Equivalent mortality and complication rates following periprosthetic distal femur fractures managed with either lateral locked plating or a distal femoral replacement

Distal femoral replacement for the treatment of periprosthetic distal femoral fractures around a total knee arthroplasty: a meta-analysis

Background

Periprosthetic fracture is a rare complication of arthroplasty but can have devastating consequences for the patient and presents a complex surgical challenge. Locking compression plate and retrograde intramedullary nail are both widely accepted surgical fixation techniques for distal femoral periprosthetic fractures around a total knee arthroplasty. Although there is still a need for further high-quality research into both techniques, there is even less literature concerning the use of distal femoral replacement to treat distal femoral periprosthetic fractures. Interest has been piqued in distal femoral replacements for the treatment of distal femoral periprosthetic fractures due to the theoretical advantages of immediate post-operative weight-bearing and lack of dependence on fracture union, but there are still understandably reservations about performing such an extensive and invasive procedure when an accepted alternative is available. This meta-analysis aims to evaluate the current literature to compare the complication rates and return to pre-operative ambulatory status of distal femoral replacement and locking compression plate.

Method

A literature search was performed to identify articles related to the management of distal femoral periprosthetic fractures around a total knee arthroplasty in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Methodological quality was assessed using the methodological index for non-randomized studies (MINORS) criteria. Articles were reviewed, and data extracted for analysis.

Results

Five articles met the inclusion criteria, reporting on 345 periprosthetic fractures. The overall rates of complications for distal femoral replacement and locking compression plate were: re-operation (6.1% vs 12.1%), infection (3.0% vs 5.3%), mortality (19.7% vs 19.3%), and return to pre-operative ambulatory status (60.9% vs 71.8%) (respectively).

Conclusion

This meta-analysis shows no statistically significant difference in the rates of re-operation, infection, mortality or return to pre-operative ambulatory status when comparing distal femoral replacement to locking compression plate.

Indications for Nonbiological Reconstruction of Posttraumatic Bone Defects About the Knee

SUMMARY

3D printing and modeling has continued to grow in popularity over the past decade because the technology has matured and become more affordable and widely available. The main indications for nonbiological reconstruction of large bone defects are principally those patients where the candidate is unlikely to be successful if reconstructed by other means. Bespoke, custom, patient-specific implants can be designed to very effectively address bone loss, incorporating design elements that are particular to the needs of any given unique clinical condition. These implants are generally designed as titanium scaffolds that encourage bony incorporation at the host implant junction both proximal and distal. These scaffolds are typically considered a cellular solid, with high porosity that also promotes bone ingrowth directly into the substance of the body of the implant. Titanium scaffolds of this type have become a useful treatment alternative for large segmental bone defects around the knee, especially distal femoral defects. These are often adult patients with local or systemic compromise, or instead they may be too young to be considered candidates for reconstruction using a megaprosthesis. The process requires careful evaluation of individual patients, then matching that patient with the best treatment option, while recognizing the expectations and demands specific to that particular patient. Several cases are presented here to illustrate the variety of indications that can be successfully addressed with this technology, highlighting the quality of the clinical outcome that can be achieved despite the complexity of the pathology encountered.

Fix or Replace? Patient Preferences for the Treatment of Geriatric Lower Extremity Fractures: A Discrete Choice Experiment

Introduction

When considering treatment options for geriatric patients with lower extremity fractures, little is known about which outcomes are prioritized by patients. This study aimed to determine the patient preferences for outcomes after a geriatric lower extremity fracture.

Materials and Methods

We administered a discrete choice experiment survey to 150 patients who were at least 60 years of age and treated for a lower extremity fracture at a Level I trauma center. The discrete choice experiment presented study participants with 8 sets of hypothetical outcome comparisons, including joint preservation (yes or no), risk of reoperation at 6 months and 24 months, postoperative weightbearing status, disposition, and function as measured by return to baseline walking distance. We estimated the relative importance of these potential outcomes using multinomial logit modeling.

Results

The strongest patient preference was for maintained function after treatment (59%, P < .001), followed by reoperation within 6 months (12%, P < .001). Although patients generally favored joint preservation, patients were willing to change their preference in favor of joint replacement if it increased function (walking distance) by 13% (SE, 66%). Reducing the short-term reoperation risk (12%, P < .001) was more important to patients than reducing long-term reoperation risk (4%, P = .33). Disposition and weightbearing status were lesser priorities to patients (9%, P < .001 and 7%, P < .001, respectively).

Discussion

After a lower extremity fracture, geriatric patients prioritized maintained walking function. Avoiding short-term reoperation was more important than avoiding long-term reoperation. Joint preservation through fracture fixation was the preferred treatment of geriatric patients unless arthroplasty or arthrodesis provides a meaningful functional benefit. Hospital disposition and postoperative weightbearing status were less important to patients than the other included outcomes.

Conclusions

Geriatric patients strongly prioritize function over other outcomes after a lower extremity fracture.

Outcomes of Geriatric Periprosthetic Distal Femur Fractures: Comparison of Fixation Versus Reconstruction

OBJECTIVE

Comparing outcomes of periprosthetic distal femur fractures treated with open reduction and internal fixation (ORIF) versus distal femoral replacement (DFR).

SETTING

Three major academic hospitals within one metropolitan area.

DESIGN

Retrospective.

PATIENTS/PARTICIPANTS

Three hundred seventy patients >64 years old with periprosthetic distal femur fractures were identified and 115 were included (65 ORIF vs. 50 DFR).

INTERVENTION

ORIF with locked plating versus DFR.

MAIN OUTCOME MEASUREMENT

One-year mortality, ambulatory status at 1 year, reoperations, and hospital readmissions.

RESULTS

No differences were observed between ORIF and DFR cohorts regarding demographics or medical history, including Charleston Comorbidity Index. DFR was associated with longer hospital stay (6.09 days ORIF vs. 9.08 days DFR, P < 0.001) and more frequent blood transfusion (12.3% ORIF vs. 44.0% DFR, P < 0.001). Logistic regression analysis using propensity score matching (PSM) demonstrated no statistically significant difference in reoperation, hospital readmission, ambulatory status at 1 year, or 1-year mortality between the 2 cohorts. Finally, applying Bayesian model averaging using PSM to identify risk factors for 1-year mortality demonstrated that increasing age, length of index hospital stay, and 90-day hospital readmission were significantly associated with 1-year mortality, regardless of type of surgical treatment.

CONCLUSION

Rehospitalization, reoperation, ambulatory status, and 1-year mortality are no different between ORIF and DFR in the treatment of geriatric periprosthetic distal femur fractures when PSM is applied to mitigate selection bias. Further study is warranted to elucidate functional outcomes, long-term sequelae, and costs of care related to these treatment options to better guide treatment planning.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Management of Distal Femur Fractures: Replacement Versus Surgical Fixation Versus Conservative Management

INTRODUCTION

Distal femur fractures are a frequently encountered injury, especially among the ageing population. Previous studies have identified that these fractures can be managed with a variety of methods and techniques which has led to an ongoing debate and investigation to decipher the optimal approach to manage these fractures.

AIM

The purpose of this study was to compare outcomes of patients managed with either distal femur replacements (DFRs), surgical fixation (SF) or conservative management. Outcomes measured included length of hospital stay, readmission rates, 30-day mortality and Oxford Knee Score.

METHODS

A retrospective review was conducted, of patients admitted with distal femur fractures between June 2020 and October 2022 at Huddersfield Royal Infirmary Hospital. Patients with both native and peri-prosthetic joints were included. All patient's medical data, including imaging and operative records, were reviewed.

RESULTS

A total of 42 patients were identified. There were six males and 36 females with a mean age of 78 years, a median age of 76 and a range of 35-102 years. Of these fractures, 15 were peri-prosthetic, and 27 were native joints. Of the patients, 30 had an SF, five had a DFR and the remaining seven were conservatively managed. Those managed with an SF had an average length of stay of 18 days, an Oxford score of 24 and two patients were readmitted within 30 days of discharge. For the DFR, the average length of stay was 16 days, an Oxford score of 22 and no patients were readmitted within 30 days. For the conservatively managed patients 21 days, an Oxford score of 25 and two patients were readmitted within 30 days of discharge. There was no 30-day mortality across all groups.

CONCLUSIONS

From our study, we can conclude that patients who managed with a DFR had the shortest length of stay in a hospital and the lowest readmission rates when compared to alternative management techniques. There was minimal difference found between the Oxford scores between all three groups. This study shows that DFR can be a safe and reliable strategy to manage distal femur fractures. Additional research is required to further compare the outcomes of these different methods of repair.

Megaprosthesis in Non-Oncologic Settings-A Systematic Review of the Literature

Modular megaprostheses (MPs) are commonly used after bone-tumor resection, but they can offer a limb salvage solution in massive bone defects. The aim of this systematic review of the Literature is to provide a comprehensive data collection concerning the use of MPs in non-oncologic cases, and to provide an overview of this topic, especially from an epidemiologic point of view. Three different databases (PubMed, Scopus, and Web of Science) were searched for relevant articles, and further references were obtained by cross-referencing. Sixty-nine studies met the inclusion criteria, reporting on cases of MP in non-oncologic cases. A total of 2598 MPs were retrieved. Among these, 1353 (52.1%) were distal femur MPs, 941 (36.2%) were proximal femur MPs, 29 (1.4%) were proximal tibia MPs and 259 (10.0%) were total femur MPs. Megaprostheses were most commonly used to treat periprosthetic fractures (1158 cases, 44.6%), in particular in the distal femur (859, 74.2%). Overall, complications were observed in 513 cases (19.7%). Type I (soft tissue failures) and type IV (infection) according to the Henderson classification were the most frequent (158 and 213, respectively). In conclusion, patients with severe post-traumatic deformities and/or significant bone loss who have had previous septic complications should be considered as oncologic patients, not because of the disease, but because of the limited therapeutic options available. The benefits of this treatment include relatively short operative times and immediate weight-bearing, thus making MP particularly attractive in the lower limb.

Optimal surgical treatment for periprosthetic distal femoral fractures after total knee arthroplasty: a Bayesian-based network analysis

BACKGROUND

The surgical methods for periprosthetic distal femoral fractures (PDFFs) after total knee arthroplasty included locking compression plate (LCP), retrograde intramedullary nailing (RIMN), and distal femoral replacement (DFR). However, the optimal treatment remains controversial. We performed a network meta-analysis (NMA) to provide the optimal surgical method for PDFFs.

