Osteoporotic distal femur fractures in the elderly: peculiarities and treatment strategies.
Keywords:
distal femur, fractures, elderly, osteoporoticAbstract
Distal femur fractures account for 4-6% of osteoporosis related fractures of the femur in the elderly population. They represent a relevant cause of morbidity and mortality in the geriatric population with a reported 1-year mortality reaching 30%. Non-displaced fractures or even displaced fractures in patients with high operative risk can be treated conservatively. However, operative treatment is the most widely accepted management option for displaced fractures. The advantage resides in early mobilization and weight-bearing, reducing risks related with a prolonged immobilization when compared with conservative treatment. On the other hand, the intrinsic difficulty of fixing an osteoporotic bone is a major concern. The presence of osteosynthesis devices or prosthetic implants in the femur can make the surgical treatment more challenging, sometimes limiting therapeutic options. Aim of the present paper is to review the most recent literature about osteoporotic distal femur fractures in the elderly, including periprosthetic and other hardware related fractures, to highlight current evidence on management options and related results as a guide for the daily clinical practice.
References
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[27] Harvin WH, Oladeji LO, Della Rocca GJ, Murtha YM, Volgas DA, Stannard JP, et al. Working length and proximal screw constructs in plate osteosynthesis of distal femur fractures. Injury. 2017 Nov;48(11):2597-2601.
[28] Park KC, Lim SJ, Song YS, Hwang KT. Factors affecting peri-implant fracture following locking plate for osteoporotic distal femur fractures. Orthop Traumatol Surg Res. 2017 Dec;103(8):1201-1204.
[29] Mau-Moeller A, Behrens M, Felser S, Bruhn S, Mittelmeier W, Bader R et al.Modulation and Predictors of Periprosthetic Bone Mineral Density following Total Knee Arthroplasty. Biomed Res Int. 2015;2015:418168.
[30] Kubiak EN, Haller JM, Kemper DD, Presson AP, Higgins TF, Horwitz DS. Does the lateral plate need to overlap the stem to mitigate stress concentration when treating Vancouver C periprosthetic supracondylar femur fracture? J Arthroplasty. 2015 Jan;30(1):104-8.
[31] McGraw P, Kumar A. Periprosthetic fractures of the femur after total knee arthroplasty. J
Orthop Traumatol. 2010;11(3):135–141.
[32] Canton G, Ratti C, Fattori R, Hoxhaj B, Murena L. Periprosthetic knee fractures. A review of epidemiology, risk factors, diagnosis, management and outcome. Acta Biomed. 2017 Jun 7;88(2S):118-128.
[33] Koso RE, Terhoeve C, Steen RG, Zura R. Healing, nonunion, and re-operation after internal fixation of diaphyseal and distal femoral fractures: a systematic review and meta-analysis. Int Orthop. 2018 Nov;42(11):2675-2683.
[34] Rodriguez EK, Boulton C, Weaver MJ, Herder LM, Morgan JH, Chacko AT, et al. Predictive factors of distal femoral fracture nonunion after lateral locked plating: A retrospective multicenter case-control study of 283 fractures. Injury. 2014 Mar;45(3):554-9.
[35] Wenger D, Andersson S. Low risk of nonunion with lateral locked plating of distal femoral fractures - A retrospective study of 191 consecutive patients. Injury. 2019 Feb;50(2):448-452.
[36] Gardner MJ, Toro-Arbelaez JB, Harrison M, Hierholzer C, Lorich DG, Helfet DL. Open Reduction and Internal Fixation of Distal Femoral Nonunions: Long-Term Functional Outcomes Following a Treatment Protocol. J Trauma. 2008 Feb;64(2):434-8.
[37] Ebraheim NA, Martin A, Sochacki KR, Liu J. Nonunion of Distal Femoral Fractures: a Systematic Review. Orthop Surg 2013;5:46–50.
[38] Moloney GB, Pan T, Van Eck CF, Patel D, Tarkin I. Geriatric distal femur fracture: Are we underestimating the rate of local and systemic complications? Injury. August 2016 Volume 47, Issue 8, Pages 1732–1736.
[39] von Rüden C, Augat P. Failure of fracture fixation in osteoporotic bone. Injury. June 2016 Volume 47, Supplement 2, Pages S3–S10.
[40] Herrera DA, Kregor PJ, Cole PA, Levy BA, Jönsson A, Zlowodzki M. Treatment of acute distal femur fractures above a total knee arthroplasty: systematic review of 415 cases (1981–2006). Acta Orthop 2008;79:22–7.
[41] Kuzyk PRT, Watts E, Backstein D. Revision Total Knee Arthroplasty for the Management of Periprosthetic Fractures. J Am Acad Orthop Surg. 2017 Sep;25(9):624-633.
