Guide Plate Technique versus Fluoroscopy-Guided Technique in the Fixation of AO/OTA 33-C Distal Femur Fractures Using a Nail–Plate Dual System: A Retrospective Comparative Study

Guide Plate Technique versus Fluoroscopy-Guided Technique in the Fixation of AO/OTA 33-C Distal Femur Fractures Using a Nail–Plate Dual System: A Retrospective Comparative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Guide Plate Technique versus Fluoroscopy-Guided Technique in the Fixation of AO/OTA 33-C Distal Femur Fractures Using a Nail–Plate Dual System: A Retrospective Comparative Study yong de wu, Bo chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9186557/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Introduction AO/OTA 33-C-type femoral fractures pose a significant clinical challenge for orthopedic surgeons. The nail–plate construct (NPC) has emerged as the predominant surgical strategy for these complex peri- and intertrochanteric fractures. However, to mitigate component interference within the implant construct, two nail–plate construct (NPC) techniques have been developed: a dedicated surgical guide device–assisted technique (NPC-GD) and a fluoroscopy-guided technique (NPC-GF).This study aimed to compare surgical outcomes, quality of life, and functional recovery in patients of AO/OTA 33-C-type femoral fractures using either NPC-GD or NPC-GF. Materials and methods A retrospective review of clinical data was conducted for patients diagnosed with AO/OTA 33-C-type femoral fractures who underwent dual-construct fixation—comprising both a locking plate and an intramedullary nail. Outcomes assessed included operative time, length of hospital stay, intraoperative and postoperative blood loss, number of intraoperative fluoroscopic images, incidence of malunion, time to radiographic fracture union, time to initiation of partial and full weight-bearing, final knee range of motion, and the Hospital for Special Surgery (HSS) knee score. Results The final analysis included 161 patients: 86 in the NPC-GD group and 75 in the NPC-GF group. NPC-GD group exhibited significantly shorter operative time (P = 0.006), lower intraoperative (P = 0.004) and postoperative (P = 0.003) blood loss, fewer intraoperative fluoroscopic images (P = 0.034), shorter time to radiographic fracture union (P = 0.037), earlier initiation of ambulation at final follow-up (P = 0.001), earlier achievement of full weight-bearing (P = 0.009), greater final knee range of motion (P = 0.009), and higher Hospital for Special Surgery (HSS) knee scores (P = 0.002). Conclusions Compared with NPC-GF, NPC-GD demonstrates superior clinical outcomes in the management of AO/OTA 33-C-type femoral fractures—specifically with respect to reduced operative complexity, diminished surgical trauma, accelerated fracture healing, and enhanced functional recovery. Distal femoral fractures Nail–plate construct Dual-plate fixation Surgical complication Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Distal femoral fractures—defined as those occurring within 9 cm of the distal femoral articular surface—account for approximately 1% of all skeletal fractures and 3–6% of all femoral fractures [ 1 ]. According to the AO/OTA classification, type 33-C (formerly 3C) fractures are complex articular injuries involving both the medial and lateral condyles, with concomitant disruption of the medial and lateral cortices. These fractures are frequently associated with bicondylar comminution, medial femoral condyle defects, osteoporosis, and extensive distal femoral fragmentation. Given their critical role in weight-bearing and knee biomechanics, surgical stabilization with internal fixation is the standard of care [ 2 ]. Conventional fixation strategies include locked plating, retrograde intramedullary nailing, and, less commonly, hybrid or external fixation [ 3 , 4 ]. Nevertheless, these approaches are associated with substantial complication rates: nonunion occurs in up to 19% of cases[ 4 ], implant failure in approximately 20% [ 6 ], Despite the benefits of dual plating, there are relatively high rates of infection following dual plating[ 7 ] and one-year mortality among elderly patients reaches 21% [ 8 ]. The modified dual-construct fixation technique has attracted growing clinical and research interest [ 9 ]. Specifically, either adjunctive medial plating (“double plating”) or the combination of a retrograde intramedullary nail with a minimally invasive lateral locking plate—the nail–plate construct (NPC)—has demonstrated advantages in accelerating time to weight-bearing and reducing risks of implant failure and nonunion [ 4 , 9 , 10 ]. However, double plating provides inherently eccentric stabilization [ 11 ], and in fractures with limited comminution, it often fails to achieve adequate nail–bone purchase, thereby compromising resistance to varus and valgus loading [ 12 ]. Moreover, medial plate insertion necessitates extensive soft-tissue dissection, increasing surgical invasiveness and potentially compromising the periosteal and metaphyseal blood supply [ 7 , 13 ]. Although the nail–plate construct (NPC) offers central fixation with enhanced biomechanical stability—and has demonstrated favorable short-term outcomes in terms of alignment restoration and early load-bearing capacity [ 14 , 15 ]—it is not without limitations. Notably, implant interference between the intramedullary nail and plate screws [ 16 ], coupled with partial or eccentric cortical engagement of certain locking screws, can complicate surgical execution and undermine overall construct stability—even when anatomical fracture reduction is achieved. To address these limitations, Georgios et al. introduced the fluoroscopy-guided nail–plate construct (NPC-GF) [ 9 ], which integrates the nail and plate via a locking compression condylar screw and employs the “perfect circle” technique under real-time fluoroscopic guidance to achieve accurate distal interlocking; proximal fixation is achieved using single-cortical screws in the lateral plate. In contrast, Li et al. [ 17 ] proposed the guide device–assisted nail–plate construct (NPC-GD), which eliminates reliance on intraoperative fluoroscopy for distal targeting. By means of a dedicated, patient-specific surgical guide, NPC-GD enables precise, bicortical distal interlocking of the plate and nail while facilitating bicortical proximal screw fixation through eccentric locking holes—thereby avoiding nail–screw interference.Comparative evidence regarding the relative advantages and limitations of these two internal fixation techniques remains limited in the current literature.Therefore, we aimed to provide preliminary evidence to better understand the role of NPC-GD in AO/OTA 33-C Distal Femur Fractures rotator cuff arthropathy by comparing patient-reported surgical outcomes, quality of life, and functional recovery for patients treated with NPC-GD vs NPC-GF for AO/OTA 33-C Distal Femur Fractures. We hypothesized that NPC-GD would yield superior clinical and functional outcomes Materials and methods Study design A retrospective cohort study was conducted on 161 patients with AO/OTA 33-C-type distal femoral fractures treated at our institution between January 2020 and January 2025. All patients underwent dual-construct fixation comprising a retrograde intramedullary nail and a lateral locking plate. The cohort consisted of 99 men and 62 women, with a mean age of 57.6 years (range, 28–80 years). High-energy mechanisms—including motor vehicle collisions and falls from height—accounted for the majority of injuries. Of the 161 patients, 86 underwent guide device–assisted nail–plate fixation (NPC-GD,Fig. 1). and 75 underwent fluoroscopy-guided nail–plate fixation (NPC-GF,Fig.2). The study was approved by the Institutional Ethics Committee (Approval No.: E20244801), and written informed consent was obtained from all participants. Inclusion and exclusion criteria Inclusion criteria were: (i) confirmed AO/OTA 33-C-type distal femoral fracture and (ii) medical fitness for surgery and capacity to adhere to standardized postoperative rehabilitation protocols. Exclusion criteria were: (i) active local infection, or concurrent major vascular or nerve injury at the fracture site; and (ii) incomplete clinical or radiographic follow-up data, or follow-up duration <12 months. Data collection Perioperative and functional outcomes—including operative time, total intraoperative and postoperative blood loss, volume of allogeneic blood transfusion, number of intraoperative fluoroscopic images, time to radiographic fracture union, knee range of motion (flexion and extension), complication rate, and Hospital for Special Surgery (HSS) knee score—were prospectively collected and compared between groups. Postoperative complications—including implant-related failure (e.g., screw cutout, plate breakage, nail migration), surgical site infection, and persistent pain requiring intervention—were systematically documented. At final follow-up, standardized radiographic assessment [6] was performed to evaluate reduction quality, classified as: excellent (anatomical reduction); good (lateral displacement < 3 mm, no shortening, angulation, or rotational deformity); fair (lateral displacement ≥ 3 mm, shortening < 1 cm, or angulation/rotational deformity 5 mm, shortening ≥ 1 cm, or angulation/rotational deformity ≥ 10°). Surgical technique Preoperative preparations (i) Confirm absence of active infection and comprehensively manage concomitant soft-tissue injuries—including skin abrasions, bullae, and areas of necrosis—to optimize conditions for aseptic surgical intervention.(ii) Implement routine preoperative skeletal traction via the tibial tubercle to mitigate soft-tissue contracture and facilitate intraoperative fracture alignment.