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

PURPOSE

This study was initiated to analyze the outcome after distal femoral replacement (DFR) for periprosthetic distal femoral fractures (PDFF).

METHODS

Data from the German Arthroplasty Registry (EPRD) were analyzed. A total of 626 patients could be identified with a DFR for PDFF. Mean age was 78.8 years, and 84.2% were female. Revisions and mortality were analyzed and compared with patient groups with a similar procedure (revision total knee arthroplasty) or similar general condition (fracture total hip arthroplasty, hip hemiarthroplasty). Matched-pair-analyses were performed.

RESULTS

Within one year after surgery, 13.2% of the patients had died and further 9.4% were revised. Within four years, 32.7% had died and 19.7% were revised. Revisions were nearly twice as high as in the comparison groups. Periprosthetic infection (PJI) was the most frequent cause for revision, resulting in a PJI rate of 12.8%, which was lower in the comparison groups. Mortality after DFR was as similar high as after fracture hip arthroplasty.

CONCLUSION

PDFF are a serious injury, and the necessary surgical treatment has a high risk of complications. Every third patient after DFR for PDFF had died and every fifth patient needed revision within 4 years after surgery. Efforts should be undertaken to provide optimal treatment to these high-risk patients to reduce unfavorable outcomes.

LEVEL OF EVIDENCE

III.

REGISTRATION OF CLINICAL TRIALS

As this is a registry-derived study of data of the German Arthroplasty Registry (EPRD), no registration was performed.

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

BACKGROUND

Our purpose was to perform a systematic review and meta-analysis to evaluate complication and revision rates for periprosthetic distal femur fractures (PPDFF) treated with: (1) ORIF using periarticular locking plates (ORIF), (2) retrograde intramedullary nail (IMN), and (3) distal femoral replacement (DFR).

METHODS

Systematic review of the literature was performed to identify eligible studies (N = 52). Identified treatment groups were: ORIF (N = 1205 cases), IMN (N = 272 cases), and DFR (N = 353 cases). Median follow-up was 30 months (range 6-96 months). Primary outcomes were: (1) major complication rates and (2) reoperation rates over the follow-up period. Secondary outcomes were incidence of deep infection, periprosthetic fracture, mortality over the follow-up period, 1-year mortality, non-union, malunion, delayed union, and hardware failure. Data for primary and secondary outcomes were pooled and unadjusted analysis was performed. Meta-analysis was performed on subset of individual studies comparing at least two of three treatment groups (N = 14 studies). Odds-ratios and their respective standard errors were determined for each treatment group combination. Maximum likelihood random effects meta-analysis was conducted for primary outcomes.

RESULTS

From the systematic review, major complication rates (p = 0.55) and reoperation rates (p = 0.20) were not significantly different between the three treatment groups. DFR group had a higher incidence of deep infection relative to IMN and ORIF groups (p = 0.03). Malunion rates were higher in IMN versus ORIF (p = 0.02). For the meta-analysis, odds of major complications were not significantly different between IMN versus DFR (OR 1.39 [0.23-8.52]), IMN versus ORIF (OR 0.86 [0.48-1.53]), or the ORIF versus DFR (OR 0.91 [0.52-1.59]). Additionally, odds of a reoperation were not significantly different between IMN versus DFR (OR 0.59 [0.08-4.11]), IMN versus ORIF (OR 1.26 [0.66-2.40]), or ORIF versus DFR (OR 0.91 [0.51-1.55]).

CONCLUSIONS

There was no difference in major complications or reoperations between the three treatment groups. Deep infection rates were higher in DFR relative to internal fixation, malunion rates were higher in IMN versus ORIF, and periprosthetic fracture rates were higher in DFR and IMN versus ORIF.

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

PURPOSE

Distal femur fractures adjacent to total knee arthroplasty are a rare yet complex problem. Recently, extramedullary locking plate and retrograde intramedullary nail fixations have become popular options, but the complication rates associated with these procedures are 15-20 %. Modified fixations were assessed in an effort to reduce complications from unstable periprosthetic fractures.

METHODS

Using experimental and finite element methods, this study compared the construct behaviours of a locking plate, a retrograde intramedullary nail, and their modifications (a spiral-blade supplemented in an intramedullary nail or a locking plate/allograft hybrid) when subjected to various fracture types, locations, loading conditions, and bony strength. The implanted models were used to assess construct stiffness, fracture micromotion, and implant stress under different osteoporotic conditions. Finally, we collected 40 cases for radiological analysis to indicate the appropriate procedure for treating periprosthetic fractures following total knee arthroplasty.

RESULTS

Regardless of the fracture type, femoral constructs fixed with a conventional or spiral-blade supplemented intramedullary nail exhibited higher axial but lower torsional stiffness than those fixed with a locking plate. Torsional deformation occurred if the lower-positioned fracture had no medial support. The locking plate/allograft construct exhibited the highest stiffness and the least micromotion. A review of 40 clinical cases confirmed the above findings regarding the locking plate/allograft construct.

CONCLUSION

The spiral-blade supplement of retrograde intramedullary nail and locking plate/allograft modified constructs significantly stabilizes the unstable fractured gaps. The locking plate/allograft is recommended for the periprosthetic fractures with deficient bone stock and severe osteoporosis to improve alignment and healing potentials.

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

BACKGROUND

Low energy distal femur fractures often occur in a fragile elderly population that is prone to local and systemic complications following operative treatment of extremity fractures. The nonunion rate and early complication rate following laterally based locked plating in this specific fracture are not well described.

METHODS

We conducted a retrospective cohort study conducted at three affiliated tertiary care hospitals to evaluate nonunion, early post operative complications, discharge disposition, length of stay, and mortality in patients over 60 years old undergoing laterally based locked plating of a low energy distal femur fracture.

RESULTS

Forty-four out of 176 patients were deceased at one year (25%). Predictors of one year mortality included older age, higher Charlson Comorbidity Index (CCI), and delay to surgery greater than 2days (p<0.001). Of 99 patients alive and with follow up at one year, 24 (24%) developed a nonunion and 21 of 24 required nonunion surgery. Development of a surgical site infection was statistically significantly correlated with development of nonunion. Age and CCI did not predict development of nonunion. Average length of stay was 10days and 82% of patients were discharged to a skilled nursing facility. Thirty eight percent of patients experienced at least one postoperative systemic complication.

CONCLUSIONS

Laterally based locked plating of the low energy geriatric distal femur fracture is most often followed by a tumultuous post-operative course with a high rate of local and systemic complications including death, nonunion, and extended hospital stays.

LEVEL OF EVIDENCE

Level III prognostic.