Best of Both Worlds? Fixation of Distal Femur Fractures with the Nail‐Plate Construct

Abstract

Objectives

Distal femoral fractures are a significant injury sustained by low‐ and high‐energy trauma. Common treatment practices are lateral locking plate or intramedullary nail fixation, with disadvantages including risk of non and malunion and limited post‐operative weightbearing status. Combining both techniques as a nail‐plate construct (NPC) theoretically achieves enhanced fixation to allow immediate weightbearing. The aim of this study is to examine radiographic union, malunion and patient‐reported outcomes in distal femur NPC fixation.

Methods

Single‐center retrospective study including all patients >18 years who sustained distal femur fractures treated with NPC. Primary outcomes were radiographic union, malunion and patient reported outcome measures at minimum 1‐year follow‐up. Secondary outcome measures included post‐operative mobility, length of stay and complications. Relevant variables of normality are reported as mean with standard deviation. Subgroup analysis of patients aged <65 and ≥65 years are provided.

Results

Sixteen patients were included in the study. Rate of radiographic union was 100%. There was no case of malunion. All patients were allowed to bear full weight immediately post‐operatively. Mean length of stay was 9.50 days, with 37.5% of patients discharged directly home. The majority (85.7%) of patients returned to pre‐injury mobility. Early post‐operative complications occurred in three patients. Three patients returned to theater. The mean EQ‐5D‐5L index value was 0.713, with 71.4% describing no problems with self‐care and 85.7% reporting no or slight problems with usual daily activities.

Conclusion

The NPC provided stable fixation permitting full weightbearing post‐operatively with no cases of non or malunion. Return to pre‐injury mobility and activity are encouraging. Based on these results we support the use of nail‐plate construct fixation in the management of distal femur fractures.

Distal femur fractures are a significant injury with potentially debilitating consequences. Combining intramedullary nail and lateral plate fixation into one technique provides a stable construct which allows patients to bear full weight immediately post‐operatively. One‐year follow‐up shows 100% union rates, 85.7% return to pre‐morbid mobility, and promising patient‐reported outcomes.

Introduction

Native and periprosthetic distal femur fractures are a significant injury associated with high morbidity and mortality rates. ¹ Classically bimodal in distribution, young patients sustain these fractures from high‐energy trauma whilst elderly patients commonly suffer low‐energy mechanisms in the setting of osteoporosis. ¹ , ² In the context of a rapidly aging population and increasing numbers of total knee arthroplasty (TKA), the rate of distal femur fractures is rising. ¹ , ³ , ⁴

The 1‐year mortality rate of geriatric distal femur fractures is 18%–40%. ¹ , ² , ⁵ The risk of venous thromboembolism in these patients is up to 25%. ⁶ Surgically managed distal femur fractures have improved post‐operative mobility. ⁷ , ⁸ Early mobilization and ability to weight bear fully have been shown to reduce mortality rates, post‐operative complications and in‐hospital length of stay. ⁹ , ¹⁰

Locked lateral plating (LP) and intramedullary nailing (IMN) are accepted methods for managing distal femoral fractures. ⁴ However, issues exist with their independent use. There is no consensus on the safety of full weightbearing post‐operatively and elderly patients generally cannot adhere to partial or non‐weightbearing instructions. This can result in protracted hospital admissions and thereby greater hospital costs and associated nosocomial complications. ¹¹ , ¹²

Used as single fixation methods, LP and IMN have nonunion rates of 3.6%–27.5%. ⁷ , ¹³ Standalone LP has a 7.6% malunion rate and a 13.3% rate of secondary surgical procedures. ⁷ Intra‐medullary nailing has a 16.4% malunion rate and 9.1% rate of secondary surgical procedures. ⁷ Dual plate fixation has been heralded as an alternative fixation technique, however nonunion and delayed union rates reach 12.5% and 33.3% respectively. ¹⁴

The nail‐plate construct is a more recently described method for distal femur fractures, combining LP and IMN to provide biomechanically advantageous fixation. This construct has the potential to reduce the risk of non and malunion and allows patients to mobilize immediately post‐operatively without weightbearing restrictions. This in turn could lead to improved post‐operative mobility thereby reducing risk of post‐operative morbidity and mortality.