[2] Athar SM, Fazal MA, Hassan M, Ashwood N. Distal Femoral Fractures in the Elderly: Does Early Treatment with Locking Plates Reduce Mortality Rates? Clin Res Open Access 2017; 3(1)
[3] Streubel PN, Ricci WM, Wong A, Gardner MJ. Mortality After Distal Femur Fractures in Elderly Patients. Clin Orthop Relat Res 2011 Apr; 469(4), 1188–1196.
[4] Jordan RW, Chahal GS, Davies M, Srinivas K. A Comparison of Mortality following Distal Femoral Fractures and Hip Fractures in an Elderly Population. Adv Orthop Surg, vol. 2014, Article ID 873785, 4 pages, 2014. https://doi.org/10.1155/2014/873785.
[5] Ehlinger M, Ducrot G, Adam P, Bonnomet F. Distal femur fractures. Surgical techniques and a review of the literature. Orthop Traumatol Surg Res. 2013 May;99(3):3, 53-60.
[6] Link BC, Babst R. Current concepts in fractures of the distal femur. Acta Chir Orthop
Traumatol Cech. 2012;79(1):11-20.
[7] Kammerlander C, Riedmüller P, Gosch M, Zegg M, Kammerlander-Knauer U, Schmid R, et al. Functional outcome and mortality in geriatric distal femoral fractures. Injury 2012, 43(7), 1096–1101.
[8] Hill BW, Cannada LK. Hoffa Fragments in the Geriatric Distal Femur Fracture: Myth or Reality?. Geriatr Orthop Surg Rehabil. 2017;8(4):252–255.
[9] Johnston AT, Tsiridis E, Eyres KS, Toms AD. Periprosthetic fractures in the distal femur following total knee replacement: A review and guide to management. Knee. 2012 Jun;19(3):156-62.
[10] Nauth A, Ristevski B, Bégué T, Schemitsch EH. Periprosthetic distal femur fractures: current concepts. J Orthop Trauma. 2011 Jun;25 Suppl 2:S82-5.
[11] Whitehouse MR, Mehendale S. Periprosthetic fractures around the knee: current concepts and advances in management. Curr Rev Musculoskelet Med. 2014;7(2):136–144.
[12] Singh JA, Jensen M, Lewallen D. Predictors of periprosthetic fracture after total knee replacement: an analysis of 21,723 cases. Acta Orthop. 2013;84(2):170–177.
[13] Rorabeck CH, Taylor JW. Classification of periprosthetic fractures complicating total knee
arthroplasty. Orthop Clin North Am. 1999;30:209–214.
[14] Backstein D, Safir O, Gross A. Periprosthetic fractures of the knee. J Arthroplasty. 2007;22(4
Suppl 1):45-9.
[15] Obakponovwe O, Kallala R, Stavrou PZ, Harwood P, Giannoudis P. The management of distal femoral fractures: a literature review. Orthop Trauma, Volume 26, Issue 3, June 2012, Pages 176-183.
[16] Senthilkumaran S, MacDonald DRW, Rankin I, Stevenson I. Total knee arthroplasty for distal femoral fractures in osteoporotic bone: a systematic literature review. Eur J Trauma Emerg Surg. 2019 Feb 28.
[17] Yaacobi E, Sanchez D, Maniar H, Horwitz DS. Surgical treatment of osteoporotic fractures: An update on the principles of management. Injury. 2017 Dec;48 Suppl 7:S34-S40.
[18] Loosen A, Fritz Y, Dietrich M. Surgical Treatment of Distal Femur Fractures in Geriatric Patients. Geriatr Orthop Surg Rehabil. 2019;10:2151459319860723. Published 2019 Jul 2.
[19] Piétu G, Ehlinger M. Minimally invasive internal fixation of distal femur fractures. Orthop
Traumatol Surg Res. 2017 Feb;103(1S):S161-S169.
[20] Paller DJ, Frenzen SW, Bartlett CS 3rd, Beardsley CL, Beynnon BD. A three-dimensional comparison of intramedullary nail constructs for osteopenic supracondylar femur fractures. J Orthop Trauma. 2013. February;27(2):93-9.
[21] Wähnert D, Hoffmeier K, Fröber R, Hofmann GO, Mückley T. Distal femur fractures of the elderly—different treatment options in a biomechanical comparison. Injury. 2011;42(7):655–659.
[22] Carmack DB, Moed BR, Kingston C, Zmurko M , Watson JT, Richardson M. Identification of the optimal intercondylar starting point for retrograde nailing: an anatomic study. J. Trauma, 55: 692-695, 2003.
[23] Thompson SM, Lindisfarne EAO, Bradley N, Solan M. Periprosthetic Supracondylar Femoral
Fractures Above a Total Knee Replacement: Compatibility Guide for Fixation With a Retrograde
Intramedullary Nail. J. Arthroplasty, August 2014, Volume 29, Issue 8, Pages
1639–1641.
