Injury, Int. J. Care Injured 45 (2014) 550–553
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Distal femoral replacement in periprosthetic fracture around total knee arthroplasty S.S. Jassim *, I. McNamara, P. Hopgood Department of Trauma and Orthopaedics, Norfolk and Norwich University Hospital, Colney Lane, Norwich, Norfolk NR4 7UY, UK
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 21 October 2013
Introduction: Total knee arthroplasty is a common orthopaedic procedure in the UK; consequently, revision surgery and periprosthetic fractures are increasing in incidence. Strategies for management of these cases include non-operative strategies, internal plate fixation and revision of the distal femoral component. One under-reported practice is to perform distal femoral replacement in cases with poor distal femoral bone stock. Materials and methods: The department’s electronic database was searched for all patients undergoing revision of total knee arthroplasty. From these, all patients having distal femoral replacement for periprosthetic fracture around the distal femoral component using the Stryker Global Modular Replacement System (GMRS) implant were filtered. A retrospective analysis of the patient notes was performed to examine the patient demographics, surgical factors and postoperative complications. Postoperative scores were performed for these patients. Results: From 2005 onwards, 11 patients (mean age 81 years, range 61–90 years) had their implants revised with a distal femoral replacement for periprosthetic fracture with associated poor bone stock. Follow up was for a mean of 33 months (range 4–72 months). One of these patients died of causes unrelated to their operation. Of the rest, all implants survived without the need of re-operation. The mean postoperative Oxford Knee Score for these patients was 22.5 (range 5–34). Conclusions: Distal femoral replacement for patients with fracture around a total knee arthroplasty has been performed in our department with few complications and acceptable functional outcomes. It is a technically challenging operation and it should be a salvage procedure reserved for patients with poor bone stock and low demands where other methods of fixation are not suitable. Level of evidence: IV. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Distal femoral replacement Periprosthetic fracture Total knee replacement
Total knee arthroplasty (TKA) is one of the most commonly performed orthopaedic operations in the U.K., with over 60,000 performed in the past year [1]. Consequently, the incidence of periprosthetic fracture is increasing, estimated at 0.3–2.5% [2]. However, with the increasing frequency of joint replacement and an ageing population, the absolute numbers are expected to increase and they pose a great challenge to surgeons to achieve adequate fixation whilst minimizing morbidity and mortality. There are multiple strategies for addressing distal femoral periprosthetic fractures [3–6], with all aiming to achieve a painfree knee that is stable, with minimal disruption to length and alignment. Current management strategies include the use of locking plates [3], intramedullary fixation [4], external fixation [5] and revision of the arthroplasty [6]. Each of these strategies has its
* Corresponding author. Tel.: +44 7771898118. E-mail address: [email protected] (S.S. Jassim). 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.10.032
own merits and limitations with respect to implant stability, the need for bone grafting, the presence of an ipsilateral total hip replacement and complications. In the case of distal femur periprosthetic fractures with limited bone stock, certain surgical options are technically impossible (Fig. 1). One strategy for managing patients presenting with periprosthetic fractures not amenable to fixation is to use a distal femoral replacement prosthesis. These prostheses have been used successfully in oncological surgery [7]; however, relatively few series of patients with different prostheses used for this indication have been reported in the literature [8–10]. Traditionally, TKA revision operations have used constrained implants to provide immediate and long-term stability [11]. In cases with poor bone stock or gross ligamentous instability, a distal femoral replacement has been shown to be a viable strategy in the provision of a stable implant in low-demand patients [12,13]. The Global Modular Rotating System (GMRS) implant (Stryker, Newbury, UK) has been designed for reconstruction
S.S. Jassim et al. / Injury, Int. J. Care Injured 45 (2014) 550–553
551
much tibial bone as possible. Once all the components had been removed, the size of the deficit was measured, to estimate the size of the femoral component required. The tibia was then cut flush and the tibia deficit built up in the standard fashion. The trial femoral component was then inserted. Rotation of the femoral component was assessed by flexing and extending the knee and observing the patella tracking. Any patella which had previously been replaced was retained. Care was taken to ensure that the leg was not lengthened. Both components were then cemented with Palacos R and G cement (Heraeus, Hanau, Germany) using a standard technique. Closure was in layers with no drains. Postoperative regime
Fig. 1. Radiograph with example of periprosthetic fracture around femoral component suitable for distal femoral replacement. Fracture line extends distal to proximal femoral border with loosening of component.
