The Journal of Arthroplasty 32 (2017) 202e206

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The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

Revision Arthroplasty

Open Reduction vs Distal Femoral Replacement Arthroplasty for

Comminuted Distal Femur Fractures in the Patients 70 Years and Older
Gavin P. Hart, MD, Jeffrey S. Kneisl, MD, Bryan D. Springer, MD, Joshua C. Patt, MD,
Madhav A. Karunakar, MD *
Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, NC

a r t i c l e i n f o a b s t r a c t

Article history: Background: The ideal management of distal femur fractures in the elderly is unclear. Acute arthroplasty
Received 5 April 2016 has the theoretical advantage of earlier mobilization. We examined the outcomes of patients 70 years
Received in revised form and older who underwent open reduction internal fixation (ORIF) vs distal femoral replacement (DFR)
3 June 2016
for comminuted, intra-articular distal femur fractures.
Accepted 7 June 2016
Methods: A retrospective review of patients with AO/OTA classification 33C distal femur fractures treated
Available online 23 June 2016
with either ORIF or DFR was performed. Outcomes including all-cause reoperation, length of stay,
fracture union, postoperative complications, use of ambulatory device and living situation at 1 year, and
Keywords:
intra-articular distal femur fractures
mortality were evaluated.
older adults Results: The study cohort included 38 patients: 10 underwent DFR and 28 ORIF. Mean patient age for
open reduction both cohorts was 82 years. No difference in comorbidities or mechanism of injury was found between
distal femoral replacement arthroplasty groups. The incidence of reoperation was 11% in the ORIF group and 10% in the DFR group. In the ORIF
comminuted distal femur fractures group, the average time to fracture union was 24 weeks, with a nonunion incidence of 18%. Twenty-three
percent of ORIF group were wheelchair dependent vs none in the DFR cohort, although not statistically
significant. Differences between the groups with respect to all-cause reoperation, living situation or need
for ambulatory device at 1 year, and 1-year mortality did not reach statistical significance.
Conclusion: Nearly 1 in 5 patients older than 70 years developed a nonunion after ORIF of an intra-
articular distal femur fracture. At 1-year follow-up, all patients in DFR group were ambulatory while 1
in 4 in the ORIF group were wheelchair bound.
© 2016 Elsevier Inc. All rights reserved.

The ideal management of intra-articular distal femur fractures
in the elderly is unclear. Over the past several decades, treatment of
these injuries has evolved from the routine use of nonoperative
techniques to condylar buttress plates, fixed-angle devices, intra-
medullary nails, cement augmentation, and recently locked
condylar plates [1-11]. Yet, despite these shifts in fixation methods,
these fractures remain associated with significant morbidity and
disability. Complications such as nonunion remain common, with a
reported incidence anywhere between 6% and 20% [12-15]. Patients
One or more of the authors of this paper have disclosed potential or pertinent
conflicts of interest, which may include receipt of payment, either direct or indirect,
institutional support, or association with an entity in the biomedical field which
may be perceived to have potential conflict of interest with this work. For full
disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2016.06.006.
* Reprint requests: Madhav A. Karunakar, MD, Department of Orthopaedic Sur-
gery, Carolinas Medical Center, 1025 Morehead Medical Plaza, Charlotte, NC 28204.
who develop a nonunion often require revision surgery, prolonging
their recovery and potentially impacting their long-term mobility.
The importance of arthroplasty in the management of fractures
of the proximal femur has only relatively recently been established.
Several randomized controlled trials have demonstrated better
outcomes with total hip arthroplasty rather than with internal
fixation for displaced femoral neck fractures in elderly patients [16-
21]. In these studies, arthroplasty was associated with lower rates
of reoperation, higher health-outcome scores, and better mobility
at the time of final follow-up. In contrast, the role of arthroplasty in
the management of intra-articular fractures of the distal femur
remains poorly defined.
The majority of the literature regarding the use of distal femoral
replacement (DFR) arthroplasty for fracture involves the treatment
of nonunion or periprosthetic fractures above total knee arthro-
plasties [22-34]. Nevertheless, a small number of authors have re-
ported on the use of DFR in the treatment of acute fractures around
native knees [27,29,31,34-36]. These studies report all-cause