The purpose of this study is to: (i) report on radiographic union and malunion rates in distal femur fractures managed with NPC; (ii) investigate patient‐reported outcome measures (PROMs) and mobility in this population at minimum 1 year post‐operatively; and (iii) report on morbidity and mortality rates. Additionally, a novel operative technique is described to assist in “linking” the individual nail and plate constructs using a locking screw.

Materials and Methods

Patients

This retrospective study was performed at Lismore Base Hospital (regional referral, Level 5 base hospital in Australia) from March 2020 to September 2022. Patients included in this study: (i) were older than 18 years of age; (ii) had sustained acute native (AO/OTA 33‐A, 33‐B, 33‐C) or periprosthetic (AO/OTA 33‐IV, 33‐V) distal femur fractures and; (iii) were managed with NPC technique fixation. Exclusion criteria included patients: (i) with periprosthetic fracture of distal femur tumor prosthesis; and (ii) treated with revision surgery for mal or nonunion of distal femur fracture. The rationale for exclusion of mal and nonunion patients is that this study aims to investigate outcomes of NPC fixation in the acute fracture setting. A previous study has shown union rates of 100% with the use of NPC fixation for revision of distal femur nonunion. ¹⁵

Demographic information included age, sex and body mass index. Pre‐injury functional status was recorded, including mobility (i.e., use of aids) and assistance (i.e., from another individual). Mechanism of injury (low‐ and high‐energy), native or periprosthetic fracture, pathological or non‐pathological fracture, operating surgeon and use of bone graft were recorded.

Ethics approval was obtained from the New South Wales Health Ethics Committee via Research Ethics and Governance Information System (ETH11681). This study conforms to the Declaration of Helsinki. Informed, verbal consent was obtained from participants for collection of 1‐year follow‐up including functional outcomes, PROMs and radiographs.

Surgical Technique

The nail and plate implants were “fixed” to one another by introducing at least one locking screw through both the distal locking holes of the nail and plate. The rationale being that this creates a more rigid and stable combined construct. Nailing techniques were either antegrade or retrograde dependent upon fracture configuration and whether an “open box” was present in patients with total knee arthroplasty. “Open box” design in a TKA refers to a femoral prosthesis with cancellous bone uncovered at the intercondylar fossa, thereby allowing insertion of a retrograde IMN. In comparison, a “closed box” prosthesis covers this area of cancellous bone and therefore precludes insertion of a retrograde IMN.

Patient Position and Approach

One surgeon preferred the use of a supine traction table for antegrade nailing. All other patients were positioned supine on a standard radiolucent operating table. A lateral, or lateral parapatellar in the case of intra‐articular distal fractures, approach to the femur was performed for reduction and plate fixation. A midline incision with medial parapatellar approach was used for retrograde femoral nailing. Antegrade femoral nailing was performed via standard lateral approach with trochanteric entry point.

Fixation Technique

Fracture reduction and temporary fixation was achieved by either direct or indirect technique through a lateral or parapatellar approach. Reduction was confirmed visually and with fluoroscopy. Nail and plate constructs were linked by placing a screw through the distal locking holes of each implant. A temporary k‐wire was placed through the distal locking hole of the IMN using the jig or fluoroscopy “perfect circles” technique. This k‐wire was left protruding laterally and used as a guide over which the lateral locking plate was placed through a corresponding locking screw hole (Figure 1A–G). This allowed for simplistic alignment of distal screw holes of both the IMN and LP, through which a “fixed” (combined) locking screw was placed. To the best of the authors' knowledge this is a novel technique that has not been previously described. The surgeons found this technique valuable, user‐friendly and that it anecdotally reduced the use of intra‐operative fluoroscopy. However, the authors did not examine fluoroscopy use or operative time in the current study. An example of a native intra‐articular distal femur fracture is provided (Figure 2A,B), with radiographs displaying union at 1 year post‐operatively (Figure 2C,D). Similarly, an example of a periprosthetic TKA distal femur fracture is given (Figure 3A,B) with union on radiographs at 1 year after NPC fixation (Figure 3C–F).

