Journal of Orthopaedic Surgery 2014;22(1):24-9
Periprosthetic fractures after total knee arthroplasty Saurabh Agarwal, Rajeev K Sharma, Jitesh Kumar Jain
Department of Orthopaedics, Indraprastha Apollo Hospital, New Delhi, India
ABSTRACT Purpose. To evaluate outcome in 20 patients treated for periprosthetic fractures after total knee arthroplasty (TKA). Methods. Records of 14 women and 6 men aged 45 to 85 (mean, 67) years who underwent operative (n=18) or conservative (n=2) treatment for periprosthetic fractures of the supracondylar femur (n=15), patella (n=3), and tibia (n=2) following minor falls (n=18) or high-velocity injury (n=2) were reviewed. The mean time from TKA to fracture was 43 (range, 14–98) months. Of the 15 supracondylar femoral fractures, 2 were managed with immobilisation in a long leg cast, 11 with internal fixation using locked compression plating, and 2 with revision arthroplasty. All 3 patellar fractures were managed with tension band wiring. Both tibial fractures were managed with revision arthroplasty. Radiographic and functional outcomes (the Knee Society scores) were assessed. Results. The mean follow-up was 35 (range, 24– 48) months. All fractures healed after a mean of
15 (range, 12–38) weeks. One patient had delayed union. Postoperative alignment was satisfactory in all patients except one (with 5º varus). The mean tibiofemoral angle was 4º valgus. The mean range of motion was 98.5º. The mean Knee Society knee score was 85 (range, 75–89) and the functional score was 76 (range, 70–85). No patient had implant failure, loss of reduction, deep infection, deep vein thrombosis, or pulmonary embolism. Conclusion. The locked compression plate is effective in managing periprosthetic femoral fractures. Periprosthetic patellar and tibial fractures are uncommon. The latter often warrant revision arthroplasty owing to the loose implant. Key words: arthroplasty, periprosthetic fractures
replacement,
knee;
INTRODUCTION The rates of periprosthetic fractures are 0.3 to 2.5% after primary total knee arthroplasty (TKA) and 1.6 to 38% after revision TKA.1–5 Most such fractures
Address correspondence and reprint requests to: Dr Saurabh Agarwal, Department of Orthopaedics, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, 110076, India. Email: [email protected]
Vol. 22 No. 1, April 2014
Periprosthetic fractures after TKA
result from low-velocity injuries such as falls owing to an unbalanced knee with coronal plane laxity. The risk factors include inflammatory arthropathies, chronic steroid use, age >70 years, poor bone stock, neurological disorders, and revision arthroplasty.6–8 Prosthesis-related factors include loosening and osteolysis secondary to polythene wear. Loosening of the tibial component is more common than that of the femoral component. The most common periprosthetic fractures after TKA are supracondylar femoral fractures (0.3– 2.5%),1–5 followed by patellar fractures (0.15–12%)9–13 and tibial fractures (0.4–1.7%).14,15 In one study, 30.5% of periprosthetic supracondylar femoral fractures were associated with anterior femoral notching.16 However, in another study 30% of TKAs had a notched femur, but only 2 periprosthetic fractures occurred (both in femurs without notching).17 The most common risk factor for periprosthetic patellar fractures after TKA is excessive patellar resection, followed by mal-alignment,18 a shorter patellar tendon,19 obesity,20 and excessive flexion of knee.21 Excessive lateral release has a deleterious effect on patellar blood supply, which can lead to fractures.13 Periprosthetic patellar fractures are frequently asymptomatic, and the diagnosis is usually made during routine radiological examination.18,19 Treatment goals are to achieve painless and stable knees with excellent alignment and range of motion. Conservative management (immobilisation in a brace or cast) is recommended for non-displaced fractures. Prolonged immobilisation may results in decreased range of motion, reduced walking capacity, and higher rates of malunion.22,23 Internal fixation is therefore preferred. Fixation with periarticular locking plates or retrograde intramedullary nails is superior to
(a)
(b)
25
