Primary Versus Salvage Distal Femoral Endoprosthetic Replacement Following Native Distal Femur Fracture: A Systematic Review and Meta-Analysis

Background Surgical management of native distal femoral fractures (DFFs) in elderly patients includes open reduction and internal fixation (ORIF) or distal femoral endoprosthetic replacement (DFR). When ORIF is complicated by nonunion or fixation failure, salvage DFR (sDFR) may be required. The comparative outcomes of primary DFR (pDFR) vs sDFR remain unclear. This systematic review and meta-analysis aimed to assess the quality of published literature and compared clinical and functional outcomes between pDFR and sDFR for native DFFs. Methods MEDLINE, Embase, and Cochrane databases were searched from inception to April 2024. Studies investigating outcomes of pDFR or sDFR following native DFFs were included. Studies evaluating periprosthetic fractures, oncologic indications, or primary arthritis were excluded. Twelve studies comprising 281 patients (230 pDFR, 51 sDFR) were included. Results Patients undergoing pDFR were significantly older (mean 79.3 vs 64.9 years; P < .001) and more comorbid (American Society of Anesthesiologists score: mean 2.99 vs 2.34; P < .001). Despite this, pDFR was associated with significantly lower reoperation (12.2% vs 23.5%; P = .04) and complication rates (15.7% vs 43.1%; P < .001) compared to sDFR. 1-year mortality rate was higher in the pDFR cohort (10.4% vs 2.0%). Functional outcomes were marginally lower in pDFR, although this was not statistically significant (76.3 vs 80.7%; P = .09). Conclusions sDFR following failed fixation of native DFFs was associated with nearly twice the risk of reoperation and postoperative complications compared to pDFR, despite being performed in a younger and less comorbid cohort. Elderly patients at risk of fixation failure may therefore benefit from pDFR.