Periprosthetic Distal Femur Fractures after Total Knee Arthroplasty: A Three-Case Experience from a Resource-Constrained LMIC Tertiary Care Center

Abstract

Background:
Periprosthetic distal femur fractures (PDFFs) following total knee arthroplasty (TKA) are increasingly encountered in elderly patients. These fractures present a complex challenge, particularly in low- and middle-income countries (LMICs) where implant options and surgical infrastructure may be limited.

Case Presentation:
We present three elderly female patients with PDFFs managed at a tertiary care center in Pakistan. All cases involved low-energy trauma and well-fixed TKA components. Diagnostic evaluation included radiographs and CT imaging with metal artifact reduction. Patients were treated using three distinct strategies: (1) open reduction and internal fixation (ORIF) with a locking plate; (2) retrograde intramedullary nailing with insert exchange; and (3) distal femoral megaprosthesis for a comminuted fracture with poor bone stock. All patients were optimized preoperatively and followed for six months, showing satisfactory radiographic and functional outcomes.

Conclusions:
In LMICs, where modular revision total knee implants may be unavailable, osteosynthesis and megaprosthesis reconstruction remain the most accessible and effective options. Careful surgical planning and patient selection are critical to achieving favorable outcomes even within resource-limited environments.