All patients were managed in a postoperative cricket-pad splint until the wound had healed. Cefuroxime was given for a further 48 h after surgery. Once the wound was dry, flexion exercises were commenced. Tinzaparin was given for thromboprophylaxis once the wound had dried and it was continued for the duration of the inpatient stay. All patients were mobilized fully weight bearing from the first postoperative day with physiotherapy assistance. Follow-up
of large segmental femoral defects in tumours, failed previous arthroplasty or trauma. This article reports the clinical and radiological results of the GMRS implant for revision total knee replacement (TKR) in patients with periprosthetic fracture around a distal femoral component. Materials and methods The modular-rotation-hinge distal-femoral replacement has been used by our department since 2005 for the management of distal femoral periprosthetic fractures with loosening of the prosthesis and revision of TKRs with inadequate bone stock. Patients who had undergone the implantation of the GMRS between January 2005 and June 2011were identified using the department’s electronic patient database (BlueSpier, Bluespier International, Droitwich, UK). A total of 16 patients were identified; 11 of them were cases of periprosthetic fracture involving the distal femoral component with a poor bone stock and that had been deemed, at the time of presentation, unsuitable for conservative management, internal fixation or simple component revision. The remaining five of these were cases of revision of a TKA. Using the patients’ electronic and paper notes and the hospital’s theatre database system, the patients’ demographic details, surgical factors and postoperative function and complications were obtained and noted.
A plain antero-posterior (AP) radiograph and a lateral knee plain radiograph were performed prior to discharge. Patients were then reviewed at 6 weeks, 6 months and then annually thereafter. Radiographs were performed at each clinic appointment to assess for loosening or radiolucency. Patients were then interviewed at follow-up to assess postoperative functional scores using the Oxford Knee Scores and Short Form-36 (SF-36). Injury classification was assessed independently by two authors (SJ and PH) using the Su classification [14] and the Rorabeck and Taylor classification [15]. The Su classification of fractures involving the distal femoral component of a TKA comprises: - Type 1 – the fracture is proximal to the femoral component, - Type 2 – The fracture originates at the proximal end of the component and extends proximally and - Type 3 – The fracture extends distal to the proximal border of the femoral component. The Rorabeck and Taylor classification of fractures involving the distal femoral component of a TKA includes: - Type 1 – the fracture is non-displaced with a well-fixed intact knee implant, - Type 2 – the fracture is displaced with an intact implant and - Type 3 – the fracture is either displaced or non-displaced but with a loose or failing implant.
Surgical technique In all cases, cefuroxime was given at the induction of anaesthesia and a tourniquet was inflated for the duration of the procedure. All knees were approached via the previous midline incision. The knee was opened through a standard medial parapatella arthrotomy with eversion of the patella. Some of the femoral components were found to be completely loose on opening the knee and they were simply removed. In the majority of cases, some of the implant was still bonded to the femur. In the cases of periprosthetic fracture, the distal femur was approached through the fracture site. The distal femur was flexed, exposing the posterior surface. The capsule was then dissected off the bone. Finally, the collateral ligaments were divided at their femoral origin. Once the distal femur had been removed, a cut was made perpendicular to the anatomical axis of the distal femur. The tibial component was then removed in a standard fashion, preserving as
Results Eleven patients received the GMRS implant. All were female with a mean age of 81 years (range 61–90) at the time of surgery. The demographic details are presented in Table 1. No patient has required re-operation of either the femoral or tibial components. None of the postoperative radiographs had features of loosening or radiolucent lines. The operative details are presented in Table 2. The operations for revision of periprosthetic fracture around the distal femoral component had a mean follow-up of 33 months (range 4–72 months). All of these injuries were classified as Su Grade 3 and all but one were classified as Rorabeck Grade 3, with one being Grade 2. All patients were able to achieve full extension
S.S. Jassim et al. / Injury, Int. J. Care Injured 45 (2014) 550–553
32 19 29 Wheelchair
1 Stick
AF – Atrial fibrillation; COPD – chronic obstructive pulmonary disease. a Moved out of area and lost to follow-up.