[24] Kulkarni SG, Varshneya A, Kulkarni GS, Kulkarni MG, Kulkarni VS, Kulkarni RM. Antegrade Interlocking Nailing for Distal Femoral Fractures. J Orthop Surg, Apr. 2012, pp. 48–54.
[25] Rommens PM, Küchle R, Hofmann A, Hessmann MH. Intramedullary Nailing of Metaphyseal Fractures of the Lower Extremity. Acta Chir Orthop Traumatol Cech. 2017;84(5):330-340.
[26] Kandemir U. Distal femur: dynamization of plating. Injury. 2018 Jun;49 Suppl 1:S44-S48.
[27] Harvin WH, Oladeji LO, Della Rocca GJ, Murtha YM, Volgas DA, Stannard JP, et al. Working length and proximal screw constructs in plate osteosynthesis of distal femur fractures. Injury. 2017 Nov;48(11):2597-2601.
[28] Park KC, Lim SJ, Song YS, Hwang KT. Factors affecting peri-implant fracture following locking plate for osteoporotic distal femur fractures. Orthop Traumatol Surg Res. 2017 Dec;103(8):1201-1204.
[29] Mau-Moeller A, Behrens M, Felser S, Bruhn S, Mittelmeier W, Bader R et al.Modulation and Predictors of Periprosthetic Bone Mineral Density following Total Knee Arthroplasty. Biomed Res Int. 2015;2015:418168.
[30] Kubiak EN, Haller JM, Kemper DD, Presson AP, Higgins TF, Horwitz DS. Does the lateral plate need to overlap the stem to mitigate stress concentration when treating Vancouver C periprosthetic supracondylar femur fracture? J Arthroplasty. 2015 Jan;30(1):104-8.
[31] McGraw P, Kumar A. Periprosthetic fractures of the femur after total knee arthroplasty. J
Orthop Traumatol. 2010;11(3):135–141.
[32] Canton G, Ratti C, Fattori R, Hoxhaj B, Murena L. Periprosthetic knee fractures. A review of epidemiology, risk factors, diagnosis, management and outcome. Acta Biomed. 2017 Jun 7;88(2S):118-128.
[33] Koso RE, Terhoeve C, Steen RG, Zura R. Healing, nonunion, and re-operation after internal fixation of diaphyseal and distal femoral fractures: a systematic review and meta-analysis. Int Orthop. 2018 Nov;42(11):2675-2683.
[34] Rodriguez EK, Boulton C, Weaver MJ, Herder LM, Morgan JH, Chacko AT, et al. Predictive factors of distal femoral fracture nonunion after lateral locked plating: A retrospective multicenter case-control study of 283 fractures. Injury. 2014 Mar;45(3):554-9.
[35] Wenger D, Andersson S. Low risk of nonunion with lateral locked plating of distal femoral fractures - A retrospective study of 191 consecutive patients. Injury. 2019 Feb;50(2):448-452.
[36] Gardner MJ, Toro-Arbelaez JB, Harrison M, Hierholzer C, Lorich DG, Helfet DL. Open Reduction and Internal Fixation of Distal Femoral Nonunions: Long-Term Functional Outcomes Following a Treatment Protocol. J Trauma. 2008 Feb;64(2):434-8.
[37] Ebraheim NA, Martin A, Sochacki KR, Liu J. Nonunion of Distal Femoral Fractures: a Systematic Review. Orthop Surg 2013;5:46–50.
[38] Moloney GB, Pan T, Van Eck CF, Patel D, Tarkin I. Geriatric distal femur fracture: Are we underestimating the rate of local and systemic complications? Injury. August 2016 Volume 47, Issue 8, Pages 1732–1736.
[39] von Rüden C, Augat P. Failure of fracture fixation in osteoporotic bone. Injury. June 2016 Volume 47, Supplement 2, Pages S3–S10.
[40] Herrera DA, Kregor PJ, Cole PA, Levy BA, Jönsson A, Zlowodzki M. Treatment of acute distal femur fractures above a total knee arthroplasty: systematic review of 415 cases (1981–2006). Acta Orthop 2008;79:22–7.
[41] Kuzyk PRT, Watts E, Backstein D. Revision Total Knee Arthroplasty for the Management of Periprosthetic Fractures. J Am Acad Orthop Surg. 2017 Sep;25(9):624-633.
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1.
Canton G, Giraldi G, Dussi M, Ratti C, Murena L. Osteoporotic distal femur fractures in the elderly: peculiarities and treatment strategies. Acta Biomed. 2019;90(12-S):25-32. doi:10.23750/abm.v90i12-S.8958
