Distal femur arthroplasty for non-union distal femur fracture with failed osteosynthesis in osteoporotic octogenarian: a case report with literature review


  • Lavindra Tomar Department of Orthopaedics, Max Super Speciality Hospital, Patparganj, Delhi, India
  • Gaurav Govil Department of Orthopaedics, Max Super Speciality Hospital, Patparganj, Delhi, India
  • Pawan Dhawan Department of Orthopaedics, Max Super Speciality Hospital, Patparganj, Delhi, India




Distal femur fracture, Total knee replacement, Locking plate, Non-union, Comminuted fracture


Distal femur fractures (DFF) in the elderly have high morbidity and management challenges. The low energy trauma commonly presents significant fracture comminution, osteoporosis, pre-existing knee arthritis, co-morbid medical conditions affecting the union, weight-bearing potential and rehabilitation with profound functional disability. An octogenarian presented with a failed osteosynthesis resulting in non-union of a distal femur fracture compounded by osteoporosis and knee arthritis. He had been non-ambulatory with a painful, deformed knee. Management with a single-stage removal of the distal femur locked plate constructs and the defect reconstruction with the distal femur arthroplasty (DFA). The outcome was a pain-free weight-bearing mobilization with a functional range of knee motion. The surgical management in the elderly for the displaced intra-articular distal femur fractures is to restore the limb length and articular congruence for a functional knee. Fixation with either a distal femur locking plate or an intramedullary nail has a propensity for non-union, malunion, knee stiffness, and failed fixation. Salvage procedure gives good functional outcomes in failed osteosynthesis with DFA. The arthroplasty allows an immediate pain-less weight-bearing potential with improved ambulatory status and quality of life. The single-stage procedure in the elderly can regain a stable, functional knee joint.   


Angers-Goulet M, Pelet S, Belzile EL, Bédard M. Total knee arthroplasty with distal femoral replacement is associated with an important complication rate. A case series. Knee. 2019;26(5):1080-7.

Bettin CC, Weinlein JC, Toy PC, Heck RK. Distal Femoral Replacement for Acute Distal Femoral Fractures in Elderly Patients. J Orthop Trauma. 2016;30(9):503-9.

Appleton P, Moran M, Houshian S, Robinson CM. Distal femoral fractures treated by hinged total knee replacement in elderly patients. J Bone Joint Surg Br. 2006;88(8):1065-70.

Hake ME, Davis ME, Perdue AM, Goulet JA. Modern Implant Options for the Treatment of Distal Femur Fractures. J Am Acad Orthop Surg. 2019;27(19):e867-75.

Cyr K, Greene H, Buckley R. C3 geriatric distal femoral fracture-ORIF or replace with a distal femoral replacement (DFR). Injury. 2021;52(6):1260-2.

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.

Karam, J., Campbell, P., David, M. Comparison of outcomes and analysis of risk factors for nonunion in locked plating of closed periprosthetic and non-periprosthetic distal femoral fractures in a retrospective cohort study. J Orthop Surg Res. 2019;14:150.

Ebraheim NA, Martin A, Sochacki KR, Liu J. Nonunion of distal femoral fractures: a systematic review. Orthop Surg. 2013;5(1):46-50.

Chin SL, Umar H, Zaharul A. Proximal and Distal Femur Replacement For Patient With Non Union Fracture Of Intertrochanteric And Supracondylar Of Femur In A District Hospital. Orthop J Sports Med. 2020;8(5-5):2325967120S00116.

Hart GP, Kneisl JS, Springer BD, Patt JC, Karunakar MA. Open Reduction vs Distal Femoral Replacement Arthroplasty for Comminuted Distal Femur Fractures in the Patients 70 Years and Older. J Arthroplasty. 2017;32(1):202-6.

Salazar BP, Babian AR, DeBaun MR, Githens MF, Chavez GA, Goodnough LH, Gardner MJ, Bishop JA. Distal Femur Replacement Versus Surgical Fixation for the Treatment of Geriatric Distal Femur Fractures: A Systematic Review. J Orthop Trauma. 2021;35(1):2-9.

Rajasekaran RB, Palanisami DR, Natesan R, Jayaramaraju D, Rajasekaran S. Megaprosthesis in distal femur nonunions in elderly patients-experience from twenty-four cases. Int Orthop. 2020;44(4):677-84.

Tandon T, Tadros BJ, Avasthi A, Hill R, Rao M. Management of periprosthetic distal femur fractures using distal femoral arthroplasty and fixation-Comparative study of outcomes and costs. J Clin Orthop Trauma. 2020;11(1):160-4.

Vaishya R, Singh AP, Hasija R, Singh AP. Treatment of resistant nonunion of supracondylar fractures femur by megaprosthesis. Knee Surg Sports Traumatol Arthrosc. 2011;19(7):1137-40.

Girgis E, McAllen C, Keenan J. Revision knee arthroplasty using a distal femoral replacement prosthesis for periprosthetic fractures in elderly patients. Eur J Orthop Surg Traumatol. 2018;28(1):95-102.

Matar HE, Bloch BV, James PJ. Distal Femoral Replacements for Acute Comminuted Periprosthetic Knee Fractures: Satisfactory Clinical Outcomes at Medium-Term Follow-up. Arthroplast Today. 2020;7:37-42.

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(9):1094-102.






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