Chinese Journal of Traumatology 18 (2015) 279e283

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Chinese Journal of Traumatology

journal homepage: http://www.elsevier.com/locate/CJTEE

Original article

Contralateral reversed distal femoral locking plate for xation of

subtrochanteric femoral fractures
Paritosh Gogna, Reetadyuti Mukhopadhyay*, Amanpreet Singh, Ashish Devgan,
Sahil Arora, Amit Batra, Sushil Kumar Yadav
Department of Orthopaedics and Rehabilitation, Pt BD Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 15 December 2014
Received in revised form
12 March 2015
Accepted 24 March 2015
Available online 14 November 2015

Purpose: Subtrochanteric fractures of the femur are being managed successfully with various intramedullary and extramedulary implants with reasonable success. However, these implants require precise
placement under image intensier guidance, which exposes the surgeon to substantial amount of radiation. It also restricts the management of these fractures at peripheral centers where facility of image
intensiers is not available. Keeping this in mind we designed this study to identify if contralateral
reversed distal femoral locking plate can be used successfully without the use of image intensier.
Methods: Twenty-four consecutive patients (18 men and 6 women) with a mean age of 28 years (range
19e47 years) suffering subtrochanteric fractures of the femur underwent open reduction and internal
xation with reversed contralateral distal femoral locking plate. The outcome was assessed at the mean
follow-up period of 3.2 years (range 2e4.6 years) using the Harris hip score.
Results: Twenty-one fractures united with the primary procedure, with a mean time of consolidation
being 11 weeks (range, 9e16 weeks). One patient developed supercial suture line infection, which
resolved with oral antibiotics. Another patient had a fall 3 weeks after surgery and broke the plate.
Repeat surgery with reversed distal femoral locking compression plate was performed along with bone
grafting and the fracture united. Two cases had nonunion, which went in for union after bone grafting.
The mean Harris hip score at the time of nal follow-up was 90.63 (range 82e97).
Conclusion: The reversed contralateral distal femoral plate is a biomechanically sound implant, which
when used for xation of the subtrochanteric fractures with minimal soft tissue stripping shows results
comparable to those achieved by using other extramedullary implants as well as intramedullary devices.
The added advantage of this implant is its usability in the absence of an image intensier.
2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Daping Hospital and the
Research Institute of Surgery of the Third Military Medical University. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords:
Femoral fractures
Bone plates
Fracture xation

1. Introduction
The Subtrochanteric region of the femur is a high stress zone
making treatment of fractures in this area a challenging job.1 High
energy trauma is the major culprit causing subtrochanteric fractures in young adults. The xation demands an implant that provides a suitable environment for fracture healing, in addition to
providing stability.2,3 The tug of war between intramedullary and

* Corresponding author. Tel.: 91 9818875814.

E-mail
addresses:
reetya_m@hotmail.com,
reetadyutim@gmail.com
(R. Mukhopadhyay).
Peer review under responsibility of Daping Hospital and the Research Institute
of Surgery of the Third Military Medical University.

extramedullary devices seem never ending. Although the intramedullary xation seems to be the current treatment of choice, it is
not without pitfalls.4 It does provide a good bending stiffness,
however the torsional control that it provides is poor; thus not an
ideal implant for the spiral fractures that are often seen in this
region.5 Patients with an intramedullary device also complain of
signicant insertion site pain. They also have abductor weakness
and impingement to a certain extent.6 The endosteal blood supply
is also hampered to a great extent.7 The use of an intramedullary
device is further challenged by a fracture extending to the intertrochanteric region. In addition, intramedullary xation is a more
tasking surgery, demanding greater amount of skill as compared to
extra-medullary stabilization.8
Various extramedullary devices have also been developed and
used over time for xing subtrochanteric fractures. The angled

http://dx.doi.org/10.1016/j.cjtee.2015.11.002
1008-1275/ 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Daping Hospital and the Research Institute of Surgery of the Third Military Medical
University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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P. Gogna et al. / Chinese Journal of Traumatology 18 (2015) 279e283

Table 1
Clinical details of patients.
Case

Sex

Age

Classication

Follow-up(year)

Full weight bearing(week)

Harris hip score

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Mean

M
M
F
M
M
M
M
F
M
M
M
F
M
M
M
F
M
F
M
M
M
F
M
M

19
33
28
45
24
25
27
35
24
26
33
20
27
29
26
19
20
21
27
27
42
24
47
23
28

A1
B2
B3
C1
B2
A3
C1
B3
A1
A3
B3
B1
B2
C1
B3
B1
B3
A3
B3
C2
A3
B3
A3
C2

2
2.1
2.2
2.4
2.4
2.5
2.6
2.7
2.7
2.8
3
3.2
3.2
3.4
3.4
3.7
3.8
3.8
3.9
3.9
4
4.3
4.4
4.6

