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

Abstract

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.

A Custom Device to Couple Proximal and Distal Femoral Stems: A Case Report and Literature Review

“…Distal femur replacement has been described as treatment for acute periprosthetic supracondylar fractures and for nonunion of periprosthetic supracondylar fractures [ 4 ]. Indications for DFR include the lack of available bone for revision arthroplasty and reduced bone quality, which precludes internal fixation.…”

“…This advantage may be even more pronounced in the elderly comorbid population in which this injury is most common. A recent multicenter study reported on DFR as the treatment for acute fractures, fracture nonunion, and periprosthetic fractures (N = 88) [ 4 ]. Nearly all patients in the series were allowed weight-bearing as tolerated immediately following the surgery.…”

Geriatric Distal Femur Fractures Treated With Distal Femoral Replacement Are Associated With Higher Rates of Readmissions and Complications

“…Case series have demonstrated favorable outcomes in patients with distal femur fracture treated with DFR. 8,13,14 There is currently an ongoing randomized trial investigating the utility of DFR for geriatric distal femur fractures (DIFFIR trial). However, there are no large trials comparing operative fixation with DFR in patients with distal femur fracture.…”

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

“…Recent evidence supports DFR as a preferred option for PDFFs owing to its advantages, including early weight-bearing and independence of fracture healing. 10 – 12 However, the disadvantages of DFR include a lack of revision options and higher costs. 13 Currently, there is a paucity of direct comparative studies on internal fixation and DFR for PDFFs.…”