Periprosthetic Distal Femur Fractures: Review of Current Treatment Options


  • Justin M Head Michigan State University Statewide Campus Systems



total knee, complication, periprosthetic fracture, revision total knee, osteoporosis, femoral notching


The geriatric population in general and specifically recipients of total knee arthroplasty (TKA) have increasing functional demands along with an increasing life expectancy. Certain intraoperative aspects of the index procedure, revision TKA, or the patient’s physiology (i.e.- osteoporosis, rheumatoid arthritis, neurologic disease) predispose the patient to post-operative periprosthetic distal femur fractures (PDFF). This review describes the epidemiology, classification, examination, and treatment options of PDFF. Osteoporosis and intraoperative anterior femoral cortex notching are primary patient and surgeon specific factors, respectively. The two most commonly used classification systems were described by Rorabeck and Kim and should be used to guide the surgeon’s choice of treatment.  The non-operative treatment of PDFF is rare, requires close radiographic follow up, and delayed union is common. Open reduction with internal fixation (ORIF) is best accomplished with minimally invasive techniques and distal locking screws. Retrograde, intra-medullary nail fixation is technically difficult, but provides earlier weight bearing and comparable time to union as ORIF.  Revision TKA is indicated in patients with adequate bone stock, a simple fracture pattern without ligamentous instability, and a loose or malaligned femoral component.  Allograft-prosthetic composite (APC) or distal femoral replacement (DFR) is indicated for patients presenting with a PDFF about poor or deficient bone stock.  Patients with PDFF present a challenge to the arthroplasty surgeon in regards to choice of treatment and increased morbidity and mortality post-operatively. Close follow up is required and fracture union is often delayed.

Author Biography

Justin M Head, Michigan State University Statewide Campus Systems

Department of Orthopedic Surgery



Maradit Kremers H, Larson DR, Crowson CS, et al. Prevalence of Total Hip and Knee Replacement in the United States. The Journal of Bone and Joint Surgery American volume. 2015;97(17):1386-1397. doi:10.2106/JBJS.N.01141.

Bezwada HP, Neubauer P, Baker J, et. al. Periprosthetic supracondylar femur fractures following total knee arthroplasty. J Arthroplasty. 2004;19: 453–458.

Figgie MP, Goldberg VM, Figgie HE III, et. al. The result of treatment of supracondylar fracture above total knee arthroplasty. J Arthroplasty. 1990; 5:267–276.

Saidi KM, Ben-Lulu O, Tsui M, Safir O, Gross AE, Backstein D. Supracondylar Periprosthetic Fractures of the Knee in the Elderly Patients: A Comparison of Treatment Using Allograft-Implant Composites, Standard Revision Components, Distal Femoral Replacement Prosthesis. J Arthroplasty. 2014;1: 110 - 114.

Dennis DA. Peri-prosthetic fractures following total knee arthroplasty. J Bone Joint Surg. 2001; 83-A: 120-128.

Delport PH, Van Audekercke R, Martens M, Mulier JC. Conservative treatment of ipsilateral supracondylar femoral fracture after total knee arthroplasty. J Trauma 1984; 24: 846–849.

Culp RW, Schmidt RG, Hanks G, Mak A, Esterhai JL, Heppenstall RB. Supracondylar fracture of the femur following prosthetic knee arthroplasty. Clin Orthop. 1987; 222:212–222

Rorabeck CH, Taylor JW. Periprosthetic fractures of the femur complicating total knee arthroplasty. Orthop Clin North Am. 1999; 30:265–277.

Schroder HM, Berthelsen A, Hassani G. Cementless porous coated total knee arthroplasty: 10-year results in a consecutive series. J Arthroplasty. 2001;16:559–567.

Johnell O, Kanis J. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporosis Int. 2006; 17: 1726–1733

Shawen SB, Belmont PJ Jr, Klemme WR, Topoleski LD, Xenos JS, Orchowski JR. Osteoporosis and anterior femoral notching in periprosthetic supracondylar femoral fractures: a biomechanical analysis. J Bone Joint Surg Am 2003;85-A(1):115-121.

Meek RMD, Norwood T, Smith R, Brenkel IJ, Howie CR. The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement. J Bone Joint Surg [Br] 2011;93-B:96-101.