MATERIALS AND METHODS

Electronic databases, including Embase, Web of Science, Cochrane Library, and PubMed, were searched for studies that compared LCP, RIMN, and DFR for PDFFs. The quality of the included studies was assessed according to the Newcastle-Ottawa scale. Pairwise meta-analysis was performed by Review Manager version 5.4. The NMA was conducted in Aggregate Data Drug Information System software version 1.16.5. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for postoperative complications and reoperations.

RESULTS

A total of 19 studies and 1198 patients were included, of whom 733 for LCP, 282 for RIMN, and 183 for DFR. Pairwise meta-analysis comparing LCP to RIMN and LCP to DFR showed no significant difference in complications and reoperations except that RIMN had a higher risk of malunion comparing to LCP (OR 3.05; 95% CI 1.46-6.34; P = 0.003). No statistically significant effects were found in the NMA of overall complications, infection, and reoperation. However, results of rank probabilities showed that DFR ranked best in overall complications and reoperation, RIMN ranked best in infection but worst in reoperation, and LCP ranked worst in infection and middle in reoperation.

DISCUSSION

We found similar complication rate and reoperation rate between LCP, RIMN, and DFR. The results of rank probabilities favored DFR, and further studies with high-level evidence are expected to verify the optimal surgical method for PDFFs.

LEVEL OF EVIDENCE

Level II; network meta-analysis.

Distal Femoral Replacement versus Operative Fixation for Periprosthetic Distal Femur Fractures: A Systematic Review and Meta-Analysis

BACKGROUND

Open reduction and internal fixation (ORIF) and distal femoral replacement (DFR) have been utilized in the management of periprosthetic distal femur fractures. At present, much of the literature has been limited to small retrospective series. The purpose of the current investigation was to present the results of pooled data to determine the complication rates associated with ORIF and DFR.

METHODS

Publications from 2010 to 2020 describing 10 or more periprosthetic distal femur fractures treated with ORIF (ie, single plate, intramedullary nail, and dual fixation) or DFR were included, resulting in 32 publications and 1,258 fractures (977 ORIF and 281 DFR). Occurrence of surgical complications, reoperations, and medical complications were evaluated and compared.

RESULTS

The rate of surgical complications (ORIF versus DFR, 20.5 versus 14.9%, P = 1.0) and reoperations (12.9 versus 12.5%, P = 1.0) following DFR were similar. However, pooled analyses demonstrated that patients treated with DFR had a higher medical complication rate (ORIF versus DFR, 8.5 versus 23.1%, P = .0006).

CONCLUSION

ORIF and DFR for the treatment of periprosthetic distal femur fractures have similar surgical complication and reoperation profiles. While this review found an increased rate of medical complication following DFR, there are limitations in quality reporting in the literature, which should be considered when interpreting the study's findings. Failed ORIF can be salvaged with DFR, but the difficulty of this reoperation is dependent on the ORIF technique that was used. With future prospective studies, this review can help guide management of these fractures.

Biomechanical analysis of different fixation methods for Rorabeck II supracondylar femoral fractures after total knee arthroplasty

BACKGROUND

Locking plate (LP) and retrograde intramedullary nailing (RIMN) are widely used to fix Rorabeck II supracondylar femoral fractures after total knee arthroplasty (TKA). The biomechanical properties of the implant used for treatment influence its longevity. Therefore, we aimed to evaluate the biomechanical stability of different fixations using finite element analysis.

METHODS

Seven finite element models (FEMs) were established, including LP groups (short LP, long LP, and double LP), RIMN groups (short RIMN and long RIMN), and mixed groups (long LP with short RIMN and long LP with long RIMN). The stress of the implants around the fracture area was calculated to evaluate the biomechanical stability under loads.

RESULTS

Stress was mainly distributed around the fracture area in all models. The stress-shielding phenomenon was most evident in the short LP. The trend in maximum equivalent stress values of implants around the fracture area for the seven internal fixations was: short LP (324.63 MPa) > short RIMN (306.37 MPa) > long LP (275.06 MPa) > long RIMN (262.74 MPa) > double LP (203.19 MPa) > long LP with short RIMN (124.42 MPa) > long LP with long RIMN (112.41 MPa). We found that the double LP can better disperse the stress than a single LP, and a long LP with long RIMN can prevent stress concentration and make the stress distribution more uniform.

CONCLUSION

From the perspective of biomechanics, long LP with long RIMN can stabilize fractures and avoid stress concentration in Rorabeck II supracondylar femoral fractures after TKA.

Knee function, quality of life, pain, and living conditions after distal femoral resection knee arthroplasty for non-tumor indications

BACKGROUND

Distal femoral resection knee arthroplasty is a limb salvage procedure. The impact of distal femoral resection arthroplasty on patient function and health status is unknown. The aim of this study was to report knee function, quality of life, knee pain, and living conditions after distal femoral resection knee arthroplasty for non-tumor indications.

METHODS

Of 52 patients (52 knees) undergoing distal femoral resection knee arthroplasty in a single institution between 2012 and 2021, 22 were excluded as 3 patients had ≤90 days follow-up, 6 had died, and 13 declined or were unable to participate for unrelated reasons. Thus, 30 patients were included and interviewed by telephone in March 2021 (mean follow-up 3.5 years after surgery). Patient completed the Oxford Knee Score (0-48, 48 best), EQ-5D-5L, and the Copenhagen Knee ROM, and information on pain and living conditions was obtained.

RESULTS

The mean age was 67.9 years (SD 13.6), and 21 (70%) were female. Mean total Oxford Knee Score was 29.9 (SD 10.5), mean Copenhagen Knee ROM flexion was 116° (SD 21.6), and mean extension was - 2° (SD10.1). Mobility aids were used by 18 (60%) patients, i.e. a cane (30%), walker (26.7%) or wheelchair (3.3%). Mean EQ-5D_index score was 0.70 (SD 0.22) and mean EQ-5D VAS score was 55.4 (SD 23.9). Nine (30%) patients used paracetamol or NSAID and 2 (6.7%) used opioids for knee pain. Mean VAS knee pain score was 1.30 (SD 2.2) at rest and 2.8 (SD 3.1) when walking. Most (90%) patients lived in their own home, with only 3 patients in nursing homes. Two-thirds (66.7%) required no home care, 5 (16.6%) received home care 1-2 times over 2 weeks, and 5 (16.6%) every day.

CONCLUSION

Distal femoral resection knee arthroplasty appears to be a viable treatment option for non-tumor indications. Acceptable patient outcomes were achieved in terms of functional status and quality of life, especially considering treatment alternatives such as femoral amputation.

Distal Femoral Replacement for Fractures Allows for Early Mobilization with Low Complication Rates: A Multicenter Review

Periprosthetic fractures around a total knee arthroplasty (TKA), comminuted and intra-articular femur fractures, or fracture nonunions in osteoporotic bone represent technically challenging problems. This is particularly true when the fracture involves a loose femoral component or the pattern results in suboptimal fixation potential. These clinical indications often arise in an older and comorbid patient population in whom a principal goal of treatment includes allowing for early mobilization. Limited data indicate that arthroplasty via distal femoral replacement (DFR) is a reasonable alternative to open reduction and internal fixation, allowing for early ambulation with low complication rates. We performed a retrospective review of trauma and arthroplasty surgeries at three tertiary referral institutions. Adult patients treated for the above with a DFR were included. Patients with active infection, open and/or high-energy injuries and revisions unrelated to fracture were excluded. Patient demographics, treatment details, and outcomes were assessed. Between 2002 and 2017, 90 DFR's were performed for the above indications with a mean follow-up of 24 months. Postoperatively, 80 patients (88%) were allowed to weight bear as tolerated, and at final follow-up, 9 patients (10%) remained dependent on a wheelchair. The average arc of motion at final follow-up was 95 degrees. There were seven (8%) implant-related complications requiring secondary surgeries: two infections, one with associated component loosening; one fracture of the hinge mechanism and one femoral component failure in conjunction with a patellofemoral dislocation (both requiring revision); one case of patellofemoral arthrosis in a patient with an unresurfaced patella; one periprosthetic fracture with associated wound dehiscence; and one case of arthrofibrosis. In each of these cases, only modular components of the DFR were exchanged. All nonmodular components cemented into the femur or tibia were retained. DFR provides a viable reconstruction option in the treatment of acute distal femur fractures, periprosthetic femur fractures, and fracture nonunions. We noted that in an elderly patient population with high comorbidities, the complication and secondary surgery rates remained relatively low, while allowing for immediate weight bearing.

Short-term outcomes of periprosthetic compared to native distal femur fractures, a national database study

BACKGROUND

Distal femur fractures (DFFx) are highly morbid injuries with a complication rate comparable to hip fractures. Rising rates of total knee arthroplasty (TKA) have led to increasing rates of periprosthetic DFFx (pDFFx). We sought to determine how pDFFx complication rates differed from native DFFx (nDFFx).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used to identify patients who sustained pDFFx or nDFFx between 2012 and 2018. Patients were further stratified by operative treatment: open reduction internal fixation (ORIF) or distal femur replacement (DFR). Multivariate logistic regression was used to compare 30-day complication rates between pDFFx versus nDFFx and, among pDFFx patients, ORIF versus DFR or revision TKA (rTKA).

RESULTS

563 patients with pDFFx and 2259 patients with nDFFx were identified between 2012 and 2018. pDFFx patients had significantly lower rates of ORIF than nDFFx patients (36.4 vs 95.4%, p < 0.001). On multivariate analysis, pDFFx were associated with a higher rate of surgical site complications (OR 2.48, p = 0.009) compared to nDFFx. There were no differences in mortality, reoperations, major complications, rate of blood transfusion, venous thromboembolism and disposition. In patients with pDFFx, patients undergoing DFR/rTKA were more likely to be discharged home versus a rehab facility, compared to those undergoing ORIF (OR 2.62, p < 0.001).

CONCLUSIONS

In this first large registry study comparing pDFFx and nDFFx, we find similar outcomes between these groups in the first 30 days after surgery. Patients with pDFFx did have higher rates of surgical site complications, including infection and dehiscence. In pDFFx patients, those undergoing DFR were more likely to return home post-operatively.