(iii) Perform meticulous preoperative skin preparation of the lower extremity to eliminate microbial reservoirs and ensure optimal surgical site sterility. Surgical Procedure NPC-GD Group: The procedure was performed under epidural or general anesthesia. After removal of preoperative traction pins, standard aseptic preparation and draping of the anterior iliac region and entire lower extremity were completed. A lateral parapatellar or lateral midline incision was made, and the vastus lateralis was split longitudinally to expose the lateral femoral condyle. The patella was medially subluxed or everted to enable direct visualization of the articular surface. For bicondylar or intercondylar fractures, provisional Kirschner wire fixation was applied to the medial and lateral condyles—taking care to avoid interference with the planned nail trajectory and lateral plate position. Anatomical reduction of the articular surface and lateral femoral wall was achieved, effectively converting intra-articular fractures into extra-articular metaphyseal injuries amenable to stable plate–nail fixation. A precontoured lateral locking plate was then applied to the lateral condyle and provisionally secured with 1–2 bicortical short screws. Distal fixation was established either with full-length screws engaging the medullary canal or, in cases of comminution or osteoporosis, with short screws (<1.6 cm) supplemented by auxiliary Kirschner wires. Intraoperative fluoroscopy confirmed provisional reduction and limb alignment. The incision was extended distally as needed, and the patella was fully everted to permit direct, unobstructed visualization of the joint surface for definitive articular reduction. The retrograde nail entry point was identified at the intersection of the femoral anatomical axis and the joint line. Under real-time fluoroscopic guidance, a guidewire was advanced retrogradely into the medullary canal, aligned precisely with the femoral axis. Sequential reaming commenced at 9 mm, increased in 0.5-mm increments, and continued until the canal diameter exceeded the selected nail diameter by 1–1.5 mm. Minor fracture displacement during reaming was controlled using a condylar reduction clamp. Obstructing Kirschner wires were either repositioned or replaced to maintain nail trajectory integrity. The retrograde intramedullary nail was then inserted over the guidewire, advanced to extend 40–60 mm beyond the distal end of the plate, and fine-tuned for depth and rotational alignment using the nail’s targeting sleeve (Figure 1B.7). Distal interlocking was achieved by inserting two fully threaded screws through the plate’s dedicated interlocking holes (Figure 1A/B.4), ensuring unimpeded, bicortical engagement. Proximal plate fixation utilized the plate’s eccentric locking holes to achieve bicortical screw purchase without impinging on the intramedullary canal. Proximal nail locking was performed using the integrated targeting device. Construct stability was verified fluoroscopically. Temporary fixation devices (Kirschner wires and short cortical screws) were systematically removed, and additional long screws were inserted as needed for supplemental fixation. Final fluoroscopic assessment confirmed optimal implant positioning, fracture reduction, and mechanical alignment. NPC-GF Group : The procedure was performed under epidural or general anesthesia. After traction pin removal, standard aseptic preparation and draping of the anterior iliac crest and lower limb were performed. An extended lateral anterior incision was utilized to access the distal femur. Following direct visualization and anatomical reduction of the articular and metaphyseal components, provisional Kirschner wire fixation was applied. Intramedullary reaming was then performed prior to nail insertion. A standard lateral locking plate was applied after reduction and provisionally secured. Real-time lateral fluoroscopy guided iterative adjustment of both plate and nail positioning to optimize alignment and achieve optimal bone–implant interface. The “perfect circle” technique was employed to align the distal locking holes of the nail with the corresponding plate interlocking holes, ensuring at least one distal locking screw passed coaxially through both the nail and the plate—thereby rigidly integrating the two constructs. Proximal plate fixation was accomplished using partially threaded cortical or locking screws. Proximal nail locking was performed using the standard targeting device. Final fluoroscopic imaging confirmed implant positioning, interlocking accuracy, and fracture reduction. Postoperative management Postoperative management includes the routine administration of prophylactic antibiotics during the perioperative period, which continues until 24 hours after surgery. Postoperative imaging, including X-ray and CT scans, was performed on the third postoperative day. The drainage tube is typically removed within 48 hours after surgery. Initiation of passive progressive knee joint mobilization via continuous passive motion (CPM) devices and active rehabilitation exercises begins on postoperative day three. Patients are permitted to ambulate with crutches while maintaining non-weight-bearing status on the affected limb. Partial weight-bearing is introduced once radiographic evidence shows blurring of the fracture line. Full weight-bearing is allowed only upon observation of well-established, continuous callus formation on follow-up X-rays, which generally occurs 2 to 3 months post-operatively. Crutches are gradually discontinued as functional recovery progresses. Regular follow-up evaluations include serial X-ray examinations and range of motion (ROM) assessments at 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. Statistical analysis Continuous variables are reported as mean ± standard deviation for normally distributed data and as median (interquartile range) for non-normally distributed data. Categorical variables are presented as frequency (percentage). Between-group comparisons of continuous variables were performed using independent-samples t-tests when data met assumptions of normality (assessed via Shapiro–Wilk test) and homoscedasticity (assessed via Levene’s test); otherwise, the Mann–Whitney U test was used. Categorical variables were analyzed using the chi-square test or Fisher’s exact test, as appropriate. A two-sided P value < 0.05 was considered statistically significant. Results Demographic data The follow-up periods for the two groups ranged from 8 to 36 months. The median follow-up time was approximately 24 weeks in the observation group and approximately 22 weeks in the control group, with no significant difference. The time interval from injury to surgery ranged from 5 to 7 days, with a mean duration of 5.3 days. No statistically significant differences were observed in the baseline demographic or clinical characteristics between the two groups (P > 0.05). The demographic data for both groups are summarized in Table 1 . Table 1 Demographic data Age (years), mean ± SD Observation group (n = 86) Control group (n = 75) P value a 72.༓±17.༒ 65.༗±2.2 0.576 b Female ratio, n (%) 11༏8 9༏7 0.781 c Time-to-surgery(d) ,mean ± SD 5.6 ± 2.༒ 6.༓±3.3 0.883 b Comorbid diseases:Hypertension/coronary heart disease/others 5 4 0.631 c BMI (kg/m2 ), mean ± SD 24.8 ± 3.8 , mean ± SD 23.2 ± 2.1 , mean ± SD 0.687 b Hospitalization (d), mean ± SD 5.5 (1–18) 0.008*a 14.55 ± 2.34 15.11 ± 3.23 0.783 b Follow-up (m), mean ± SD 24.51 ± 6.54 22.11 ± 5.23 0.791 b There was no significant difference . a P<.05 was considered statistically significant. b t test . c Pearson χ 2 test The condition during the perioperative period All surgical procedures in the 161 patients were successfully completed without any major complications, including vascular, infectious, or nerve-related injuries. All incisions achieved primary healing, with no instances of skin hematoma, wound dehiscence, or tissue necrosis observed. Postoperative radiographic evaluations confirmed satisfactory fracture reduction and stable internal fixation, with no evidence of screw penetration into the joint cavity. The observation group demonstrated significant advantages over the control group in terms of a shorter operative duration, reduced intraoperative blood loss, decreased postoperative drainage volume, and fewer C-arm fluoroscopy exposures, with all differences being statistically significant (P < 0.05). The surgical outcomes for both groups are summarized in Table 2 . Table 2 Surgical Period Data Operation time (min, x ± s) Observation group (n = 86) Control group (n = 75) P value a 110.89 ± 18.78 166.28 ± 23.73 0.006 b Total hospital stay (days, x ± s) 12.89 ± 1.63 12.72 ± 1.70 0.653 b Follow-up time (months, x ± s) 22.19 ± 4.79 20.8 ± 4.64 0.745 b Intraoperative blood loss (ml, x ± s) 385.36 ± 80.45 515.36 ± 80.51 0.004 b Postoperative drainage blood loss (ml, x ± sl) 99.03 ± 23.70 146.72 ± 15.70 0.003 b C-arm fluoroscopy usage frequency (times, mean ± SD) 8.17 ± 2.24 16.56 ± 3.20 0.034 b There were statistically significant differences in Operation duration, intraoperative blood loss, postoperative drainage blood loss, and the number of fluoroscopy with C-arm. a P<.05 was considered statistically significant. b t test Follow-up results Following surgery, patients in both the observation and control groups progressively transitioned from non-weight-bearing to partial weight-bearing and eventually to full weight-bearing while engaging in standardized rehabilitation protocols. Knee joint function gradually improved over time, with no occurrence of recurrent fractures or clinically significant activity limitations observed during the follow-up period. The time to initiation of ambulation and achievement of full weight-bearing was significantly shorter in the observation group than in the control group (P < 0.05). At the final follow-up assessment, the observation group presented significantly greater range of motion (ROM) and Hospital for Special Surgery (HSS) scores than did the control group (P 0.05). The follow-up data for both groups are summarized in Table 3 . Table 3 Follow-up Data: Last Follow-up Time to weight-bearing(d, x ± s ) Observation group (n = 86) Control group (n = 75) P value a 18.72 ± 2.25 25.84 ± 4.83 0.001 b Time to full weight(w, x ± s ) 7.17 ± 1.98 14.6 ± 3.49 0.009 b knee joint range of motion( o , x ± s 114.17 ± 14.57 100.40 ± 18.48 0.009 b HSS score( score, x ± s ) 85.617 ± 3.87 73.36 ± 7.40 0.002 b Shortening deformity [case (%)] 3(0.08) 2(0.08) 0.999 c varus-valgus deformity[case (%)] 0(0.00) 0(0.00) - There was a statistically significant difference inTime to weight-bearing, full weight-bearing time, knee joint range of motion, HSS score, shortening deformity and varus-valgus deformity a P<.05 was considered statistically significant . b t test. c Pearson χ 2 test Three days post-operatively, radiographic evaluation revealed no significant differences in the quality of fracture reduction between the groups. By the end of the follow-up period, radiological evidence of fracture healing was confirmed in all patients. The mean time to fracture healing was significantly shorter in the observation group than in the control group (P < 0.05), as presented in Table 4 . Representative radiographic images of a patient from the observation group are displayed in Fig. 3 , while those from the control group are shown in Fig. 4 . Table 4 Image Data Fracture reduction [cases (%)] Observation group (n = 86) Control group (n = 75) P value a 0.847 b excellent 22(61.00) 18(72.00) fair 11(30.56) 5(20.00) shortening deformity 3(8.43) 2(0.00) poor. 0(0.00) 0(0.00) Time for fracture healing [cases (%)] 0.037 b 24week 11(31.63) 12(48.00) There was a statistically significant difference in healing time of fractures a P<.05 was considered statistically significant. b Pearson χ 2 test Discussion Owing to the inherent complexity of AO/OTA 33-C-type distal femoral fractures, approximately 1 in 4 patients developed a recalcitrant nonunion after attempted nonunion repair[18]. Fixation with a dual column construct was associated with decreased risk of recalcitrant nonunion[18-20]. However, the dual-plate technique entails extensive soft-tissue dissection and provides suboptimal biomechanical stability. Henderson et al. [19] reported complication rates as high as 32% with dual-plate fixation.In contrast, a recent meta-analysis by Mohammad et al. [20] demonstrated that, compared with conventional isolated plate or intramedullary nail fixation, NPC confers significantly greater resistance to axial and torsional displacement—and is associated with lower rates of complications, reoperation, implant failure, nonunion, and malunion.In study, intraoperative outcomes—including operative duration, intraoperative blood loss, and fluoroscopic