To Fix or Revise

Differences in Periprosthetic Distal Femur Fracture Management Between Trauma and Arthroplasty Surgeons

Noelle L. Van Rysselberghe, MD; Sean T. Campbell, MD; L. Henry Goodnough, MD, PhD; Derek F. Amanatullah, MD, PhD; Michael J. Gardner, MD; Julius A. Bishop, MD


J Am Acad Orthop Surg. 2022;30(1):e17-e24. 

In This Article


This study was institutional review board exempt. Images from nine geriatric patients with distal femur fractures above total knee arthroplasties were selected and incorporated into an online survey (Qualtrics XM Software). Fractures were selected to include a variety of patterns, which were classified as follows: two simple fracture patterns proximal to the anterior flange (one Su I and one Su II), three comminuted fractures proximal to the anterior flange (all Su II), three comminuted fractures distal to the anterior flange (Su III), and one simple fracture distal to the anterior flange[7] (Su III, Figure 1). All fractures were displaced, and no patient had radiographic evidence of prosthesis loosening (Lewis and Rorabeck type II).[17] Provided history included approximate patient age (ie, late 70s or early 80s) and mechanism of injury (low-energy ground-level fall in all cases). All cases were geriatric patients, with ages ranging from mid-60s to early 90s. All patients denied antecedent pain, instability, or other problems with their total knee arthroplasty. Collected demographic data included: years in practice (0 to 5, 6 to 10, 11 to 20, and 21+), academic versus community practice (academic defined as formal affiliation with a university center), whether respondents worked with trainees, and type of fellowship completed (options: trauma, arthroplasty, both, or others). Data were also collected regarding the average number of total knee arthroplasties done per month (0, 1 to 5, and >5) and the average number of periprosthetic distal femur fractures treated monthly (0, 1 to 3, and >3). Exclusion criteria included nonpracticing orthopaedic surgeons and surgeons who did not complete a formal trauma or arthroplasty fellowship.

Figure 1.

Radiographs showing examples of periprosthetic distal femur fractures used in the survey with classifications listed. A, Comminuted fracture originating at the anterior flange and traveling proximally (Su II). B, Comminuted fracture distal to the anterior flange (Su III). C, Simple fracture proximal to the anterior flange (Su I). D, Simple fracture with extension distal to the anterior flange (Su III).

Respondents were asked what their preferred treatment option would be for each of the nine cases. Options included: (1) fracture fixation or referral for fixation, or (2) DFR or referral for DFR. At the conclusion of the survey, respondents selected the single most important factor in their treatment decision (options: location of the fracture, presence or absence of comminution, and patient history of a well-functioning knee arthroplasty).

The survey was published on the Orthopaedic Trauma Association (OTA) website, which orthopaedic surgeons visit with the intention of voluntarily completing research surveys. The link was also circulated to all participating sites and alumni of the Insall Knee Society Travelling Fellowship, which includes surgeons in both academic and community practice environments. Responses were collected for one year.

Chi-square and Fisher exact tests were used to assess for differences in treatment recommendations between type of fellowship completed, practice environment, years in practice, surgeons working with or without trainees, and number of periprosthetic distal femur fractures treated monthly. Prism 8 was used for all statistical analyses (version 8.4.2; GraphPad). The significance level was set at 0.05.