Comparison of locking compression plate and distal femoral replacement for periprosthetic distal femoral fractures: a retrospective study

OBJECTIVE

To compare the clinical outcomes of locking compression plate (LCP) and distal femoral replacement (DFR) for periprosthetic distal femoral fractures (PDFFs) after total knee arthroplasty.

METHODS

This retrospective study identified patients with PDFFs in an institutional database between January 2012 and December 2021. Demographic data and clinical outcomes, including postoperative complications, reoperation, 1-year mortality, Knee Society Scores (KSS) and Knee Society Functional Score (KSFS) were analysed.

RESULTS

In total, 12 patients treated with LCP and six patients treated with DFR were included. There was no significant difference between the LCP and DFR groups in terms of postoperative complications (25.0% versus 33.3%, respectively), reoperation (8.3% versus 0.0%), respectively, 1-year mortality (8.3% versus 16.7%, respectively) or mean ± SD KSS (80.3 ± 8.3 versus 78.0 ± 2.5, respectively). However, the mean ± SD KSFS was significantly better for patients with LCP than for those with DFR (51.8 ± 12.5 versus 37.0 ± 6.7, respectively).

CONCLUSION

DFR provides similar clinical outcomes compared with LCP for PDFFs. Patients with advanced age may benefit from DFR to allow early weight bearing.

A comparison of distal femoral replacement versus fixation in treating periprosthetic supracondylar femur fractures: a systematic review and meta-analysis

BACKGROUND

The treatment of periprosthetic femur fractures around a total knee replacement remains a technical challenge for the orthopedic surgeon. Management options include non-operative treatment, plate fixation, intramedullary nailing and distal femur replacement (DFR), with few studies comparing fixation with DFR. This is an up-to-date meta-analysis in the literature to directly compare clinical outcomes between fixation and distal femoral replacement in the treatment of supracondylar periprosthetic femur fractures.

METHODS

A stratified literature search of the Medline, EMBASE and Cochrane databases was performed. All studies in English language were searched from inception to July 2022. The search was performed with the following MeSH terms: Periprosthetic fracture AND ORIF OR Internal Fixation AND Distal Femur Replacement. The search was conducted using a predesigned search strategy where all eligible literature was critically appraised for methodological quality using the Cochrane collaboration tool. We included Level I, II and III studies comparing fixation with DFR in the treatment of periprosthetic supracondylar femur fractures. Data from eligible studies were extracted by two authors (NP and AR) and a table created which included author, year, sample size, mean age, measured parameters, follow-up period, fracture classification, length of stay (days), mortality rate, revision rate and complication rate.

RESULTS

The extracted data were pooled for meta-analysis using RevMan® v5.3.5 software (Nordic Cochrane Centre, Copenhagen, Denmark) and forest plots constructed. A p value < 0.05 was considered statistically significant and confidence intervals (CI) set to 95%. A total of six studies were included in the meta-analysis (n = 406). 153 patients underwent distal femur replacement and 253 patients underwent fixation with a mean follow-up time of 71.4 months. The results of this analysis suggest no statistically significant difference in measured outcomes.

CONCLUSION

The results of this meta-analysis suggest no proven statistically significant difference between DFR and fixation in terms of length of hospital stay, mortality rate, revision rate and complication rate for the treatment of periprosthetic supracondylar femur fractures. Further prospective randomized research may help to define the specific indications for each treatment option which must include fracture configuration. Early functional outcome and cost-effectiveness have yet to be evaluated in the available literature.

Does distance from joint line influence complications after distal femur fractures in native and periprosthetic knees?

BACKGROUND

Distal femur fractures are projected to increase in incidence secondary to an aging population and growing utilization of total knee arthroplasty. Surgical management is the standard of care, but optimal treatment for far distal fractures is still unclear. Our study investigates if there are distal femur fractures too distal to be treated with lateral locked plating in periprosthetic fractures.

METHODS

One hundred and ten consecutive patients treated with locked plating for distal femur fractures around a total knee replacement were identified using CPT codes. Fractures were classified by length of the distal fracture segment and Su classification. Complications studied were nonunion, malunion, infection, further fracture related surgery, readmission within 90 days, and mortality within 1 year of surgery. Sixty six fractures met inclusion criteria of 180 days of follow-up or sustaining a complication prior to180 days.

RESULTS

The size of the distal fracture segment and Su classification did not correlate with increased complication rate in periprosthetic distal femur fractures.

CONCLUSIONS

There was no difference between complications following lateral locked plating of distal femur fractures based on the size of the distal fracture segment in periprosthetic fractures. Lateral locked plating is an effective treatment modality for these fractures regardless of how distal the fracture extends.

Distal femoral replacement or internal fixation for management of periprosthetic distal femur fractures: A systematic review

BACKGROUND

The number of periprosthetic fractures above a total knee arthroplasty continues to increase. These fractures are associated with a high risk of morbidity and mortality. Techniques for addressing these fractures include open reduction internal fixation (ORIF) and revision arthroplasty, including distal femoral replacement (DFR). The primary aim of this review is to compare mortality and reoperation rates between ORIF and DFR when used to treat periprosthetic distal femur fractures.

METHODS

A systematic review including MEDLINE, Embase and Cochrane Library databases was completed from inception to April 10, 2021. Studies including a comparator cohort were meta-analyzed.

RESULTS

Fourteen studies were identified for inclusion, of which, five had sufficient homogeneity for inclusion in a meta-analysis. 30-day and 2-year mortality was 4.1% and 14.6% in the DFR group. There was no statistically significant difference between ORIF and DFR (log Odds-Ratio (OR) = -0.14, 95 %CI: -0.77 to 0.50). The reoperation rate in the DFR group was 9.3% versus 14.8% for ORIF, with no difference between groups (log OR = 0.10, 95 %CI: -0.59 to 0.79). There was no difference in rates of deep infection (log OR = 0.22, 95 %CI: -0.83 to 1.28). Direct comparison of functional outcomes was not possible, though did not appear significant.

CONCLUSION

DFR in the setting of periprosthetic distal femur fractures is equivalent to ORIF with respect to mortality and reoperation rate and thus a safe and reliable treatment strategy. DFR may be more reliable in complex fracture patterns where the ability to obtain adequate fixation is difficult.

Practical approach to the native distal femur fractures in the elderly: A rapid review over the recent trends

Significant work has been done in recent years on treatment strategies for distal femur fractures. Inclusive reviews on periprosthetic fractures of distal femur have been carried out recently, but there is a lack of such reviews on the subject of native distal femur fractures in the recent literature. In this narrative review, we are set out to address the latest updates on geriatric non-periprosthetic distal femur fractures, and perform a rapid review over different treatment options, arriving at a summarized proposed treatment algorithm.

Distal Femoral Replacement for Periprosthetic Fractures After TKA: Australian Orthopaedic Association National Joint Replacement Registry Review

BACKGROUND

Distal femoral replacement (DFR) is a potential treatment option following periprosthetic fracture (PPF) of a total knee arthroplasty (TKA). However, there is limited literature regarding implant survivorship and complication rates. The aim of this study was to examine patient demographics and trends in usage, implant survivorship and modes of failure, and patient mortality following DFR for PPF captured by a national joint replacement registry.

METHODS

A retrospective registry review was performed using data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). In total, 306 DFR were performed for PPF of a known primary TKA. Eighty-five percent of patients were female, and the mean age was 76.4 years. Kaplan-Meier estimates of implant and patient survivorship were performed.

RESULTS

The number of DFR performed for PPF has doubled over the past five years. The cumulative percent second revision rate at six years was 12%. The most common indications for revision were infection (37%) and aseptic loosening (33%). Patient survivorship after DFR was 97% and 83% at five and ten years, respectively.

CONCLUSION

A national registry review has identified the increasing prevalence of DFR for PPF after primary TKA and demonstrated implant survivorship of 88% at midterm follow-up. Surgeons may consider DFR as an acceptable and durable treatment option.

LEVEL OF EVIDENCE

Level III - Case Series.

Clinical Outcomes Following Distal Femur Replacement for Periprosthetic Distal Femur Fractures: A Systematic Review and Meta-Analysis

BACKGROUND

Management of periprosthetic distal femur fractures (PDFFs) is often complicated by poor bone quality and limited bone stock making fixation attempts challenging and prone to failure. Distal femoral replacement (DFR) is being used to treat such injuries although outcome data are mostly from small case series. We sought to systematically review the literature on DFR for PDFF to summarize their outcomes.

METHODS

PubMed, MEDLINE (EBSCO), and Cochrane Central Database were searched to identify reports of PDFFs treated with DFR. Articles reporting on 5 or more knees were systematically reviewed for clinical function, complications, and mortality. Random effects meta-analysis was used to create summary estimates and publication bias also assessed.

RESULTS

Of 287 identified and screened articles, 15 were included, 14 retrospective, reporting on 352 knees. Following DFR, 87% (95% confidence interval [CI] 71-95) of patients were able to ambulate. The mean postoperative Knee Society Score was 80 (95% CI 77-84). The risk of periprosthetic joint infection was 4.3% (95% CI 2.2-8.2). One-year postoperative mortality rate was 10% (95% CI 6-18). There was some evidence of publication bias with a trend toward smaller studies reporting lower infection risk and mortality.

CONCLUSION

DFR for PDFFs is associated with high functional outcomes and a relatively modest risk of infection. The periprosthetic joint infection and 1-year mortality rates reported here should be considered lower bounds estimates due to publication bias and loss to follow-up. Further investigation of long-term outcomes following DFR for PDFFs is warranted though short-term functional outcomes are promising.

Patient safety in distal femoral resection knee arthroplasty for non-tumor indications: a single-center consecutive cohort study of 45 patients

BACKGROUND

Distal femoral resection knee arthroplasty may be a viable option for several indications other than bone tumors. Resection knee arthroplasty appears to be becoming more common, but patients requiring this type of surgery are often elderly and with high comorbidity. The aim of this study was to report in-hospital complications, readmissions, reoperations, and mortality after distal femoral resection knee arthroplasty for non-tumor indications.