FIGURE 1.

Description of fixation technique. (A–C) radiographs of a periprosthetic distal femur intra‐articular fracture (AO/OTA 33‐C2‐IVB1), with total hip arthroplasty proximally. (D–G) intramedullary nailing (IMN) fixation was performed using a standard technique. When retrograde IMN was performed, the distal jig was used to insert k‐wires through the distal locking holes. When antegrade IMN was performed the distal locking screws of the nail were identified using “perfect‐circles” technique and k‐wires were inserted into the locking holes. The protruding k‐wires were then used as a guide over which the distal femur plate was placed, and screw(s) were then inserted through both plate and nail–thereby “combining” the construct. In our experience two screws were placed through both nail and plate in most instances, but certainly one screw minimum in each case. Plate fixation was then completed by standard technique with stab incisions for proximal fixation.

FIGURE 2.

Example of nail‐plate construct (NPC) fixation technique in native distal femur fracture. (A, B) Pre‐operative radiographs of a native distal femur fracture (AO/OTA 33‐C2‐3). (C, D) One‐year post‐operative radiographs of the previous fracture displaying fixation with NPC screw‐linked technique. Fracture union has been achieved with no malunion.

FIGURE 3.

Example of nail‐plate construct (NPC) fixation technique in periprosthetic total knee arthroplasty (TKA) distal femur fracture. (A, B) Pre‐operative radiographs of a periprosthetic TKA distal femur fracture (AO/OTA 33‐A2‐V3B1). (C–F) One‐year post‐operative radiographs of aforementioned fracture showing fixation with NPC screw‐linked technique. Fracture union is evident with no malunion.

Post‐operative Protocol

All patients received prophylactic antibiotics on induction, as well as chemical deep vein thrombosis (DVT) prophylaxis peri‐operatively. All patients were allowed to immediately bear full weight and were encouraged to range their hip and knee as tolerated.

Outcome Measures

The primary outcome measures were radiographic union and malunion at minimum 1 year follow‐up. One year follow‐up was selected to reflect minimum follow‐up in previously published clinical research on NPC distal femur fixation. ¹³ , ¹⁶ Radiographic union was assessed by two researchers with a minimum of 4 years' experience in orthopedic surgery using the modified radiographic union scale in tibial (RUST) fractures. The modified RUST score has been validated for use in distal femur fractures, with a score of ≥11 dictating radiographic union. ¹⁷ Malunion was defined as ≥5^o to allow comparison to previous studies on distal femur fracture fixation. ⁷

Patient reported outcome measures were recorded in the form of the EuroQol 5 Dimensions (EQ‐5D‐5L). This is a validated, generalized tool used to measure quality of life across five domains: mobility, self‐care, usual activities, pain, and depression. ¹⁸

Secondary outcome measures were pre‐ vs. post‐operative mobility, day of first‐time mobilization post‐operatively, post‐operative weightbearing status, post‐operative length of stay (LOS), discharge destination and any post‐operative complication or return to theater.

All operations were performed by two Fellowship‐accredited Orthopedic surgeons. Follow‐up was performed via either face‐to‐face or telemedicine appointment at minimum 1 year post‐operatively.