Raab GE, Davis CM 3rd. Early healing with locked condylar plating of periprosthetic fractures around the knee. J Arthroplasty. 2005;20: 984–989.

DiGioia AM, Rubash HE: Periprosthetic fractures of the femur after total knee arthroplasty: A literature review and treatment algorithm. Clin Orthop 1991;271:135-142.

Berry DJ. EPIDEMIOLOGY: Hip and Knee. Clin Orthop. 1999;30:183–190.

Lesh ML, Schneider DJ, Deol G, et al. The consequences of anterior femoral notching in total knee arthroplasty. A biomechanical study. J Bone Joint Surg Am 2000;82:1096–1101.

Gujarathi N, Putti AB, Abboud RJ, MacLean JG, Espley AJ, Kellett CF. Risk of periprosthetic fracture after anterior femoral notching. Acta Orthop. 2009 Oct;80(5):553-6.

Ritter MA, Thong AE, Keating EM, Faris PM, Meding JB, Berend ME, Pierson JL, Davis KE. The effect of femoral notching during total knee arthroplasty on the prevalence of postoperative femoral fractures and on clinical outcome. J Bone Joint Surg Am. 2005;87(11):2411-4.

Conlisk N, Howie CR, Pankaj P. An efficient method to capture the impact of total knee replacement on a variety of simulated patient types: A finite element study. Med Eng Phys. 2016 Sep;38(9):959-68.

Kim K, Egol KA, Hozack WJ, Parvizi J. Periprosthetic fractures after total knee arthroplasties. Clin Orthop Relat Res. 2006;446: 167–75.

Bonanzinga T, Zahar A, Dütsch M, Lausmann C, Kendoff D, Gehrke T. How Reliable Is the Alpha-defensin Immunoassay Test for Diagnosing Periprosthetic Joint Infection? A Prospective Study. Clin Orthop Relat Res. 2016 Jun 24.

Merkel KD, Johnson EW Jr. Supracondylar fracture of the femur after total knee arthroplasty. J Bone Joint Surg Am. 1986;68:29–43.

Moran MC, Brick GW, Sledge CB, Dysart SH, Chien EP. Supracondylar femoral fracture following total knee arthroplasty. Clin Orthop Relat Res. 1996;324:196–209.

Egol KA, Kubiak EN, Fulkerson E, et al. Biomechanics of locked plates and screws. J Orthop Trauma. 2004;18:488–93.

Kregor PJ, Hughes JL, Cole PA. Fixation of distal femoral fractures above total knee arthroplasty utilizing the Less Invasive Stabilization System (L.I.S.S.). Injury. 2001;32:SC64–SC75.

Althausen PL, Lee MA, Finkemeier CG. Operative stabilization of supracondylar femur fractures above total knee arthroplasty: a comparison of four treatment methods. J Arthroplasty. 2003;18:834–839.

Ricci WM, Loftus T, Cox C, et al. Locked plates combined with minimally invasive insertion technique for the treatment of periprosthetic supracondylar femur fractures above a total knee arthroplasty. J Orthop Trauma. 2006;20:190–196.

Weber D, Peter RE. Distal femoral fractures after knee arthroplasty. Int Orthop. 1999;23:236–9.

Hassan S, Swamy GN, Malhotra R, Badhe NP. Periprosthetic fracture of the distal femur after total knee arthroplasty; prevalence and outcomes following treatment. J Bone Joint Surg (Br). 2012;94-B Suppl 24:6.

Norrish AR, Jibri ZA, Hopgood P. The LISS plate treatment of supracondylar fractures above a total knee replacement: a case control study. Acta Orthop Belg. 2009;75:642–8.

Streubel PN, Gardner MJ, Morphed S, Collinge CA, Gallagher B, Ricci WM. Are extreme distal periprosthetic supracondylar fractures of the femur too distal to fix using a lateral locked plate?. Bone & Joint J. 2010; 92-B(4), 527-534.

Hoffman MF, Jones CB, Sietsema DL, Koenig SJ, Tornetta P. Outcome of periprosthetic distal femoral fractures following knee arthroplasty. Injury. 2012;43:1084–9.