http://dx.doi.org/10.1016/j.arth.2016.06.006
0883-5403/© 2016 Elsevier Inc. All rights reserved.
 G.P. Hart et al. / The Journal of Arthroplasty 32 (2017) 202e206
reoperation rates from 0% to 33%, with 63% to 100% of surviving
patients regaining their preinjury ambulatory status at 1 year. The
purpose of this study was to review our experience treating intra-
articular distal femur fractures in an elderly cohort of patients.
Specifically, we wished to compare the outcomes of patients older
than 70 years treated for intra-articular distal femur fractures with
DFR with those treated with open reduction internal fixation
(ORIF).
Methods
After obtaining institutional review board approval, we per-
formed a retrospective review of patients treated for distal femur
fractures at our institution from 2007 to 2012. Patients were
included if they were aged 70 years or older and had sustained a
comminuted, intra-articular (AO/OTA classification 33C) distal fe-
mur fracture (Fig. 1). Exclusion criteria included an inability to
ambulate before injury, fractures above a total knee arthroplasty,
and the presence of bilateral injuries. Using our electronic medical
record and total joint registry, demographic data (age, gender,
comorbidities), as well as fracture type, treatment method, reason
for DFR (if applicable), were documented. Outcomes recorded
included all-cause reoperation, hospital length of stay, hospital
disposition, fracture union, time to union, postoperative compli-
cations, need for ambulatory assistive device at 1 year, and living
situation at 1 year.
Surgery was performed after each patient was medically opti-
mized and informed consent was obtained. All patients were
treated by surgeons trained in trauma or arthroplasty. The decision
to proceed with DFR or ORIF was made by the attending surgeon
caring for the patient. The indication for ORIF or DFR was obtained
by retrospectively reviewing the original operative note. Fractures
were treated with ORIF if the fracture pattern was felt to be
amenable to operative fixation, specifically if there was sufficient
bone stock to permit predictable fracture fixation. Indications given
for proceeding with DFR included “concomitant knee arthritis,”
“significant fracture comminution,” “inadequate bone stock to
achieve fixation,” and “potential for earlier mobilization.”
Fig. 1. Injury radiograph from a study patient illustrating a comminuted, intra-
articular (AO/OTA classification 33C) distal femur fracture.
203
The type of prosthesis used for ORIF or DFR was at the discretion
of the treating surgeon. Patients undergoing ORIF were treated
with either the Smith and Nephew PERI-LOC locking distal femur
plate (Smith and Nephew, Memphis, TN) or the Synthes LCP locking
distal femur plate (Synthes, West Chester, PA). Fracture fixation was
performed through an anterolateral approach to the distal femur.
The intra-articular components of the fractures were reduced un-
der direct visualization, and fixation performed with a combination
of independent 3.5-mm screws and the above laterally based
locking plates (Fig. 2). Patients who underwent DFR were treated
with the Biomet Orthopaedic Salvage System (Biomet, Warsaw, IN)
or the Zimmer Segmental System Distal Femur (Zimmer, Warsaw,
IN) or the Stryker Global Modular Replacement System (Stryker,
Mahwah, NJ). The distal femur was resected through a midline skin
incision and medial parapatellar arthrotomy. The distal femur was
cut immediately above the proximal extent of the fracture, and the
DFR prosthesis was cemented or press-fit based on attending
preference (Fig. 3).
Fracture type was determined by reviewing the original injury
