Very Distal Femoral Periprosthetic Fractures: Replacement versus Fixation, a Systematic Review.

Abstract

OBJECTIVES\nTo synthesize all-cause reoperations and complications data, as well as secondary clinical and functional outcomes, following the management of very distal femur periprosthetic fractures (vDFPFs) in a geriatric patient population with either a distal femoral locking plate (DFLP) or with distal femoral replacement (DFR).\n\n\nDATA SOURCES\nMEDLINE, Embase and Web of Science, were searched for English-language articles from inception to March 16, 2020 in accordance to PRISMA guidelines.\n\n\nSTUDY SELECTION\nStudies reporting the management of vDFPFs in adults over the age of 65 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.\n\n\nDATA EXTRACTION\nThree reviewers independently extracted data from the included studies. Study validity was assessed using the methodological index for non-randomized studies (MINORS), a quality assessment tool for non-randomized controlled studies in surgery.\n\n\nDATA SYNTHESIS\nTwenty-five studies with 649 vDFPFs were included for analysis. There were 440 knees in the DFLP group (mean age range: 65.9 to 88.3 years) and 209 knees in the DFR group (mean age range: 71.0 to 84.8 years). Due to the literature s heterogeneity, the data was qualitatively synthesized.Conclusions: vDFPFs in the elderly treated with DFR underwent fewer reoperations relative to DFLP (0% to 45% vs. 0% to 77%, respectively). Time to weightbearing 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.\n\n\nLEVEL OF EVIDENCE\nTherapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.