exposure—were significantly more favorable in the NPC-GD group than in the NPC-GF group. The anatomically precontoured lateral locking plate used in NPC-GD facilitated conversion of comminuted 33-C fractures into more stable, extra-articular metaphyseal (AO/OTA 33-A or 33-B) configurations, enabling reliable subsequent retrograde nailing. Critically, the dedicated surgical guide enabled precise, fluoroscopy-free, bicortical distal interlocking—eliminating nail–screw interference and obviating iterative image-guided adjustments. By contrast, in the NPC-GF technique, the intramedullary nail is typically inserted prior to plate application [9,21]. Reaming during nail insertion inevitably disrupts the fracture hematoma and further destabilizes comminuted fragments, particularly in osteoporotic bone. Subsequent anatomical reduction and plate fixation thus require prolonged surgical manipulation, contributing to increased blood loss and soft-tissue trauma[22]. Moreover, achieving coaxial alignment between the plate and nail—necessary to implement the “perfect circle” technique for distal interlocking—necessitates repeated fluoroscopic imaging, prolonging operative time and elevating radiation exposure and infection risk. The broader soft-tissue dissection required for plate application, coupled with greater periosteal stripping and compromised vascularity of the fracture zone [17,19], likely contributed to the observed delay in fracture healing in the NPC-GF group. The NPC-GD group exhibited shorter time to radiographic fracture union earlier initiation of ambulation at final follow-up, earlier achievement of full weight-bearing, greater final knee range of motion , and higher Hospital for Special Surgery (HSS) knee scores.Previous biomechanical and clinical studies indicate that optimal fracture healing requires controlled interfragmentary micromotion, with an ideal strain magnitude of 2–10% at the fracture site [4,23]. Excessively rigid fixation may induce stress shielding, resulting in inadequate mechanical stimulation of the fracture site and thereby impairing callus formation and osseous healing[5]. In the NPC-GD construct, distal interlocking is achieved via coordinated engagement of the intramedullary nail, plate interlocking holes, and a dedicated surgical guide—preventing the instability commonly associated with short or eccentrically placed distal screws resulting from nail–plate interference. This configuration enables efficient axial load transmission through the intramedullary nail while substantially enhancing resistance to horizontal shear forces [4]. Crucially, the proximal plate segment lacks interlocking features to mitigate stress concentration at the nail–plate junction—thereby preserving physiologically appropriate load distribution across the femoral shaft. To ensure robust proximal fixation independent of the intramedullary nail, the plate incorporates an offset eccentric locking hole design, permitting secure bicortical screw purchase without compromising nail integrity or trajectory.In the NPC-GF group, distal interlocking typically permits secure engagement of only a single screw through both the nail and plate due to alignment constraints under fluoroscopic guidance; achieving dual distal interlocking is technically challenging and frequently unattainable. In contrast, the NPC-GD technique—by virtue of its dedicated guide device—enables reliable, reproducible placement of two bicortical distal interlocking screws, thereby enhancing distal construct stability and load-sharing capacity. Collectively, these biomechanical advantages support earlier initiation of functional rehabilitation, accelerated restoration of knee range of motion, and enhanced fracture healing. Consistent with these principles, Liporace FA et al. [24] demonstrated that integrating a plate–screw interlocking system with image-free guided instrumentation significantly improves axial and torsional stability in complex periprosthetic and periarticular femoral fractures,and can offer stable, balanced fixation allowing for immediate weight bearing and early mobilization. The guide plate–assisted plate–screw interlocking system offers three principal advantages: (i) the laterally positioned locking plate minimizes medial soft-tissue dissection and enables precise, reproducible implant placement via a patient-specific surgical guide—thereby streamlining surgical execution; (ii) it synergistically combines the biomechanical benefits of intramedullary load sharing with the angular stability of lateral plating, effectively mitigating the most frequent mode of construct failure—varus collapse secondary to eccentric loading [25],this enhanced stability facilitates earlier initiation of functional rehabilitation[26,27],and (iii) proximal femoral fixation is achieved via bicortical screw placement through eccentric locking holes, ensuring high mechanical stability without reliance on the intramedullary nail. This study has several limitations. First, it is a single-center, retrospective cohort study with a relatively modest sample size, potentially limiting statistical power and generalizability.Second, although current AO/OTA principles support rigid integration of the nail and plate to promote balanced load distribution[5,24,28]—and such integration is increasingly employed in revision surgery for nonunion following nail–plate construct fixation [28]—the biomechanical rationale and clinical evidence supporting mandatory rigid interlocking remain incompletely defined[29]. Crucially, the potential impact of this interlocking configuration on secondary fracture healing—particularly regarding callus formation, strain distribution, and adaptive remodeling—warrants rigorous evaluation through controlled biomechanical testing and prospective clinical studies. Conclusion Our findings indicate that the NPC-GD technique—featuring a guide plate–assisted, rigidly interlocked plate–screw–nail construct—effectively overcomes key limitations of conventional single-modality fixation for complex distal femoral fractures. By synergistically integrating the biomechanical advantages of both intramedullary nailing and locking plating—while minimizing their respective drawbacks, including implant interference, excessive soft-tissue dissection, and suboptimal load sharing—NPC-GD achieves enhanced structural integrity and more physiologically appropriate interfragmentary strain distribution. Clinical outcomes demonstrate accelerated fracture healing, earlier functional rehabilitation, and superior short- to midterm functional recovery—supporting its potential as a robust, reproducible, and clinically viable strategy for the management of highly comminuted AO/OTA 33-C distal femoral fractures. Abbreviations NPC;Nail-plate construct HSS;Hospital for Special Surgery knee score NPC-GD;Interlocking of the nail plate construct guided by a dedicated guide device. NPC-GF;Interlocking of the nail-plate construct guided by fluoroscopic imaging Declarations Consent for publication All individual person’s data consent to publish. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Declaration of competing interest The authors did not receive support from any organization for the submitted work. Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript References Elsoe R, Ceccotti AA, Larsen P (2018) Population-based epidemiology and incidence of distal femur fractures. 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Injury 56:112557. https:doi: 10.1016/j.injury.2025.112557 Hoffmann MF, Jones CB, Sietsema DL, Tornetta P 3rd, Koenig SJ (2013) Clinical outcomes of locked plating of distal femoral fractures in a retrospective cohort. J Orthop Surg Res 8:43 https: doi: 10.1186/1749-799X-8-43 Jankowski JM, Szukics PF, Shah JK et al (2021) Comparing Intramedullary Nailing Versus Locked Plating in the Treatment of Native Distal Femur Fractures: Is One Superior to the Other?. Indian journal of orthopaedics 55:646–654. https://doi:10.1007/s43465-020-00331-z Quinzi DA, Childs S, Lipof J et al (2020) The Treatment of Periprosthetic Distal Femoral Fractures After Total Knee Replacement: A Critical Analysis Review. JBJS reviews 8:e2000003.https://doi:10.2106/JBJS.RVW.20.00003 Li QW, Wu B, Chen B (2022) Modified fixation for periprosthetic supracondylar femur fractures:Two case reports and review of the literature. World journal of clinical cases.10:12328–12336. https://doi:10.12998/wjcc.v10.i33.12328 Roddy E, Davis K, Wilson P, Kleweno C, Dunbar RP, Barei D (2025) Outcomes of Nonunion Repair for Distal Femur Fracture. J Orthop Trauma 39:621-628.https://doi: 10.1097/BOT.0000000000003047. PMID: 40709936 Bologna MG , Claudio MG , Shields KJ et al (2019) Dual plate fixation results in improved union rates in comminuted distal femur fractures compared to single plate fixation. Journal of orthopaedics.18:76–79. https://doi:10.1016/j.jor.2019.09.022. Daher M, Parsons A, Mauffrey C, Richard R (2025) Nail-plate combination versus single construct for the management of distal femoral fractures: a meta-analysis. Eur J Orthop Surg Traumatol. 35:124. https://doi: 10.1007/s00590-025-04239-y Attum B, Douleh D, Whiting PS et al (2017) Outcomes of Distal Femur Nonunions Treated With a Combined Nail/Plate Construct and Autogenous Bone Grafting. Journal of orthopaedic trauma 31:e301–e304.https:// doi:0.1097/BOT.0000000000000926 Nester M, Borrelli J Jr (2023) Distal femur fractures management and evolution in the last century. Int Orthop. 2023 Aug;47(8):2125-2135. https:// doi: 10.1007/s00264-023-05782-1 Yu X, Guo Y, Kang Q et al (2013) Effects and mechanisms of mechanical stress on secondary fracture healing. Frontiers in bioscience (Landmark edition) 18:1344–1348. https://doi:10.2741/4183 Liporace FA, Yoon RS (2019) Nail Plate Combination Technique for Native and Periprosthetic Distal Femur Fractures. J Orthop Trauma33:e64-e68.https://doi: 10.1097/BOT.0000000000001332 Hussain MS, Dailey SK, Avilucea FR (2018) Stable Fixation and Immediate Weight-Bearing After Combined Retrograde Intramedullary Nailing and Open Reduction Internal Fixation of Noncomminuted Distal Interprosthetic Femur Fractures. Journal of orthopaedic trauma 32:e237–e240. https://doi:10.1097/BOT.0000000000001154 Halstrom JR, Litten RM, Alcaide DM, McIlwain RN, Spitler CA, Johnson JP (2026) Outcomes of Periprosthetic Distal Femur Fractures by Fixation Construct: A Retrospective Cohort Study. J Am Acad Orthop Surg Glob Res Rev 10:e25.00422.https://doi: 10.5435/JAAOSGlobal-D-25-00422 Mau M, Thorne T, Payne C, Roach K, Svetgoff R, Kellam PJ, DeKeyser GJ, Warner SJ, Marchand LS, Haller J (2025) Dual Implants for Geriatric Distal Femur Fractures Results in Greater Healthy Days at Home. J Orthop Trauma 23.https://doi: 10.1097/BOT.0000000000002999 Wagner RK, Raats JH, Ponds NHM, Borgida JS, Brameier DT, Harris MB, Kloen P, Janssen SJ, Ly TV, Weaver MJ (2025) Risk factors for failure of distal femoral nonunion repair. Eur J Orthop Surg Traumatol 35:343.https:// doi: 10.1007/s00590-025-04460-9 Nauth A, Haller J, Augat P, Anderson DD, McKee MD, Shearer D, Jenkinson R, Pape HC (2024) Distal femur fractures:basic science and international perspectives. OTA Int 7 :e320.https:// doi: 10.1097/OI9.0000000000000320 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 08 