¹Soroka University Medical Center, Beer Sheva, Israel
²Ben-Gurion University of the Negev Faculty of Health Sciences, Beer Sheva, Israel

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Objectives and questions: Anterior femoral notching during TKA is thought to weaken the distal femur, potentially increasing periprosthetic fracture risk, but its clinical impact remains debated. This study examines whether notching independently predicts such fractures and assesses related clinical outcomes using the Tayside classification system for cortical violations.

Material and methods: A retrospective cohort study was conducted on 715 patients who underwent primary TKA. Patients divided into Group 1 without notching (control group) and Group 2 with any presence of notching according to Tayside classification system, which assesses cortical violations based on the extent of involvement. Fracture incidence and additional multivariate analysis were used to control for confounding factors, including bone quality (presence of osteoporosis) and demographics.

Results: PPFs were significantly more frequent in the notching group (2.67%) than in the control group (0.24%) (p < 0.01). Despite 6.68% of patients having osteoporosis, no correlation with PPFs was found. All fractures occurred in female patients due to falls. A cortical defect >2.5 mm was a potential predictor of femoral weakness, with larger defects in the notching group (2.20 ± 0.54 mm) vs. control (0.02 ± 0.16 mm), p < 0.01. PPF incidence was 1.33% for Grade 1 and 2 defects and 0.33% for Grade 3 defects.

Discussion and conclusions: Preventive strategies, including meticulous surgical technique and tailored postoperative rehabilitation, are essential to minimize PPF risk. Anterior femoral notching compromises femoral integrity, with defects >2.5 mm significantly increasing fracture risk. Careful surgical planning, especially in patients with poor bone quality or advanced age, is crucial to optimize outcomes and reduce complications.