external fixation, dynamic condylar screw fixation, and blade plate fixation.24–28 This study evaluated outcome in 20 patients treated for periprosthetic fractures after TKA. MATERIALS AND METHODS Records of 14 women and 6 men aged 45 to 85 (mean, 67) years who underwent operative (n=18) or conservative (n=2) treatment between January 2002 and December 2010 for periprosthetic fractures of the supracondylar femur (n=15), patella (n=3), and tibia (n=2) following minor falls (n=18) or high-velocity injury (n=2) were reviewed. The mean time from TKA to fracture was 43 (range, 14–98) months. Of the 15 supracondylar femoral fractures, 2 were Roraback and Lewis type 1 (undisplaced fractures with intact prosthesis-bone interface) and managed with immobilisation in a long leg cast, 11 were type 2 (displaced fractures with intact prosthesis-bone interface) and managed with internal fixation with a distal femoral locked compression plate under fluoroscopy by a percutaneous technique in 8 cases and by open reduction in 3 cases, and 2 were type 3 (displaced fractures with loose femoral component) and managed with revision arthroplasty (Fig.1). Fixation of 2 fractures was augmented with bone grafting (structural allografts) owing to deficient bone stock. All 3 patellar fractures were associated with disrupted extensor mechanism with a well-fixed implant (Ortiguera and Berry type 2) and managed with open reduction and internal fixation using tension band wiring (Fig. 2). Both tibial fractures were adjacent to the stem with a loose implant (Felix type 2) and managed with revision arthroplasty. One
(c)
Figure 1 (a) Periprosthetic supracondylar femoral fractures extending distally fixed with (b) locked compression plating or (c) revision arthroplasty.
26
Journal of Orthopaedic Surgery
S Agarwal et al.
of them was strengthened with a proximal tibial lock compression plate (Fig. 3). Postoperatively, active and passive knee physiotherapy was started immediately. Non-weight
bearing mobilisation was allowed for 6 weeks and gradually progressed to full weight bearing, depending on radiographic evidence of bone union. Patients were followed up at 2, 6, and 8 weeks, and then at 3 and 6 months, and yearly thereafter. Coronal alignment of the knee (the angle between the mechanical axes of the tibia and femur) on anteroposterior radiographs was assessed. The fracture was defined as united when callus was visible across at least 3 cortices on both anteroposterior and lateral radiographs. Delayed healing was defined as a fracture united after >6 months without an additional surgical procedure.29 Non-union was defined as a fracture with no features of progressive healing on 3 consecutive radiographs taken at a one-month interval after 6 months of follow up and necessitating an additional procedure.30 Functional outcome was assessed using the Knee Society knee and functional scores. RESULTS
Figure 2 A periprosthetic patellar fracture fixed with tension band wiring.
The mean follow-up was 35 (range, 24–48) months. All fractures healed after a mean time of 15 (range, 12–38) weeks (Table). One patient had delayed union at 38 weeks. Postoperative alignment was satisfactory in all patients except one (with 5º varus). The mean tibiofemoral angle was 4º valgus. The mean range of
Figure 3 A periprosthetic tibial fracture fixed with revision arthroplasty using a long stem and strengthened with a proximal tibial locked compression plate.
Vol. 22 No. 1, April 2014
Periprosthetic fractures after TKA
motion was 98.5º. The mean Knee Society knee score was 85 (range, 75–89) and the functional score was 76 (range, 70–85). One patient developed a superficial infection, which was treated with debridement. No patient had implant failure, loss of reduction, deep infection, deep vein thrombosis, or pulmonary embolism. DISCUSSION Prevention of periprosthetic fractures after TKA is important. Most such fractures are associated with bone loss and implant loosening causing instability around the knee and thus fall. Improvement of bone loss prior to revision arthroplasty can halve the cost of management for such periprosthetic fractures.31 We regularly give bisphosphonates to all patients undergoing TKA to prevent periprosthetic osteolysis.
