When Is Distal Femoral Replacement Indicated? Insights From Periprosthetic and Native Distal Femoral Fractures Around the Knee.

The incidence of periprosthetic and native distal femoral fractures is rising with the increasing utilization of total knee arthroplasty and an aging global population. These injuries present significant clinical challenges, most commonly affecting elderly patients. While fixation-based strategies remain widely employed, distal femoral replacement has emerged as an increasingly utilized alternative. The purpose of this narrative review is to examine the current indications, implant considerations, and clinical evidence supporting the use of distal femoral replacement in the management of both periprosthetic and native distal femoral fractures. Distal femoral replacement demonstrates broadly equivalent outcomes to conventional fixation and allows for immediate full weight-bearing and expedited rehabilitation, which is particularly important in elderly patients. Surgeon expertise, familiarity with available implant systems, and a coordinated multidisciplinary perioperative approach are important contributors to optimizing outcomes. Distal femoral replacement is a safe, reliable, and increasingly relevant treatment strategy for carefully selected patients presenting with periprosthetic or native distal femoral fractures. It is most appropriately indicated in elderly or low-demand patients with severe metaphyseal comminution, significant osteoporosis, preexisting osteoarthritis, a loose or malrotated femoral component, or fractures not amenable to stable internal fixation. Future prospective studies and randomized controlled trials are needed to better define patient selection criteria, standardize outcome reporting, and formally evaluate cost-effectiveness.