Reliability of current classification systems for periprosthetic distal femur fractures.

INTRODUCTION: This study aims to determine which Periprosthetic Distal Femur Fracture (PDFF) classification system is the most reliable. The secondary aim was to determine which classification system correlated most accurately with the surgical management recommended and delivered. METHODS: Between 2011 and 2019, 83 patients with 83 PDFFs that extended to the femoral component of a total knee arthroplasty (TKA) were retrospectively identified from a trauma database. Minimum follow-up was 1 year. Age, BMI, time from TKA, operative management, and Nottingham Hip Fracture Scores were collected, and AP and lateral radiographs used to classify all fractures using seven established classification systems by two observers blinded to management. In patients treated operatively (n = 69), preoperative radiographs were reviewed by two surgeons with expertise in trauma and knee revision who recommended fixation or distal femoral replacement (DFR) requirement. RESULTS: Mean age was 80.7 years (SD9.4) and 50 (84.7%) were female. PDFFs occurred at a mean 9.5 years (SD5.2) after primary TKA. Mean follow-up was 3.8 years (SD2.9). Management was fixation in 47, DFR in 22 and non-operative for 14. The Fakler classification demonstrated highest interobserver reliability (ICC=0.948), followed by the Rorabeck (ICC=0.903), UCS (ICC=0.850) and Chen (ICC=0.906). The Neer classification demonstrated weakest agreement (ICC=0.633). Overall accuracy of predicting DFR requirement (as determined by two experts) was highest for the Fakler system (83.9%). Compared with actual management delivered the Rorabeck system was most accurate (94.1%). Multivariate regression demonstrated that the ultimate need for DFR (n = 22) was independently associated with medial comminution (HR 2.66 (1.12-6.35 95%CI), p = 0.027) and fractures distal to the anterior flange and posterior condyle of the femoral component (HR 2.45 (1.13-5.31), p = 0.024). CONCLUSION: The Fakler classification showed highest interobserver agreement and was most accurately predictive of the management recommended by two experts. No classification system accurately predicted the fractures that required DFR, and none included medial comminution which was independently associated with DFR requirement. There remains a need for a PDFF classification system that reliably guides operative management of PDFFs.

Functional outcome following arthroscopic repair of massive rotator cuff tears is equal to smaller rotator cuff tears: a retrospective case-control study.

Background: There is a paucity of studies comparing patient-reported outcomes of arthroscopic massive rotator cuff repairs against non-massive rotator cuff repairs. The aim of this study is to assess the Quick Disabilities of the Arm, Shoulder and Hand questionnaire and Oxford Shoulder Score at a minimum of one-year follow-up according to the size of the rotator cuff tear. Methods: A retrospective case-control study was undertaken. All patients underwent rotator cuff repairs using the same technique by a single surgeon. Quick Disabilities of the Arm, Shoulder and Hand questionnaire and Oxford Shoulder Score were collected pre-operatively and at final review with a minimum follow-up of one year. Patients with massive rotator cuff repairs were compared to patients who had non-massive rotator cuff repairs. Results: Eighty-two patients were included in the study of which 42 (51%) underwent massive rotator cuff repair. The mean follow-up period was 17.5 months. Quick Disabilities of the Arm, Shoulder and Hand questionnaire improved significantly (p < 0.001) from 46.1 pre-operatively to 15.6 at final follow-up for massive rotator cuff repairs. Oxford Shoulder Score improved significantly (p < 0.001) from 26.9 pre-operatively to 41.4 at final follow-up for massive rotator cuff repairs. There was no significant difference in the final Quick Disabilities of the Arm, Shoulder and Hand questionnaire (p = 0.35) or Oxford Shoulder Score (p = 0.45) between the groups. No revision surgery was required within the follow-up period. Conclusion: Arthroscopic massive rotator cuff repairs have comparable functional outcome to smaller rotator cuff repair in the short-term and should be considered in a selected group of patients.