Statistic Methods

Normal data was reported as mean with standard deviation (SD). Interobserver agreement on non and malunion was calculated using exact agreement calculation. A RUST score ≥11 was defined as “union,” whilst a score <11 as “nonunion.” ¹⁷ Similarly, malunion was defined by union in ≥5^o from native alignment. ⁷ Assessments were performed independently by two researchers, with agreement calculated by the number of times a set of ratings were the same, divided by the total number of units of observation that were rated, multiplied by 100. All data analysis was performed using Microsoft® Excel (2021).

Results

A total of 17 patients were identified for this study. One patient was excluded as the indication for surgery was infected nonunion following lateral plate fixation, with treatment requiring temporary cement spacer followed by staged bone grafting using a custom‐printed implant. As a heterogenous population was included in this study, subgroup breakdown is provided for analysis of results in patients ≥65 years and <65 years of age.

Demographics and Follow‐up

Patient demographics are displayed in Table 1. Of the 16 patients included, 12 patients were ≥65 years of age. All fractures in the younger age group were of a native distal femur. In the older cohort two had native distal femur fractures, eight had periprosthetic fractures proximal to a total knee arthroplasty and two had distal femur fractures distal to a total hip arthroplasty. In the cohort ≥65 years of age, 11 patients sustained fractures falling from a standing height and one patient sustained a pathological fracture leaning forward whilst getting dressed. In the younger cohort, two fractures were related to motor vehicle accidents, one resulted from a fall at home, and one occurred in a long‐standing spinal injury patient whilst performing physiotherapy external rotation exercises. AO/OTA Classifications are shown in Table 2.

TABLE 1.

Patient demographics.

Baseline Variables	All ages (n = 16)	Age < 65years (n = 4)	Age ≥ 65 (n = 12)
Age in years, median (range)	72.5 (30–93)	43.8 (30–56)	77.5 (68–93)
Gender female, number (%)	11 (69)	1 (25)	10 (83.3)
Body mass index, mean (std deviation)	29.1 (5.63)	27.2 (4.69)	29.7 (5.96)
Low‐energy fracture, number (%)	14 (87.5)	2 (50)	12 (100)
Closed fracture, number (%)	15 (93.8)	3 (75)	12 (100)

TABLE 2.

AO/OTA fracture classification.

AO/OTA classification	All ages	Age < 65years	Age ≥ 65
33‐A1	3	1	2
33‐A2	1	1	0
33‐A3	1	1	0
33‐C3	1	1	0
33‐IV3C	2	0	2
33‐V3B	5	0	5
33‐V3C	3	0	3

Mean follow‐up was 17.5 months (SD 5 months). At follow‐up, two patients were identified as deceased from causes not immediately related to their surgical care. Of the remaining 14 patients, at 1 year follow‐up all responded to their questionnaire and 11 patients had X‐rays performed.

Radiographic Union and Malunion

At 1‐year post‐operatively the radiographic union rate was 100%. There was no loss of position or implant failure resulting in malunion. Interobserver agreement on nonunion and malunion was 100%.

Mobilization and Length of Stay

Six patients were mobilized day 1 post‐operatively, with 78.6% of patients having mobilized by day 2. On subgroup analysis, all patients <65 years and 75% in the ≥65 year cohort were mobilized by day 2.

The mean LOS was 9.50 (SD 8.16) days. The mean LOS in the ≥65 years of age group was 7.9 (SD 5.09). The mean LOS in the younger age group was 7.33 (SD 3.21) on removal of an outlier that had an extended ICU stay for pre‐existing respiratory disease. In the younger age group, all patients were discharged home. Of the older cohort two were discharged home, one returned to a nursing home and nine were transferred to rehabilitation.

At 1 year, 12 patients (85.7%) had no change in pre‐ and post‐operative use of mobility aid. One patient went from needing no aids to mobilizing with a single‐point walking stick. The other patient went from using a 4‐wheeled walker to requiring a wheelchair. Pre‐operatively, no patients required assistance from another individual to mobilize. At follow‐up, 85.7% continued to mobilize without assistance. One patient required stand‐by‐assistance, whilst another required active assistance. All these increases in mobility requirements occurred in the older age cohort.

