High revision rates and mortality after distal femoral replacement for periprosthetic distal femoral fractures: analysis from the German Arthroplasty Registry (EPRD).

PURPOSE: This study was initiated to analyze the outcome after distal femoral replacement (DFR) for periprosthetic distal femoral fractures (PDFF). METHODS: Data from the German Arthroplasty Registry (EPRD) were analyzed. A total of 626 patients could be identified with a DFR for PDFF. Mean age was 78.8 years, and 84.2% were female. Revisions and mortality were analyzed and compared with patient groups with a similar procedure (revision total knee arthroplasty) or similar general condition (fracture total hip arthroplasty, hip hemiarthroplasty). Matched-pair-analyses were performed. RESULTS: Within one year after surgery, 13.2% of the patients had died and further 9.4% were revised. Within four years, 32.7% had died and 19.7% were revised. Revisions were nearly twice as high as in the comparison groups. Periprosthetic infection (PJI) was the most frequent cause for revision, resulting in a PJI rate of 12.8%, which was lower in the comparison groups. Mortality after DFR was as similar high as after fracture hip arthroplasty. CONCLUSION: PDFF are a serious injury, and the necessary surgical treatment has a high risk of complications. Every third patient after DFR for PDFF had died and every fifth patient needed revision within 4 years after surgery. Efforts should be undertaken to provide optimal treatment to these high-risk patients to reduce unfavorable outcomes. LEVEL OF EVIDENCE: III. REGISTRATION OF CLINICAL TRIALS: As this is a registry-derived study of data of the German Arthroplasty Registry (EPRD), no registration was performed.

Early complications and reoperation rates are similar amongst open reduction internal fixation, intramedullary nail, and distal femoral replacement for periprosthetic distal femur fractures: a systematic review and meta-analysis.

BACKGROUND: Our purpose was to perform a systematic review and meta-analysis to evaluate complication and revision rates for periprosthetic distal femur fractures (PPDFF) treated with: (1) ORIF using periarticular locking plates (ORIF), (2) retrograde intramedullary nail (IMN), and (3) distal femoral replacement (DFR). METHODS: Systematic review of the literature was performed to identify eligible studies (N = 52). Identified treatment groups were: ORIF (N = 1205 cases), IMN (N = 272 cases), and DFR (N = 353 cases). Median follow-up was 30 months (range 6-96 months). Primary outcomes were: (1) major complication rates and (2) reoperation rates over the follow-up period. Secondary outcomes were incidence of deep infection, periprosthetic fracture, mortality over the follow-up period, 1-year mortality, non-union, malunion, delayed union, and hardware failure. Data for primary and secondary outcomes were pooled and unadjusted analysis was performed. Meta-analysis was performed on subset of individual studies comparing at least two of three treatment groups (N = 14 studies). Odds-ratios and their respective standard errors were determined for each treatment group combination. Maximum likelihood random effects meta-analysis was conducted for primary outcomes. RESULTS: From the systematic review, major complication rates (p = 0.55) and reoperation rates (p = 0.20) were not significantly different between the three treatment groups. DFR group had a higher incidence of deep infection relative to IMN and ORIF groups (p = 0.03). Malunion rates were higher in IMN versus ORIF (p = 0.02). For the meta-analysis, odds of major complications were not significantly different between IMN versus DFR (OR 1.39 [0.23-8.52]), IMN versus ORIF (OR 0.86 [0.48-1.53]), or the ORIF versus DFR (OR 0.91 [0.52-1.59]). Additionally, odds of a reoperation were not significantly different between IMN versus DFR (OR 0.59 [0.08-4.11]), IMN versus ORIF (OR 1.26 [0.66-2.40]), or ORIF versus DFR (OR 0.91 [0.51-1.55]). CONCLUSIONS: There was no difference in major complications or reoperations between the three treatment groups. Deep infection rates were higher in DFR relative to internal fixation, malunion rates were higher in IMN versus ORIF, and periprosthetic fracture rates were higher in DFR and IMN versus ORIF.

Periprosthetic Fractures of the Distal Femur: Is Open Reduction and Internal Fixation or Distal Femoral Replacement Superior?