3 11 L F 86 11
1 9 1 140 (90–180) 98 (70–120) 87.5 (50–110)
Discussion
Rheumatoid arthritis, COPD Ischaemic heart disease 3 12 L 82 10
F
3 2 18 2 R L F F 84 90 8 9
26.6 (6–52) 11:0
in the knee and the mean maximum flexion at follow-up was 87.58 (range 508–1108). The mean postoperative SF-36 score for the nine patients available for follow-up was 45.1 (range 24–68) for mental health and 28.9 (range 18–48) for physical health; the mean Oxford Knee Score was 22.6 (range 5–32). Complications included: wound cellulitis (2) treated with a short course of antibiotics, anaemia (2) requiring a 2-unit transfusion of packed red cells, permanent foot drop (1) and a leg ulcer (1). One patient died 1 month after discharge from unrelated urosepsis and multi-organ failure.
5
48 30 40
Anaemia requiring 2 unit blood transfusion Anaemia requiring 2 unit blood transfusion
18
36 24 33 38 25 26 Nil Wound cellulitis 16 6
52
Walking frame 1 Stick 1 Stick Rheumatoid arthritis, hypertension Rheumatoid arthritis Hypertension 3 16 L 81 7
F
Nil 2 17 R 88 6
F
Hypertension AF 2 3 6 16 L R 81 86 4 5
F F
3 2 5 4 R R 77 87 2 3
F F
Length of stay in days (range) Operating surgeon (consultant: supervised registrar) Method of anaesthesia General anaesthesia General anaesthesia and epidural injection Sedation and spinal anaesthesia Total length of surgery in minutes (range) Tourniquet time in minutes (range) Maximum post-operative flexion achieved in degrees (range)
1 Stick Walking frame Walking frame Wheelchair
– – –
68 26 32
Ipsilateral foot drop and leg ulcer Died
27
50 53 18 29 14 28 Nil Nil 20 18
a
57 48
a a
1 Stick Walking frame 1 Stick Walking frame 1 Stick
1 Stick Walking frame 1 Stick Walking frame Walking frame Wheelchair
15 30
32
17 61 1
F
L
10
3
Rheumatoid arthritis, lung cancer AF Hypertension
2 Sticks
2 Sticks
33
Deep vein thrombosis, wound cellulitis Nil Nil
30
38
Peri-prosthetic fracture
Post-operative Oxford Knee Score Length of stay (days) Post-operative mobility Pre-operative mobility Co-morbidities American Society of Anaesthesiologists (ASA) Grade Years since primary operation Side Sex Age at surgery Patient
Table 1 Patient characteristics and post-operative surgical information.
Table 2 Operative finding s and surgical procedure.
