Periprosthetic Distal Femur Fracture after Total Knee Arthroplasty: A Systematic Review

Abstract

This study was designed to itemize and analyze the classification of fracture types and their corresponding outcomes in an attempt to provide a better understanding of the current treatment methods. Two PubMed searches were performed using the words "periprosthetic distal femur fracture" and "periprosthetic supracondylar femur fracture" in studies that were published in the previous 10 years (2004-2014). Data from 41 articlesthat met the general inclusion criteria, were collected and categorized into fracture type and treatment method groupings. Healing outcome and complications were the two parameters used to analyze the data. Treatment techniques were grouped in the following categories: locking plate, non-locking plate, intramedullary nail/rod, screw, blade plate, cerclage wires, allograft, external fixation, revision arthroplasty, non-operative, and other. Classification systems by Lewis and Rorabeck, the Association for Osteosynthesis/Orthopedic Trauma Association (AO/OTA), Su et al., Neer et al., Kim et al., Backstein et al., and the Société Française de Chirurgie Orthopédique et Traumatologique were reported. In total 448 fractures were identified, of which Rorabeck type II was the most common fracture studied. The two most successful treatment options for periprosthetic distal femur fractures were locking plate (87%) and intramedullary nail/rod (84%). The most frequent complications associated with periprosthetic distal femur fractures included non/mal/delayed union and the need for revision. Locking plates used to treat Rorabeck type II fractures had a complication rate of 35% and those treated with intramedullary nailing had a higher complication rate of 53%. In conclusion, the most frequent type of periprosthetic distal femur fracture after total knee arthroplasty was Rorabeck type II. The most common treatments for these types of fractures are locked plating and intramedullary nailing, with similar healing rates of 87% and 84%, respectively. However, the complication rate for locked plating was lower than for intramedullary nailing.

Keywords: Distal femur; Periprosthetic fracture; Systematic review; Total knee arthroplasty.

Figure 1

Flow chart illustrating the process of including and excluding studies.

Figure 2

Periprosthetic distal femur fractures (Su type I, Rorabeck type I) was treated with a distal femoral locking plate that spanned the entire interprosthetic zone. (A) preoperative, (B) postoperative day one, (C) union and full‐weight bearing at 17 weeks.

Figure 3

Periprosthetic distal femur fractures (Su Type II, Rorabeck type II) were treated with a distal femoral locking plate showing; (A) preoperative anteroposterior radiograph; (B) preoperative lateral radiograph; (C) postoperative anteroposterior radiographs demonstrating acceptable reduction of the periprosthetic distal femur fracture treated with reverse locking plate fixation; (D) postoperative lateral radiograph; (E) postoperative anteroposterior radiographs at 3 months demonstrating minimal callus formation and sustained fracture reduction in weight bearing patient; (F) postoperative lateral radiograph at 3 months.

Figure 4

Periprosthetic distal femur fracture (Su type III, Rorabeck type III) was treated with a distal femoral locking plate showing: (A) preoperative anteroposterior radiograph; (B) preoperative lateral radiograph; (C) postoperative anteroposterior radiographs; (D) postoperative lateral radiograph; (E) postoperative anteroposterior radiographs at 3 months; (F) postoperative lateral radiograph at 3 months.