Elsevier

Injury

Volume 49, Issue 2, February 2018, Pages 392-397
Injury

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

https://doi.org/10.1016/j.injury.2017.11.040Get rights and content

Abstract

Introduction

Management of distal femur fractures above total knee arthroplasty (TKA) remains challenging. Two common surgical options are locked lateral plating (LLP) and distal femoral arthroplasty (DFR). Unfortunately, approximately 30–50% of patients may die within one year of injury, require further surgery, or not regain prior mobility performance. We compared 87 LLP to 53 DFR patients – to our knowledge the largest comparative study – focusing on 90- and 365-day mortality, mobility maintenance, and further surgery.

Methods

We performed a retrospective review of patients at least 55 years old who sustained femur fractures near a primary TKA (essentially OTA-33 or Su types 1, 2, or 3) from 2000 to 2015 assigning cohort based on treatment: LLP or DFR. We excluded patients having prior care for the injury, whose surgery was not for fracture (e.g. loosening), or having other surgical intervention (e.g. intramedullary nail).

Results

Results Cohorts were similar based on body mass index and age adjusted Charlson Comorbidity Index (aaCCI). LLP was more common than DFR for fractures above and at the level of the implant, but similar for fractures within the implant for patients with aaCCI ≥ 5. LLP and DFR had similar mortality at 90 days (9% vs 4%) and 365 days (22% vs 10%), need for additional surgery (9% vs 3%), and survivors maintaining ambulation (77% vs 81%). Patients whose surgery occurred 3 or more days after presentation had similar mortality risk to those whose surgery was before 3 days. The mean age of one year survivors was 77 whereas for patients who died it was 85. Neither surgical choice nor aaCCI was associated with increased risk in time to surgery.

Conclusions

Fracture location, remaining bone stock, and patient’s prior mobility and current comorbidities must guide treatment. Our study suggests that 90- and 365-day mortality, final mobility, and re-operation rate are not statistically different with LLP vs DFR management.

Introduction

Recent studies have highlighted the poor prognosis of geriatric patients with distal femur fractures [1], [2], [3], [4]. Surgeons managing this injury with a locked lateral plate (LLP) might expect one quarter of their patients to die within a year and another quarter to experience infection, nonunion, or other further surgery [5]. Distal femur fractures near a prior primary total knee arthroplasty (TKA) are estimated to occur with an incidence of 0.3-2.5% [6], [7], [8], [9], [10], [11]. LLP is one standard surgical option for this injury, yet many authors report nonunion in the 10–20% range as summarized in a recent thorough review [12]. Patients who fail further standard fracture care may eventually progress to distal femoral replacement (DFR), and these patients continue to have a higher rate of complications than patients initially managed with DFR, have incurred a greater cost, and have endured multiple major surgeries [13]. The next question in this thought process is thus: might patients with peri-TKA femur fractures benefit from index DFR management instead of LLP?

Section snippets

Methods

We performed an Institutional Review Board-approved retrospective cohort study of patients treated for distal femur periprosthetic fractures at a single network of tertiary referral hospitals between 2000 and 2015. Patients were identified by reviewing operative logs of all femur fracture surgeries and manually reviewing imaging to confirm implant used. All fractures fit the general classification of OTA-33. We included patients who were at least 55 years old, had a femur fracture near an

Results

A total of 87 LLP and 53 DFR patients fit inclusion and exclusion criteria. Table 1 presents demographic data. The LLP and DFR groups had no significant differences in any measured demographic category except LLP patients had a higher rate of diabetes causing end organ damage. Table 2 presents implant choice based on fracture location, with subgroup analysis based on aaCCI. LLP was used more frequently for all fracture location and aaCCI pairings, except for aaCCI  5 patients with fractures

Discussion

Our series of 87 LLP and 53 DFR represents the largest distal femur peri-TKA fracture study which reports on DFR outcomes, to the best of our knowledge. The next largest we identified [20] reported on 83 LLP and 17 DFR. We found three other authors reported their comparison experiences with at least 10 patients per cohort [21], [22], [23]. Their outcomes are summarized in Table 9. Most other authors discuss only LLP [9], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35],

Conclusion

The management of femur fractures above TKA remains challenging. Approximately 20% of patients may die within one year of injury, 30% may not regain prior mobility performance, and 10% may require at least one further operation. Factors such as fracture location and remaining bone stock, as well as patient’s prior mobility and current comorbidities must guide treatment. Our current study suggests that 90- and 365 day mortality, final mobility, and re-operation rate are not statistically

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      Citation Excerpt :

      Additionally, Song et al. investigated whether lateral locked plating could be used with good effect in both periprosthetic as well as native knees, but their numbers were limited [26]. Numerous other studies have investigated whether intramedullary nailing or distal femoral replacement is superior for different fracture morphologies and patient populations, with conflicting results [4,6–10,13,17,27–29]. Given the expected increase in periprosthetic distal femur fractures, the often complex nature of these fractures, and the multiple features that make achieving fixation challenging, our study sought to assess understand the capability of lateral locked plating to treat very distal periprosthetic distal femur fractures.

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