Complications
Post-operative SF-36 (Physical)
Post-operative SF-36 (Mental)
552
There are a number of reports regarding the use of a distal femoral replacement for treatment of non-tumour cases [12,16– 18]; however, none has reported upon the use of the Stryker GMRS implant (Figs. 2 and 3). We have presented 11 patients who have received a distal femoral replacement in our unit since 2005 for a periprosthetic fracture around the femoral component of a TKA. All patients in this cohort warranted use of the GMRS implant due to deficient distal femoral bone stock around their TKR from a combination of fracture patterns and loss of bone. It was felt that treatment nonoperatively or with other fixation methods would have been inadequate. Other studies have reported a wide variation in the outcomes of patients on using a rotating modular TKR for non-tumour cases. Clinical outcomes for distal femoral replacements have been previously described [12], highlighting their ability to reduce pain and restore function. Many outcomes have been presented amongst data for all types of fixation of periprosthetic fractures around a TKA [8]. Mortazavi and colleagues [9] reviewed 20 patients who underwent revision of their prostheses with a distal femoral arthroplasty and reported almost half experiencing complications, including infection, loosening and femoral component fracture. The authors supported its use in complex periprosthetic fractures with a loss of bone stock. Springer and colleagues [10] reported an improvement in range of motion and knee scores in a cohort of 25 patients having a modular kinematic rotating hinge implant, although only a small proportion of these implants were used to treat acute periprosthetic fractures. In keeping with these findings, we found that the GMRS implant was able to compensate for bone loss, relieve knee pain and provide stability to our patients. All our patients were able to mobilize fully weight bearing after surgery and most were able to return to using their preoperative form of walking aid, with only two patients requiring additional assistance. Our mean postoperative functional scores are inferior to those of other studies [9], although the patients in our series are older and have greater co-morbidities. In keeping with other studies [10,13], we found a relatively high complication rate, which is probably in keeping with the multiple medical co-morbidities and age associated with this group of
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553
Figs. 2 and 3. Antero-posterior and lateral radiographs demonstrating treatment of injury with distal femoral replacement.
patients. Seven patients developed some form of complication, the most common being wound cellulitis and intra-operative blood loss requiring transfusion. Unlike other studies, no patients required revision of the implant for aseptic loosening, although the patients have only been followed up for a mean of 2.75 years. The limitations for this study are that it is a retrospective analysis involving a relatively small number of patients. During the same period, we would have expected to treat approximately 90 periprosthetic fractures around a TKR. This group therefore represents a relatively small proportion of the number of such fractures treated. In addition, we have no control group for comparison. In conclusion, the short-term results of the GMRS distal femoral replacement in a group of patients requiring revision of a TKR for periprosthetic fracture with a loose femoral prosthesis and inadequate distal femoral bone stock, which is not suitable for other internal fixation methods, appear encouraging. Complication rates are high and the functional outcome score relatively poor, reflecting the demographics of the patients. While close clinical and radiological surveillance is ongoing, it appears that distal femoral replacement is a viable, albeit technically challenging, option for a distal femur periprosthetic fracture of a TKA with loss of bone stock in sedentary, low-demand patients in order to provide a functionally acceptable knee. Author’s contribution All authors have made substantial contributions to the conception and design of the study, data interpretation and drafting of the article. Each of the authors has read and concurs with the content in the final manuscript. Conflict of interest None of the authors have any conflicts of interest to declare. There was no funding or sponsorship of this study.