Morbidity and Mortality

Six post‐operative complications occurred in five patients. Three patients (18.8%) required return to theater. Two patients returned to theater for post‐operative infection. The other patient experienced irritation from an implant and underwent removal of distal femoral plate 1 year after index fixation. Three patients experienced early post‐operative complications; pulmonary embolus diagnosed day 1 post‐operatively, hospital‐acquired pneumonia and urosepsis. All complications occurred in the group ≥65 years of age.

Two patients in the ≥65 years of age cohort were deceased at 1‐year follow‐up. Each patient had discharged from hospital post‐operatively, with their death not related to immediate post‐operative causes.

Patient‐reported Outcomes

Patient‐reported outcome measures (EQ‐5D‐5L) at minimum 1 year post‐operatively are reported in Table 3 for patients <65 years of age and in Table 4 for patients ≥65 years. Overall, 50% of patients described no issues with mobility and a further 28.6% reported only slight issues with mobility. Regarding self‐care, 71.4% described no problems and 21.4% reported slight issues. The majority (85.7%) of patients reported no or slight problems with usual daily activities. Six patients (42.9%) reported no pain, with no patients describing severe or extreme pain. The overall EQ‐5D‐5L mean index value was 0.713 (SD 0.200); the younger cohort scoring 0.767 (SD 0.158) and the older cohort scoring 0.691 (0.222).

TABLE 3.

EQ‐5D‐5L PROMs for individual domains in patients <65 years of age.

Domain	Mobility	Self‐care	Usual activities	Pain/discomfort	Anxiety/depression
1. No issues	3	2	2	2	3
2. Slight issues	0	2	2	2	0
3. Moderate issues	0	0	0	0	1
4. Severe issues	0	0	0	0	0
5. Extreme issues	1	0	0	0	0

TABLE 4.

EQ‐5D‐5L PROMs for individual domains in patients ≥65 years of age.

Domain	Mobility	Self‐care	Usual activities	Pain/discomfort	Anxiety/depression
1. No issues	4	8	1	4	5
2. Slight issues	4	1	7	3	4
3. Moderate issues	1	0	1	3	1
4. Severe issues	0	0	1	0	0
5. Extreme issues	1	1	0	0	0

Discussion

Main Findings

The evidence available on the use of the NPC in acute distal femur fractures consists of biomechanical and small clinical studies, but the results to date are highly promising. To the authors' knowledge, no studies have yet investigated malunion rates or PROMs in this patient cohort.

Our study revealed a union rate of 100%, consistent with other published data on NPC fixation. ³ , ¹³ , ¹⁶ There were no cases of malunion or implant failure in our study. These results compare favorably to the significant mal and nonunion rates in isolated LP or IMN fixation techniques. ⁷ , ¹³ Our study supports that NPC fixation for distal femur fractures yields excellent radiographic union results in the setting of immediate full weightbearing.

Of note, two patients in this cohort were treated for pathological fracture in the setting of multiple myeloma. Due to the aberrant physiological processes in pathological fractures, previous studies have recorded a nonunion rate of 33% in long bone fractures secondary to multiple myeloma. ¹⁹ Despite this, both patients in our study achieved radiographic union. Whilst this is an interesting observation, additional study will need to be performed to better understand the role and effects of NPC fixation in pathological distal femur fractures.

