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

Abstract

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.

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

“…Quinci et al [ 13 ] reported a reoperation rate of 19%. In the studies included by Rubinger et al [ 14 ] reoperation rates ranged from 0 to 45%. Recent analysis from the AOANJRR reported revision rates of 12% for DFR in PDFF after 6 years [ 16 ] and 12% after 4 years in native knee fractures [ 17 ].…”

Cochrane in CORR®: Interventions for Treating Fractures of the Distal Femur in Adults

“…While there was a suggestion that distal femoral locking plates delivered slightly better PROM scores than did distal femoral replacements [9], the magnitude of the apparent difference was small (and it was questionable as to whether it was a statistical difference at all), and differences in the patients treated with each approach could have accounted for this small difference. The authors characterized the evidence on this topic as being "low certainty," and we agree.…”

Surgical approaches to periprosthetic femoral fractures for plate fixation or revision arthroplasty

“…1,2 Complication rates are high following both fixation and revision arthroplasty. [3][4][5][6][7] Periprosthetic femoral fractures are complex and their surgical management should be performed or supervised by experienced surgeons. The necessary expertise and instrumentation for revision arthroplasty must also be available if fixation is planned.…”