BACKGROUND: The purpose of this study is to compare open reduction and internal fixation (ORIF) to distal femoral replacement (DFR) for treatment of displaced periprosthetic distal femur fractures. METHODS: We identified 72 patients with minimum 2-year follow-up following a displaced periprosthetic distal femur fracture: 50 were treated with ORIF and 22 with DFR. Outcomes were assessed with multivariate regression analysis and include Knee Society Scores (KSS), infection rates, revision incidence, and mortality. RESULTS: Patients treated with DFR had a higher Charlson comorbidity index (5.2 vs 3.8; P = .006). The mean postoperative KSS were similar between groups, but the Knee Society Functional Scores were higher in the ORIF group (P = .01). Six ORIF patients (12%) and 3 DFR patients (14%) underwent a revision surgery (P = .1). In the ORIF group, 3 revisions were associated with periprosthetic infection, and 3 revisions occurred for aseptic nonunion. In the DFR group, 1 infection was treated with irrigation and debridement, and 2 cases of patellar maltracking resulted in 1 liner exchange with soft tissue release and 1 femoral revision for malrotation. More patients in the ORIF group required repeat revisions, with twice as many total revisions (P < .001). Six ORIF patients and 7 DFR patients died within 2 years (P = .26). CONCLUSION: The Knee Society Functional Score favored ORIF, but the total incidence of revision was higher in the ORIF cohort. Given the high mortality and the substantial risk of reoperation in both groups, additional studies are needed regarding the prevention of and optimal treatment for patients with periprosthetic distal femur fractures.

Predictors of Functional Recovery Following Periprosthetic Distal Femur Fractures.

BACKGROUND: Treatment options for periprosthetic distal femur fractures include open reduction internal fixation (ORIF) and distal femoral replacement (DFR). The purpose of this study was to evaluate the complications, and functional recovery (ambulatory status, living situation, mortality) in patients undergoing operative treatment (DFR and ORIF) of periprosthetic distal femur fractures. METHODS: A retrospective review of 58 patients with distal femoral periprosthetic fractures treated with either ORIF or DFR was conducted. Surgical complications, discharge disposition, ambulatory status, living situation at 1 year, and mortality at 1 year were compared between patients treated with ORIF and DFR. Outcomes at 1 year were also compared between patients older and younger than 85 years of age. RESULTS: Fifty-eight patients with a mean age of 80 years (range, 61-95 years) met inclusion criteria. The mean follow-up was 29.5 months (range, 5-81 months). Patients undergoing DFR were significantly older than those who underwent ORIF (83 vs 78, P < .01). The 1-year mortality rate was 20.6%. There was no difference between groups with respect to mortality, complications, discharge disposition, or ambulatory status and living situation at 1 year. Patients who lost the ability to ambulate at 1 year were significantly older than patients who maintained the ability to ambulate (87.5 vs 76.4 years, P < .05). Patients older than 85 years were more likely to lose the ability to ambulate and to live in a skilled nursing facility at 1 year (P < .01). CONCLUSION: Distal femoral periprosthetic fractures have a high morbidity and mortality. Age at time of injury, not treatment rendered, is predictive of ambulatory status and living independence after periprosthetic distal femur fractures.

Modified fixations for distal femur fractures following total knee arthroplasty: a biomechanical and clinical relevance study.