12
13
11
16

91
95
89
94
91
90
86
97
93
92
93
90
95
94
97
90
83
92
89
82
84
86
88
94
90.625

12
16
12
15
14
9
10
9
10
12
14
13
9
10
11
12
12
12

blade plate and the dynamic condylar screw being the ones that
have been most widely used in this area.3 These extramedullary
devices when used through a minimally invasive technique, put in
the submuscular zone; preserve both the periosteal and endosteal
blood supply in addition to providing stability and an environment
apt for fracture healing.9 We intend to present a reversed contralateral distal femoral locking compression plate (DFLCP) as an
biomechanically sound alternative extramedullary devise for

Complication

Secondary procedure

Nonunion
Nonunion

Grafting at 1 year
Grafting at 1 year 3 months

Implant breakage
Supercial infection

Rexation along with grafting

1 cm shortening

xation of subtrochanteric fractures in adults at centers where an

image intensier is not available at the facility.
2. Material and methods
We treated 24 consecutive patients (18 men and 6 women), with
subtrochanteric fractures of the femur at our center using reversed
DFLCP. The mean age of the patients was 28 years (range 19e47

Fig. 1. (a) Preoperative radiographs of a 24 years old male with type A1 subtrochanteric fracture of the femur. (b) Postoperative radiographs of the same patient. (c) Radiographs at
nal follow-up showing consolidation of the fracture.

P. Gogna et al. / Chinese Journal of Traumatology 18 (2015) 279e283

years) and the mean follow-up period was 3.2 years (range 2e4.6
years, Table 1). Exclusion criteria were patients with open injuries,
pathological fractures, ipsilateral distal femoral fractures, ipsilateral
neck or inter-trochanteric fractures and associated pelvic injury. All
patients were put on skeletal traction till surgery. The mean time
between presentation and surgery was 1.2 days (range 0e3 days).
According to AO classication, 6 fractures were type A (two A1, and
four A3), 12 were type B (two B1, three B2, and seven B3), and ve
were type C (three C1 and two C2). All fractures were open reduced,
with care to minimally damage the soft tissue cover. Skin incision
was made beginning at the greater trochanter and extending along
the shaft. Fascia was incised along the skin incision. The fracture
was exposed and reduced under vision, and a plate of appropriate
length was placed with its proximal end at the trochanteric ridge.
Post xation alignment was acceptable as the cases were reduced
under direct vision taking care about the length and rotation. We
did not denude the bone; only the fracture site was exposed to
attain direct anatomical reduction. Being a locking plate, it did not
require any periosteal stripping. For the purpose of xation in the
proximal femur, the target was to drive long screws up to the
femoral calcar in two rows of locking screws through the proximal
expanded part of the locking plate and 6e8 cortices purchased in
the distal fracture fragment. In 14 patients, in view of the spiral
conguration of the fracture, it was xed with inter-fragmentary
screws and neutralized with a plate. After xation, we moved the

281

hip joint through the complete range of motion and checked the
stability. All wounds were closed over drain, which was removed
24 h after surgery. Physiotherapy in the form of static quadriceps
exercises, ankle pump and active toe movements were encouraged
immediately after operation. Supervised physiotherapy in the form
of knee bending and nonweight-bearing walking was initiated as
soon as the pain subsided, usually on the third postoperative day.
Patients were reviewed at 2 weeks for suture removal, thereafter
fortnightly for 2 months, and then at monthly interval for 6 months
for clinic-radiological evaluation and complications if any; thereafter, clinical assessment was made at 6 monthly intervals. Functional outcome was assessed using the Harris hip score. Union was
dened as bridging of three of the four cortices and disappearance
of fracture line on the plain radiographs for a patient who was able
to bear full weight. Nonunion was dened as a fracture that did not
heal within 9 months.
3. Results
We were able to attain a union rate of 87.5% with the primary
procedure (Figs. 1e3), with a mean time to full weight bearing
being 12 weeks (range 9e16 weeks). The average operative time
was 45 min with just one incidence of postoperative infection.
There was a single case of limb length discrepancy of 1 cm, which
was well compensated by the patient. One patient had supercial

Fig. 2. (a) Preoperative radiographs of a 27 years old male with type C1 subtrochanteric fracture of the femur. (b) Fracture was reduced and xed using Lag screws, and reverse
DFLCP was applied as a neutralization plate.