27
Treatment outcome for periprosthetic fracture is related to the degree of bone loss.32–34 Fixation with periarticular locked compression plates27,35–37 or retrograde intramedullary nails38–40 is superior to cast immobilisation, external fixation, dynamic compression plate fixation, and dynamic condylar screw fixation. We preferred to use periarticular locked compression plates for internal fixation, as using a retrograde intramedullary nail is limited by the narrow or closed intercondylar space of the TKA prosthesis. Enlargement of the notch is often required and may raise concern about 3rd body wear.41 Using a minimally invasive technique, the locked compression plate can be inserted through a small incision into the submuscular periosteal plane, thus minimising damage to the periosteal blood supply and promoting healing. The plate is precontured so it helps in reducing the fracture fragments. Multiple screws are inserted at different
Table Patient characteristics and outcomes Sex/age (years)
Periprosthetic supracondylar femoral fracture F/49
Time Comorbidity from surgery to fracture (months)
21
F/75 F/75 F/67 F/79 F/45 M/68 F/75
47 24 49 14 38 67 24
M/62 F/61 M/75 F/58
33 87 36 49
F/81
48
F/61
39
M/65 Periprosthetic patellar fracture F/67
98
F/55 F/67 Periprosthetic tibial fracture M/85 M/70
25 47
45
39 25
Rheumatoid arthritis, diabetes mellitus Rheumatoid arthritis Hypertension Hypertension Right total hip arthroplasty (THA), diabetes mellitus, hypertension Rheumatoid arthritis, bilateral THA, diabetes mellitus -
Treatment
Time to Range of Knee Func- Followunion motion score tional up (weeks) score (months)
Long leg cast immobilisation
16
05º–90º
75
70
24
Long leg cast immobilisation Locked compression plating Locked compression plating Locked compression plating Locked compression plating Locked compression plating Locked compression plating
14 14 12 12 14 16 14
05º–100º 0º–100º 0º–110º 0º–110º 0º–105º 0º–95º 0º–95º
83 87 89 89 87 85 85
75 80 80 80 85 75 70
34 24 26 36 35 30 36
Locked compression plating Locked compression plating Locked compression plating Locked compression plating
12 14 16 12
0º–110º 0º–100º 0º–100º 0º–110º
89 87 87 89
80 75 75 80
36 24 34 34
Locked compression plating with bone grafting Bilateral THA, avascular necrosis Revision arthroplasty with of left shoulder, hypertension structural bone grafting Hypertension Revision arthroplasty
14
0º–80º
80
75
36
12
0º–95º
87
70
30
-
0º–100º
75
75
29
Tension band wiring
38
05º–110º
80
70
48
Tension band wiring Tension band wiring
12 12
0º–95º 10º–100º
83 80
80 80
48 48
Revision arthroplasty Revision arthroplasty
-
0º–100º 0º–90º
87 85
70 75
32 24
Rheumatoid arthritis, hypertension -
28
Journal of Orthopaedic Surgery
S Agarwal et al.