METHODS

We retrospectively identified a consecutive cohort of 45 knees (45 patients) treated with distal femoral resection knee arthroplasty in a single institution between 2012 and 2021. Indications for surgery were failure of osteosynthesis (8), primary fracture treatment (2), periprosthetic fracture (22), and revision arthroplasty with severe bone loss (13). A major reoperation was defined as a major component exchange procedure or amputation. Mean follow-up was 3.9 years.

RESULTS

The mean age was 71.3 years (SD 12.3), and 64.4% were female; 8.9% were ASA I, 40% ASA II, and 51% ASA III. Median length of stay was 7 days (range 3-19) with no major in-hospital complications, but 55.6% (n = 25) required blood transfusion. The 90-day readmission rate was 17.8% (n = 8), of which 50% was prosthesis-related. Four patients (8.9%) underwent major reoperation due to infection (n = 2), mechanical failure (n = 1), or periprosthetic fracture (n = 1). The mortality rate was 0% ≤ 90 days and 2.2% ≤1 year.

CONCLUSIONS

Distal femoral resection knee arthroplasty in this fragile patient population appears to be a viable and safe option considering that it is a limp salvage procedure most cases.

Cost-effectiveness of fixation versus arthroplasty for geriatric distal femur fractures

INTRODUCTION

Geriatric distal femur fractures are challenging to treat. The high mortality rate associated with a loss of mobility in this population has led some authors to compare distal femur fractures to femoral neck fractures with respect to the importance of rapidly regaining mobility in the geriatric population. Acute distal femur replacement has been advocated by some as a preferred treatment over internal fixation because arthroplasty may facilitate a more rapid return to a patient's baseline mobility level. The purpose of this study was to systematically review the literature on the costs and outcomes of fixation and arthroplasty in the geriatric distal femur fracture population and to employ decision modeling techniques to generate evidence-based treatment recommendations.

METHODS

A systematic literature review of clinical studies published since 2000 was conducted to synthesize the available data on outcomes, reoperation rates, and mortality rates after fixation or arthroplasty for distal femur fractures in patients with an average age greater than 70 years. A Markov decision analysis model was created. Costs, health state utilities, reoperation rates, and mortality rates were derived from the systematic literature review and publicly available data. The model was analyzed via probabilistic statistical analysis as well as sensitivity analyses with a willingness-to-pay threshold set at $100,000 per QALY and a 5-year time horizon.

RESULTS

From a US societal perspective, fixation was associated with a greater quality of life benefit (2.44 QALYs vs. 2.34 QALYs) and lower cost ($25,556 vs. $65,536) compared with distal femur replacement for geriatric distal femur fractures. Probabilistic analysis demonstrated that 82 in 100 model outcomes favored fixation over arthroplasty and 18 in 100 model outcomes favored distal femur replacement. Sensitivity analyses demonstrated that this result was robust to small deviations in the cost and functional outcome variables in the model.

CONCLUSION

Compared to distal femur replacement, ORIF is likely to be a more cost-effective treatment for distal femur fractures in the geriatric patient population, though this recommendation is tempered by the relatively low quality of evidence available on the comparative functional outcomes of these treatments.

To Fix or Revise: Differences in Periprosthetic Distal Femur Fracture Management Between Trauma and Arthroplasty Surgeons

INTRODUCTION

This study sought to determine the effect of trauma fellowship training on the surgical decision to fix or revise to distal femoral replacement in periprosthetic distal femur fractures.

METHODS

An anonymous online survey including nine cases of geriatric periprosthetic distal femur fractures was distributed through the Orthopaedic Trauma Association website. Respondents were asked whether they would recommend fixation or revision to distal femoral replacement. Fractures were classified by the location relative to the anterior flange (proximal or distal) and the presence or absence of comminution. Recommendations were compared between type of fellowship completed (trauma, arthroplasty, or both), practice setting, and number of periprosthetic distal femur fractures treated monthly.

RESULTS

One hundred fifty-one surgeon survey responses were included. Completion of a trauma fellowship was associated with a higher likelihood of recommending fixation for any periprosthetic distal femur fracture compared with arthroplasty training (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.97 to 3.29; P < 0.0001). Disagreement was significant for comminuted proximal (OR 6.90, 95% CI 3.24 to 14.68; P < 0.0001), simple distal (OR 20.90, 95% CI 6.41 to 67.71; P < 0.001), and comminuted distal fractures (OR 2.47, 95% CI 1.66 to 3.68; P < 0.0001). Dual fellowship-trained surgeons were less likely to recommend fixation than surgeons who completed a trauma fellowship alone (OR 0.60, 95% CI 0.39 to 0.93; P = 0.027) and more likely to recommend fixation than surgeons who completed an arthroplasty fellowship alone (OR 1.70, 95% CI 1.13 to 2.63; P = 0.012). Surgeons who treat three or more periprosthetic distal femur fractures monthly showed a significant preference for fracture fixation compared with lower volume surgeons (OR 2.45, 95% CI 1.62 to 3.68; P < 0.0001).

DISCUSSION

Fellowship-trained trauma surgeons show a notable preference for fracture fixation over distal femoral replacement for periprosthetic distal femur fractures, as compared with arthroplasty-trained surgeons. Additional research is needed to clarify surgical indications that maximize outcomes for these injuries.

Distal Femur Replacement Versus Open Reduction and Internal Fixation for Treatment of Periprosthetic Distal Femur Fractures: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare complications and functional outcomes of treatment with primary distal femoral replacement (DFR) versus open reduction and internal fixation (ORIF).

DATA SOURCES

PubMed, Embase, and Cochrane databases were searched for English language studies up to May 19, 2020, identifying 913 studies.

STUDY SELECTION

Studies that assessed complications of periprosthetic distal femur fractures with primary DFR or ORIF were included. Studies with sample size ≤5, mean age <55, nontraumatic indications for DFR, ORIF with nonlocking plates, native distal femoral fractures, or revision surgeries were excluded. Selection adhered to the PRISMA criteria.

DATA EXTRACTION

Study quality was assessed using previously reported criteria. There were 40 Level IV studies, 17 Level III studies, and 1 Level II study.

DATA SYNTHESIS

Fifty-eight studies with 1484 patients were included in the meta-analysis. Complications assessed {incidence rate ratio [IRR] [95% confidence interval (CI)]: 0.78 [0.59-1.03]} and reoperation or revision [IRR (95% CI): 0.71 (0.49-1.04)] were similar between the DFR and ORIF cohorts. The mean knee range of motion was greater in the ORIF cohort (DFR: 90.47 vs. ORIF: 100.36, P < 0.05). The mean Knee Society Score (KSS) (DFR: 79.41 vs. ORIF: 82.07, P = 0.35) and return to preoperative ambulatory status were similar [IRR (95% CI): 0.82 (0.48-1.41)].

CONCLUSIONS

In comparing complications among patients treated for periprosthetic distal femur fracture with DFR or ORIF, there was no difference between the groups. There were also no differences in functional outcomes, although knee range of motion was greater in the ORIF group. This systematic review and meta-analysis highlights the need for future prospective trials evaluating the outcomes of these divergent treatment strategies.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Distal Femoral Replacement as a Primary Treatment Method for Distal Femoral Fractures in the Elderly

Distal femoral fractures account for 3-6% of all femoral fractures with a similar demographic as patients suffering from proximal femoral fractures. The mortality risk can be high in such injuries, which has prompted NHS England to extend the scope of the Best Practice Tariff to include all fragility fractures of the femur. Poor bone quality, intra-articular extension, and significant comminution can make these fractures difficult to manage with fixation techniques, while early mobilisation is a key outcome in the treatment of this injury. In this study, a comprehensive literature search was performed based on keywords, and abstracts were reviewed to identify relevant articles. The following factors were analysed: time to surgery, time to full weight-bearing, the average hospital stay, post-operative mobility status, and complications. A total of 233 abstracts were identified using the pre-determined search criteria, and, subsequently, articles were excluded following author review. A total of 10 relevant articles were included in this review, with five used for review and comparison between distal femoral replacement (DFR) and fixation. This resulted in a sample of 200 patients treated with DFR with over 87% ambulatory at follow-up and a re-operation rate of 13.3% compared to 78% and 13.5%, respectively, in those treated with open reduction internal fixation (ORIF) procedure. Despite a limited pool of evidence, the literature suggests that DFR offers an option that potentially allows immediate weight-bearing and leaves most patients ambulatory at follow-up. Although DFR is more costly than other operative techniques, it avoids complications associated with fixation such as non-union and can reduce the risk of further surgery through direct complications or a need for delayed arthroplasty, which is deemed more complex secondary to fixation. Early mobilisation is a key step in reducing morbidity and mortality among this cohort of patients, and a procedure such as DFR should be more widely considered to help achieve this outcome.

Revision rate is higher in patients with periprosthetic femur fractures following revision arthroplasty in comparison with ORIF following our algorithm: a two-center 1 analysis of 129 patients

Purpose

Effective therapy of periprosthetic femur fractures of the hip (PPF) are challenging due to patients’ frailty and complexity of fracture patterns. The aim of this cohort study was to analyze the radiological and functional outcome following PPF.

Methods

A retrospective, multicenter study in the period 2009–2019 of patients with PPF at two level I trauma centers in Germany was performed. PPF were classified according to the Vancouver classification system. Demographic data, American Society of Anesthesiologists (ASA) classification, type of surgery, complications, and reoperation rate were obtained from patient records. The functional outcome was assessed by the modified Harris-Hip Score (mHHS), general health using the EQ-5D, and radiological outcome by Beals & Tower (B&T) criteria.

Results

A total of 129 patients with a mean age of 79 years (range 43–102) were included. 70% of all patients were female and 68% of the patients had an ASA score ≥ 3. 20 patients suffered from a Vancouver A, 90 from a Vancouver B and 19 from a Vancouver C fracture. 14% of the patients died within the first 2 years after surgery. The reoperation rate after open reduction and internal fixation (ORIF) (n = 60) was 8% and after revision arthroplasty (RA) (n = 47) 30% (OR 3.4, 95% CI [1.21–10.2]). Mean mHHS (n = 32) was 53 ± 19.4 and EQ-VAS was 50 ± 24.6. According to B&T criteria, 82% of patients treated with ORIF (n = 17) and 62% after RA (n = 13) showed an excellent outcome.