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P. Gogna et al. / Chinese Journal of Traumatology 18 (2015) 279e283

Fig. 3. (a) Preoperative radiographs of a 26 years old male with type A3 subtrochanteric fracture of the femur. (b) Postoperative radiographs of the same patient showing optimal
reduction using reverse DFLCP. (c) Radiographs at nal follow-up.

suture line infection, which resolved with a ten-day course of an

oral antibiotic. We did not observe any implant back out though
one patient presented with a broken plate due to domestic fall
three weeks after surgery. Repeat surgery with reversed DFLCP was
performed along with bone grafting and the fracture united. In the
rest of the 2 cases, bone grafting of the fracture site was performed
with cortico-cancellous graft harvested from ipsilateral iliac crest at
1 year and 1 year 3 months respectively, which resulted in union.
The functional outcome of the patients was evaluated as per Harris
hip score. The mean Harris hip score at one-year follow-up was
90.63 (range 82e97).
4. Discussion
The DFLCP has long been used in distal fractures of the femur
with good long-term results.10 It is a biomechanically sound
implant to be used in the subtrochanteric region as well. The shape
of a reversed contralateral distal femoral plate ts well with the
contour of the greater trochanter and the shaft of the plate ts well
with the anterolateral curve of the femur. The use of locking screws
further leaves a gap between the bone and the implant thus preserving the periosteal bold supply of the bone.3 The placement of
the proximal end of the plate at the trochanteric ridge ensures at
least one row of screws in the femoral calcar. Also, it was observed
even if the most proximal screw went into the neck. It, being of a
locking nature ensured sufcient hold. We achieved a union rate of
87.5% in our study group further conrming the bio-mechanically
sound principle of this technique. Our union rate was comparable
to that achieved by Siebenrock et al.11
Pakuts12 compared intramedullary devices with extramedullary
implants for xation of unstable intertrochanteric fractures. He
observed that the mean time to union was 10 weeks when he used
an intramedullary device (Gamma nail) as against 15 weeks in the
group of patients treated with dynamic condylar screw. They
concluded that extramedulary devices result in early ambulation;
however we were able to achieve union in a mean time period of 11

weeks, which is comparable to the Gamma Nail group in their series. Use of locking plate as an internal xator reduces the plate
contact area thus preserving the vascularity and enhances healing;
the chances of osteoporosis at the plate bone interface is also
reduced.13 Thus, using an extra-medullary implant with minimal
soft tissue stripping we can achieve a quick callus formation and
good union rate thus allowing our patients an early rehabilitation
and weight bearing comparable to that by an intramedullary
xation.14
Of the various extramedullary devices available for xation of a
fracture in this region, the angled blade plate and the dynamic
condylar screw are the ones most widely used.3 Although the
angled blade achieves good results particularly in comminuted
fractures, its use is technically demanding requiring a tri-planar
orientation.15 The use of the dynamic condylar screw also requires signicant level of skill and an image intensier.7
Rohilla et al16 using a mini incision technique of dynamic
condylar screw xation achieved results comparable to ours. They
showed union at a mean interval of 16 weeks post surgery with full
weight bearing at a mean of 11 weeks post surgery. Although
Rantanen et al17 reported higher complication rates with the use of
intra-medullary devices and higher rates of refracture and xation
failure put against extramedullary devices, intramedullary devices
seem to be the implant of choice at most centers for subtrochanteric fracture xation today, with reports suggesting better
postoperative restoration of walking ability. The recovery after
intramedullary nailing may be faster and better with less complication because of its biomechanical benet with central buttress
and a shortened lever arm.18
The use of the reversed contralateral distal femoral plate is
however a good option by surgeons working at centers without
access to an image intensier; with results comparable to that
achieved by other modes of xation, be it intramedullary or
extramedullary. Ouyang et al19 using the reverse less invasive stabilization system plates showed complete union in all his 26 elderly
patients with subtrochanteric femur fractures. He also observed

