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Fixation Modalities for Medial Void in Distal Femur Fractures: A Narrative Review

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Review Article | Vol 12 | Issue 1 | January-June 2026 | page: 21-24 | Sachin Kale, Ashok Ghodke, Tejaswini Milind Patankar, Gaurav Kanade, Abhilash Srivastava, Sagar Deshpande

DOI: https://doi.org/10.13107/ti.2026.v12.i01.80 Submitted: 09/02/2026; Reviewed: 04/03/2026; Accepted: 21/03/2026; Published: 10/04/2026

Authors: Sachin Kale [1], Ashok Ghodke [2], Tejaswini Milind Patankar [2], Gaurav Kanade [1], Abhilash Srivastava [1], Sagar Deshpande [3]

[1] Department of Orthopaedics, Dr. D.Y. Patil Medical College, Navi Mumbai, Maharashtra, India. [2] Department of Orthopaedics, M G M Medical College Kamote Navi Mumbai, Maharashtra, India [3] Department of Physiotherapy, Dr. D.Y. Patil Medical College, Navi Mumbai, Maharashtra, India. Address of Correspondence Dr. Sachin Kale Department of Orthopaedics, Dr. D.Y. Patil Medical College, Navi Mumbai, Maharashtra, India. E-mail: sachinkale@gmail.com

Abstract

Medial void in distal femur fractures—resulting from metaphyseal comminution, cortical bone loss, or segmental defects—predisposes constructs to varus collapse, non-union, and hardware failure if left unsupported. This narrative review synthesises current fixation strategies to address the medial defect, including: (1) lateral locked plating with augmentation (subchondral rafting, kickstand/medial column screws, bone graft and substitutes, and cement augmentation), (2) dual plating with a medial buttress, (3) nail–plate combination constructs, and (4) emerging concepts such as far cortical locking and linked constructs. Across biomechanical and clinical studies, strategies that restore a medial buttress or create a stable load-sharing environment reduce varus collapse, improve radiographic parameters, and may shorten time to union in comminuted, osteoporotic, or peri‑articular patterns. Technique selection should be individualised by patient factors (bone quality, soft tissue, comorbidities), fracture morphology (AO/OTA 33‑A3/C3, periprosthetic, non‑union), and intra‑operative reduction behaviour. We propose a pragmatic, reduction‑first algorithm prioritising medial column support, balanced construct flexibility, adequate working length, and biological preservation. Future work should include comparative trials of dual plating versus nail–plate constructs with standardised indications and patient‑reported outcomes. Keywords: Distal femur fracture, Medial void, Dual plating, Nail–plate construct, Cement augmentation, Far cortical locking, Kickstand screw