References [1] National Joint Registry, www.njrcentre.org.uk [Accessed 07.08.11]. [2] Rorabeck CH, Taylor JW. Periprosthetic fractures of the femur complicating total knee arthroplasty. Orthop Clin North Am 1999;30:265–77. [3] Healy WL, Siliski JM, Incavo SJ. Operative treatment of distal femoral fractures proximal to total knee replacements. J Bone J Surg (Am) 1993;75A:27–34. [4] Ritter MA, Keating EM, Faris PM, Medring JB. Rush rod fixation of supracondylar fractures above total knee arthroplasties. J Arthroplasty 1995;10: 213–6. [5] Biswas SP, Kurer MH, Mackenney RP. External fixation for femoral shaft fracture after Stanmore total knee replacement. J Bone J Surg (Br) 1992;74B:313–4. [6] Johnston AT, Tsiridis E, Eyers KS, Toms AD. Periprosthetic fractures in the distal femur following total knee replacement: a review and guide to management. Knee 2012;19:156–62. [7] Capanna R, Morris HG, Campanacci D, Delben M, Campanacci M. Modular uncemented prosthetic reconstruction after resection of tumours of the distal femur. J Bone J Surg [Br] 1994;76–B:178–86. [8] McGraw P, Kumar A. Periprosthetic fractures of the femur after total knee arthroplasty. J Orthop Traumatol 2010;11:135–41. [9] Mortazavi J, Kurd MF, Bender B, Post Z, Parvizi J, Purtill JJ. Distal femoral arthroplasty for the treatment of periprosthetic fractures after total knee arthroplasty. J Arthroplasty 2010;25:775–80. [10] Springer BD, Slim FH, Hanssen AD, Lewallen DG. The modular segmental kinematic rotating hinge for non-neoplastic limb salvage. Clin Orthop Relat Res 2004;421:181–7. [11] Lombardi Jr AV, Berend KR. The role of constraint in revision TKA: striking the balance. Orthopedics 2006;29:847–9. [12] Berend KR, Lombardi Jr AV. Distal femoral replacement in non-tumour cases with severe bone loss and instability. Clin Orthop Relat Res 2009;467:485–92. [13] Pour AE, Parvizi J, Slenker N. Rotating hinged total knee replacement: use with caution. J Bone J Surg (Am) 2007;89:1735. [14] Su ET, DeWal H, DiCesare. Periprosthetic femoral fractures above total knee replacements. J Am Acad Orthop Surg 2004;12:12–20. [15] Rorabeck CH, Taylor JW. Classification of periprosthetic fractures complicating total knee arthroplasty. Orthop Clin North Am 1999;30:209–14. [16] Appleton P, Moran M, Houshian S, Robinson CM. Distal femoral fractures treated by hinged total knee replacement in elderly patients. J Bone J Surg (Br) 2006;88:1065–70. [17] Barrack RL. Evolution of the rotating hinge for complex total knee arthroplasty. Clin Orthop Relat Res 2001;392:292–9. [18] Springer BD, Sim FH, Hanssen AD, Lewallen DG. The kinematic rotating hinge prosthesis for complex knee arthroplasty. Clin Orthop Relat Res 2001;392: 283–91.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Distal femoral replacement in periprosthetic fracture around total knee arthroplasty S.S. Jassim *, I. McNamara, P. Hopgood Department of Trauma and Orthopaedics, Norfolk and Norwich University Hospital, Colney Lane, Norwich, Norfolk NR4 7UY, UK
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 21 October 2013
Introduction: Total knee arthroplasty is a common orthopaedic procedure in the UK; consequently, revision surgery and periprosthetic fractures are increasing in incidence. Strategies for management of these cases include non-operative strategies, internal plate fixation and revision of the distal femoral component. One under-reported practice is to perform distal femoral replacement in cases with poor distal femoral bone stock. Materials and methods: The department’s electronic database was searched for all patients undergoing revision of total knee arthroplasty. From these, all patients having distal femoral replacement for periprosthetic fracture around the distal femoral component using the Stryker Global Modular Replacement System (GMRS) implant were filtered. A retrospective analysis of the patient notes was performed to examine the patient demographics, surgical factors and postoperative complications. Postoperative scores were performed for these patients. Results: From 2005 onwards, 11 patients (mean age 81 years, range 61–90 years) had their implants revised with a distal femoral replacement for periprosthetic fracture with associated poor bone stock. Follow up was for a mean of 33 months (range 4–72 months). One of these patients died of causes unrelated to their operation. Of the rest, all implants survived without the need of re-operation. The mean postoperative Oxford Knee Score for these patients was 22.5 (range 5–34). Conclusions: Distal femoral replacement for patients with fracture around a total knee arthroplasty has been performed in our department with few complications and acceptable functional outcomes. It is a technically challenging operation and it should be a salvage procedure reserved for patients with poor bone stock and low demands where other methods of fixation are not suitable. Level of evidence: IV. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Distal femoral replacement Periprosthetic fracture Total knee replacement
Total knee arthroplasty (TKA) is one of the most commonly performed orthopaedic operations in the U.K., with over 60,000 performed in the past year [1]. Consequently, the incidence of periprosthetic fracture is increasing, estimated at 0.3–2.5% [2]. However, with the increasing frequency of joint replacement and an ageing population, the absolute numbers are expected to increase and they pose a great challenge to surgeons to achieve adequate fixation whilst minimizing morbidity and mortality. There are multiple strategies for addressing distal femoral periprosthetic fractures [3–6], with all aiming to achieve a painfree knee that is stable, with minimal disruption to length and alignment. Current management strategies include the use of locking plates [3], intramedullary fixation [4], external fixation [5] and revision of the arthroplasty [6]. Each of these strategies has its