PURPOSE: Distal femur fractures adjacent to total knee arthroplasty are a rare yet complex problem. Recently, extramedullary locking plate and retrograde intramedullary nail fixations have become popular options, but the complication rates associated with these procedures are 15-20 %. Modified fixations were assessed in an effort to reduce complications from unstable periprosthetic fractures. METHODS: Using experimental and finite element methods, this study compared the construct behaviours of a locking plate, a retrograde intramedullary nail, and their modifications (a spiral-blade supplemented in an intramedullary nail or a locking plate/allograft hybrid) when subjected to various fracture types, locations, loading conditions, and bony strength. The implanted models were used to assess construct stiffness, fracture micromotion, and implant stress under different osteoporotic conditions. Finally, we collected 40 cases for radiological analysis to indicate the appropriate procedure for treating periprosthetic fractures following total knee arthroplasty. RESULTS: Regardless of the fracture type, femoral constructs fixed with a conventional or spiral-blade supplemented intramedullary nail exhibited higher axial but lower torsional stiffness than those fixed with a locking plate. Torsional deformation occurred if the lower-positioned fracture had no medial support. The locking plate/allograft construct exhibited the highest stiffness and the least micromotion. A review of 40 clinical cases confirmed the above findings regarding the locking plate/allograft construct. CONCLUSION: The spiral-blade supplement of retrograde intramedullary nail and locking plate/allograft modified constructs significantly stabilizes the unstable fractured gaps. The locking plate/allograft is recommended for the periprosthetic fractures with deficient bone stock and severe osteoporosis to improve alignment and healing potentials.

A case of recurrent proximal femoral fracture after open reduction and internal fixation with bilateral locking plates for a Rorabeck type II periprosthetic fracture.

INTRODUCTION AND IMPORTANCE: Periprosthetic distal femur fractures (PDFFs) are rare complications that may occur during or after total knee arthroplasty (TKA). The incidence of PDFFs is increasing. Plate internal fixation has demonstrated positive results. However, there is limited research available on the recurrence of periimplant fractures following open reduction and internal fixation with bilateral locking plates. CASE PRESENTATION: A 70-year-old female patient was diagnosed with a Rorabeck type II fracture. Based on the patient's physical condition and available surgical options, minimally invasive open reduction, bilateral plate fixation, and allograft artificial bone grafting were chosen. The postoperative recovery was successful. However, the patient experienced a fall 2 months after the surgery, resulting in a proximal femoral fracture. After considering the patient's condition and family preferences, conservative treatment was ultimately decided upon. CLINICAL DISCUSSION: Minimally invasive bilateral Locking Compression Plate (LCP) as a surgical approach can effectively reduce surgical risks prior to the procedure. Careful selection of screws and the use of C-arm fluoroscopy during plate contouring and fixation are essential to prevent screw penetration through the contralateral cortex. Treatment outcomes were not impacted in patients with normal bone mass; however, in this particular case, the patient had severe osteoporosis, significantly increasing the risk of refracture. It is crucial to improve postoperative monitoring and raise awareness about safety among patients and their families. CONCLUSION: The management of periprosthetic distal femur fractures (PDFFs) is influenced by the type of fracture and bone quality. Mechanical stability and stress dispersion of internal fixation are key factors to consider. In the perioperative setting, involving experienced clinicians is essential to reduce the risk of secondary injuries that may impact treatment outcomes, especially when choosing screws for fixation in patients with low bone density.

Geriatric distal femur fracture: Are we underestimating the rate of local and systemic complications?

BACKGROUND: Low energy distal femur fractures often occur in a fragile elderly population that is prone to local and systemic complications following operative treatment of extremity fractures. The nonunion rate and early complication rate following laterally based locked plating in this specific fracture are not well described. METHODS: We conducted a retrospective cohort study conducted at three affiliated tertiary care hospitals to evaluate nonunion, early post operative complications, discharge disposition, length of stay, and mortality in patients over 60 years old undergoing laterally based locked plating of a low energy distal femur fracture. RESULTS: Forty-four out of 176 patients were deceased at one year (25%). Predictors of one year mortality included older age, higher Charlson Comorbidity Index (CCI), and delay to surgery greater than 2days (p<0.001). Of 99 patients alive and with follow up at one year, 24 (24%) developed a nonunion and 21 of 24 required nonunion surgery. Development of a surgical site infection was statistically significantly correlated with development of nonunion. Age and CCI did not predict development of nonunion. Average length of stay was 10days and 82% of patients were discharged to a skilled nursing facility. Thirty eight percent of patients experienced at least one postoperative systemic complication. CONCLUSIONS: Laterally based locked plating of the low energy geriatric distal femur fracture is most often followed by a tumultuous post-operative course with a high rate of local and systemic complications including death, nonunion, and extended hospital stays. LEVEL OF EVIDENCE: Level III prognostic.