angles, thus preventing toggling of fracture fragments and varus collapse. Even unicortical purchase is strong enough to secure fracture fragments in the presence of a prosthesis. Traditional plate fixation is prone to varus collapse.42 Fixed angle blade plates or 95º condylar plates can prevent varus collapse, but are difficult to insert in the presence of a prosthesis. In 10 periprosthetic supracondylar femoral fractures internally fixed with conventional plating, the nonunion rate was 50%.43 However, a 100% union rate was achieved in a series of periprosthetic supracondylar femoral fractures fixed with the locking plates, and only one patient needed bone grafting.35 The union rate was 86% in 24 periprosthetic supracondylar femoral fractures fixed with the locking plates.36 Good alignment and early return to previous functional status was achieved after fixation with the locking plates.26 86 to 90% union rates were achieved with most patients returning to their preoperative functional status, with stable prosthesis and good bone stock.42,44 Nonetheless, high complication rates have also been reported.27 There were 2 nonunion, one delayed union, one deep infection, and one implant failure in a series of 18 periprosthetic supracondylar femoral fractures fixed with the locking plates.27 In our study, a 100% union rate was achieved, with excellent alignment with no implant failure. When the supracondylar periprosthetic fracture extends distally to the proximal border of the femoral
component (Su type 3),45 stability of fixation depends on the number of screws that can be placed to hold the small distal fragment. In our series, such cases could be adequately fixed using the locking compression plate. Extreme distal periprosthetic supracondylar fractures can be adequately fixed using a lateral locking plate.46 Periprosthetic patellar fractures are not common. Management options include open reduction and internal fixation with screws or tension band wiring, partial patellectomy, patelloplasty and extensor mechanism reconstruction, and cylindrical cast immobilisation. Most such fractures are associated with a stable implant and intact extensor mechanism,19 and can be managed with immobilisation in a cylindrical cast. With the modern condylar designs of prosthesis, periprosthetic tibial fractures after TKA have become rare. Such fractures are usually associated with a loose implant, deficient bone stock, and instability, and are best managed with revision arthroplasty with an intramedullary nail. In revision arthroplasty, bone defects can be treated with increased resection and component shift, use of bone grafts or prosthetic augments.47 DISCLOSURE No conflicts of interest were declared by the authors.
REFERENCES 1. Healy WL, Siliski JM, Incavo SJ. Operative treatment of distal femoral fractures proximal to total knee replacements. J Bone Joint Surg Am 1993;75:27–34. 2. Inglis AE, Walker PS. Revision of failed knee replacements using fixed-axis hinges. J Bone Joint Surg Br 1991;73:757–61. 3. Merkel KD, Johnson EW Jr. Supracondylar fracture of the femur after total knee arthroplasty. J Bone Joint Surg Am 1986;68:29–43. 4. Ritter MA, Faris PM, Keating EM. Anterior femoral notching and ipsilateral supracondylar femur fracture in total knee arthroplasty. J Arthroplasty 1988;3:185–7. 5. Schroder HM, Berthelsen A, Hassani G, Hansen EB, Solgaard S. Cementless porous-coated total knee arthroplasty: 10-year results in a consecutive series. J Arthroplasty 2001;16:559–67. 6. Cain PR, Rubash HE, Wissinger HA, McClain EJ. Periprosthetic femoral fractures following total knee arthroplasty. Clin Orthop Relat Res 1986;208:205–14. 7. Engh GA, Ammeen DJ. Periprosthetic fractures adjacent to total knee implants: treatment and clinical results. Instr Course Lect 1998;47:437–48. 8. Meek RM, Norwood T, Smith R, Brenkel IJ, Howie CR. The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement. J Bone Joint Surg Br 2011;93:96–101. 9. Keating EM, Haas G, Meding JB. Patella fracture after post total knee replacements. Clin Orthop Relat Res 2003;416:93–7. 10. Ortiguera CJ, Berry DJ. Patellar fracture after total knee arthroplasty. J Bone Joint Surg Am 2002;84:532–40. 11. Parvizi J, Kim KI, Oliashirazi A, Ong A, Sharkey PF. Periprosthetic patellar fractures. Clin Orthop Relat Res 2006;446:161–6. 12. Chang MA, Rand JA, Trousdale RT. Patellectomy after total knee arthroplasty. Clin Orthop Relat Res 2005;440:175–7. 13. Grace JN, Sim FH. Fracture of the patella after total knee arthroplasty. Clin Orthop Relat Res 1988;230:168–75. 14. Healy WL. Tibial fractures below total knee arthroplasty. In: Insall JN, Scott WN, Scuderi GR, editors. Current concepts in primary and revision total knee arthroplasty. Philadelphia: Lippincott-Raven; 1996:163–7. 15. Felix NA, Stuart MJ, Hanssen AD. Periprosthetic fractures of the tibia associated with total knee arthroplasty. Clin Orthop Relat Res 1997;345:113–24.
