A Dual-Implant Approach to Vancouver C Femur Fractures: Improved Outcomes with Retrograde Nail and Lateral Plate Fixation Compared to Lateral Locked Plating

Objectives: To compare lateral locked plating (LLP) to a combined treatment approach utilizing a retrograde intramedullary nail (rIMN) alongside a minimally invasive lateral locked periprosthetic plating system (PPS) (Smith Memphis, TN) in the management of Vancouver C periprosthetic femoral fractures. Methods: Design: Retrospective chart review Setting: Single, academic, Level-1 Trauma center Patient Selection Criteria: All adult patients who underwent fixation of a Vancouver C periprosthetic femur fracture (AO/OTA Type 32C IVC/D) with a rIMN and PPS (NP Group) or LLP (LLP group) between 2019 and 2025 with follow-up to union, reoperation, or a minimum of one year were included. Patients in the NP group were recommended to fully bear weight immediately while patients in the LLP group were recommended to remain non-weight bearing for 8 weeks. Outcome Measures and Comparisons: The primary outcome was fracture union. Secondary outcomes included implant failure, infection, and alignment immediately postoperatively and at final follow-up. Primary and secondary outcome measures were compared between the NP and LLP groups. Results: A total of 52 patients were included. 31 in the NP group (68% female, mean age 79 years (range, 67 – 99)) and 21 in the LLP group (67% female, 69 years (range, 53 – 85)), (p = 0.54 for sex, p = 0.26 for age). In both groups, the lateral plate extended proximal to the hip prosthesis by at least 3 screw holes. There were no differences when comparing body mass index, diabetes, smoking status, mechanism of injury, or fracture classification between groups (p > 0.05). In the NP group the mean immediate aLDFA was 82 degrees range (79-87 degrees) compared to 80 degrees (range 79 - 87 degrees) at final follow-up (p = 0.37; 95% CI -5.08 to 12.9). In the LLP group the mean immediate aLDFA was 80 degrees (range, 63 – 87 degrees), compared to 82 degrees (range 69 – 87 degrees) at final follow-up (p = 0.43; 95% CI, –5.35 to 2.37). There was no difference in alignment both immediately postoperatively and at final follow-up between groups (p = 0.20 and 0.45, respectively). There were 2 reoperations (6%) in the NP group, both a removal of a loose interlocking screw. There were 3 reoperations (14%) in the LLP group, all nonunions without implant failure that were revised to nail-plate constructs and subsequently achieved union. There was no difference in reoperation between groups (p = 0.68). There were 0 nonunions in the NP group compared to 3 (14%) in the LLP group (p = 0.03). There were no cases of implant failure or infection. Conclusions: Retrograde nail/plate combination demonstrated a high union rate when treating Vancouver C periprosthetic femur fractures. When compared to lateral locked plating alone which does not facilitate immediate weight-bearing, this implant combination demonstrated lower rates of nonunion with the benefit of allowing immediate post-operative weight bearing. Level of Evidence: Level III