May, 2026 Reviewers agreed at journal 11 Apr, 2026 Reviewers invited by journal 06 Apr, 2026 Editor assigned by journal 23 Mar, 2026 Submission checks completed at journal 23 Mar, 2026 First submitted to journal 21 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9186557","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":618250825,"identity":"b627b790-da86-4f84-821e-62b605f00079","order_by":0,"name":"yong de wu","email":"","orcid":"","institution":"China Three Gorges University","correspondingAuthor":false,"prefix":"","firstName":"yong","middleName":"","lastName":"de wu","suffix":""},{"id":618250826,"identity":"f581efe4-fdc7-45c6-b9ac-acf29b4ecccf","order_by":1,"name":"Bo chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYBAC+/b2A4d/VNjwsLE3EKnFgOdM4mOGM2kyfDwHiNUikWBszNh2yEZOIoFILeYSCWnSBWwHeNgkH2+8wVBjE01Qi2XPw2PSM3ju8LBJpxVbMBxLy20gqOd4QpoEj8QzoJYcMwnGhsNEaDmQYCbBY3AY6LAzRGoxOAH0Pk8CUIsED5FaJHvOJD6ccSCNh40H6JcEYvzCz95+4MDHfzb28u2HN974UGNDhF+QHUl01CBpIVXHKBgFo2AUjAwAADPGPoSCQy+EAAAAAElFTkSuQmCC","orcid":"","institution":"China Three Gorges University","correspondingAuthor":true,"prefix":"","firstName":"Bo","middleName":"","lastName":"chen","suffix":""}],"badges":[],"createdAt":"2026-03-21 14:53:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9186557/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9186557/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106635885,"identity":"4f1a9348-f409-44a5-94d7-f800bbcf1f49","added_by":"auto","created_at":"2026-04-10 16:51:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":164447,"visible":true,"origin":"","legend":"\u003cp\u003eObservation Group: NPC-GD\u003c/p\u003e\n\u003cp\u003eA. Specific lateral locking plate: 3: Proximal eccentric locking screw hole, 4: Two plate-screw interlocking screw holes at the condyle\u003c/p\u003e\n\u003cp\u003eB. Schematic diagram of the plate-screw interlocking system under guide plate technology: 1. External guide, 2. Intramedullary nail, 3: Proximal eccentric locking screw hole, 4: Two plate-screw interlocking screw holes at the condyle, 5. Reduction-assisted fixation channel (2.0 Kirschner wire can be placed), 6. Locking sleeve, 7. Guide plate locking hole\u003c/p\u003e\n\u003cp\u003eC. Distribution of distal screws in the plate-screw interlocking system under guide plate technology\u003c/p\u003e\n\u003cp\u003eD. Schematic diagram of the plate-screw interlocking system after plate-screw interlocking under guide plate technology\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9186557/v1/6f43c9efbf9b4135307ccbe2.png"},{"id":106726723,"identity":"f54927ff-3080-4c39-b002-a481d3ad3f49","added_by":"auto","created_at":"2026-04-12 18:37:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":69518,"visible":true,"origin":"","legend":"\u003cp\u003ethe control group, NPC-GF\u003c/p\u003e\n\u003cp\u003eFluoroscopic imaging guidance was employed to achieve precise interlocking fixation in the distal femur (1. yellow screw), while the proximal femur was stabilized using a half-cortical screw (2. orange screw).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9186557/v1/9e380b8c454b3254002187eb.png"},{"id":106635887,"identity":"95215f37-ee4c-40c5-80c0-97877f8bf398","added_by":"auto","created_at":"2026-04-10 16:51:27","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":571174,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eObservation Group\u003c/strong\u003e: Reduction of the NPC-GD technology. Representative imaging findings from a 50-year-old male patient with a type 3C distal femoral fracture.\u003c/p\u003e\n\u003cp\u003eA. Preoperative anteroposterior radiograph showing comminuted intra-articular fracture of the distal femur, with temporary skeletal traction applied via the tibial tubercle.\u003c/p\u003e\n\u003cp\u003eB. Preoperative three-dimensional computed tomography (3D CT) reconstruction demonstrating the extent and morphology of the comminuted articular fracture.\u003c/p\u003e\n\u003cp\u003eC. Anteroposterior radiograph obtained three days postoperatively, indicating satisfactory anatomical reduction.\u003c/p\u003e\n\u003cp\u003eD. Lateral radiograph obtained three days postoperatively, confirming adequate alignment and fixation.\u003c/p\u003e\n\u003cp\u003eE. Anteroposterior radiograph at two-year follow-up, showing complete bony union.\u003c/p\u003e\n\u003cp\u003eF. Lateral radiograph at two-year follow-up, confirming fracture healing with maintained reduction.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9186557/v1/b0dce50cb015e13d2605e480.png"},{"id":106635888,"identity":"5aa7e5a8-30f3-4b88-8f48-0ccca7904e6e","added_by":"auto","created_at":"2026-04-10 16:51:27","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":563013,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eControl Group\u003c/strong\u003e: Reduction of the NPC-GF technology. Representative imaging findings from a 44-year-old female patient with a type 3C distal femoral comminuted fracture involving the articular surface are presented.\u003c/p\u003e\n\u003cp\u003eA. Preoperative anteroposterior radiograph demonstrating a comminuted fracture of the distal femur involving the articular surface, with temporary skeletal traction applied at the tibial tubercle.\u003c/p\u003e\n\u003cp\u003eB. Preoperative three-dimensional computed tomography (3D CT) scan confirming the extent of the comminuted intra-articular fracture.\u003c/p\u003e\n\u003cp\u003eC. Postoperative anteroposterior radiograph obtained on postoperative day three, revealing satisfactory fracture reduction and alignment.\u003c/p\u003e\n\u003cp\u003eD. Postoperative lateral radiograph obtained on postoperative day three, confirming adequate reduction.\u003c/p\u003e\n\u003cp\u003eE. Follow-up anteroposterior radiograph taken 15 months postoperatively, demonstrating complete fracture healing.\u003c/p\u003e\n\u003cp\u003eF. Follow-up lateral radiograph taken 15 months postoperatively, confirming consolidated fracture healing.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-9186557/v1/f34e8cc986228e053083b35a.png"},{"id":106959057,"identity":"0993315a-f05a-4fbb-9f33-c2983e066b5a","added_by":"auto","created_at":"2026-04-15 08:44:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2742914,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9186557/v1/0bbb4906-aab4-44ff-82bf-8ef5aff75df3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Guide Plate Technique versus Fluoroscopy-Guided Technique in the Fixation of AO/OTA 33-C Distal Femur Fractures Using a Nail–Plate Dual System: A Retrospective Comparative Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDistal femoral fractures\u0026mdash;defined as those occurring within 9 cm of the distal femoral articular surface\u0026mdash;account for approximately 1% of all skeletal fractures and 3\u0026ndash;6% of all femoral fractures [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. According to the AO/OTA classification, type 33-C (formerly 3C) fractures are complex articular injuries involving both the medial and lateral condyles, with concomitant disruption of the medial and lateral cortices. These fractures are frequently associated with bicondylar comminution, medial femoral condyle defects, osteoporosis, and extensive distal femoral fragmentation. Given their critical role in weight-bearing and knee biomechanics, surgical stabilization with internal fixation is the standard of care [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Conventional fixation strategies include locked plating, retrograde intramedullary nailing, and, less commonly, hybrid or external fixation [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Nevertheless, these approaches are associated with substantial complication rates: nonunion occurs in up to 19% of cases[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], implant failure in approximately 20% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], Despite the benefits of dual plating, there are relatively high rates of infection following dual plating[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and one-year mortality among elderly patients reaches 21% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe modified dual-construct fixation technique has attracted growing clinical and research interest [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Specifically, either adjunctive medial plating (\u0026ldquo;double plating\u0026rdquo;) or the combination of a retrograde intramedullary nail with a minimally invasive lateral locking plate\u0026mdash;the nail\u0026ndash;plate construct (NPC)\u0026mdash;has demonstrated advantages in accelerating time to weight-bearing and reducing risks of implant failure and nonunion [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, double plating provides inherently eccentric stabilization [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and in fractures with limited comminution, it often fails to achieve adequate nail\u0026ndash;bone purchase, thereby compromising resistance to varus and valgus loading [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Moreover, medial plate insertion necessitates extensive soft-tissue dissection, increasing surgical invasiveness and potentially compromising the periosteal and metaphyseal blood supply [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the nail\u0026ndash;plate construct (NPC) offers central fixation with enhanced biomechanical stability\u0026mdash;and has demonstrated favorable short-term outcomes in terms of alignment restoration and early load-bearing capacity [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u0026mdash;it is not without limitations. Notably, implant interference between the intramedullary nail and plate screws [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], coupled with partial or eccentric cortical engagement of certain locking screws, can complicate surgical execution and undermine overall construct stability\u0026mdash;even when anatomical fracture reduction is achieved.