There is no consensus on the ideal surgical management of distal femur fractures. Nail fixation allows minimal fracture site disruption and stimulated healing from reaming of the intramedullary canal. ²⁰ With strong biomechanical properties, fixed‐angle plates are designed for osteoporotic bones. ²⁰ However, biomechanical studies have shown that as a load‐bearing device lateral plating is more likely to result in implant failure than IMN. ³ The same biomechanical studies have revealed high risk of catastrophic failure of the bony cortex in fractures fixed with a load‐sharing IMN. ³ Isolated lateral plate fixation has nonunion rates of 8.8% and malunion rates of 7.6%. ⁷ Similarly, IMN fixation has nonunion and malunion rates of 3.6% and 16.4% respectively. ⁷

Liporace et al. explained the rationale that combining the advantages of a lateral locking construct with a load‐sharing central beam results in energy being more evenly distributed between bone and implants. ³ Additionally, linking the constructs with locking screws and spanning the femur allows for smoother transition of forces and therefore more stable, early weightbearing. ³ Similarly, Kontakis et al. described improved torsional stability, greater axial strength and reduced load to failure with use of the NPC in comparison to isolated LP or IMN fixation. ²¹ Biomechanical studies show that weightbearing post‐operatively risks implant failure and malunion in isolated fixation techniques, whilst the NPC permits immediate weightbearing with reduced risk of failure. Three separate studies investigating the use of NPC fixation in distal femur fractures have revealed 100% union rate at follow‐up without implant failure. ³ , ¹¹ , ¹³

Patient‐reported Outcome Measures

The EQ‐5D‐5L mean index value was 0.713 (SD 0.200) at minimum 1‐year follow‐up, weight‐adjusted for the general Australian population. In subgroup analysis, the mean index value in the age group ≥65 years of age was 0.691, which compares favorably to a study that surveyed isolated LP or IMN fixation in a similar age group at 4 months post‐operatively scoring only 0.37 and 0.38 respectively. ²⁰ Another study in patients >65 years of age managed with either LP or IMN reported EQ‐5D‐5L index value <0.40 at 9‐month follow‐up. ¹¹ In our cohort of patients <65 years of age a mean index value of 0.767 was scored, which is comparable to a study that reported an EQ‐5D index of 0.70 for LP and 0.76 for IMN fixation at 1 year in a similar younger cohort. ²² Despite limited studies for comparison, these results indicate that patient reported outcomes in nail‐plate fixation might be superior to isolated fixation methods in the elderly population.

Mobility

The majority of our patients had no change in their use of mobility aids from pre‐ to post‐operatively. Fifty percent of patients described no problems with their mobility at 1‐year follow‐up, whilst another 28.6% reported only slight issues. Self‐care did not pose any issue in 71.4% of patients and 85.7% of patients reported no or slight problems with usual daily activities. Most of our patients returned to independent mobility and activities of daily living with no or minimal impediment. This is likely a reflection that the early weightbearing NPC fixation provides allows a more effective period of rehabilitation and therefore return to pre‐morbid function.

Early weightbearing and mobilization reduces the rate of post‐operative non‐surgical complications and mortality. ¹⁰ In our cohort, 78.6% of patients had mobilized by day 2. In patients aged ≥65 years our study had a 1‐year mortality of 16.7%, which compares favorably to a rate of 18–25% in isolated LP or IMN fixation. ⁵ , ¹²

In the setting of elderly patients who have weightbearing limitations post‐operatively, the length of stay in distal femur fractures managed with isolated LP or IMN is 26–29 days. ¹¹ , ¹² Our mean length of stay was 9.5 days, including an outlier patient that had an extended stay of 35 days for pre‐existing respiratory disease.

This study has similarly shown promising results in patients <65 years of age with no cases of non or malunion and all patients full weightbearing within 2 days post‐operatively. The decision to use NPC fixation in younger patients was made by the operative surgeon on a case‐by‐case basis, subject to whether isolated fixation would allow immediate weightbearing post‐operatively or not. Due to this decision‐making process and the small study population the authors accept that further research is required to determine which young patients are appropriate candidates for NPC fixation.

Morbidity and Mortality

Similarly, early post‐operative complications were lower in our study compared to patients managed with isolated fixation techniques. Lateral plate fixation of distal femur fractures has early post‐operative complications of 20%–37.5%, including venous thromboembolism, respiratory complications, cardiac complications, and others. ⁵ , ²² Our study had a lower rate of 18.8%.

