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

Disclosures

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

In This Article

Results

One hundred fifty-six practicing orthopaedic surgeons completed the survey. These included 74 fellowship-trained traumatologists, 61 fellowship-trained arthroplasty surgeons, and 16 surgeons with dual fellowship training in trauma and arthroplasty. Five respondents did not complete a formal trauma or arthroplasty fellowship and were therefore excluded from final analysis, leaving 151 surgeons. Seven respondents in the trauma group completed additional fellowships, including hip preservation (one), tumor (five), and shoulder/elbow (one). For analysis of the primary question, respondents were divided into two groups based on whether they had completed a trauma fellowship. This left 90 surgeons in the trauma group and 61 surgeons in the arthroplasty group for comparison (Table 1).

As expected, surgeons in the arthroplasty group conducted more primary total knee arthroplasties monthly (P < 0.0001), whereas fellowship-trained trauma surgeons were more likely to fix greater than three periprosthetic distal femur fractures monthly (P < 0.0001). No differences were observed in academic versus community practice environment (P > 0.999), years in practice (P = 0.361), or percentage of respondents working with trainees in each group (P = 0.114).

Considering all cases together, completion of a trauma fellowship was associated with a higher likelihood of recommending fracture fixation over revision to DFR (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.97 to 3.29; P < 0.0001, Table 2). When stratifying by fracture type, trauma fellowship-trained surgeons were significantly more likely to recommend fracture fixation for comminuted fractures proximal to the anterior flange (OR 6.90, 95% CI 3.24 to 14.68; P < 0.0001, Table 2, Figures 1 and 2), simple fractures distal to the anterior flange (OR 20.90, 95% CI 6.41 to 67.71; P < 0.0001, Table 2, Figure 1), and comminuted fractures distal to the anterior flange (OR 2.47, 95% CI 1.66 to 3.68; P < 0.0001, Table 2). Both groups selected fixation in nearly all simple proximal fractures (P = 0.169). When excluding simple proximal fractures, completion of a trauma fellowship was associated with a 2.7 times greater likelihood of recommending fracture fixation (OR 2.78, 95% CI 2.11 to 3.65, P < 0.0001).

Figure 2.

Radiographs of a female patient in her late 80s showing a comminuted periprosthetic distal femur fracture proximal to the anterior flange of a well-fixed constrained condylar total knee arthroplasty. Surgeons who had completed a trauma fellowship were significantly more likely to recommend fracture fixation over distal femoral replacement for this case, as compared with arthroplasty surgeons (odds ratio 6.90, 95% confidence interval 3.24 to 14.68; P < 0.0001).

To assess the effect of dual fellowship training versus single fellowship training on surgical decision-making, responses were compared between surgeons who completed trauma and arthroplasty fellowships and surgeons who completed only one of these (Table 3). This revealed that dual fellowship-trained surgeons were less likely to recommend surgical fixation over reconstructive arthroplasty than surgeons who completed a trauma fellowship alone (OR 0.60, 95% CI 0.39 to 0.93; P = 0.027). They were also more likely to recommend fixation than surgeons who completed an arthroplasty fellowship alone (OR 1.70, 95% CI 1.13 to 2.63; P = 0.012). When stratifying by fracture types, dual fellowship-trained surgeons were less likely than surgeons who completed a trauma fellowship alone to recommend fixation for comminuted proximal fractures (OR 0.17, 95% CI 0.05 to 0.59; P = 0.013) and for simple distal fractures, than surgeons who completed an arthroplasty fellowship alone (OR 11.47, 95% CI 1.87 to 125.4; P = 0.007).

To explore the role of surgeon familiarity and practice patterns on decision-making, survey responses were compared between surgeons in both groups who reported treating more than three periprosthetic distal femur fractures monthly and those who reported treating less than three (Table 4). This revealed that higher volume surgeons were significantly more likely to recommend fixation over reconstructive arthroplasty for all fracture patterns compared with lower volume surgeons (OR 2.45, 95% CI 1.62 to 3.68; P < 0.0001). When stratifying by the fracture pattern, this discrepancy was significant for comminuted distal (OR 2.99, 95% CI 1.76 to 5.05, P < 0.0001), comminuted proximal (OR 4.79, 95% CI 1.24 to 20.51, P = 0.019), and simple distal fractures (OR 6.68, 95% CI 1.08 to 71.55, P = 0.046), with no significant disagreement for simple proximal fractures (P > 0.999).

Responses were also compared between surgeons in academic and community practice environments and between surgeons who worked with and without trainees. This revealed no significant differences in recommendations associated with these variables (academic vs community practice [OR 1.16, 95% CI 0.44 to 1.51; P = 0.299], years in practice [P = 0.435], and working with trainees [OR 1.31, 95% CI 0.49 to 1.74; P = 0.069]). When asked about the most important variable in determining whether they would choose fixation or revision, responses were similar between trauma and arthroplasty groups and included location of the fracture (trauma: 74%, arthroplasty: 75%), predictability (trauma: 12%, arthroplasty: 13%), comminution (trauma: 6%, arthroplasty: 3%), history of a well-functioning knee arthroplasty (trauma: 6%, arthroplasty: 3%), and familiarity with the procedure (trauma: 2%, arthroplasty: 5%).

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