Surgical Tips and Tricks for Distal Femur Plating

Christopher Lee, MD; Dane Brodke, MD; Ajay Gurbani, MD


J Am Acad Orthop Surg. 2021;29(18):770-779. 

In This Article

Abstract and Introduction


Distal femur fractures are challenging fractures to treat, with nonunion rates as high as 22%. Precontoured locking plates have mitigated some earlier causes of failure, while introducing new challenges. The recognition of troublesome injury patterns and appropriate preoperative planning can avoid common pitfalls. Adjunctive techniques, including the use of a radiolucent triangle, an external fixator, unicortical plates, and crossing K-wires, can assist with fracture reduction and maintenance. It is important to understand the common pitfalls involved with distal femur plating and to consider a wide array of techniques to combat these challenges.


Distal femur fractures (Orthopaedic Trauma Association classification types 33A, 33B, and 33C) are relatively uncommon, with a prevalence of 0.5% of all fractures.[1] However, with an aging population that continues to grow, a corresponding increase in distal femur fractures has occurred, with the incidence most recently reported as 8.7/100,000/yr.[2] These fractures frequently occur in the presence of osteoporotic bone, with intraarticular extension common. Furthermore, with the ever-growing increase in arthroplasty, periprosthetic fractures have similarly become more frequent, encompassing up to 30% of distal femur fractures.[2]

As lateral precontoured locked plating has become a mainstay of treatment, new challenges including mechanical failure and plate-induced deformity have emerged.[3,4] Although initial studies on lateral locked plating seemed promising for union rates, recent reports have suggested nonunion rates ranging from 10% to 22%.[5–12] Some complications can be attributed to factors under surgeon control. The purpose of this article was to highlight surgical strategies to overcome common malreduction and implant-related problems and provide injury-specific technical tips.