References

1. Kregor PJ, Stannard JA, Zlowodzki M, Cole PA. Treatment of distal femur fractures using the Less Invasive Stabilization System (LISS): early clinical results. J Orthop Trauma. 2004;18(8):509–520. 2. Schütz M, Müller M, Krettek C, Hontzsch D, Regazzoni P, Ganz R, et al. Minimally invasive fracture stabilisation of distal femoral fractures with the LISS: technique and early results. Injury. 2001;32(Suppl 3):SC32–SC47. 3. Ricci WM, Streubel PN, Morshed S, Collinge CA, Nork SE, Gardner MJ. Risk factors for failure of locked plate fixation of distal femur fractures: an analysis of 335 cases. J Orthop Trauma. 2014;28(2):83–89. 4. Tripathy SK, Goyal T, Sen RK, et al. Dual‑Plating in distal femur fracture: a systematic review. Cureus. 2021;13(1):e12685. 5. Thorne TJ, Arrington ED. Dual plating of distal femoral fractures. JBJS Rev. 2024;12(6):e23.00247. 6. Kook I, et al. The impact of medial‑first dual plating for reduction of distal femur fractures. Sci Rep. 2025;15. 7. Leal JA, et al. Medial augmentation of distal femur fractures using the contralateral lateral distal femoral locking plate. OTA Int. 2024;7(3):e335. 8. Chen SR, Shaikh H, Turvey BR, et al. Supplemental medial column screw fixation of distal femur fractures treated with a laterally based locked plate: technical trick. J Orthop Trauma. 2023;37:e175–e180. 9. Henningsen J, et al. Increased stiffness with medial column screw in distal femur fracture models: a biomechanical study. Injury. 2025. 10. Dimitroulias A, et al. Linking a nail and a plate for distal femur fractures. SICOT‑J. 2024;10:8. 11. Liporace FA, Yoon RS. Distal femur: nail–plate combination and the linked construct. OTA Int. 2022;5(3):e200. 12. Saraglis G, et al. Linked nail/plate construct for complex distal femur fractures: effectiveness and union. SICOT‑J. 2024;10:20. 13. Baumann AN, et al. Nail‑plate combination constructs versus single traditional constructs for distal femur fractures: comparative outcomes. Injury. 2024. 14. Xu W, et al. Comparison of retrograde nail plus lateral plate versus dual plating in AO/OTA 33C distal femur fractures: a retrospective cohort. Sci Rep. 2025;15. 15. Bäumlein M, et al. Cement augmentation of angular stable plate fixation in distal femur: biomechanical effects of fenestrated condylar screws. BMC Musculoskelet Disord. 2020;21:282. 16. Wähnert D, et al. Implant augmentation in the treatment of distal femoral fractures: a biomechanical investigation. Injury. 2013;44(6):785–789. 17. DeBaun MR, et al. Calcium phosphate cement and locked plate augmentation of large distal femoral defects: comparative study. Knee. 2019;26(5):1040–1048. 18. Bottlang M, Doornink J, Fitzpatrick DC, et al. Far cortical locking enables flexible fixation with periarticular locking plates. Clin Orthop Relat Res. 2011;469:1757–1765. 19. Bottlang M, et al. Dynamic fixation of distal femur fractures using far cortical locking screws: prospective observational study. J Orthop Trauma. 2014;28(12):e276–e283. 20. Stockton DJ. Distal Femur Fractures—OTA Core Curriculum; selected readings and references (includes Ricci et al.). 2021.
How to Cite this article: Kale S, Srivastava A, Deore S, Yadav A, Kushdeep, Datta S | The Three-Stitch Technique for Antegrade Humerus Nailing: A Minimally Invasive Approach to Improved Functional Outcomes and Reduced Complications in Humerus Shaft Fractures Narrative review | January-June 2026; 12(1): 15-20 | https://doi.org/10.13107/ti.2026.v12.i01.78

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Complicated Tibial Plateau Fractures in Young Patients: Functional Outcome with Dual Plating through two Incision Technique

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Vol 5 | Issue 1 | Jan-April 2019 | page: 28-31 |Abdul Qadir, Muhammad Muzzammil, Muhammad Tahir Lakho, Maratib Ali.

Author: Abdul Qadir [1],Muhammad Muzzammil [1], Muhammad Tahir Lakho [1], Maratib Ali [2]

1 Dept. Of orthopaedic surgery, Dr. Ruth  K.M Pfau Civil Hospital Karachi – Pakistan.

2 Dept. Of orthopaedic surgery, Jinnah Postgraduate Medical Center, Karachi Pakistan.

Address of Correspondence

Dr. Abdul Qadir
Orthopedic surgeon
Dr. Ruth K.M Pfau civil hospital
Dow university of health sciences
Karachi pakistan

Abstract

Objective: Motorbike accidents contribute one of the most important factors of tibial plateau fracture among young populations in Karachi Pakistan. Most surgeons feel challenging to treatment complicated bicondylar fractures of the tibial plateau.This prospective study was designed to evaluate the functional outcomes of dual plating through a two-incisions technique for the fixation of complicated bicondylar tibial plateau fractures in young patients in Karachi Pakistan.

Methods: This prospective study includes 94 cases of Type V and VI tibial plateau fractures of young patient’s age range from 15 to 45 years, operated between January 2014 and December 2016 conducted in two public sector hospital of Karachi Pakistan (Jinnah Post Graduate Medical Center, Civil Hospital Karachi). Exclusion criteria include patients with multiple fractures on the same side or same bone, age >45 years, open contaminated fracture, open fracture,and patients with head injuries. All cases were operated either by lateral locking plate fixation by anterolateral approach or dual plating through double incisions. These all cases were followed for a minimum of 24 months radiologically and clinically. The statistical analysis was performed using software SPSS 20.0 to analyze the data.