Conclusion

Patients with a PPF of the hip are elderly and at increased operative risk. In cases with a stable prosthesis, ORIF provides good radiological outcome with low reoperation rates. In case of RA, the risk for revision surgery is higher.

Very Distal Femoral Periprosthetic Fractures: Replacement Versus Fixation: A Systematic Review

OBJECTIVES

To synthesize all-cause reoperations and complications data as well as secondary clinical and functional outcomes, after the management of very distal femur periprosthetic fractures (vDFPFs) in a geriatric patient population with either a distal femoral locking plate (DFLP) or distal femoral replacement (DFR).

DATA SOURCES

MEDLINE, Embase, and Web of Science were searched for English language articles from inception to March 16, 2020, in accordance to the PRISMA guidelines.

STUDY SELECTION

Studies reporting the management of vDFPFs in adults older than 65 years with either a DFLP or DFR were included. To ensure this review solely focused on very distal femoral periprosthetic fractures, only fractures of the following classifications were included: (1) Lewis and Rorabeck type II or III, (2) Su and Associates' Classification of Supracondylar Fractures of the Distal Femur type III, (3) Backstein et al type F2, and/or (4) Kim et al type II or III.

DATA EXTRACTION

Three reviewers independently extracted data from the included studies. Study validity was assessed using the methodological index for nonrandomized studies (MINORS), a quality assessment tool for nonrandomized controlled studies in surgery.

DATA SYNTHESIS

Twenty-five studies with 649 vDFPFs were included for analysis. There were 440 knees in the DFLP group (mean age range: 65.9-88.3 years) and 209 knees in the DFR group (mean age range: 71.0-84.8 years). Because of the literature's heterogeneity, the data were qualitatively synthesized.

CONCLUSIONS

vDFPFs in the elderly treated with DFR underwent fewer reoperations relative to DFLP (0%-45% vs. 0%-77%, respectively). Time to weight-bearing was observably shorter in DFR studies relative to DFLP studies. Functional outcomes and postoperative range of motion indicated a trend for DFLP knees to outperform DFR knees. Future research should include prospective studies and cost-effectiveness evaluations to better understand the utility of DFR for these fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Contemporary Distal Femoral Replacements for Supracondylar Femoral Fractures Around Primary and Revision Total Knee Arthroplasties

BACKGROUND

There is a paucity of data on the outcomes of distal femoral replacements (DFRs) in patients with total knee arthroplasty (TKA) periprosthetic fractures. We sought to characterize these patients' survivorship free from rerevision.

METHODS

We retrospectively identified 49 patients, including 34 after primary TKA (primary cohort), 9 after revision TKA, and 6 conversions for failed open reduction and internal fixation (revision cohort) that underwent DFR for a periprosthetic femur fracture. The mean age was 76 years, and 40 patients (82%) were female. The mean follow-up was 4 years. Femoral fixation included 44 cemented stems (90%) and 5 cementless stems (10%). Survivorship free from rerevision was characterized by the Kaplan-Meier method; cox proportional regression was used to analyze the risk factors for rerevision.

RESULTS

Survivorship free from any rerevision at 5 years in the primary and revision cohort was 93% and 18%, respectively. The revision cohort had a 5.3× higher risk of re-revision (P = .008). Survivorship free from re-revision for aseptic loosening at 5 years in the primary and revision cohort was 93% and 53%, respectively. Two of the 3 patients with cementless stems in the primary cohort underwent early rerevision for aseptic loosening, but patients with prior primary TKAs treated with cemented femoral fixation (n = 31) had a 97% 5-year survivorship free from re-revision.

CONCLUSION

Patients with periprosthetic fractures around prior primary TKAs treated with DFRs with cemented femoral fixation had a 97% 5-year survivorship free from any re-revision. DFRs for periprosthetic femur fractures around revision TKAs or conversions of failed open reduction and internal fixations have a 5× increased risk of rerevision.

Clinical Outcome After Replacement of Distal Femur/Proximal Tibia in a Heterogeneous Patient Cohort: Function Following Tumour, Trauma, and Loosening

BACKGROUND

Distal femur and proximal tibia replacements as limb-salvage procedures with good outcome parameters for patients with tumours have been broadly described. However, the overall midterm outcome in a mixed, heterogeneous patient collective is still unclear.

PATIENTS AND METHODS

We retrospectively analysed 59 consecutive patients (33 for primary and 26 for revision surgery) between 1998 and 2017. Indication for implantation was tumour (n=16), periprosthetic fracture (n=14), traumatic fracture (n=14), infection (n=10), aseptic loosening (n=3), and pathological fracture (n=2). The mean follow-up duration was 3 years. Clinical functions were evaluated by Toronto Extremity Salvage Score and Knee Society Score. Knee extension and flexion force were measured.

RESULTS

The overall survival rate of arthroplasties was 59% (n=35). Major complications were observed in 36 (61%) patients. During the follow-up period, 14 (24%) patients died. We recorded periprosthetic joint infection in 21 (36%) patients, recurrence of tumour in two (3%), and aseptic implant failure in three (5%). The mean Toronto Extremity Salvage Score was 66±33, and the mean Knee Society Score was 49±30. The mean extension force on the operated side was significantly reduced at 60° and 180° compared to the healthy side (p=0.0151 and p=0.0411, respectively).

CONCLUSION

Distal femur and proximal tibia replacements showed limited clinical function in a heterogeneous patient collective. Indication for implantation should be considered carefully.

Immediate weight-bearing is safe following lateral locked plate fixation of periprosthetic distal femoral fractures

PURPOSE

This study aimed to determine whether unrestricted weight-bearing as tolerated (WBAT) following lateral locking plate (LLP) fixation of periprosthetic distal femoral fractures (PDFFs) is associated with increased failure and reoperation, compared with restricted weight-bearing (RWB).

MATERIALS AND METHODS

In a retrospective cohort study of consecutive patients with unilateral PDFFs undergoing LLP fixation, patients prescribed WBAT were compared with those prescribed 6 weeks of RWB. The primary outcome measure was reoperation. Kaplan-Meier and Cox multivariable analyses were performed.

RESULTS

There were 43 patients (mean age 80.9 ± 11.7 years, body mass index 26.8 ± 5.7 kg/m² and 86.0% female): 28 WBAT and 15 RWB. There were more interprosthetic fractures in the RWB group (p = 0.040). Mean follow-up was 3.8 years (range 1.0-10.4). Eight patients (18.6%) underwent reoperation. Kaplan-Meier analysis demonstrated no difference in 2-year survival between WBAT (80.6%, 95% CI 65.3-95.9) and RWB (83.3%, 95% CI 62.1-100.0; p = 0.54). Cox analysis showed increased reoperation risk with medial comminution (hazard ratio 10.7, 95% CI 1.5-80; p = 0.020) and decreased risk with anatomic reduction (hazard ratio 0.11, 95% CI 0.01-1.0; p = 0.046). Immediate weight-bearing did not significantly affect the risk of reoperation compared with RWB (relative risk 1.03, 95% CI 0.61-1.74; p = 0.91).

CONCLUSIONS

LLP fixation failure was associated with medial comminution and non-anatomic reductions, not with postoperative weight-bearing. Medial comminution should be managed with additional fixation. Weight-bearing restrictions additional to this appear unnecessary and should be avoided.

Review of patient-reported outcomes in periprosthetic distal femur fractures after total knee arthroplasty: a plate or intramedullary nail?

Purpose

This study reviewed the literature regarding the patient-reported treatment outcomes of using either open reduction and internal fixation (ORIF) with a plate and screw system or intramedullary nail (IMN) fixation for periprosthetic distal femur fractures around a total knee arthroplasty.

Methods

A total of 13 studies published in the last 20 years met the inclusion criteria. The studies included 347 patients who were allocated to ORIF (n = 249) and IMN (n = 98) groups according to the implants used. The primary outcome measures were the Knee Society Score or the Western Ontario and McMaster Universities osteoarthritis index. The secondary outcome measures included knee range of motion and the rates of complications, including non-union, malunion, infection, revision total knee arthroplasty, and reoperation. Statistical significance was set at P < 0.05.

Results

The mean Knee Society Scores of ORIF and IMN groups were 83 and 84, respectively; the mean postoperative range of motion of the knee were 99° and 100°, respectively (P < 0.05); the non-union rates were 9.4 and 3.8%, respectively (P > 0.05); the malunion rates were 1.8 and 7.5%, respectively (P < 0.05); surgical site infection rates were 2 and 1.3%, respectively (P > 0.05); the reoperation rates were 9.6 and 5.1%, respectively (P > 0.05); and revision rates of total knee arthroplasty were 2 and 1%, respectively (P > 0.05).

Conclusion

Based on the patient-reported outcome assessments, both ORIF with a plate and screw system and IMN fixation are well-accepted techniques for periprosthetic distal femur fractures around a TKA, and they produce similar functional outcomes.

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.

Early Surgery Does Not Improve Outcomes for Patients with Periprosthetic Femoral Fractures-Results from the Registry for Geriatric Trauma of the German Trauma Society

Background and Objectives: Appropriate timing of surgery for periprosthetic femoral fractures (PFFs) in geriatric patients remains unclear. Data from a large international geriatric trauma register were analyzed to examine the outcome of patients with PFF with respect to the timing of surgical stabilization. Materials and Methods: The Registry for Geriatric Trauma of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie (DGU)) (ATR-DGU) was analyzed. Patients treated surgically for PFF were included in this analysis. As outcome parameters, in-house mortality rate and mortality at the 120-day follow-up as well as mobility, the EQ5D index score and reoperation rate were analyzed in relation to early (<48 h) or delayed (≥48 h) surgical stabilization. Results: A total of 1178 datasets met the inclusion criteria; 665 fractures were treated with osteosynthesis (56.4%), and 513 fractures were treated by implant change (43.5%). In contrast to the osteosynthesis group, the group with implant changes underwent delayed surgical treatment more often. Multivariate logistic regression analysis of mortality rate (p = 0.310), walking ability (p = 0.239) and EQ5D index after seven days (p = 0.812) revealed no significant differences between early (<48 h) and delayed (≥48 h) surgical stabilization. These items remained insignificant at the follow-up as well. However, the odds of requiring a reoperation within 120 days were significantly higher for delayed surgical treatment (OR: 1.86; p = 0.003). Conclusions: Early surgical treatment did not lead to decreased mortality rates in the acute phase or in the midterm. Except for the rate of reoperation, all other outcome parameters remained unaffected. Nevertheless, for most patients, early surgical treatment should be the goal, so as to achieve early mobilization and avoid secondary nonsurgical complications. If early stabilization is not possible, it can be assumed that orthogeriatric co-management will help protect these patients from further harm.