\u003c/p\u003e \u003cp\u003eTo address these limitations, Georgios et al. introduced the fluoroscopy-guided nail\u0026ndash;plate construct (NPC-GF) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], which integrates the nail and plate via a locking compression condylar screw and employs the \u0026ldquo;perfect circle\u0026rdquo; technique under real-time fluoroscopic guidance to achieve accurate distal interlocking; proximal fixation is achieved using single-cortical screws in the lateral plate. In contrast, Li et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] proposed the guide device\u0026ndash;assisted nail\u0026ndash;plate construct (NPC-GD), which eliminates reliance on intraoperative fluoroscopy for distal targeting. By means of a dedicated, patient-specific surgical guide, NPC-GD enables precise, bicortical distal interlocking of the plate and nail while facilitating bicortical proximal screw fixation through eccentric locking holes\u0026mdash;thereby avoiding nail\u0026ndash;screw interference.Comparative evidence regarding the relative advantages and limitations of these two internal fixation techniques remains limited in the current literature.Therefore, we aimed to provide preliminary evidence to better understand the role of NPC-GD in AO/OTA 33-C Distal Femur Fractures rotator cuff arthropathy by comparing patient-reported surgical outcomes, quality of life, and functional recovery for patients treated with NPC-GD vs NPC-GF for AO/OTA 33-C Distal Femur Fractures. We hypothesized that NPC-GD would yield superior clinical and functional outcomes\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy design\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA retrospective cohort study was conducted on 161 patients with AO/OTA 33-C-type distal femoral fractures treated at our institution between January 2020 and January 2025. All patients underwent dual-construct fixation comprising a retrograde intramedullary nail and a lateral locking plate. The cohort consisted of 99 men and 62 women, with a mean age of 57.6 years (range, 28\u0026ndash;80 years). High-energy mechanisms\u0026mdash;including motor vehicle collisions and falls from height\u0026mdash;accounted for the majority of injuries. Of the 161 patients, 86 underwent guide device\u0026ndash;assisted nail\u0026ndash;plate fixation (NPC-GD,Fig. 1). and 75 underwent fluoroscopy-guided nail\u0026ndash;plate fixation (NPC-GF,Fig.2). The study was approved by the Institutional Ethics Committee (Approval No.: E20244801), and written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInclusion and\u0026nbsp;exclusion criteria\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInclusion criteria were: (i) confirmed AO/OTA 33-C-type distal femoral fracture and (ii) medical fitness for surgery and capacity to adhere to standardized postoperative rehabilitation protocols. Exclusion criteria were: (i) active local infection, or concurrent major vascular or nerve injury at the fracture site; and (ii) incomplete clinical or radiographic follow-up data, or follow-up duration \u0026lt;12 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData collection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePerioperative and functional outcomes\u0026mdash;including operative time, total intraoperative and postoperative blood loss, volume of allogeneic blood transfusion, number of intraoperative fluoroscopic images, time to radiographic fracture union, knee range of motion (flexion and extension), complication rate, and Hospital for Special Surgery (HSS) knee score\u0026mdash;were prospectively collected and compared between groups. Postoperative complications\u0026mdash;including implant-related failure (e.g., screw cutout, plate breakage, nail migration), surgical site infection, and persistent pain requiring intervention\u0026mdash;were systematically documented. At final follow-up, standardized radiographic assessment [6] was performed to evaluate reduction quality, classified as: excellent (anatomical reduction); good (lateral displacement \u0026lt; 3 mm, no shortening, angulation, or rotational deformity); fair (lateral displacement \u0026ge; 3 mm, shortening \u0026lt; 1 cm, or angulation/rotational deformity \u0026lt; 10\u0026deg;); or poor (lateral displacement \u0026gt; 5 mm, shortening \u0026ge; 1 cm, or angulation/rotational deformity \u0026ge; 10\u0026deg;).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSurgical technique\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePreoperative preparations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(i) Confirm absence of active infection and comprehensively manage concomitant soft-tissue injuries\u0026mdash;including skin abrasions, bullae, and areas of necrosis\u0026mdash;to optimize conditions for aseptic surgical intervention.(ii) Implement routine preoperative skeletal traction via the tibial tubercle to mitigate soft-tissue contracture and facilitate intraoperative fracture alignment.(iii) Perform meticulous preoperative skin preparation of the lower extremity to eliminate microbial reservoirs and ensure optimal surgical site sterility.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSurgical Procedure\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNPC-GD Group:\u003c/em\u003e\u003c/strong\u003eThe procedure was performed under epidural or general anesthesia. After removal of preoperative traction pins, standard aseptic preparation and draping of the anterior iliac region and entire lower extremity were completed. A lateral parapatellar or lateral midline incision was made, and the vastus lateralis was split longitudinally to expose the lateral femoral condyle. The patella was medially subluxed or everted to enable direct visualization of the articular surface. For bicondylar or intercondylar fractures, provisional Kirschner wire fixation was applied to the medial and lateral condyles\u0026mdash;taking care to avoid interference with the planned nail trajectory and lateral plate position. Anatomical reduction of the articular surface and lateral femoral wall was achieved, effectively converting intra-articular fractures into extra-articular metaphyseal injuries amenable to stable plate\u0026ndash;nail fixation. A precontoured lateral locking plate was then applied to the lateral condyle and provisionally secured with 1\u0026ndash;2 bicortical short screws. Distal fixation was established either with full-length screws engaging the medullary canal or, in cases of comminution or osteoporosis, with short screws (\u0026lt;1.6 cm) supplemented by auxiliary Kirschner wires. Intraoperative fluoroscopy confirmed provisional reduction and limb alignment. The incision was extended distally as needed, and the patella was fully everted to permit direct, unobstructed visualization of the joint surface for definitive articular reduction. The retrograde nail entry point was identified at the intersection of the femoral anatomical axis and the joint line. Under real-time fluoroscopic guidance, a guidewire was advanced retrogradely into the medullary canal, aligned precisely with the femoral axis. Sequential reaming commenced at 9 mm, increased in 0.5-mm increments, and continued until the canal diameter exceeded the selected nail diameter by 1\u0026ndash;1.5 mm. Minor fracture displacement during reaming was controlled using a condylar reduction clamp. Obstructing Kirschner wires were either repositioned or replaced to maintain nail trajectory integrity. The retrograde intramedullary nail was then inserted over the guidewire, advanced to extend 40\u0026ndash;60 mm beyond the distal end of the plate, and fine-tuned for depth and rotational alignment using the nail\u0026rsquo;s targeting sleeve (Figure 1B.7). Distal interlocking was achieved by inserting two fully threaded screws through the plate\u0026rsquo;s dedicated interlocking holes (Figure 1A/B.4), ensuring unimpeded, bicortical engagement. Proximal plate fixation utilized the plate\u0026rsquo;s eccentric locking holes to achieve bicortical screw purchase without impinging on the intramedullary canal. Proximal nail locking was performed using the integrated targeting device. Construct stability was verified fluoroscopically. Temporary fixation devices (Kirschner wires and short cortical screws) were systematically removed, and additional long screws were inserted as needed for supplemental fixation. Final fluoroscopic assessment confirmed optimal implant positioning, fracture reduction, and mechanical alignment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNPC-GF Group\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003eThe procedure was performed under epidural or general anesthesia. After traction pin removal, standard aseptic preparation and draping of the anterior iliac crest and lower limb were performed. An extended lateral anterior incision was utilized to access the distal femur. Following direct visualization and anatomical reduction of the articular and metaphyseal components, provisional Kirschner wire fixation was applied. Intramedullary reaming was then performed prior to nail insertion. A standard lateral locking plate was applied after reduction and provisionally secured. Real-time lateral fluoroscopy guided iterative adjustment of both plate and nail positioning to optimize alignment and achieve optimal bone\u0026ndash;implant interface. The \u0026ldquo;perfect circle\u0026rdquo; technique was employed to align the distal locking holes of the nail with the corresponding plate interlocking holes, ensuring at least one distal locking screw passed coaxially through both the nail and the plate\u0026mdash;thereby rigidly integrating the two constructs. Proximal plate fixation was accomplished using partially threaded cortical or locking screws. Proximal nail locking was performed using the standard targeting device. Final fluoroscopic imaging confirmed implant positioning, interlocking accuracy, and fracture reduction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePostoperative\u0026nbsp;management\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostoperative management includes the routine administration of prophylactic antibiotics during the perioperative period, which continues until 24 hours after surgery. Postoperative imaging, including X-ray and CT scans, was performed on the third postoperative day. The drainage tube is typically removed within 48 hours after surgery. Initiation of passive progressive knee joint mobilization via continuous passive motion (CPM) devices and active rehabilitation exercises begins on postoperative day three. Patients are permitted to ambulate with crutches while maintaining non-weight-bearing status on the affected limb. Partial weight-bearing is introduced once radiographic evidence shows blurring of the fracture line. Full weight-bearing is allowed only upon observation of well-established, continuous callus formation on follow-up X-rays, which generally occurs 2 to 3 months post-operatively. Crutches are gradually discontinued as functional recovery progresses. Regular follow-up evaluations include serial X-ray examinations and range of motion (ROM) assessments at 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eStatistical analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eContinuous variables are reported as mean \u0026plusmn; standard deviation for normally distributed data and as median (interquartile range) for non-normally distributed data. Categorical variables are presented as frequency (percentage). Between-group comparisons of continuous variables were performed using independent-samples\u0026nbsp;t-tests when data met assumptions of normality (assessed via Shapiro\u0026ndash;Wilk test) and homoscedasticity (assessed via Levene\u0026rsquo;s test); otherwise, the Mann\u0026ndash;Whitney\u0026nbsp;U\u0026nbsp;test was used. Categorical variables were analyzed using the chi-square test or Fisher\u0026rsquo;s exact test, as appropriate. A two-sided\u0026nbsp;P\u0026nbsp;value \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eDemographic data\u003c/h2\u003e\n \u003cp\u003eThe follow-up periods for the two groups ranged from 8 to 36 months. The median follow-up time was approximately 24 weeks in the observation group and approximately 22 weeks in the control group, with no significant difference. The time interval from injury to surgery ranged from 5 to 7 days, with a mean duration of 5.3 days. No statistically significant differences were observed in the baseline demographic or clinical characteristics between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The demographic data for both groups are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic data\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eAge (years), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eObservation group (n\u0026thinsp;=\u0026thinsp;86)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eP value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e72.