radiographs. The fractures were classified according to the AO/OTA
classification [37,38]. Fracture union and time to union was deter-
mined by the treating physician and recorded from the original
clinic notes. Hospital disposition was categorized as home, reha-
bilitation facility, skilled nursing facility, or death. Living situation
at 1 year was categorized as home, nursing facility, or death.
Postoperative complications included myocardial infarction, stroke,
death, deep vein thrombosis (DVT), pulmonary embolus, superficial
or deep infection, nonunion, and malunion.
Descriptive statistics of the patient samples were calculated. T
tests were conducted for comparisons between groups of
continuous variables, chi-square tests for comparisons between
groups of unranked categorical variables, and Fisher exact test
where appropriate. Significance was set at the P < .05 level for all
analyses.
Fig. 2. Postoperative radiograph demonstrating operative fixation of a comminuted,
intra-articular distal femur fracture.
204 G.P. Hart et al. / The Journal of Arthroplasty 32 (2017) 202e206
Fig. 3. Postoperative radiograph demonstrating distal femoral replacement for a
comminuted, intra-articular distal femur fracture.
Results
A total of 229 patients underwent treatment for 230 distal fe-
mur fractures at our institution from 2007 to 2012. One patient died
before treatment, and 33 fractures were treated nonoperatively.
The remaining 196 fractures were classified according to the AO/
OTA system, allowing the exclusion of 61 A-type and B-type frac-
tures as well as 69 periprosthetic fractures. Twenty-eight of these
remaining 66 total C-type fractures were then excluded as they
occurred in patients younger than 70 years of age, leaving the 38
fractures included in the study. Of these patients, 10 underwent
DFR and 28 ORIF (Fig. 4).
Demographic information can be found in Table 1. The mean
patient age for the ORIF cohort was 82.0 years (range, 70.2-96.7),
while the mean patient age for the DFR cohort was 81.8 years
(range, 70.9-91.7; P ¼ .95). All of the patients in the DFR were
women (10/10), while 83.4% of the patients in the ORIF group (26/
28) were women. The 2 groups had similar overall preoperative
health with a mean Charlson comorbidity index of 1.10 (range, 0-3)
in the DFR group and 1.86 (range, 0-7) in the ORIF group (P ¼ .29). In
the DFR group, 90% of patients (9/10) sustained their injury as a
result of a fall, with the other patient injured in a motor vehicle
accident. Eighty-nine percent (25/28) of the patients in the ORIF
group were injured following a fall, while 11% (3/28) were injured
in a motor vehicle accident. No difference in mechanism of injury
was found between the groups (P ¼ .99).
Mean hospital length of stay was 7.5 days (range, 3-25) in the
ORIF group and 7.3 days (range, 4-12) in the DFR group (P ¼ .41).
There was no difference between the cohorts with respect to
discharge disposition. Eighty percent of patients who underwent
DFR required discharge to a skilled nursing facility, in comparison
with 79% of those who underwent ORIF. No difference in post-
operative complications was observed between the groups. In the
DFR group, there was 1 deep vein thrombosis, 1 superficial infec-
tion, and 1 deep infection, while in the ORIF group, 1 superficial
infection and 1 deep infection occurred (P ¼ .46). No other post-
operative complications occurred in the study population.
Average time to fracture union was 24.2 weeks (range, 9-128).
Five (18%) of the patients who underwent ORIF developed a
nonunion. Three of these patients went on to undergo revision
