co±Cr alloy implants [20]. There were no cases of
loss of ®xation or reduction except loosening of a dis-
6. Discussion
Fractures of the distal femur in the elderly popu-
lation are dicult to manage as these patients cannot

A. Kumar et al. / Injury, Int. J. Care Injured 31 (2000) 169±173
173
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In this series, two of the four patients who had a
preexisting implant in the femur sustained fracture of
the femoral shaft just above the nail without signi®cant
trauma. Both patients had a femoral prosthesis from
previous total hip arthroplasty. Similar complication
has been reported previously after using lateral devices
[17,18] and a retrograde nail [8] in the absence of other
implants in the femur. Though titanium has a modulus
of elasticity close to the bone, as compared to other
alloys, an area of high stress concentration between
two intramedullary implants caused the fracture of the
shaft of the osteoporotic femur. Although good results
have been reported after using a supracondylar nail in
the management of femoral fractures in the presence
of other femoral implants [11], we recommend caution
after using this implant in such cases.
[5] Schatzker J, Lambert DC. Supracondylar fractures of the
femur. Clinical Orthopaedics and Related Research
1979;138:77±83.
[6] Moore TJ, Watson T, Green SA, Garland DE, Chandler RW.
Complications of surgically treated supracondylar fractures of
the femur. Journal of Trauma 1987;27:402±6.
[7] Radford PJ, Howell CJ. The AO dynamic condylar screw for
fractures of the femur. Injury 1992;23:89±93.
[8] Lucas SE, Seligson D, Henry SL. Intramedullary supracondylar
nailing of femoral fractures. Clinical Orthopaedics and Related
Research 1993;296:200±6.
[9] Danziger MB, Caucci D, Zecher SB, Segal D, Covall DJ.
Treatment of intercondylar and supracondylar distal femur frac-
tures using the GSH supracondylar nail. American Journal of
Orthopaedics 1995;24:684±90.
At the latest follow up, the majority of the surviving
patients were satis®ed with the functional outcome
after surgery. A satisfactory average range of motion
of 100.68 was achieved considering that elderly patients
gain signi®cantly less knee ¯exion than younger
patients [21]. Only one patient, who had bilateral
severe osteoarthritis with genu valgum, failed to
achieve a knee ¯exion of 908 but the movement
achieved was similar to the opposite uninjured knee.
We have not used any rating scale to measure the
functional outcome after surgery, as none of these
scales take into account the age of the patient, the
fracture subtype, associated injuries and preexisting
conditions which can a€ect the functional outcome [5].
[10] Reddy MR, Goswami V, Lin K, Sinha AK, Chana GS.
Treatment of supracondylar fractures of the femur in elderly
patients with retrograde intramedullary interlocking nail.
International Journal of Orthopaedic Trauma 1996;6:15±8.
[11] Ward PJ, Goodwin MI. The use of the supracondylar nail in
the management of femoral fractures in the presence of other
femoral implants in the very elderly. Injury 1998;29:671±5.
[12] Gynning JB, Hansen D. Treatment of distal femoral fractures
with intramedullary supracondylar nails in elderly patients.
Injury 1999;30:43±6.
[13] Marks DS, Isbister ES, Porter KM. Zickel supracondylar nail-
ing for supracondylar femoral fractures in elderly or in®rm
patients. Journal of Bone and Joint Surgery 1994;76B:596±601.
[14] Muller ME, Allgower M, Schneider R, Willenegger H. The
comprehensive classi®cation of fractures of long bones. Manual
of internal ®xation, 3rd ed. Berlin: Springer-Verlag, 1991.
[15] Benum P. The use of bone cement as an adjunct to internal ®x-
ation of supracondylar fractures of osteoporotic femurs. Acta
Orthopaedica Scandinavica 1977;48:52±6.
Therefore, comparison among various studies
becomes dicult.
a
In conclusion, we believe that a retrograde supra-
condylar nail, in this case the AIM titanium nail, is a
useful alternative implant for the management of the
osteoporotic fractures of the distal femur, particularly
the extra-articular AO type A fracture in the elderly
population. Further studies with a larger number of
patients and di€erent types of fractures are rec-
ommended.
[16] Mize RD, Bucholz RW, Grogan DP. Surgical treatment of dis-
placed, comminuted fractures of the distal end of the femur.
Journal of Bone and Joint Surgery 1982;64A:871±9.
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lar fractures of the femur. Treatment by internal ®xation.
Journal of Bone and Joint Surgery 1989;71A:95±104.
[18] Sanders R, Regazzoni P, Reudi TP. Treatment of supracondy-
lar±intercondylar fractures of the femur using the dynamic con-
dylar screw. Journal of Orthopaedic Trauma 1989;3:214±22.
[19] Firoozbakhsh K, Behzadi K, DeCoster TA, Moneim MS,
Naraghi FF. Mechanics of retrograde nail versus plate ®xation
for supracondylar femur fractures. Journal of Orthopaedic
Trauma 1995;9:152±7.
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