༓\u0026plusmn;17.༒\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e65.༗\u0026plusmn;2.2\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.576\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eFemale ratio, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e11༏8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e9༏7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.781\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eTime-to-surgery(d) ,mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e5.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.༒\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e6.༓\u0026plusmn;3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.883\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eComorbid diseases:Hypertension/coronary heart disease/others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.631\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eBMI (kg/m2 ), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e24.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e\n \u003cp\u003e, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e23.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\n \u003cp\u003e, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.687\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eHospitalization (d), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003cp\u003e5.5 (1\u0026ndash;18)\u003c/p\u003e\n \u003cp\u003e0.008*a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e14.55\u0026thinsp;\u0026plusmn;\u0026thinsp;2.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e15.11\u0026thinsp;\u0026plusmn;\u0026thinsp;3.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.783\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eFollow-up (m), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e24.51\u0026thinsp;\u0026plusmn;\u0026thinsp;6.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e22.11\u0026thinsp;\u0026plusmn;\u0026thinsp;5.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.791\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eThere was no significant difference .\u003csup\u003ea\u003c/sup\u003e P\u0026lt;.05 was considered statistically significant.\u003csup\u003eb\u003c/sup\u003et test .\u003csup\u003ec\u003c/sup\u003e Pearson \u0026chi;\u003csup\u003e2\u003c/sup\u003etest\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eThe condition during the perioperative period\u003c/h2\u003e\n \u003cp\u003eAll surgical procedures in the 161 patients were successfully completed without any major complications, including vascular, infectious, or nerve-related injuries. All incisions achieved primary healing, with no instances of skin hematoma, wound dehiscence, or tissue necrosis observed. Postoperative radiographic evaluations confirmed satisfactory fracture reduction and stable internal fixation, with no evidence of screw penetration into the joint cavity. The observation group demonstrated significant advantages over the control group in terms of a shorter operative duration, reduced intraoperative blood loss, decreased postoperative drainage volume, and fewer C-arm fluoroscopy exposures, with all differences being statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The surgical outcomes for both groups are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSurgical Period Data\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eOperation time (min, x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eObservation group (n\u0026thinsp;=\u0026thinsp;86)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eP value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e110.89\u0026thinsp;\u0026plusmn;\u0026thinsp;18.78\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e166.28\u0026thinsp;\u0026plusmn;\u0026thinsp;23.73\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.006\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eTotal hospital stay (days, x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c2\"\u003e\n \u003cp\u003e12.89\u0026thinsp;\u0026plusmn;\u0026thinsp;1.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e\n \u003cp\u003e12.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.653\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eFollow-up time (months, x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c2\"\u003e\n \u003cp\u003e22.19\u0026thinsp;\u0026plusmn;\u0026thinsp;4.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e\n \u003cp\u003e20.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.745\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eIntraoperative blood loss (ml, x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c2\"\u003e\n \u003cp\u003e385.36\u0026thinsp;\u0026plusmn;\u0026thinsp;80.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e\n \u003cp\u003e515.36\u0026thinsp;\u0026plusmn;\u0026thinsp;80.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.004\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePostoperative drainage blood loss (ml, x\u0026thinsp;\u0026plusmn;\u0026thinsp;sl)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c2\"\u003e\n \u003cp\u003e99.03\u0026thinsp;\u0026plusmn;\u0026thinsp;23.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e\n \u003cp\u003e146.72\u0026thinsp;\u0026plusmn;\u0026thinsp;15.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.003\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eC-arm fluoroscopy usage frequency (times, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c2\"\u003e\n \u003cp\u003e8.17\u0026thinsp;\u0026plusmn;\u0026thinsp;2.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e\n \u003cp\u003e16.56\u0026thinsp;\u0026plusmn;\u0026thinsp;3.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.034\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eThere were statistically significant differences in Operation duration, intraoperative blood loss, postoperative drainage blood loss, and the number of fluoroscopy with C-arm.\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003e P\u0026lt;.05 was considered statistically significant. \u003csup\u003eb\u003c/sup\u003e t test\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003cp\u003eFollow-up results\u003c/p\u003e\n \u003cp\u003eFollowing surgery, patients in both the observation and control groups progressively transitioned from non-weight-bearing to partial weight-bearing and eventually to full weight-bearing while engaging in standardized rehabilitation protocols. Knee joint function gradually improved over time, with no occurrence of recurrent fractures or clinically significant activity limitations observed during the follow-up period. The time to initiation of ambulation and achievement of full weight-bearing was significantly shorter in the observation group than in the control group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). At the final follow-up assessment, the observation group presented significantly greater range of motion (ROM) and Hospital for Special Surgery (HSS) scores than did the control group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); however, no statistically significant difference in residual deformity was observed between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The follow-up data for both groups are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFollow-up Data: Last Follow-up\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eTime to weight-bearing(d,\u003cem\u003ex\u0026thinsp;\u0026plusmn;\u0026thinsp;s\u003c/em\u003e)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eObservation group (n\u0026thinsp;=\u0026thinsp;86)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eP value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e18.72\u0026thinsp;\u0026plusmn;\u0026thinsp;2.25\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e25.84\u0026thinsp;\u0026plusmn;\u0026thinsp;4.83\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eTime to full weight(w,\u003cem\u003ex\u0026thinsp;\u0026plusmn;\u0026thinsp;s\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e7.17\u0026thinsp;\u0026plusmn;\u0026thinsp;1.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e14.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.009\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eknee joint range of motion(\u003csup\u003eo\u003c/sup\u003e\u003csub\u003e,\u003c/sub\u003e\u003cem\u003ex\u0026thinsp;\u0026plusmn;\u0026thinsp;s\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e114.17\u0026thinsp;\u0026plusmn;\u0026thinsp;14.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e100.40\u0026thinsp;\u0026plusmn;\u0026thinsp;18.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.009\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eHSS score( score, \u003cem\u003ex\u0026thinsp;\u0026plusmn;\u0026thinsp;s\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e85.617\u0026thinsp;\u0026plusmn;\u0026thinsp;3.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e73.36\u0026thinsp;\u0026plusmn;\u0026thinsp;7.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.002\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eShortening deformity [case (%)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e3(0.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e2(0.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.999\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003evarus-valgus deformity[case (%)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e0(0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e0(0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eThere was a statistically significant difference inTime to weight-bearing, full weight-bearing time, knee joint range of motion, HSS score, shortening deformity and varus-valgus deformity\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003e P\u0026lt;.05 was considered statistically significant .\u003csup\u003eb\u003c/sup\u003et test.\u003csup\u003ec\u003c/sup\u003e Pearson \u0026chi;\u003csup\u003e2\u003c/sup\u003etest\u003c/p\u003e\n \u003cp\u003eThree days post-operatively, radiographic evaluation revealed no significant differences in the quality of fracture reduction between the groups. By the end of the follow-up period, radiological evidence of fracture healing was confirmed in all patients. The mean time to fracture healing was significantly shorter in the observation group than in the control group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), as presented in Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Representative radiographic images of a patient from the observation group are displayed in Fig. \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, while those from the control group are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eImage Data\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eFracture reduction [cases (%)]\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eObservation group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;86)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eP value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.847\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eexcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e22(61.