surgery, 1 requiring an irrigation, debridement, and revision ORIF
for an infected nonunion, while the other 2 underwent revision
ORIF with bone grafting. One of the patients in the DFR group
developed a deep infection requiring a return to the operating room
for irrigation and debridement. The overall incidence of secondary
surgery was 11% (3/28) in the ORIF group and 10% (1/10) in the DFR
group, not reaching statistical significance (P > .9).
There was no difference between the DFR and ORIF groups with
respect to hospital disposition. One (10%) of the DFR patients died
before leaving the hospital. The remainder of the DFR patients were
discharged to either a rehabilitation facility (1/10; 10%) or a skilled
nursing facility (8/10; 80%). In the ORIF group, 2 (7%) were able to
be discharged to home, while 4 (14%) were discharged to a reha-
bilitation facility and 22 (79%) to a skilled nursing facility (P ¼ .45).
One-year follow-up was available for 29 of the initial 38 patients
(76%), 7 of 10 of the DFR cohort, and 22 of 28 of the ORIF cohort. All
patients with 1-year follow-up in the DFR group required an
ambulatory device, with 43% (3/7) requiring a cane and 57% (4/7)
requiring a walker. No patients in the DFR group were wheelchair
dependent at 1-year follow-up. In the ORIF cohort, 27% (6/22) of
patients were able to ambulate independently at 1 year, while 14%
(3/22) required a cane, 36% (8/22) required a walker, and 23% (5/22)
were wheelchair dependent. There was no statistical difference
between the DFR and ORIF groups in need for an ambulatory device
at 1 year (P ¼ .29).
With respect to living situation, 71% (5/7) of the DFR patients
were living at home at 1 year, with the remaining 29% (2/7) living at
a nursing facility. In the ORIF group, 82% (18/22) were living at
home while 18% (4/22) were living at a nursing facility. There was
no difference between the groups with respect to living situation at
1 year (P ¼ .61).
Discussion
Intra-articular distal femur fractures present operative chal-
lenges for physicians and result in significant morbidity for elderly
patients. Prolonged periods of protected weight bearing, limited
fixation secondary to poor bone stock, and increased risk of
nonunion [12-15] pose technical challenges. We retrospectively
evaluated the experience at our institution treating comminuted,
complete articular distal femur fractures in patients older than 70
years with either ORIF or DFR arthroplasty. While we were not able
to demonstrate a statistical difference between the groups with
respect to all-cause reoperation, we did find that almost 1 in 5
patients in the ORIF group developed a nonunion. Furthermore, at 1
year, all surviving patients in the DFR group were ambulatory,
while 23% of the surviving patients in the ORIF group were
wheelchair dependent.
The outcomes of the patients in the ORIF group are similar to
those presented in previous studies of patients undergoing locked
plating for distal femur fractures. The 18% nonunion rate we
observed in our ORIF group is consistent with the range of 6% to 20%
in the existing literature [12-15,36,39-41]. Two of these studies
[40,41] reported the ambulatory status of patients at 1 year from
injury, albeit in patients with fractures above a total knee arthro-
plasty. Together these studies were comprised of 81 patients. At
mean follow-ups of 12 and 18 months, 81% (66/81) of patients had
returned to their preinjury ambulatory status, 11% (9/81) of patients
had lost a level of ambulation (ie, requiring a cane after previously
ambulating without assistive device), and 7% (6/81) required the
 G.P. Hart et al. / The Journal of Arthroplasty 32 (2017) 202e206 205