Modular megaprostheses in the treatment of periprosthetic fractures of the femur

Background

Periprosthetic fractures (PPF) of the femur remain challenging, especially in patients with previous multiple revisions. Modular megaprostheses (mMPs) are rarely used in this indication; however, in some cases mMPs seem to be the last chance for limb salvage. We aimed to evaluate the clinical outcome of PPFs of the femur treated by modular mMPs at our institution.

Patients and methods

In this study 33 patients (27 female; mean age 79 years) with a PPF after total hip or total knee arthroplasty (no tumor indications) were treated using modular proximal (mPFR; n = 12), distal (mDFR; n = 14) or total (mTFR; n = 7) femur replacement. A retrospective evaluation regarding mortality and revision rates was performed. Failures with need for revision were classified.

Results

At a mean follow up of 60 months (range 0–178 months), the total mortality rate as well as total revision rate were both found to be 39%. At 1 year follow-up the mortality rate was highest within the mDFR group, and less revisions were necessary in the mPFR group, however both findings were not significantly. Those patients, who had revision surgery before PPF, were found to have higher revision rate after implantation of mMP. In the mPFR group, dislocation was the most frequent failure, within the mDFR and the mTFR group infection. In one case amputation of the lower limb was necessary.

Conclusion

mMPs represent a valuable option in PPFs of the femur. Infection and dislocation remain the most frequent complications. Prospective clinical studies are required to further define the outcome of mMPs in PPFs of the femur.

Management of low periprosthetic distal femoral fractures

AIMS

Debate continues regarding the optimum management of periprosthetic distal femoral fractures (PDFFs). This study aims to determine which operative treatment is associated with the lowest perioperative morbidity and mortality when treating low (Su type II and III) PDFFs comparing lateral locking plate fixation (LLP-ORIF) or distal femoral arthroplasty (DFA).

METHODS

This was a retrospective cohort study of 60 consecutive unilateral (PDFFs) of Su types II (40/60) and III (20/60) in patients aged ≥ 60 years: 33 underwent LLP-ORIF (mean age 81.3 years (SD 10.5), BMI 26.7 (SD 5.5); 29/33 female); and 27 underwent DFA (mean age 78.8 years (SD 8.3); BMI 26.7 (SD 6.6); 19/27 female). The primary outcome measure was reoperation. Secondary outcomes included perioperative complications, calculated blood loss, transfusion requirements, functional mobility status, length of acute hospital stay, discharge destination and mortality. Kaplan-Meier survival analysis was performed. Cox multivariate regression analysis was performed to identify risk factors for reoperation after LLP-ORIF.

RESULTS

Follow-up was at mean 3.8 years (1.0 to 10.4). One-year mortality was 13% (8/60). Reoperation was more common following LLP-ORIF: 7/33 versus 0/27 (p = 0.008). Five-year survival for reoperation was significantly better following DFA; 100% compared to 70.8% (95% confidence interval (CI) 51.8% to 89.8%, p = 0.006). There was no difference for the endpoint mechanical failure (including radiological loosening); ORIF 74.5% (56.3 to 92.7), and DFA 78.2% (52.3 to 100, p = 0.182). Reoperation following LLP-ORIF was independently associated with medial comminution; hazard ratio (HR) 10.7 (1.45 to 79.5, p = 0.020). Anatomical reduction was protective against reoperation; HR 0.11 (0.013 to 0.96, p = 0.046). When inadequately fixed fractures were excluded, there was no difference in five-year survival for either reoperation (p = 0.156) or mechanical failure (p = 0.453).

CONCLUSION

Absolute reoperation rates are higher following LLP fixation of low PDFFs compared to DFA. Where LLP-ORIF was well performed with augmentation of medial comminution, there was no difference in survival compared to DFA. Though necessary in very low fractures, DFA should be used with caution in patients with greater life expectancies due to the risk of longer term aseptic loosening. Cite this article: Bone Joint J 2021;103-B(4):635-643.

Functional outcome after lower limb periprosthetic fractures

INTRODUCTION

Periprosthetic fractures (PPFx) occur more and more often following joint replacement. The aim of this study was to investigate the functional outcome of patients treated with lower limb periprosthetic fractures in our institution.

METHODS

Between 2007 and 2016 75 patients were managed with 13 intraoperative and 62 postoperative fractures. Fifty-nine fractures occurred around THR and 16 around TKR. Fractures were classified according to Unified Classification System (UCS) and the treatment was according to this algorithm. Functional outcome was assessed with the Harris Hip Scores and the Knee Society Score (KSS).

RESULTS

Follow up time was 52.9 months (range 12-100 m.). The mean age of patients was 75.1 years (range 54-87 years), there were 6 males and 69 females. Harris Hip Scores were available for 42 patients and the average score was 82 (range 68-96). The KSS was available in nine patients and the average score was 124 (range 102-141). Eventually, radiographic union was observed in all cases.

CONCLUSION

In this series of patients, fixation of lower limb periprosthetic fractures was found to be associated with good results despite the different fracture patterns studied. Larger studies with subgroup analysis of different fracture patterns are desirable to throw more light in this complex group of patients.

Does early surgery improve outcomes for periprosthetic fractures of the hip and knee? A systematic review and meta-analysis

INTRODUCTION

Previous evidence has established that early surgery is beneficial to improve outcomes for individuals with native hip fractures in the elderly population. Patients who sustain a periprosthetic fracture have been demonstrated to have similar demographics and outcomes as those with native fractures around the hip and knee. We therefore set out to determine if there is a similar difference in perioperative outcomes between early and delayed surgery for periprosthetic fractures of the hip and knee through a systematic review and meta-analysis.

METHODS

Literature search outputs were screened for studies meeting the inclusion criteria. The groups of early surgery and delayed surgery were defined by study authors. The primary outcome measure was 30 day mortality. Where there was sufficient study homogeneity, a random-effects meta-analysis was performed. Individual study risk of bias was assessed using the ROBINS-I criteria, with the GRADE criteria used for independent outcome evaluation. The review protocol was registered on PROSPERO prior to commencement (Registration number CRD42019149360).

RESULTS

The inclusion criteria was met in 11 studies (n = 3006). Mean time to surgery from admission for reporting studies was 64 h. 59.6% patients underwent early surgery as defined by the study authors. We identified a significantly lower risk of 30 day mortality for those with early surgery versus delayed surgery (RR 0.21; 95% CI 0.05, 0.90; p = 0.04, n = 2022). There were also significantly better outcomes for early versus delayed surgery regarding: medical complications, length of stay, transfusion risk, and reoperation. The quality of evidence for all the individual outcomes was low or very low.

CONCLUSIONS

There is evidence that delaying surgery in those with periprosthetic fractures of the hip and knee has a deleterious impact on mortality and other important patient outcomes. There are, however, notable limitations to the existing available literature, with further appropriately designed large-scale studies required to confirm these findings.

[Locking plate fixation of distal periprosthetic femoral fractures : Clinical outcome and mortality]

Hintergrund

Die Versorgung distaler periprothetischer Femurfrakturen (PFF) stellt aufgrund des geriatrischen Patientenkollektivs eine große interdisziplinäre Herausforderung dar und erfolgt (abhängig vom Frakturtyp) häufig mittels winkelstabiler Plattenosteosynthese (WPO), wobei bisher nur wenige Daten zum klinischen Outcome existieren. Ziel der Untersuchung ist die Identifikation von Risikofaktoren für ein schlechtes Outcome und erhöhte Mortalität.

Methoden

In dieser retrospektiven Studie wurden 36 Fälle mit distaler PFF untersucht. Eingeschlossen wurden nur Versorgungen mit WPO. Neben relevanten Vorerkrankungen (ASA-Score, Charlson Index), der Frakturmorphologie und relevante Komplikationen, wurden u.a. die 1- und 3-Jahres-Mortalität, sowie das klinische Outcome mit Hilfe des Lysholm-Scores erfasst.

Ergebnisse

Die 1- und 3- Jahres Mortalität betrug 9% bzw. 26%, wobei dies ausschließlich ASA 3 und 4 Patienten betraf. Der Lysholm Score zeigte eine hohe Variabilität (65 ± 27 Punkte) mit höheren Werten in der ASA 1-2 Subgruppe (82 vs. 63 Punkte) aber unabhängig vom Frakturtyp. Als Risikofaktoren für die 3-Jahres Mortalität konnten der präoperative ASA-Score, der Charlson Komorbiditätsindex und das Patientenalter identifiziert werden.

Diskussion

Die dargestellte Fallserie weist eine hohe absolute Mortalitätsrate auf, auch wenn diese im Vergleich zu bisher publizierten Daten, etwas geringer war. Die Rate an Sekundärdislokationen, fehlender Frakturheilung oder Folgeoperationen war ebenfalls gering. Die WPO erscheint daher als geeignete Versorgung für Frakturen mit stabiler Prothese. Jedoch besteht eine hohe Variabilität im klinischen Outcome unabhängig vom Frakturtyp, sowie signifikant erhöhte Mortalitätsraten bei vorerkrankten Patienten.