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e18(72.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003efair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e11(30.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e5(20.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eshortening deformity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e3(8.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e2(0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003epoor.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e0(0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e0(0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eTime for fracture healing [cases (%)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.037\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;24week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e25(69.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e13(52.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;24week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e11(31.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e12(48.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003cp\u003eThere was a statistically significant difference in healing time of fractures\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003e P\u0026lt;.05 was considered statistically significant. \u003csup\u003eb\u003c/sup\u003ePearson \u0026chi;\u003csup\u003e2\u003c/sup\u003etest\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u0026nbsp;Owing to the inherent complexity of AO/OTA 33-C-type distal femoral fractures, approximately 1 in 4 patients developed a recalcitrant nonunion after attempted nonunion repair[18]. Fixation with a dual column construct was associated with decreased risk of recalcitrant nonunion[18-20]. However, the dual-plate technique entails extensive soft-tissue dissection and provides suboptimal biomechanical stability. Henderson et al. [19] reported complication rates as high as 32% with dual-plate fixation.In contrast, a recent meta-analysis by Mohammad et al. [20] demonstrated that, compared with conventional isolated plate or intramedullary nail fixation, NPC confers significantly greater resistance to axial and torsional displacement\u0026mdash;and is associated with lower rates of complications, reoperation, implant failure, nonunion, and malunion.In study, intraoperative outcomes\u0026mdash;including operative duration, intraoperative blood loss, and fluoroscopic exposure\u0026mdash;were significantly more favorable in the NPC-GD group than in the NPC-GF group. The anatomically precontoured lateral locking plate used in NPC-GD facilitated conversion of comminuted 33-C fractures into more stable, extra-articular metaphyseal (AO/OTA 33-A or 33-B) configurations, enabling reliable subsequent retrograde nailing. Critically, the dedicated surgical guide enabled precise, fluoroscopy-free, bicortical distal interlocking\u0026mdash;eliminating nail\u0026ndash;screw interference and obviating iterative image-guided adjustments. By contrast, in the NPC-GF technique, the intramedullary nail is typically inserted prior to plate application [9,21]. Reaming during nail insertion inevitably disrupts the fracture hematoma and further destabilizes comminuted fragments, particularly in osteoporotic bone. Subsequent anatomical reduction and plate fixation thus require prolonged surgical manipulation, contributing to increased blood loss and soft-tissue trauma[22]. Moreover, achieving coaxial alignment between the plate and nail\u0026mdash;necessary to implement the \u0026ldquo;perfect circle\u0026rdquo; technique for distal interlocking\u0026mdash;necessitates repeated fluoroscopic imaging, prolonging operative time and elevating radiation exposure and infection risk. The broader soft-tissue dissection required for plate application, coupled with greater periosteal stripping and compromised vascularity of the fracture zone [17,19], likely contributed to the observed delay in fracture healing in the NPC-GF group.\u003c/p\u003e\n\u003cp\u003eThe NPC-GD group exhibited shorter time to radiographic fracture union earlier initiation of ambulation at final follow-up, earlier achievement of full weight-bearing, greater final knee range of motion , and higher Hospital for Special Surgery (HSS) knee scores.Previous biomechanical and clinical studies indicate that optimal fracture healing requires controlled interfragmentary micromotion, with an ideal strain magnitude of 2\u0026ndash;10% at the fracture site [4,23]. Excessively rigid fixation may induce stress shielding, resulting in inadequate mechanical stimulation of the fracture site and thereby impairing callus formation and osseous healing[5]. In the NPC-GD construct, distal interlocking is achieved via coordinated engagement of the intramedullary nail, plate interlocking holes, and a dedicated surgical guide\u0026mdash;preventing the instability commonly associated with short or eccentrically placed distal screws resulting from nail\u0026ndash;plate interference. This configuration enables efficient axial load transmission through the intramedullary nail while substantially enhancing resistance to horizontal shear forces [4]. Crucially, the proximal plate segment lacks interlocking features to mitigate stress concentration at the nail\u0026ndash;plate junction\u0026mdash;thereby preserving physiologically appropriate load distribution across the femoral shaft. To ensure robust proximal fixation independent of the intramedullary nail, the plate incorporates an offset eccentric locking hole design, permitting secure bicortical screw purchase without compromising nail integrity or trajectory.In the NPC-GF group, distal interlocking typically permits secure engagement of only a single screw through both the nail and plate due to alignment constraints under fluoroscopic guidance; achieving dual distal interlocking is technically challenging and frequently unattainable. In contrast, the NPC-GD technique\u0026mdash;by virtue of its dedicated guide device\u0026mdash;enables reliable, reproducible placement of two bicortical distal interlocking screws, thereby enhancing distal construct stability and load-sharing capacity. Collectively, these biomechanical advantages support earlier initiation of functional rehabilitation, accelerated restoration of knee range of motion, and enhanced fracture healing. Consistent with these principles,\u0026nbsp;Liporace FA\u0026nbsp;et al. [24] demonstrated that integrating a plate\u0026ndash;screw interlocking system with image-free guided instrumentation significantly improves axial and torsional stability in complex periprosthetic and periarticular femoral fractures,and\u0026nbsp;can offer stable, balanced fixation allowing for immediate weight bearing and early mobilization.\u003c/p\u003e\n\u003cp\u003eThe guide plate\u0026ndash;assisted plate\u0026ndash;screw interlocking system offers three principal advantages: (i) the laterally positioned locking plate minimizes medial soft-tissue dissection and enables precise, reproducible implant placement via a patient-specific surgical guide\u0026mdash;thereby streamlining surgical execution; (ii) it synergistically combines the biomechanical benefits of intramedullary load sharing with the angular stability of lateral plating, effectively mitigating the most frequent mode of construct failure\u0026mdash;varus collapse secondary to eccentric loading [25],this enhanced stability facilitates earlier initiation of functional rehabilitation[26,27],and (iii) proximal femoral fixation is achieved via bicortical screw placement through eccentric locking holes, ensuring high mechanical stability without reliance on the intramedullary nail. This study has several limitations. First, it is a single-center, retrospective cohort study with a relatively modest sample size, potentially limiting statistical power and generalizability.Second, although current AO/OTA principles support rigid integration of the nail and plate to promote balanced load distribution[5,24,28]\u0026mdash;and such integration is increasingly employed in revision surgery for nonunion following nail\u0026ndash;plate construct fixation [28]\u0026mdash;the biomechanical rationale and clinical evidence supporting mandatory rigid interlocking remain incompletely defined[29]. Crucially, the potential impact of this interlocking configuration on secondary fracture healing\u0026mdash;particularly regarding callus formation, strain distribution, and adaptive remodeling\u0026mdash;warrants rigorous evaluation through controlled biomechanical testing and prospective clinical studies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur findings indicate that the NPC-GD technique\u0026mdash;featuring a guide plate\u0026ndash;assisted, rigidly interlocked plate\u0026ndash;screw\u0026ndash;nail construct\u0026mdash;effectively overcomes key limitations of conventional single-modality fixation for complex distal femoral fractures. By synergistically integrating the biomechanical advantages of both intramedullary nailing and locking plating\u0026mdash;while minimizing their respective drawbacks, including implant interference, excessive soft-tissue dissection, and suboptimal load sharing\u0026mdash;NPC-GD achieves enhanced structural integrity and more physiologically appropriate interfragmentary strain distribution. Clinical outcomes demonstrate accelerated fracture healing, earlier functional rehabilitation, and superior short- to midterm functional recovery\u0026mdash;supporting its potential as a robust, reproducible, and clinically viable strategy for the management of highly comminuted AO/OTA 33-C distal femoral fractures.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eNPC;Nail-plate construct\u003c/p\u003e\n\u003cp\u003eHSS;Hospital for Special Surgery knee score\u003c/p\u003e\n\u003cp\u003eNPC-GD;Interlocking of the nail plate construct guided by a dedicated guide device.\u003c/p\u003e\n\u003cp\u003eNPC-GF;Interlocking of the nail-plate construct guided by fluoroscopic imaging\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll individual person’s data consent to publish.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not receive support from any organization for the submitted work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The authors declare that no funds, grants, or other support were received during the preparation of this manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eElsoe R, Ceccotti AA, Larsen P (2018) Population-based epidemiology and incidence of distal femur fractures. International orthopaedics 42:191\u0026ndash;196. https://doi:10.1007/s00264-017-3665-1\u003c/li\u003e\n\u003cli\u003eRinehart D, Youngman T, Ahn J, Huo M (2021) Review of patient-reported outcomes in periprosthetic distal femur fractures after total knee arthroplasty: a plate or intramedullary nail? Arthroplasty 3:24.https://doi: 10.1186/s42836-021-00080-w\u003c/li\u003e\n\u003cli\u003eTahami M, Vaziri AS, Tahmasebi MN et al (2022) Practical approach to the native distal femur fractures in the elderly: A rapid review over the recent trends. Injury 53:2389\u0026ndash;2394.https://doi:10.1016/j.injury.2022.05.014.