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29
16. Lesh ML, Schneider DJ, Deol G, Davis B, Jacobs CR, Pellegrini VD Jr. The consequences of anterior femoral notching in total knee arthroplasty. A biomechanical study. J Bone Joint Surg Am 2000;82:1096–101. 17. Ritter MA, Thong AE, Keating EM, Faris PM, Meding JB, Berend ME, et al. The effect of femoral notching during total knee arthroplasty on the prevalence of postoperative femoral fractures and on clinical outcome. J Bone Joint Surg Am 2005;87:2411–4. 18. Chalidis BE, Tsiridis E, Tragas AA, Stavrou Z, Giannoudis PV. Management of periprosthetic patellar fractures. A systematic review of literature. Injury 2007;38:714–24. 19. Seo JG, Moon YW, Park SH, Lee JH, Kang HM, Kim SM. A case-control study of spontaneous patellar fractures following primary total knee replacement. J Bone Joint Surg Br 2012;94:908–13. 20. Rosenberg AG, Andriacchi TP, Barden R, Galante JO. Patellar component failure in cementless total knee arthroplasty. Clin Orthop Relat Res 1988;236:106–14. 21. Melloni P, Valls R, Veintemillas M. Imaging patellar complications after knee arthroplasty. Eur J Radiol 2008;65:478–82. 22. Chen F, Mont MA, Bachner RS. Management of ipsilateral supracondylar femur fractures following total knee arthroplasty. J Arthroplasty 1994;9:521–6. 23. Culp RW, Schmidt RG, Hanks G, Mak A, Esterhai JL Jr, Heppenstall RB. Supracondylar fracture of the femur following prosthetic knee arthroplasty. Clin Orthop Relat Res 1987;222:212–22. 24. Jabczenski FF, Crawford M. Retrograde intramedullary nailing of supracondylar femur fractures above total knee arthroplasty. A preliminary report of four cases. J Arthroplasty 1995;10:95–101. 25. Murrell GA, Nunley JA. Interlocked supracondylar intramedullary nails for supracondylar fractures after total knee arthroplasty. A new treatment method. J Arthroplasty 1995;10:37–42. 26. Norrish AR, Jibri ZA, Hopgood P. The LISS plate treatment of supracondylar fractures above a total knee replacement: a case-control study. Acta Orthop Belg 2009;75:642–8. 27. Fulkerson E, Tejwani N, Stuchin S, Egol K. Management of periprosthetic femur fractures with a first generation locking plate. Injury 2007;38:965–72. 28. Kaab MJ, Stockle U, Schutz M, Stefansky J, Perka C, Haas NP. Stabilisation of periprosthetic fractures with angular stable internal fixation: a report of 13 cases. Arch Orthop Trauma Surg 2006;126:105–10. 29. Hammacher ER, van Meeteren MC, van der Werken C. Improved results in treatment of femoral shaft fractures with the unreamed femoral nail? A multicenter experience. J Trauma 1998;45:517–21. 30. Canadian Orthopaedic Trauma Society. Nonunion following intramedullary nailing of the femur with and without reaming. Results of a multicenter randomized clinical trial. J Bone Joint Surg Am 2003;85:2093–6. 31. Lavernia CJ. Cost-effectiveness of early surgical intervention in silent osteolysis. J Arthroplasty 1998;13:277–9. 32. Wang CJ, Wang JW, Weng LH, Hsu CC, Huang CC, Chen HS. The effect of alendronate on bone mineral density in the distal part of the femur and proximal part of the tibia after total knee arthroplasty. J Bone Joint Surg Am 2003;85:2121–6. 