Biomechanical evaluation of the docking nail concept in periprosthetic fracture fixation around a stemmed total knee arthroplasty

Intramedullary femoral nails provide an ideal mechanical axis for periprosthetic fracture fixation. Slotted nails allow a connection to a total knee arthroplasty (TKA) stem. This study aims to compare implant and construct stiffness, interfragmentary movement and cycles to failure between an antegrade slotted femoral nail construct docked to a TKA stem and a distal femoral locking plate in a human periprosthetic femoral fracture model. In eight pairs of fresh-frozen human femora with stalked TKA, a 10 mm transverse osteotomy gap was set simulating a Rorabeck type II, Su type I fracture. The femora were pairwise instrumented with either an antegrade slotted nail coupled to the prosthesis stem, or a locking plate. Cyclic testing with a progressively increasing physiologic loading profile was performed at 2 Hz until catastrophic construct failure. Relative movement at the osteotomy site was monitored by means of optical motion tracking. In addition, four-point bending implant stiffness, torsional implant stiffness and frictional fit of the stem-nail connection were investigated via separate non-destructive tests. Intramedullary nails exhibited significantly higher four-point bending and significantly lower torsional implant stiffness than plates, P < 0.01. Increasing difference between nail and stem diameters decreased frictional fit at the stem-nail junction. Nail constructs provided significantly higher initial axial bending stiffness and cycles to failure (200 ± 83 N/mm; 16'871 ± 5'227) compared to plate constructs (93 ± 35 N/mm; 7'562 ± 1'064), P = 0.01. Relative axial translation at osteotomy level after 2'500 cycles was significantly smaller for nail fixation (0.14 ± 0.11 mm) compared with plate fixation (0.99 ± 0.20 mm), P < 0.01. From a biomechanical perspective, the docking nail concept offers higher initial and secondary stability under dynamic axial loading versus plating in TKA periprosthetic fracture fixation.

The Treatment of Periprosthetic Distal Femoral Fractures After Total Knee Replacement: A Critical Analysis Review

Periprosthetic distal femoral fracture after total knee arthroplasty carries substantial morbidity and mortality regardless of fixation technique. Surgical treatment is favored in most patients compared with conservative therapy because of high rates of nonunion, malunion, and reoperation after casting or bracing. Internal fixation techniques including retrograde intramedullary nailing and locked plating are favored for surgical treatment in most fractures when bone stock in the distal fragment allows for appropriate fixation. In the setting of deficient distal femoral bone stock or femoral component loosening, revision arthroplasty with distal femoral replacement is the favored technique. Further studies with regard to the use of intramedullary nailing, locked plating, and distal femoral replacement are necessary to refine the indications for each technique and to define the use of combinations of these fixation techniques.

Complication Rates after Lateral Plate Fixation of Periprosthetic Distal Femur Fractures: A Multicenter Study

OBJECTIVE

Periprosthetic fractures of the distal femur can be challenging injuries to treat; nonunion rates of up to 22% have been reported. The purpose of this study was to determine the rate of complications and nonunion in a multicenter series, and to identify patient or surgical factors that were associated with nonunion.

DESIGN

Retrospective comparative study SETTING: Three Level 1 trauma centers PATIENTS: Fifty-five patients with a periprosthetic distal femur fracture proximal to a total knee arthroplasty. Minimum follow up for inclusion was six months or until union or failure.

INTERVENTION

Surgical fixation using a precontoured lateral locking plate MAIN OUTCOME MEASUREMENT: Fracture union was the primary outcome. Patient demographic and injury variables (age, comorbidities, fracture classification and characteristics) and surgical technique factors (mode of plate fixation, plate material, working length, screw density, and proximal screw type) were identified and compared between patients who developed a nonunion and those who did not. Regression analysis was performed to identify independent risk factors for nonunion.

RESULTS

The overall rate of nonunion was 18% and the total complication rate was 24%. After additional surgery, 49 of 55 patients went on to heal (89%). There were no statistical differences in patient demographic or injury variables between the union and nonunion groups, and none of the variables studied were independent risk factors for nonunion in the regression analysis.

CONCLUSIONS

In this series of 55 patients with periprosthetic distal femur fractures treated with precontoured lateral locking plates, 18% developed nonunion and the overall complication rate was 24%. No patient or surgical variables were identified as risk factors. Future research should seek to identify patients at high risk for complication and nonunion who could benefit from alternative fixation strategies or distal femoral replacement.

Demographics, Treatment, and Cost of Periprosthetic Femur Fractures: Fixation Versus Revision

Introduction:

Periprosthetic femur fractures (PPFX) are complications of both total hip and knee arthroplasty and may be treated with open reduction and internal fixation (ORIF) or revision arthroplasty. Differences in treatment and fracture location may be related to patient demographics and lead to differences in cost. Our study examined the effects of demographics and treatment of knee and hip PPFXs on length of stay (LOS) and cost.

Methods:

Of all, 932 patients were identified with hip or knee PPFXs in the National Inpatient Sample from January 2013 to September 2015. Age, gender, race, mortality, comorbidity level, LOS, total cost, procedure type, geographic region, and hospital type were recorded. A generalized linear regression model was conducted to analyze the effect of fracture type on LOS and cost.

Results:

Differences in gender (66% vs 83.7% female, P < .01), comorbidities (fewer in hips, P < .01), and costs (US$30 979 vs US$27 944, P < .01) were found between the hip and knee groups. Knees had significantly higher rates of ORIF treatment (80.7% vs 39.1%) and lower rates of revision arthroplasties (19.3% vs 60.9%) than hip PPFXs (P < .01). Within both groups, patients with more comorbidities, revision surgery, and blood transfusions were more likely to have a longer LOS and higher cost.

Conclusion:

Periprosthetic femur fractures patients are not homogenous and treatment varies between hip and knee locations. For knee patients, those treated with ORIF were younger, with fewer comorbidities than those treated with revision. Conversely, hip patients treated with ORIF were older, with more comorbidities than those treated with revision. Hips had higher costs than knees, and cost correlated with revision arthroplasty and more comorbidities. In both hip and knee groups, longer LOS was associated with more comorbidities and being treated in urban teaching hospitals. Total cost had the strongest associations with revision procedures as well as number of comorbidities and blood product use.

Do patients that fracture with normal DXA-measured BMD have normal bone?

Patients that sustain "osteoporosis-related" fractures may have normal BMD at the hips and spine, but rarely have normal bone when other clinically available studies are considered. Such data often exist and can inform clinical decisions regarding osteoporosis therapy.

PURPOSE

Dual-energy X-ray absorptiometry (DXA) measured bone mineral density (BMD) at the hip and spine is widely used to diagnose osteoporosis. However, patients that sustain "osteoporosis-related" fractures often have normal BMD at these sites. The aim of this study was to explore whether older adults with fracture, but normal reported hip and spine BMD, also have normal bone using additional clinically available assessments.

METHODS

This retrospective electronic medical record study included 387 patients evaluated by a university-based fracture liaison service with spine and hip DXA; 32 (8.3%) had normal spine/hip BMD reported. In this cohort, clinically available bone data including 0.3 and ultradistal radius T-scores, trochanteric T-scores, lumbar spine trabecular bone score (TBS), L1 opportunistic CT Hounsfield units (HU), and femoral cortical index (FCI) were assessed.

RESULTS

One or more of the above noted studies were available in 30/32 patients. UD and 0.3 radius results were available in 21 patients, and 18 (85.7%) had T-scores < - 1.0. Trochanteric values were available in 16; T-scores were < - 1.0 in 18.8%. TBS data were available in 24; partially degraded or degraded values were present in 41.7%. L1 opportunistic CT was available in 25 patients, 80% were below normal, and < 150 HU. Finally, femoral cortical index (FCI) was measurable in 9 subjects; 66.7% were below < 0.4. When including all additional available data in the skeletal assessment, only 5/387 (1.3%) were identified with normal bone.

CONCLUSION

Patients with normal spine/hip BMD who sustain fracture rarely have normal bone when all available data are considered.

Does a Competing Risk Analysis Show Differences in the Cumulative Incidence of Revision Surgery Between Patients with Oncologic and Non-oncologic Conditions After Distal Femur Replacement?

BACKGROUND

Distal femur replacement is frequently used for limb salvage after bone tumor resections. It is also used in patients with severe bone loss because of traumatic conditions or revision TKA. Some studies on distal femur replacement reported on revision-free survival without distinguishing between patients with oncologic diagnoses and those without, although these patients might be incomparable because of their differences in important patient- and disease-specific characteristics. This may lead to an inaccurate and undifferentiated interpretation of the results of survival analyses.

QUESTIONS/PURPOSES

(1) What is the overall cumulative incidence of revision surgery after cemented and cementless distal femoral replacement, as determined with a competing risk analysis? (2) Does the cumulative incidence of revision surgery change over time? (3) Are there differences in the cumulative incidence of revision surgery between patients with oncologic conditions and those without who are treated with cemented or cementless distal femoral replacement?

METHODS

A total of 403 patients were possible candidates for distal femoral replacement. Of these, 56 patients elected to undergo different procedures, 83 were excluded because an expendable growing prosthesis was implanted, and 28 were lost to follow-up. Therefore, 229 patients who underwent distal femoral replacement for oncologic or non-oncologic reasons between 1983 and 2016 were retrospectively included in this study. The type of fixation method (cemented or cementless) was obtained from the patients' medical records, operation reports, and radiographic analyses from plain radiographs. All radiographs were standardized and obtained at standard time intervals in our institution. No algorithm regarding the fixation approach was followed. According to our data, patients receiving cementless fixation were younger and therefore likely to be more active than those receiving cemented fixation. The median follow-up duration of the overall cohort was 85 months (range 0.1-391 months). Patients who died or had revision surgery before the 2-year minimum follow-up interval were adequately considered using competing risk calculation. The reasons for revision surgery were classified using the classification system proposed by the International Society for Limb Salvage. A competing risk analysis was performed to estimate the cumulative incidence function of revision, accounting for death as a competing event. To evaluate the influence of potential prognostic factors, including diagnosis (oncologic versus non-oncologic), fixation (cemented versus cementless), year of distal femoral replacement, age, and sex on the occurrence of revision surgery, univariate and multivariable Fine and Gray models were applied.

RESULTS

The competing risks analysis revealed cumulative incidences of revision surgery for any cause (Types 1 to 5) of 26% (95% CI, 20.3%-31.9%) at 12 months, 37.9% (95% CI, 31.3%-44.4%) at 24 months, 52.6% (95% CI, 45.1%-59.5%) at 5 years, and 58.2% (95% CI, 50.1%-65.4%) at 10 years for all patients. Rotating hinge-type prostheses showed a lower cumulative incidence of revision surgery (41.6%; 95% CI, 31.8%-51%) than fixed-hinge prostheses did (64%; 95% CI, 50.5%-74.5% ) at 5 years (Gray's test: p = 0.01). According to the multivariate Fine and Gray model, the year of surgery did not have any effect on the risk of revision surgery (1994 to 2003: hazard ratio 0.70; 95% CI, 0.46-1.07); 2004 to 2016: HR 0.83; 95% CI, 0.52-1.34; p = 0.26). The multivariate analysis, adjusted for disease, sex, age, cementation, and year of surgery, revealed a difference in the risk of revision surgery between patients with oncologic disease and those with non-oncologic disease (HR 0.44 for oncologic versus non-oncologic; 95% CI, 0.22-0.87; p = 0.02) and a reduction in the risk of overall revision with cemented fixation in patients with oncologic disease (HR 0.53; 95% CI, 0.29-0.98; p = 0.03).

