Reverse distal femoral locking compression plate a salvage option in nonunion of proximal femoral fractures.

Sir,

We read with keen interest the article entitled, “Reverse distal femoral locking compression plate a salvage option in nonunion of proximal femoral fractures”1 in Indian Journal of Orthopaedics. This study narrates to a common problem encountered in orthopaedic practice and deals with challenges encountered in managing failed proximal femoral (PF) fracture fixation.

Nevertheless, we have a few concerns which we would like to share.

Article title involves the terminology PF fractures, but as we go through the article the fractures included in the study were 18 subtrochanteric fractures and two cases of ipsilateral fracture neck and shaft femur.1 Moreover, the authors have excluded the nonunion intertrochanteric fractures. Hence, the terminology PF fracture is apparently not suitable for the study

Author has emphasized the careful evaluation of intraoperative lateral radiograph while inserting proximal screws in anteverted femoral neck. However, the lateral decubitus position was used while operating the patients, and hence it is difficult and cumbersome to take lateral images and to evaluate them for the position of screws. This fact needs to be addressed in the study

Distal femoral locking compression plate (DF-LCP) is a 95° fixed angle device.2 When it is applied proximally using the locking screws, the screws will go at an angle of 95°, passing through Ward's triangle and will occupy the lower portion of the femoral head. The superior part of the head will not be engaged, leading to weak fixation. Moreover, maintenance of neck-shaft angle (NSA) of 130° with 95° device is difficult, without compromising the NSA, as is clearly evident in the radiographs shown in Figures 1c and 4b of the article1

Author has included cases of nonunion and delayed union in the study while evaluating the DF-LCP. However, in concluding the study results, they talked only of nonunion, without mentioning of delayed union cases (14 cases of subtrochanteric delayed union – as mentioned in materials and methods)

As rightly mentioned by the authors in cases of nonunion, fixation in compression mode (absolute stability) is desirable, which they achieved using DF-LCP. However, authors have also talked about the use of long plates through minimally invasive surgical approach (relative stability). It seems that two philosophies (absolute and relative stability) were being combined in few of their cases.34 This fact should have been elaborated in the study.

Lack of anterior curvature and limited screw options in proximal femur were the disadvantages enumerated by the authors of PF-LCP. Nonetheless, screws in proximal part of PF-LCP are at different angles (95°, 120°, and 135°), meant to engage the entire head of femur for adequate fixation of PF fractures

In the last, we would like to know how authors have ruled out infection as a cause of delayed or nonunion. Moreover, there is no mention of average time of union, limb length discrepancy, and coxa vara observed in the study.

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Conflicts of interest

There are no conflicts of interest.