More is More — What You Get By Adding a Nail to a Plate in Distal Femoral Fractures — What Now?

Value is not always perceived in dollars saved if the result is a nonunion

I read the CORRelations post “More is More — What You Get By Adding a Nail to a Plate in Distal Femoral Fractures” with interest. As an orthopaedic trauma surgeon, I would be intrigued to hear what our “non-trauma” call-taking colleagues thought about this concept!

When this approach was first shared, I thought that it was yet another example of treatment overkill. Too many of us turn a blind eye to cost, and when we do so, we can add needlessly to patients’ costs of care. Remember that value equals quality divided by cost, so, if the nail/plate construct does not improve outcomes in ways that patients can perceive, and in ways that justify the increased cost (both in terms of the additional implant and surgical time), we should resist the urge to use it.

But distal femoral nonunions are a disaster. We often attribute nonunions to the high stiffness of the lateral locking plate, but that can’t be the whole story if the nail/plate combo is as effective as it seems, since certainly adding a nail to the picture can’t decrease the construct’s overall stiffness. Regardless, if the addition of the nail materially reduces the odds of nonunion or hardware failure, the cost savings is probably substantial. And certainly avoiding a nonunion boosts the numerator in the value equation (quality) from the patient’s point of view.

Taken together, it sounds like a good value.

My bottom line is this: If you’re looking at the injury films and a concern about hardware failure or subsequent nonunion weighs heavily on your mind, I believe the nail/plate construct is the way to go.