Some clinicians have concerns regarding surgical site complications with NPC technique, including infection, stiffness, screw backout and implant irritation requiring removal. Of the limited studies currently available in the NPC population the rate of these complications ranges from 3.7% to 20%. ³ , ¹³ , ²³ In patients having isolated LP or IMN fixation, comparable complication rates exist from 5.3% to 15%. ⁷ , ²² , ²⁴

Our study reports a surgical site complication rate in three patients (18.8%). Two patients returned to theater for debridement in the setting of post‐operative infection, both of whom achieved bony union at follow‐up. Interestingly, both these patients had previously undergone revision operation from short IM nail to total hip arthroplasty, which was then complicated by distal femur periprosthetic fracture. Revision surgery comes with a significant risk of infection, with one study reporting an infection rate of 5.8%. ²⁵ Our patients had additional risk factors including diabetes, emphysema and renal cancer. The third patient underwent removal of hardware because of irritation.

The surgical site complications in our study are comparable to other studies involving patients managed with NPC or isolated fixation technique. However, we report slightly reduced length of stay and lower rates of morbidity and mortality which may be attributable to improved mobility in the immediate post‐operative period with NPC fixation. The authors appreciate that studies investigating complications in NPC patients are small and that care needs to be taken in drawing definitive conclusions.

Limitations

We recognize that there are limitations to our study. This was a single‐center study in a regional hospital and thus the sample size is small. However, distal femur fractures make up only 0.4% of all adult fractures and therefore studies across multiple centers and greater timeframes are required for larger numbers. ¹ With mean follow‐up of 17.5 months, this is considered a short‐term follow‐up publication. However, this follow‐up period is comparable to other literature on distal femur operative fixation. The study population is purposely heterogenous to investigate the applicability of this surgical technique in both young and elderly age groups, as well as varying energy mechanisms of injury. Future research will benefit from exploring the use of this technique in more homogenous populations. As the majority of our patients were ≥65 years of age, the authors recognize that the results of this study pertain more strongly to the elderly age group. Early mobilization in trauma patients is important in reducing morbidity and mortality, and thus the authors made the decision to include younger patients who more commonly sustain high‐energy distal femoral fractures. This study has shown promising results regarding union and post‐operative mobilization in this young population, however future prospective studies investigating a younger age bracket will be able to better delineate the indication for NPC in this cohort. To our knowledge, this is the first paper investigating PROMs and malunion rates in distal femur NPC fixation. The authors look forward to further investigating the NPC technique with a greater sample size and longer follow‐up period.

Conclusion

The nail‐plate construct provides stable fixation of the distal femur fracture with the benefit of immediate full‐weightbearing post‐operatively. In our patient cohort, there were no cases of non or malunion. In an elderly population this allows improved mobility post‐operatively, which may result in reduced length of stay, early complications, and mortality rates at 1 year. Therefore, the authors support the use of nail‐plate construct fixation in distal femur fractures and look forward to larger, prospective trials investigating this technique.

Conflict of Interest Statement

The authors declare no conflict of interest.

Ethics Statement

Ethics approval was obtained from the New South Wales Health Ethics Committee via Research Ethics and Governance Information System (ETH11681). This study conforms to the Declaration of Helsinki.

Author Contributions

Conceptualization: BP and HD. Methodology: BP and HD. Investigation: BP, HD and AW. Formal Analysis: BP, HD and AW. Resources: BP and AW. Writing–Original Draft: BP. Writing–Review and Editing: BP, AW and HD. Visualization: BP and AW. Supervision: HD. Funding Acquisition: nil.

Funding Information

The authors have no funding to disclose. This research received no specific grant from any funding agency in the public, commercial, or not‐for‐profit sectors.

Consent to Participate and Publish

Informed consent for study participation and research publication was obtained from all patients.

Data Availability Statement

The dataset supporting the conclusions of this article is included within the article and its additional file.