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

Abstract and Introduction


Introduction: This study sought to determine the effect of trauma fellowship training on the surgical decision to fix or revise to distal femoral replacement in periprosthetic distal femur fractures.

Methods: An anonymous online survey including nine cases of geriatric periprosthetic distal femur fractures was distributed through the Orthopaedic Trauma Association website. Respondents were asked whether they would recommend fixation or revision to distal femoral replacement. Fractures were classified by the location relative to the anterior flange (proximal or distal) and the presence or absence of comminution. Recommendations were compared between type of fellowship completed (trauma, arthroplasty, or both), practice setting, and number of periprosthetic distal femur fractures treated monthly.

Results: One hundred fifty-one surgeon survey responses were included. Completion of a trauma fellowship was associated with a higher likelihood of recommending fixation for any periprosthetic distal femur fracture compared with arthroplasty training (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.97 to 3.29; P < 0.0001). Disagreement was significant for comminuted proximal (OR 6.90, 95% CI 3.24 to 14.68; P < 0.0001), simple distal (OR 20.90, 95% CI 6.41 to 67.71; P < 0.001), and comminuted distal fractures (OR 2.47, 95% CI 1.66 to 3.68; P < 0.0001). Dual fellowship-trained surgeons were less likely to recommend fixation than surgeons who completed a trauma fellowship alone (OR 0.60, 95% CI 0.39 to 0.93; P = 0.027) and 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). Surgeons who treat three or more periprosthetic distal femur fractures monthly showed a significant preference for fracture fixation compared with lower volume surgeons (OR 2.45, 95% CI 1.62 to 3.68; P < 0.0001).

Discussion: Fellowship-trained trauma surgeons show a notable preference for fracture fixation over distal femoral replacement for periprosthetic distal femur fractures, as compared with arthroplasty-trained surgeons. Additional research is needed to clarify surgical indications that maximize outcomes for these injuries.


Periprosthetic distal femur fractures above total knee arthroplasties are morbid injuries that are increasingly common.[1–5] Mortality rates have been reported up to 27% at one year, which is slightly higher than those of hip fractures.[2] Despite increasing incidence and high morbidity, the optimal treatment remains unknown. Surgical options include open reduction and surgical fixation, typically with a retrograde intramedullary nail or lateral locking plate construct, or revision to distal femoral replacement (DFR).

Traditionally, advantages of primary DFR have included immediate weight bearing, lack of dependence on fracture healing (particularly in very distal fractures or patients at risk for nonunion), and the ability to address preexisting problems with the total knee arthroplasty, such as loosening or malalignment.[4,6–8] Advocates of DFR cite high nonunion rates after fixation[9] and higher complication rates after conversion DFR after failed surgical fixation, as compared with primary DFR.[10] However, in the absence of a loose or otherwise poorly functioning total knee arthroplasty, there are few widely accepted indications for acute DFR over surgical fixation.

The traditional advantages of DFR have also been challenged by recent research suggesting that even very distal fractures can heal uneventfully after surgical fixation[11] and that fixation can be maintained with immediate weight bearing using a variety of constructs.[12–16] Furthermore, surgical fixation offers a less invasive procedure, which preserves bone stock and has more salvage options should a major complication occur.

With two viable treatment options and limited evidence to guide surgical decision-making, the decision to fix or revise is primarily dependent on surgeon discretion. Biases from fellowship training or past experience likely factor into this decision but have not been described. The purpose of this study was to examine the effect of fellowship training background on treatment preference for fixation versus revision to DFR in a series of geriatric periprosthetic distal femur fractures with varying morphologies. We hypothesized that the completion of a trauma fellowship compared with an arthroplasty fellowship would be associated with a preference for fixation over revision to DFR.