Author's reply.

Sir,

Thank you for your interest1 shown in the article, “Reverse distal femoral locking compression plate a salvage option in nonunion of proximal femoral fractures”1 in Indian Journal of Orthopaedics.

Ipsilateral neck femur with shaft femur is a challenging condition in respect to implant selection. We have included this condition as we have demonstrated the successful outcome in this condition using distal femoral plate.

It is recommended to start the case in lateral position only when you are able to see a proper lateral view on the C-arm. Thickness of patient and quality of C-arm are the influencing factors. In supine position, managing these nonunions, we feel it difficult because of posterior sagging at fracture site.

The distal femoral locking compression plate (DF-LCP) is a fixed-angle device when locking screws are used. We have used 6.5 mm nonlocking cancellous screws in neck femur cases. Furthermore, the 95% angulations of locking screws help get purchase in already operated proximal femoral (PF) cases where the tracks of previous implants are a main issue for purchase. Multiple holes in distal part of plate give you many options to get adequate purchase in proximal femur.

We have included cases of nonunion and delayed union in the study while evaluating the DF-LCP. However, in concluding the study results, we talked only of nonunion, without mentioning of delayed union cases (14 cases of subtrochanteric delayed union – as mentioned in materials and methods). We accept it as a shortcoming.

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. We have used minimally invasive surgery approach in few cases as it is mentioned in the paper. We have opened the fracture site and dynamic compression plate holes of the plate were used to achieve the compression.

Lack of anterior curvature and limited screw options in proximal femur were the limitations 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 entire head of femur for adequate fixation of PF fractures. We have not compared this aspect of plate with distal femoral plate. We have ruled out infections clinically and with blood investigations. We could not mention the average time of union as different PF fractures were managed using this technique.

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