\u003c/li\u003e\n\u003cli\u003eDewar CP, O\u0026apos;Hara GN, Roebke LJ, McKeon J, Martin KD (2024) Percutaneous Screw Fixation of Proximal Fifth Metatarsal Fractures. JBJS Essent Surg Tech 14:e23.00078.https://doi: 10.2106/JBJS.ST.23.00078\u003c/li\u003e\n\u003cli\u003eBabhulkar S, Trikha V, Babhulkar S, Gavaskar AS (2024) Current Concepts in Management of Distal Femur Fractures. Injury2:111357.https://doi: 10.1016/j.injury.2024.111357. Epub 2024 Aug 2\u003c/li\u003e\n\u003cli\u003eZhang J, Wei Y, Yin W, Shen Y, Cao S (2018) Biomechanical and clinical comparison of single lateral plate and double plating of comminuted supracondylar femoral fractures. Acta Orthop Belg84:141-148. PMID: 30462596\u003c/li\u003e\n\u003cli\u003eThorne TJ, Nelson CT, Lisitano LSJ, Higgins TF, Rothberg DL, Haller JM, Marchand LS (2024) Dual Plating of Distal Femoral Fractures. JBJS Essent Surg Tech 14:e23.00018.https://doi: 10.2106/JBJS.ST.23.00018\u003c/li\u003e\n\u003cli\u003eHernefalk B, Br\u0026uuml;ggemann A, Mohammed J et al (2022) Lower mortality in distal femoral fractures in the presence of a knee arthroplasty:an observational study on 2,725 fractures from the Swedish Fracture Register. Acta orthopaedica.93:684\u0026ndash;688.https://doi:10.2340/17453674.2022.4376\u003c/li\u003e\n\u003cli\u003eSaraglis G, Khan A, Sharma A et al (2024) The linked nail/plate construct for the management of distal femur fractures in the elderly. SICOT-J 10:20. https://doi:10.1051/sicotj/2024016\u003c/li\u003e\n\u003cli\u003eKontakis MG, Giannoudis PV (2023) Nail plate combination in fractures of the distal femur in the elderly: A new paradigm for optimum fixation and early mobilization?.Injury 54:288\u0026ndash;291.https://doi:10.1016/j.injury.2022.11.035.\u003c/li\u003e\n\u003cli\u003eBergin PF, Weber TG, Gerow DE et al (2018) Intraosseous Plating for the Management of Cortical Defects.Journal of orthopaedic trauma.32:S12\u0026ndash;S17. https://doi:10.1097/BOT.0000000000001095\u003c/li\u003e\n\u003cli\u003ePfeufer D, Zeller A, Mehaffey S et al (2019) Weight-bearing restrictions reduce postoperative mobility in elderly hip fracture patients. Archives of orthopaedic and trauma surgery 139:1253\u0026ndash;1259.https://doi:10.1007/s00402-019-03193-9\u003c/li\u003e\n\u003cli\u003eXu W, Lin W, Chen T, Liu H, Xiong Y, Wu J (2025) Modified plate-nail fixation for periprosthetic distal femur fractures following total knee arthroplasty in elderly patients - A technical note. Injury 56:112557. https:doi: 10.1016/j.injury.2025.112557\u003c/li\u003e\n\u003cli\u003eHoffmann MF, Jones CB, Sietsema DL, Tornetta P 3rd, Koenig SJ (2013) Clinical outcomes of locked plating of distal femoral fractures in a retrospective cohort. J Orthop Surg Res 8:43 https: doi: 10.1186/1749-799X-8-43\u003c/li\u003e\n\u003cli\u003eJankowski JM, Szukics PF, Shah JK et al (2021) Comparing Intramedullary Nailing Versus Locked Plating in the Treatment of Native Distal Femur Fractures: Is One Superior to the Other?. Indian journal of orthopaedics 55:646\u0026ndash;654. https://doi:10.1007/s43465-020-00331-z\u003c/li\u003e\n\u003cli\u003eQuinzi DA, Childs S, Lipof J et al (2020) The Treatment of Periprosthetic Distal Femoral Fractures After Total Knee Replacement: A Critical Analysis Review. JBJS reviews 8:e2000003.https://doi:10.2106/JBJS.RVW.20.00003\u003c/li\u003e\n\u003cli\u003eLi QW, Wu B, Chen B (2022) Modified fixation for periprosthetic supracondylar femur fractures:Two case reports and review of the literature. World journal of clinical cases.10:12328\u0026ndash;12336. https://doi:10.12998/wjcc.v10.i33.12328\u003c/li\u003e\n\u003cli\u003eRoddy E, Davis K, Wilson P, Kleweno C, Dunbar RP, Barei D (2025) Outcomes of Nonunion Repair for Distal Femur Fracture. J Orthop Trauma 39:621-628.https://doi: 10.1097/BOT.0000000000003047. PMID: 40709936\u003c/li\u003e\n\u003cli\u003eBologna MG , Claudio MG , Shields KJ et al (2019) Dual plate fixation results in improved union rates in comminuted distal femur fractures compared to single plate fixation. Journal of orthopaedics.18:76\u0026ndash;79. https://doi:10.1016/j.jor.2019.09.022.\u003c/li\u003e\n\u003cli\u003eDaher M, Parsons A, Mauffrey C, Richard R (2025) Nail-plate combination versus single construct for the management of distal femoral fractures: a meta-analysis. Eur J Orthop Surg Traumatol. 35:124. https://doi: 10.1007/s00590-025-04239-y\u003c/li\u003e\n\u003cli\u003eAttum B, Douleh D, Whiting PS et al (2017) Outcomes of Distal Femur Nonunions Treated With a Combined Nail/Plate Construct and Autogenous Bone Grafting. Journal of orthopaedic trauma 31:e301\u0026ndash;e304.https:// doi:0.1097/BOT.0000000000000926\u003c/li\u003e\n\u003cli\u003eNester M, Borrelli J Jr (2023) Distal femur fractures management and evolution in the last century. Int Orthop. 2023 Aug;47(8):2125-2135. https:// doi: 10.1007/s00264-023-05782-1\u003c/li\u003e\n\u003cli\u003eYu X, Guo Y, Kang Q et al (2013) Effects and mechanisms of mechanical stress on secondary fracture healing. Frontiers in bioscience (Landmark edition) 18:1344\u0026ndash;1348. https://doi:10.2741/4183\u003c/li\u003e\n\u003cli\u003eLiporace FA, Yoon RS (2019) Nail Plate Combination Technique for Native and Periprosthetic Distal Femur Fractures. J Orthop Trauma33:e64-e68.https://doi: 10.1097/BOT.0000000000001332\u003c/li\u003e\n\u003cli\u003eHussain MS, Dailey SK, Avilucea FR (2018) Stable Fixation and Immediate Weight-Bearing After Combined Retrograde Intramedullary Nailing and Open Reduction Internal Fixation of Noncomminuted Distal Interprosthetic Femur Fractures. Journal of orthopaedic trauma 32:e237\u0026ndash;e240. https://doi:10.1097/BOT.0000000000001154\u003c/li\u003e\n\u003cli\u003eHalstrom JR, Litten RM, Alcaide DM, McIlwain RN, Spitler CA, Johnson JP (2026) Outcomes of Periprosthetic Distal Femur Fractures by Fixation Construct: A Retrospective Cohort Study. J Am Acad Orthop Surg Glob Res Rev 10:e25.00422.https://doi: 10.5435/JAAOSGlobal-D-25-00422\u003c/li\u003e\n\u003cli\u003eMau M, Thorne T, Payne C, Roach K, Svetgoff R, Kellam PJ, DeKeyser GJ, Warner SJ, Marchand LS, Haller J (2025) Dual Implants for Geriatric Distal Femur Fractures Results in Greater Healthy Days at Home. J Orthop Trauma 23.https://doi: 10.1097/BOT.0000000000002999\u003c/li\u003e\n\u003cli\u003eWagner RK, Raats JH, Ponds NHM, Borgida JS, Brameier DT, Harris MB, Kloen P, Janssen SJ, Ly TV, Weaver MJ (2025) Risk factors for failure of distal femoral nonunion repair. Eur J Orthop Surg Traumatol 35:343.https:// doi: 10.1007/s00590-025-04460-9\u003c/li\u003e\n\u003cli\u003eNauth A, Haller J, Augat P, Anderson DD, McKee MD, Shearer D, Jenkinson R, Pape HC (2024) Distal femur fractures:basic science and international perspectives. OTA Int 7 :e320.https:// doi: 10.1097/OI9.0000000000000320\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Distal femoral fractures, Nail–plate construct, Dual-plate fixation, Surgical complication","lastPublishedDoi":"10.21203/rs.3.rs-9186557/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9186557/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction\u003c/p\u003e \u003cp\u003eAO/OTA 33-C-type femoral fractures pose a significant clinical challenge for orthopedic surgeons. The nail\u0026ndash;plate construct (NPC) has emerged as the predominant surgical strategy for these complex peri- and intertrochanteric fractures. However, to mitigate component interference within the implant construct, two nail\u0026ndash;plate construct (NPC) techniques have been developed: a dedicated surgical guide device\u0026ndash;assisted technique (NPC-GD) and a fluoroscopy-guided technique (NPC-GF).This study aimed to compare surgical outcomes, quality of life, and functional recovery in patients of AO/OTA 33-C-type femoral fractures using either NPC-GD or NPC-GF.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMaterials and methods\u003c/b\u003e A retrospective review of clinical data was conducted for patients diagnosed with AO/OTA 33-C-type femoral fractures who underwent dual-construct fixation\u0026mdash;comprising both a locking plate and an intramedullary nail. Outcomes assessed included operative time, length of hospital stay, intraoperative and postoperative blood loss, number of intraoperative fluoroscopic images, incidence of malunion, time to radiographic fracture union, time to initiation of partial and full weight-bearing, final knee range of motion, and the Hospital for Special Surgery (HSS) knee score.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResults\u003c/b\u003e The final analysis included 161 patients: 86 in the NPC-GD group and 75 in the NPC-GF group. NPC-GD group exhibited significantly shorter operative time (P\u0026thinsp;=\u0026thinsp;0.006), lower intraoperative (P\u0026thinsp;=\u0026thinsp;0.004) and postoperative (P\u0026thinsp;=\u0026thinsp;0.003) blood loss, fewer intraoperative fluoroscopic images (P\u0026thinsp;=\u0026thinsp;0.034), shorter time to radiographic fracture union (P\u0026thinsp;=\u0026thinsp;0.037), earlier initiation of ambulation at final follow-up (P\u0026thinsp;=\u0026thinsp;0.001), earlier achievement of full weight-bearing (P\u0026thinsp;=\u0026thinsp;0.009), greater final knee range of motion (P\u0026thinsp;=\u0026thinsp;0.009), and higher Hospital for Special Surgery (HSS) knee scores (P\u0026thinsp;=\u0026thinsp;0.002).\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusions\u003c/b\u003e Compared with NPC-GF, NPC-GD demonstrates superior clinical outcomes in the management of AO/OTA 33-C-type femoral fractures\u0026mdash;specifically with respect to reduced operative complexity, diminished surgical trauma, accelerated fracture healing, and enhanced functional recovery.\u003c/p\u003e","manuscriptTitle":"Guide Plate Technique versus Fluoroscopy-Guided Technique in the Fixation of AO/OTA 33-C Distal Femur Fractures Using a Nail–Plate Dual System: A Retrospective Comparative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-10 16:51:23","doi":"10.21203/rs.3.rs-9186557/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-08T19:41:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80994862745365385095420751631161019284","date":"2026-04-11T12:30:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-06T08:35:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-23T11:48:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-23T11:48:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Orthopaedic and Trauma Surgery","date":"2026-03-21T14:45:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"64b0da8c-33ca-4d0f-9357-21d206492df1","owner":[],"postedDate":"April 10th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-08T19:41:29+00:00","index":13,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-10T16:51:23+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-10 16:51:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9186557","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9186557","identity":"rs-9186557","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}