Ehlinger M, Adam P, Abane L, Rahme M, Moor BK, Arlettaz Y. Treatment of periprosthetic femoral fractures of the knee. Knee Surg Sports Traumatol Arthr. 2011;19:1473–89.

Pao JL, Jiang CC. Retrograde intramedullary nailing for nonunions of supracondylar femur fracture of osteoporotic bones. J Formos Med Assoc. 2005;104:54–59.

Murrell GA, Nunley JA. Interlocked supracondylar interlocked nails for supracondylar fractures after total knee arthroplasty. A new treatment method. J Arthroplasty. 1995;10:37–42.

Meneghini RM, Keyes BJ, Reddy KK, Maar DC Modern Retrograde Intramedullary Nails Versus Periarticular Locked Plates for Supracondylar Femur Fractures After Total Knee Arthroplasty, J Arthroplasty. 2014; 7:1478-1481.

Thompson SA, Lindisfarne AE, Bradley N, Solan M. Periprosthetic supracondylar femoral fractures above a total knee replacement: compatibility guide for fixation with a retrograde intramedullary nail. J Arthroplasty. 2014; 29:1639–164.

Service BC, Kang K, Turnbull N, Langford J, Haidukewych G, Koval KJ. Influence of femoral component design on retrograde femoral nail starting point. J Orthop Trauma, 2015; 29:380–384.

Kilicoglu OI, Akgül T, Sağlam Y, Yazıcıoğlu O. Comparison of locked plating and intramedullary nailing for periprosthetic supracondylar femur fractures after knee arthroplasty. Acta Orthop Belg. 2013;79:417–21.

Engh GA, Ammeen DJ. Periprosthetic fractures adjacent to total knee implants. Treatment and clinical results. J Bone Joint Surg Am. 1997;79: 1100–1113.

Keeney JA. Periprosthetic total knee arthroplasty fractures: revision arthroplasty technique. J Knee Surg. 2013;26:19–26.

Srinivasan K, Macdonald DA, Tzioupis CC, Giannoudis PV. Role of long stem revision knee prosthesis in periprosthetic and complex distal femoral fractures: a review of eight patients. Injury. 2005; 36:1094–1102

Cordeiro EN, Costa RC, Carazzato JG, Silva JDS. Periprosthetic fractures in patients with total knee arthroplasties. Cain Orthop. 1990; 252:182–189.

Kassab M, Zalzal P, Azores GMS, Pressman A, Liberman B, Gross AE. Management of periprosthetic femoral fractures after total knee arthroplasty using a distal femoral allograft. J Arthroplasty. 2004; 19:361–368.

Backstein D, Safir O, Gross A. Management of bone loss: structural grafts in revision total knee arthroplasty. Clin Orthop. 2006; 446:104–112.

Berend KR, Lombardi AV. Distal femoral replacement in non tumor cases with severe bone loss and instability. Clin Orthop Relat Res. 2009;467:485–92.

Mortazavi SM, Kurd MF, Bender B, Post Z, Parvizi J, Purtill JJ. Distal Femoral Arthroplasty for the Treatment of Periprosthetic Fractures After Total Knee Arthroplasty. J Arthroplasty 2010; 25:775-780.

Streubel PN, Ricci WM, Wong A, Gardner MJ. Mortality after distal femur fractures in elderly patients. Clin Orthop Relat Res. 2011;469:1188–96.

Christodoulou A, Terzidis I, Ploumis A, Metsovitis S, Koukoulidis A, Toptsis C. Supracondylar femoral fractures in elderly patients treated with the dynamic condylar screw and the retrograde intramedullary nail: a comparative study of the two methods. Arch Orthop Trauma Surg. 2005;125:73–9.

Boyd AD,Wilber JH. Patterns and complications of femur fractures below the hip in patients over 65 years of age. J Orthop Trauma. 1992;6:167–74.

Dunlop DG, Brenkel IJ. The supracondylar intramedullary nail in elderly patients with distal femoral fractures. Injury. 1999;30:475–84

Bolhofner BR, Carmen B, Clifford P. The results of open reduction and internal fixation of distal femur fractures using a biologic (indirect) reduction technique. J Orthop Traum. 1996;10:372–7.




How to Cite

Head, J. M. (2018). Periprosthetic Distal Femur Fractures: Review of Current Treatment Options. Reconstructive Review, 7(4).




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