* Corresponding author. Tel.: +44 7771898118. E-mail address: [email protected] (S.S. Jassim). 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.10.032
own merits and limitations with respect to implant stability, the need for bone grafting, the presence of an ipsilateral total hip replacement and complications. In the case of distal femur periprosthetic fractures with limited bone stock, certain surgical options are technically impossible (Fig. 1). One strategy for managing patients presenting with periprosthetic fractures not amenable to fixation is to use a distal femoral replacement prosthesis. These prostheses have been used successfully in oncological surgery [7]; however, relatively few series of patients with different prostheses used for this indication have been reported in the literature [8–10]. Traditionally, TKA revision operations have used constrained implants to provide immediate and long-term stability [11]. In cases with poor bone stock or gross ligamentous instability, a distal femoral replacement has been shown to be a viable strategy in the provision of a stable implant in low-demand patients [12,13]. The Global Modular Rotating System (GMRS) implant (Stryker, Newbury, UK) has been designed for reconstruction
S.S. Jassim et al. / Injury, Int. J. Care Injured 45 (2014) 550–553
551
much tibial bone as possible. Once all the components had been removed, the size of the deficit was measured, to estimate the size of the femoral component required. The tibia was then cut flush and the tibia deficit built up in the standard fashion. The trial femoral component was then inserted. Rotation of the femoral component was assessed by flexing and extending the knee and observing the patella tracking. Any patella which had previously been replaced was retained. Care was taken to ensure that the leg was not lengthened. Both components were then cemented with Palacos R and G cement (Heraeus, Hanau, Germany) using a standard technique. Closure was in layers with no drains. Postoperative regime
Fig. 1. Radiograph with example of periprosthetic fracture around femoral component suitable for distal femoral replacement. Fracture line extends distal to proximal femoral border with loosening of component.
All patients were managed in a postoperative cricket-pad splint until the wound had healed. Cefuroxime was given for a further 48 h after surgery. Once the wound was dry, flexion exercises were commenced. Tinzaparin was given for thromboprophylaxis once the wound had dried and it was continued for the duration of the inpatient stay. All patients were mobilized fully weight bearing from the first postoperative day with physiotherapy assistance. Follow-up
of large segmental femoral defects in tumours, failed previous arthroplasty or trauma. This article reports the clinical and radiological results of the GMRS implant for revision total knee replacement (TKR) in patients with periprosthetic fracture around a distal femoral component. Materials and methods The modular-rotation-hinge distal-femoral replacement has been used by our department since 2005 for the management of distal femoral periprosthetic fractures with loosening of the prosthesis and revision of TKRs with inadequate bone stock. Patients who had undergone the implantation of the GMRS between January 2005 and June 2011were identified using the department’s electronic patient database (BlueSpier, Bluespier International, Droitwich, UK). A total of 16 patients were identified; 11 of them were cases of periprosthetic fracture involving the distal femoral component with a poor bone stock and that had been deemed, at the time of presentation, unsuitable for conservative management, internal fixation or simple component revision. The remaining five of these were cases of revision of a TKA. Using the patients’ electronic and paper notes and the hospital’s theatre database system, the patients’ demographic details, surgical factors and postoperative function and complications were obtained and noted.
A plain antero-posterior (AP) radiograph and a lateral knee plain radiograph were performed prior to discharge. Patients were then reviewed at 6 weeks, 6 months and then annually thereafter. Radiographs were performed at each clinic appointment to assess for loosening or radiolucency. Patients were then interviewed at follow-up to assess postoperative functional scores using the Oxford Knee Scores and Short Form-36 (SF-36). Injury classification was assessed independently by two authors (SJ and PH) using the Su classification [14] and the Rorabeck and Taylor classification [15]. The Su classification of fractures involving the distal femoral component of a TKA comprises: - Type 1 – the fracture is proximal to the femoral component, - Type 2 – The fracture originates at the proximal end of the component and extends proximally and - Type 3 – The fracture extends distal to the proximal border of the femoral component. The Rorabeck and Taylor classification of fractures involving the distal femoral component of a TKA includes: - Type 1 – the fracture is non-displaced with a well-fixed intact knee implant, - Type 2 – the fracture is displaced with an intact implant and - Type 3 – the fracture is either displaced or non-displaced but with a loose or failing implant.