33. Soininvaara TA, Jurvelin JS, Miettinen HJ, Suomalainen OT, Alhava EM, Kröger PJ. Effect of alendronate on periprosthetic bone loss after total knee arthroplasty: a one-year, randomized, controlled trial of 19 patients. Calcif Tissue Int 2002;71:472– 7. 34. Nehme A, Maalouf G, Tricoire JL, Giordano G, Chiron P, Puget J. Effect of alendronate on periprosthetic bone loss after cemented primary total hip arthroplasty: a prospective randomized study [in French]. Rev Chir Orthop Reparatrice Appar Mot 2003;89:593–8. 35. Kregor PJ, Stannard JA, Zlowodzki M, Cole PA. Treatment of distal femur fractures using the less invasive stabilization system: surgical experience and early clinical results in 103 fractures. J Orthop Trauma 2004;18:509–20. 36. Ricci WM, Loftus T, Cox C, Borrelli J. Locked plates combined with minimally invasive insertion technique for the treatment of periprosthetic supracondylar femur fractures above a total knee arthroplasty. J Orthop Trauma 2006;20:190–6. 37. Anakwe RE, Aitken SA, Khan LA. Osteoporotic periprosthetic fractures of the femur in elderly patients: outcome after fixation with the LISS plate. Injury 2008;39:1191–7. 38. Chen YH, Chen WM, Huang CK, Chen TH. Retrograde intramedullary Huckstep nailing for supracondylar fracture of femur after total knee arthroplasty. J Chin Med Assoc 2003;66:755–8. 39. Chettiar K, Jackson MP, Brewin J, Dass D, Butler-Manuel PA. Supracondylar periprosthetic femoral fractures following total knee arthroplasty: treatment with a retrograde intramedullary nail. Int Orthop 2009;33:981–5. 40. Gliatis J, Megas P, Panagiotopoulos E, Lambiris E. Midterm results of treatment with a retrograde nail for supracondylar periprosthetic fractures of the femur following total knee arthroplasty. J Orthop Trauma 2005;19:164–70. 41. Gliatis J. Periprosthetic distal femur fracture: plate versus nail fixation. Opinion: intramedullary nail. J Orthop Trauma 2007;21:220–1. 42. Davison BL. Varus collapse of comminuted distal femur fractures after open reduction and internal fixation with a lateral condylar buttress plate. Am J Orthop (Belle Mead NJ) 2003;32:27–30. 43. Figgie MP, Goldberg VM, Figgie HE 3rd, Sobel M. The results of treatment of supracondylar fracture above total knee arthroplasty. J Arthroplasty 1990;5:267–76. 44. Erhardt JB, Grob K, Roderer G, Hoffmann A, Forster TN, Kuster MS. Treatment of periprosthetic femur fractures with the non-contact bridging plate: a new angular stable implant. Arch Orthop Trauma Surg 2008;128:409–16. 45. Su ET, DeWal H, Di Cesare PE. Periprosthetic femoral fractures above total knee replacements. J Am Acad Orthop Surg 2004;12:12–20. 46. Streubel PN, Gardner MJ, Morshed S, Collinge CA, Gallagher B, Ricci WM. Are extreme distal periprosthetic supracondylar fractures of the femur too distal to fix using a lateral locked plate? J Bone Joint Surg Br 2010;92:527–34. 47. Daines BK, Dennis DA. Management of bone defects in revision total knee arthroplasty. J Bone Joint Surg Am 2012;94:1131– 9.