Fig. 4. Patient flow diagram illustrating creation of final treatment cohorts. DFR, distal femoral replacement; ORIF, open reduction internal fixation.

use of a wheelchair after previously being ambulatory. In our study, deep infection rate of 16% (15/93 patients) and an all-cause reop-
nearly 1 in 4 of the patients in our ORIF group were wheelchair eration rate of 40% (37/93 patients) at a mean follow-up of 51.2
dependent at a year. months. Ambulatory status at final follow-up was included in 2 of
Several small series have examined the use of DFR for the the studies. The first reported wheelchair dependence at final
treatment of acute fractures of native distal femurs among a follow-up in 20% (1/5 patients) [27]. The second study [31] strati-
number of other indications [27,29,31]. In total, 7 patients with fied patients into “good to excellent” or “fair to poor” based on
acute distal femur fractures treated with DFR as well as 111 patients patients' level of knee pain, walking ability, SF-36 and Knee Society
treated with DFR for the management of nonunion, periprosthetic scores. Ten patients (10/44; 23%) were classified as having “limited
distal femur fractures, ligamentous instability, and congenital knee walking ability” at final follow-up.
dislocation were presented. These studies reported a combined A study comparing DFR to ORIF for the treatment of supra-
condylar femur fractures in the elderly has been previously pub-
Table 1 lished [36]. The series included patients aged 75 years or older who
Demographic Information for the Distal Femoral Replacement (DFR) and Open were able to walk independently preoperatively and who had an
Reduction Internal Fixation (ORIF) Groups. American Society of Anesthesiologists score of 2 or less. The authors
DFR ORIF P Value were able to compare 4 patients who underwent ORIF to 6 patients
Mean age 81.8 y (range, 70.9-91.7) 82.0 y (range, 70.2-96.7) .95
who underwent DFR with a mean age of 85.8 years. During the
Sex 100% 92.9% .99 acute hospitalization, the authors reported that 5 of the 6 patients
Female 10/10 26/28 who underwent DFR were able to ambulate independently at
Charlson 1.10 (0-3) 1.86 (0-7) .29 discharge compared to just 1 of 4 in the ORIF group. At a mean of
comorbidity
30.2-month follow-up, the authors reported a mean Oxford knee
index
Mechanism of score of 27.5 in the ORIF group and 32.5 in the DFR group. No
injury comparative statistics are included with the data. No deep in-
Fall 9/10 (90%) 25/28 (89%) .99 fections or reoperations were reported by the authors.
MVA 1/10 (10%) 3/28 (11%) Rosen et al also reported on the use of DFR for the treatment of
MVA, motor vehicle accident. acute, non-periprosthetic femur fractures in 24 patients with a
206 G.P. Hart et al. / The Journal of Arthroplasty 32 (2017) 202e206
mean age of 76 years, the majority with AO/OTA type C fractures
[35]. All patients were independent community ambulators before
their injury. At a mean follow-up of 11 months, all patients had
returned to full weight bearing and preinjury level of ambulation,
although 7 patients required an additional assistive device. The all-
cause reoperation rate was 4% (1/24 patients), with 1 patient
revised for hinge dislocation. No deep infections occurred.
The largest series exploring the use of DFR for acute, non-
periprosthetic distal femur fractures included 54 fractures in 52
patients with a mean age of 82 years (range, 55-98) [34]. The au-
thors reported an all-cause reoperation rate of 18.1% at 3-year
follow-up, with a deep infection rate of 1.8%. Differing from the
previously discussed studies, all patients in this series were pri-
marily household ambulators preoperatively, likely representing a
frailer population and perhaps accounting for the observed 1-year
mortality of 42% (22/52 patients).
We feel the biggest strength of our study is a homogeneous and
stringently defined patient cohort. By limiting the included patients
to ambulatory individuals 70 years and older with only AO/OTA
classification 33C distal femur fractures, we believe we have
created a study population that would widely be considered can-
didates for either ORIF or DFR. Our study is limited by its retro-
spective nature and relatively small numbers. The low incidence of
distal femur fractures, especially when further restricted to AO/OTA
classification 33C fractures in patients 70 years and older, makes
this a difficult injury to study in large numbers. Additionally, we
concede that our study is likely underpowered and that there might
truly be a difference in all-cause reoperation as well as 1-year
mobility between the 2 treatment modalities.
While our study is limited by small numbers, we do feel our
results have important quality of life implications. The relatively
high rate of nonunion and 1-year disability found in the ORIF group
represent unfortunate outcomes for this vulnerable population. The
promise of DFR for the treatment of comminuted, complete artic-
ular distal femur fractures is the possibility of earlier mobilization,
potentially allowing patients to better avoid the long-term
disability associated with these injuries. In light of our study and
the existing literature, we feel a well-designed, prospective, ran-
domized controlled trial comparing ORIF and DFR for comminuted,
complete articular distal femur fractures in the elderly could
potentially help improve outcomes in this population and be an
important contribution to a gap in the literature.
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