Surgical technique In all cases, cefuroxime was given at the induction of anaesthesia and a tourniquet was inflated for the duration of the procedure. All knees were approached via the previous midline incision. The knee was opened through a standard medial parapatella arthrotomy with eversion of the patella. Some of the femoral components were found to be completely loose on opening the knee and they were simply removed. In the majority of cases, some of the implant was still bonded to the femur. In the cases of periprosthetic fracture, the distal femur was approached through the fracture site. The distal femur was flexed, exposing the posterior surface. The capsule was then dissected off the bone. Finally, the collateral ligaments were divided at their femoral origin. Once the distal femur had been removed, a cut was made perpendicular to the anatomical axis of the distal femur. The tibial component was then removed in a standard fashion, preserving as
Results Eleven patients received the GMRS implant. All were female with a mean age of 81 years (range 61–90) at the time of surgery. The demographic details are presented in Table 1. No patient has required re-operation of either the femoral or tibial components. None of the postoperative radiographs had features of loosening or radiolucent lines. The operative details are presented in Table 2. The operations for revision of periprosthetic fracture around the distal femoral component had a mean follow-up of 33 months (range 4–72 months). All of these injuries were classified as Su Grade 3 and all but one were classified as Rorabeck Grade 3, with one being Grade 2. All patients were able to achieve full extension
S.S. Jassim et al. / Injury, Int. J. Care Injured 45 (2014) 550–553
32 19 29 Wheelchair
1 Stick
AF – Atrial fibrillation; COPD – chronic obstructive pulmonary disease. a Moved out of area and lost to follow-up.
3 11 L F 86 11
1 9 1 140 (90–180) 98 (70–120) 87.5 (50–110)
Discussion
Rheumatoid arthritis, COPD Ischaemic heart disease 3 12 L 82 10
F
3 2 18 2 R L F F 84 90 8 9
26.6 (6–52) 11:0
in the knee and the mean maximum flexion at follow-up was 87.58 (range 508–1108). The mean postoperative SF-36 score for the nine patients available for follow-up was 45.1 (range 24–68) for mental health and 28.9 (range 18–48) for physical health; the mean Oxford Knee Score was 22.6 (range 5–32). Complications included: wound cellulitis (2) treated with a short course of antibiotics, anaemia (2) requiring a 2-unit transfusion of packed red cells, permanent foot drop (1) and a leg ulcer (1). One patient died 1 month after discharge from unrelated urosepsis and multi-organ failure.
5
48 30 40
Anaemia requiring 2 unit blood transfusion Anaemia requiring 2 unit blood transfusion
18
36 24 33 38 25 26 Nil Wound cellulitis 16 6
52
Walking frame 1 Stick 1 Stick Rheumatoid arthritis, hypertension Rheumatoid arthritis Hypertension 3 16 L 81 7
F
Nil 2 17 R 88 6
F
Hypertension AF 2 3 6 16 L R 81 86 4 5
F F
3 2 5 4 R R 77 87 2 3
F F
Length of stay in days (range) Operating surgeon (consultant: supervised registrar) Method of anaesthesia General anaesthesia General anaesthesia and epidural injection Sedation and spinal anaesthesia Total length of surgery in minutes (range) Tourniquet time in minutes (range) Maximum post-operative flexion achieved in degrees (range)
1 Stick Walking frame Walking frame Wheelchair
– – –
68 26 32
Ipsilateral foot drop and leg ulcer Died
27
50 53 18 29 14 28 Nil Nil 20 18
a
57 48
a a
1 Stick Walking frame 1 Stick Walking frame 1 Stick
1 Stick Walking frame 1 Stick Walking frame Walking frame Wheelchair
15 30
32
17 61 1
F
L
10
3
Rheumatoid arthritis, lung cancer AF Hypertension
2 Sticks
2 Sticks
33
Deep vein thrombosis, wound cellulitis Nil Nil
30
38
Peri-prosthetic fracture
Post-operative Oxford Knee Score Length of stay (days) Post-operative mobility Pre-operative mobility Co-morbidities American Society of Anaesthesiologists (ASA) Grade Years since primary operation Side Sex Age at surgery Patient
Table 1 Patient characteristics and post-operative surgical information.