CONCLUSION

This study indicates that even with newer implants, there was a high incidence of revision surgery after distal femoral replacement. According to our analysis, patients with oncologic diagnoses have a lower likelihood of revision when the stem is cemented whereas the type of fixation did not impact patients with non-oncologic diagnoses. Because of differences in patient demographics (age, etiology of disease, and use of chemotherapy) and outcomes of fixation, oncologic and non-oncologic patients should be analyzed separately in survival studies about distal femoral replacement.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Equivalent union rates between intramedullary nail and locked plate fixation for distal femur periprosthetic fractures - a systematic review

BACKGROUND

The incidence of periprosthetic fracture following total knee arthroplasty continues to rise as the number of knee arthroplasty procedures increases. Management of periprosthetic fractures can be complex, with locked compression plating (LCP) and intramedullary nailing (IMN) being the most commonly used treatment options. We performed a systematic review to report and compare the clinical and radiographic outcomes of patients treated with intramedullary nail fixation versus plate fixation for periprosthetic fractures of the distal femur.

METHODS

Several databases were screened. Studies evaluating intramedullary nail fixation or locked plate fixation for distal femur periprosthetic fractures were included. Primary and secondary variables as mentioned below, when included, were analyzed and compared.

RESULTS

One prospective comparative study, 9 retrospective comparative studies, and 28 retrospective case series with 1,188 patients were included in this review. No statistically significant differences were found between IMN and LCP when analyzing union rate or time to union. Plating demonstrated a statistically significant decrease in the overall complication rate and reoperation rate when compared with IMN (p<0.003). IMN demonstrated a slightly higher percentage of patients reaching full weight bearing status and a quicker time to full weight bearing (100% and 7.6 weeks) when compared to plating (94% and 15.8 weeks). A higher percentage of patients treated with IMN returned to preinjury activity when compared to those treated with plating (70.8% vs. 61.6%).

CONCLUSIONS

Both intramedullary nail and locked plate fixation offer unique benefits in terms of clinical and radiographic outcomes for treatment of periprosthetic distal femur fractures after total knee arthroplasty. While the standard of care remains controversial, an increase in the recent literature has allowed for better clarification of the significant clinicoradiologic advantages and disadvantages of both popular treatment options.

Periprosthetic osseointegration fractures are infrequent and management is familiar

Aims

Osseointegrated prosthetic limbs allow better mobility than socket-mounted prosthetics for lower limb amputees. Fractures, however, can occur in the residual limb, but they have rarely been reported. Approximately 2% to 3% of amputees with socket-mounted prostheses may fracture within five years. This is the first study which directly addresses the risks and management of periprosthetic osseointegration fractures in amputees.

Methods

A retrospective review identified 518 osseointegration procedures which were undertaken in 458 patients between 2010 and 2018 for whom complete medical records were available. Potential risk factors including time since amputation, age at osseointegration, bone density, weight, uni/bilateral implantation and sex were evaluated with multiple logistic regression. The mechanism of injury, technique and implant that was used for fixation of the fracture, pre-osseointegration and post fracture mobility (assessed using the K-level) and the time that the prosthesis was worn for in hours/day were also assessed.

Results

There were 22 periprosthetic fractures; they occurred exclusively in the femur: two in the femoral neck, 14 intertrochanteric and six subtrochanteric, representing 4.2% of 518 osseointegration operations and 6.3% of 347 femoral implants. The vast majority (19/22, 86.4%) occurred within 2 cm of the proximal tip of the implant and after a fall. No fractures occurred spontaneously. Fixation most commonly involved dynamic hip screws (10) and reconstruction plates (9). No osseointegration implants required removal, the K-level was not reduced after fixation of the fracture in any patient, and all retained a K-level of ≥ 2. All fractures united, 21 out of 22 patients (95.5%) wear their osseointegration-mounted prosthetic limb longer daily than when using a socket, with 18 out of 22 (81.8%) reporting using it for ≥ 16 hours daily. Regression analysis identified a 3.89-fold increased risk of fracture for females (p = 0.007) and a 1.02-fold increased risk of fracture per kg above a mean of 80.4 kg (p = 0.046). No increased risk was identified for bilateral implants (p = 0.083), time from amputation to osseointegration (p = 0.974), age at osseointegration (p = 0.331), or bone density (g/cm2, p = 0.560; T-score, p = 0.247; Z-score, p = 0.312).

Conclusion

The risks and sequelae of periprosthetic fracture after press-fit osseointegration for amputation should not deter patients or clinicians from considering this procedure. Females and heavier patients are likely to have an increased risk of fracture. Age, years since amputation, and bone density do not appear influential.

Cite this article: Bone Joint J 2020;102-B(2):162–169.

Analysis of mortality after surgical treatment of periprosthetic distal femur fractures

INTRODUCTION

The incidence of periprosthetic fractures of the knee is increasing due to the increase in the number of total knee arthroplasties performed, together with population aging. We found few studies that analyze mortality in our setting after surgery. Our objective was to evaluate mortality and survival after surgical treatment of periprosthetic fractures of the distal femur in our environment.

MATERIAL AND METHOD

We conducted a retrospective observational study of a consecutive series of 97 patients surgically treated in our centre for periprosthetic knee fracture between 2007-2015, with a minimum follow-up of 12months. Diverse sociodemographic, clinical and surgical variables were analyzed. A consultation was made to the National Death Index of the Ministry of Health for the analysis of mortality and survival was analyzed using the Kaplan-Meier method.

RESULTS

We reviewed a total of 97 patients with an average age of 75years, of which 86 were women and 11 were men. Of the patients, 50.5% of patients had some comorbidity. The average delay until the intervention was 3.1days. With respect to the treatment, 45 patients were operated by osteosynthesis with plate (49.5%), 40 with intramedullary nail (41.2%) and 9 with revision of the arthroplasty (9.3%). A total of 30 deaths were recorded during the follow-up, with cumulative mortality in the first year, at 3 and at 10 years of 7.2%, 17.5% and 30.9%, respectively, progressively increasing in people over 75years. There was no significant difference in mortality rates with the osteosynthesis method. The main complication was pseudoarthrosis (6.2%).

CONCLUSIONS

Periprosthetic knee fractures are associated with high rates of complications and mortality. The patient's age and the lesion itself are non-modifiable factors that can influence mortality after surgery, while other variables such as the type of intervention or surgical delay did not show differences in mortality rates in our study.

Acute Distal Femoral Replacement for Fractures About the Knee in the Elderly

Distal femoral replacement (DFR) is a reasonable treatment option when used for select indications. In the setting of comminuted intra-articular distal femoral fractures, distal femoral arthroplasty should be considered in low-demand patients with poor bone quality. This article summarizes the existing literature plus the authors' personal experience with DFR use for distal femoral fractures of the native knee.

Total knee arthroplasty with distal femoral replacement is associated with an important complication rate. A case series

BACKGROUND

With the aging population and an increasing number of total knee arthroplasties (TKAs) performed yearly worldwide, revision surgeries for many causes (septic or aseptic loosening, periprosthetic femoral fractures (PDFF), non-unions, malunions) are more frequent and challenging. Distal femoral replacement (DFR) is sometimes the only option to restore knee function and quality of life. DFR in non-oncologic patient is still a rare indication and few reports are published on this topic, with a non-consistent variety of functional results, complication rates and survivorship.

METHODS

We present a retrospective series of patients who underwent a DFR for a non-oncologic indication between 2010 and 2017. Nineteen patients were available for a full evaluation (clinical and radiological) with a mean follow-up of 48.3 months (range 15-99). Goniometry was performed at the six-week postoperative visit. Complications were reported. Osteolysis and/or signs of aseptic loosening were described using the Knee Society Radiographic Evaluation. Survivorship was calculated for aseptic loosening, infection, and revision for any cause.

RESULTS

The mean Knee Society Score was good for the pain score (42.2, range 10-50) and fair for the function score (60.6, range 0-100). Four deep infections (21.1%) were successfully treated with mobile parts exchange and debridement. Three patients presented femoral osteolysis ≥5 years after the DFR. Survivorship for aseptic loosening was 100% at four years, 81.8% after five years and 53.3% after eight years.

CONCLUSIONS

TKA with DFR is a valuable option for patients with a severe bone loss and poor bone quality in the distal femur. DFR restores an acceptable quality of life but is related to an important complication rate.

Comparison of outcomes and analysis of risk factors for non-union in locked plating of closed periprosthetic and non-periprosthetic distal femoral fractures in a retrospective cohort study

BACKGROUND

The primary aim was to compare the outcomes of locked plating of closed distal femur periprosthetic and non-periprosthetic fractures by testing the hypothesis that outcomes would be worse in the periprosthetic group. The secondary aim of this study was to identify risk factors for non-union.

METHODS

A single-center study over an 8-year period utilizing a retrospective cohort design was performed. Sixty-eight patients with periprosthetic fractures and 57 patients with non-periprosthetic fractures met inclusion criteria for the study. There was a significant difference between groups in mean age (80.1 years periprosthetic vs. 70.9 years non-periprosthetic (p < 0.001)). Statistical analysis between groups was used to assess the outcomes of time to union, incidence of non-union, post-operative functionality, incidence of complications, progression to revision surgery, and mortality. A secondary multivariable analysis was used to assess risk factors for non-union and factors positively associated with union.

RESULTS

There were no significant differences in outcomes between groups. Union rates were 83.8% (57/68) in the periprosthetic group and 78.9% (45/57) in the non-periprosthetic group (p = 0.648). Comminution was identified as a significant risk factor for non-union (p = 0.005). Use of a submuscular technique had a significant positive association with union (p = 0.006).

CONCLUSIONS

Outcomes of surgical treatment for periprosthetic and non-periprosthetic distal femur fractures are similar. There is a significant risk of non-union in locked plating of both groups.