P. Gogna et al. / Chinese Journal of Traumatology 18 (2015) 279e283

that his results were comparable to those attained by intramedullary xation. Gogna et al20 have used proximal humerus
locking plate for xation of paediatric subtrochanteric fractures and
attained a 100% union rate at a mean of 8.75 weeks (range 6e14
weeks) thus, supporting the fact that locking periarticular plates
are a viable option for xation of subtrochanteric fractures.
Using this method, one needs to reduce the fracture under
vision, ensuring that the distal expanded part of the plate falls just
short of the trochanteric tip, as the target is no longer to insert a hip
screw, visualization with an image intensier in not required. The
reason why we chose DFLCP rather than any other plates in our
series is that it is readily available and familiar, provides multiple
options for screw xation in the proximal part of the fracture, it
adheres closely to the anatomy of the proximal femur and the
implant is cheaper compared with the LISS. With contralateral
reversed DFLCP, the surgeon is able to insert at least two rows of
long screws up to the femoral calcar providing enough stability. The
initial mid-term result of our series is quite encouraging.
Our study has its own set of limitations. It is a small series with
different congurations of subtrochanteric fractures. The follow-up
period is short and there is lack of a control group. However, the
strength of the study is that it is a single institutional study with
cases treated by the same team of surgeons. The ndings of our
study show that reversed contralateral DFLCP, when used for xation of the subtrochanteric fractures shows results comparable to
those achieved by using other extra-medullary implants as well as
intramedullary devices. The added advantages of this implant are
its familiarity by the surgeons and usability in the absence of an
image intensier.
References
1. Kyle RF, Cabanela ME, Russell TA, et al. Fractures of the proximal part of the
femur. Instr Course Lect. 1995;44:227e253.
2. Crist BD, Khala A, Hazelwood SJ, et al. A biomechanical comparison of locked
plate xation with percutaneous insertion capability versus the angled blade
plate in a subtrochanteric fracture gap model. J Orthop Trauma. 2009;23:
622e627.
3. Lati MH, Ganthel K, Rukmanikanthan S, et al. Prospects of implant with
locking plate in xation of subtrochanteric fracture: experimental demonstration of its potential benets on synthetic femur model with supportive

4.

5.

6.
7.

8.

9.
10.
11.

12.
13.

14.

15.

16.

17.

18.
19.

20.

283

hierarchical nonlinear hyperelastic nite element analysis. Biomed Eng Online.

2012;11:23.
Starr AJ, Hay MT, Reinert CM, et al. Cephalomedullary nails in the treatment of
high-energy proximal femur fractures in young patients: a prospective randomized comparison of trochanteric versus piriformis fossa entry portal.
J Orthop Trauma. 2006;20:240e246.
Tencer AF, Johnson KD, Johnston DW, et al. A biomechanical comparison of
various methods of stabilization of subtrochanteric fractures of the femur.
J Orthop Res. 1984;2:297e305.
Neher C, Ostrum RF. Treatment of subtrochanteric femur fractures using a
submuscular xed low-angle plate. Am J Orthop. 2003;32:29e33.
Vaidya SV, Dholakia DB, Chatterjee A. The use of a dynamic condylar screw and
biological reduction techniques for subtrochanteric femur fracture. Injury.
2003;34:123e128.
Boldin C, Seibert FJ, Fankhauser F, et al. The proximal femoral nail (PFN)da
minimal invasive treatment of unstable proximal femoral fractures: a prospective study of 55 patients with a follow-up of 15 months. Acta Orthop Scand.
2003;74:53e58.
van Meeteren MC, van Rief YE, Roukema JA. Condylar plate xation of subtrochanteric femoral fractures. Injury. 1996;27:715e717.
Ma CH, Tu YK, Yu SW, et al. Reverse LISS plates for unstable proximal femoral
fractures. Injury. 2010;41:827e833.
Siebenrock KA, Muller U, Ganz R. Indirect reduction with a condylar blade plate
for osteosynthesis of subtrochanteric femoral fractures. Injury. 1998;29:
C7eC15.
Pakuts AJ. Unstable subtrochanteric fractures-gamma nail versus dynamic
condylar screw. Int Orthop. 2004;28:21e24.
Perren SM. Evolution of the internal xation of long bone fractures. The scientic basis of biological internal xation: choosing a new balance between
stability and biology. J Bone Jt Surg Br. 2002;84:1093e1110.
Hotz TK, Zellweger R, Kach KP. Minimal invasive treatment of proximal femur
fractures with the long gamma nail: indication, technique, results. J Trauma.
1999;47:942e945.
Yoo MC, Cho YJ, Kim KI, et al. Treatment of unstable peritrochanteric femoral
fractures using a 95 degrees angled blade plate. J Orthop Trauma. 2005;19:
687e692.
Rohilla R, Singh R, Magu NK, et al. Mini-incision dynamic condylar screw xation for comminuted subtrochanteric hip fractures. J Orthop Surg (Hong Kong).
2008;16:150e155.
Rantanen J, Aro HT. Intramedullary xation of high subrochanteric femoral
fractures: a study comparing two implant designs, the gamma nail and the
intramedullary hip screw. J Orthop Trauma. 1998;12:249e252.
Stern R. Are there advances in the treatment of extracapsular hip fractures in
elderly? Injury. 2007;38:S77eS87.
Ouyang Y, Wang Y, Fan C, et al. Using the contralateral reverse less invasive
plating system for subtrochanteric femur fractures in elderly patients. Med
Princ Pract. 2012;21:334e339.
Gogna P, Mohindra M, Verma S, et al. Adult proximal humerus locking plate for
xation of paediatric subtrochanteric fractures. Musculoskelet Surg. 2014;98:
189e194.