Table 2 Operative finding s and surgical procedure.
Complications
Post-operative SF-36 (Physical)
Post-operative SF-36 (Mental)
552
There are a number of reports regarding the use of a distal femoral replacement for treatment of non-tumour cases [12,16– 18]; however, none has reported upon the use of the Stryker GMRS implant (Figs. 2 and 3). We have presented 11 patients who have received a distal femoral replacement in our unit since 2005 for a periprosthetic fracture around the femoral component of a TKA. All patients in this cohort warranted use of the GMRS implant due to deficient distal femoral bone stock around their TKR from a combination of fracture patterns and loss of bone. It was felt that treatment nonoperatively or with other fixation methods would have been inadequate. Other studies have reported a wide variation in the outcomes of patients on using a rotating modular TKR for non-tumour cases. Clinical outcomes for distal femoral replacements have been previously described [12], highlighting their ability to reduce pain and restore function. Many outcomes have been presented amongst data for all types of fixation of periprosthetic fractures around a TKA [8]. Mortazavi and colleagues [9] reviewed 20 patients who underwent revision of their prostheses with a distal femoral arthroplasty and reported almost half experiencing complications, including infection, loosening and femoral component fracture. The authors supported its use in complex periprosthetic fractures with a loss of bone stock. Springer and colleagues [10] reported an improvement in range of motion and knee scores in a cohort of 25 patients having a modular kinematic rotating hinge implant, although only a small proportion of these implants were used to treat acute periprosthetic fractures. In keeping with these findings, we found that the GMRS implant was able to compensate for bone loss, relieve knee pain and provide stability to our patients. All our patients were able to mobilize fully weight bearing after surgery and most were able to return to using their preoperative form of walking aid, with only two patients requiring additional assistance. Our mean postoperative functional scores are inferior to those of other studies [9], although the patients in our series are older and have greater co-morbidities. In keeping with other studies [10,13], we found a relatively high complication rate, which is probably in keeping with the multiple medical co-morbidities and age associated with this group of
S.S. Jassim et al. / Injury, Int. J. Care Injured 45 (2014) 550–553
553
Figs. 2 and 3. Antero-posterior and lateral radiographs demonstrating treatment of injury with distal femoral replacement.
patients. Seven patients developed some form of complication, the most common being wound cellulitis and intra-operative blood loss requiring transfusion. Unlike other studies, no patients required revision of the implant for aseptic loosening, although the patients have only been followed up for a mean of 2.75 years. The limitations for this study are that it is a retrospective analysis involving a relatively small number of patients. During the same period, we would have expected to treat approximately 90 periprosthetic fractures around a TKR. This group therefore represents a relatively small proportion of the number of such fractures treated. In addition, we have no control group for comparison. In conclusion, the short-term results of the GMRS distal femoral replacement in a group of patients requiring revision of a TKR for periprosthetic fracture with a loose femoral prosthesis and inadequate distal femoral bone stock, which is not suitable for other internal fixation methods, appear encouraging. Complication rates are high and the functional outcome score relatively poor, reflecting the demographics of the patients. While close clinical and radiological surveillance is ongoing, it appears that distal femoral replacement is a viable, albeit technically challenging, option for a distal femur periprosthetic fracture of a TKA with loss of bone stock in sedentary, low-demand patients in order to provide a functionally acceptable knee. Author’s contribution All authors have made substantial contributions to the conception and design of the study, data interpretation and drafting of the article. Each of the authors has read and concurs with the content in the final manuscript. Conflict of interest None of the authors have any conflicts of interest to declare. There was no funding or sponsorship of this study.
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