Results: A total of 94 patients (45 Single Plating and 49 Dual Plating)were operated during the study period of 2 years. However, four patients (4 single plating and 0 dual plating) were lost during follow-up who could not be tracked. Both groups were somewhat similar in relation to the age, mechanism of injury, fracture pattern, and soft tissue injury. Preoperatively, there was a significant increase in surgical time with the dual plating group; however, the mean time of reduction between the two groups was not significant. The decision to put bone graft was at the choice of the operating surgeon and was an intra operative decision with 74 (78.7%) patients receiving the bone graft. Post-operatively, there was no immediate difference in between the groups considering thermal alignment and reduction. It took approximately 4–5 months for the fractures to get united. There was normal union,non union or implant failure seen among those patients. There were 10 cases with superficial infection in wounds of dual plating group which were treated with culture sensitive antibiotics for average 2 weeks, healed subsequently. There were three patients found having an incidence of deep infection in a double plating group, wherein 2 patients were positive with Staphylococcus aureus and 1 patient with Escherichia coli was isolated. Extensive wound irrigation and lavage with antibiotic cement beads were given. Repeated irrigation and lavage were done again after 2 weeks with the removal of beads followed by prolonged course of antibiotic therapy for 6 weeks after which the infection resolved.A total of 38 (77%) patients in a double plating group regained full flexion (135°) and full extension (0°) with a good alignment and no pain and instability as compared to single plating group, seen in 30 (66%) patients at follow-up.

Conclusion: Dual plating by two-incision method resulted in better functional outcome regarding limb alignment and range of movements at knee joint with an acceptable soft tissue complication rate in young patients.

Keywords: Complicated tibial plateau fracture, Young patients, Double incision, Dual plating.

References

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9. Phisitkul P, McKinley TO, Nepola JV, Marsh JL. Complications of locking plate fixation in complex proximal tibia injuries. J Orthop Trauma 2007;21:83-91.

10. Dendrinos GK, Kontos S, Katsenis D, Dalas A. Treatment of highenergy tibial plateau fractures by the ilizarov circular fixator. J Bone Joint Surg Br 1996;78:710-7.

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12. Higgins TF, Klatt J, Bachus KN. Biomechanical analysis of bicondylar tibial plateau fixation: How does lateral locking plate fixation compare to dual plate fixation? J Orthop Trauma 2007;21:301-6.

13. Horwitz DS, Bachus KN, Craig MA, Peters CL. A biomechanical analysis of internal fixation of complex tibial plateau fractures. J Orthop Trauma 1999;13:545-9.

14. Jiang R, Luo CF, Wang MC, Yang TY, Zeng BF. A comparative study of less invasive stabilization system (LISS) fixation and two-incision double plating for the treatment of bicondylar tibial plateau fractures. Knee 2008;15:139-43.

15. Barei DP, Nork SE, Mills WJ, Henley MB, Benirschke SK. Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique. J Orthop Trauma 2004;18:649-57.

16. Papagelopoulos PJ, Partsinevelos AA, Themistocleous GS, Mavrogenis AF, Korres DS, Soucacos PN, et al. Complications after tibia plateau fracture surgery. Injury 2006;37:475-84.

17. Yoo BJ, Beingessner DM, Barei DP. Stabilization of the posteromedial fragment in bicondylar tibial plateau fractures: A mechanical comparison of locking and nonlocking single and dual plating methods. J Trauma 2010;69:148-55.

18. Moore TM, Patzakis MJ, Harvey JP. Tibial plateau fractures: Definition, demographics, treatment rationale, and long-term results of closed traction management or operative reduction. J Orthop Trauma 1987;1:97-119.

19. Stevens DG, Beharry R, McKee MD, Waddell JP, Schemitsch EH. The long-term functional outcome of operatively treated tibial plateau fractures. J Orthop Trauma 2001;15:312-20.

20. Zhang Y, Fan DG, Ma BA, Sun SG. Treatment of complicated tibial plateau fractures with dual plating via a 2-incision technique. Orthopedics 2012;35:e359-64.

21. Gosling T, Schandelmaier P, Muller M, Hankemeier S, Wagner M, Krettek C, et al. Single lateral locked screw plating of bicondylar tibial plateau fractures. Clin OrthopRelat Res 2005;439:207-14.

How to Cite this article:  Qadir A, Muzzammil M, Lakho M T, Ali M. Complicated Tibial Plateau Fractures in Young Patients: Functional Outcome with Dual Plating through two Incision Technique. Trauma International Jan-Aprl 2019;5(1):28-31.

 

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