Open reduction and internal fixation versus distal femoral replacement for periprosthetic distal femur fractures: a systematic review and meta-analysis

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Abstract Objectives: This systematic review and meta-analysis compares open reduction and internal fixation (ORIF) versus distal femoral replacement (DFR) for periprosthetic distal femur fractures (PDFF), focusing on patient-reported outcomes, perioperative measures, functional results, and complications. Data Sources: Following PRISMA guidelines, PubMed, Embase, Scopus, and ScienceDirect were searched from January 2010 through November 2024 using keywords and MeSH strategies. Study Selection: Studies were eligible if they compared outcomes of ORIF and DFR for PDFFs and included ≥10 patients. Exclusion criteria included noncomparative studies, primary arthroplasty indications, and nonperiprosthetic fractures. Data Extraction: Two independent reviewers extracted data on demographics, interventions, patient-reported outcomes, functional outcomes, and complications. Quality was assessed using the Newcastle–Ottawa Scale. Discrepancies were resolved by a third author. Data Synthesis: Random-effects meta-analyses were used to calculate pooled incidence rates and risk ratios with 95% confidence intervals. Heterogeneity was assessed via I 2 and Cochran Q. Thirteen retrospective cohort studies (n = 881; ORIF: 554, DFR: 327) were included. Conclusions: Knee Society Functional Scores were significantly better for ORIF vs DFR in the 2 studies reporting this metric (53 vs 39, P = 0.012; 52 vs 37, P = 0.027). There was no significant difference in Oxford Knee Scores (MD = −0.11, 95% confidence intervals: [−1.74, 1.52], P = 0.85). Mean time to weight bearing was shorter for DFR vs ORIF (2 vs 78 days, respectively; P = 0.04), although risk ratios for returning to preoperative mobility and achieving unassisted ambulation were statistically insignificant. The rate of reoperation was significantly higher for ORIF versus DFR (12% vs 7%, respectively; P = 0.048). ORIF may offer advantages in patient-reported functional outcomes compared with DFR. Although DFR allows for immediate weight bearing, this advantage may not imply superior long-term mobility. Level of Evidence: Level III.

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