Periprosthetic fractures after total knee arthroplasty Saurabh Agarwal, Rajeev K Sharma, Jitesh Kumar Jain
Department of Orthopaedics, Indraprastha Apollo Hospital, New Delhi, India
ABSTRACT Purpose. To evaluate outcome in 20 patients treated for periprosthetic fractures after total knee arthroplasty (TKA). Methods. Records of 14 women and 6 men aged 45 to 85 (mean, 67) years who underwent operative (n=18) or conservative (n=2) treatment for periprosthetic fractures of the supracondylar femur (n=15), patella (n=3), and tibia (n=2) following minor falls (n=18) or high-velocity injury (n=2) were reviewed. The mean time from TKA to fracture was 43 (range, 14–98) months. Of the 15 supracondylar femoral fractures, 2 were managed with immobilisation in a long leg cast, 11 with internal fixation using locked compression plating, and 2 with revision arthroplasty. All 3 patellar fractures were managed with tension band wiring. Both tibial fractures were managed with revision arthroplasty. Radiographic and functional outcomes (the Knee Society scores) were assessed. Results. The mean follow-up was 35 (range, 24– 48) months. All fractures healed after a mean of
15 (range, 12–38) weeks. One patient had delayed union. Postoperative alignment was satisfactory in all patients except one (with 5º varus). The mean tibiofemoral angle was 4º valgus. The mean range of motion was 98.5º. The mean Knee Society knee score was 85 (range, 75–89) and the functional score was 76 (range, 70–85). No patient had implant failure, loss of reduction, deep infection, deep vein thrombosis, or pulmonary embolism. Conclusion. The locked compression plate is effective in managing periprosthetic femoral fractures. Periprosthetic patellar and tibial fractures are uncommon. The latter often warrant revision arthroplasty owing to the loose implant. Key words: arthroplasty, periprosthetic fractures
replacement,
knee;
INTRODUCTION The rates of periprosthetic fractures are 0.3 to 2.5% after primary total knee arthroplasty (TKA) and 1.6 to 38% after revision TKA.1–5 Most such fractures
Address correspondence and reprint requests to: Dr Saurabh Agarwal, Department of Orthopaedics, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, 110076, India. Email: [email protected]
Vol. 22 No. 1, April 2014
Periprosthetic fractures after TKA
result from low-velocity injuries such as falls owing to an unbalanced knee with coronal plane laxity. The risk factors include inflammatory arthropathies, chronic steroid use, age >70 years, poor bone stock, neurological disorders, and revision arthroplasty.6–8 Prosthesis-related factors include loosening and osteolysis secondary to polythene wear. Loosening of the tibial component is more common than that of the femoral component. The most common periprosthetic fractures after TKA are supracondylar femoral fractures (0.3– 2.5%),1–5 followed by patellar fractures (0.15–12%)9–13 and tibial fractures (0.4–1.7%).14,15 In one study, 30.5% of periprosthetic supracondylar femoral fractures were associated with anterior femoral notching.16 However, in another study 30% of TKAs had a notched femur, but only 2 periprosthetic fractures occurred (both in femurs without notching).17 The most common risk factor for periprosthetic patellar fractures after TKA is excessive patellar resection, followed by mal-alignment,18 a shorter patellar tendon,19 obesity,20 and excessive flexion of knee.21 Excessive lateral release has a deleterious effect on patellar blood supply, which can lead to fractures.13 Periprosthetic patellar fractures are frequently asymptomatic, and the diagnosis is usually made during routine radiological examination.18,19 Treatment goals are to achieve painless and stable knees with excellent alignment and range of motion. Conservative management (immobilisation in a brace or cast) is recommended for non-displaced fractures. Prolonged immobilisation may results in decreased range of motion, reduced walking capacity, and higher rates of malunion.22,23 Internal fixation is therefore preferred. Fixation with periarticular locking plates or retrograde intramedullary nails is superior to
(a)
(b)
25
external fixation, dynamic condylar screw fixation, and blade plate fixation.24–28 This study evaluated outcome in 20 patients treated for periprosthetic fractures after TKA. MATERIALS AND METHODS Records of 14 women and 6 men aged 45 to 85 (mean, 67) years who underwent operative (n=18) or conservative (n=2) treatment between January 2002 and December 2010 for periprosthetic fractures of the supracondylar femur (n=15), patella (n=3), and tibia (n=2) following minor falls (n=18) or high-velocity injury (n=2) were reviewed. The mean time from TKA to fracture was 43 (range, 14–98) months. Of the 15 supracondylar femoral fractures, 2 were Roraback and Lewis type 1 (undisplaced fractures with intact prosthesis-bone interface) and managed with immobilisation in a long leg cast, 11 were type 2 (displaced fractures with intact prosthesis-bone interface) and managed with internal fixation with a distal femoral locked compression plate under fluoroscopy by a percutaneous technique in 8 cases and by open reduction in 3 cases, and 2 were type 3 (displaced fractures with loose femoral component) and managed with revision arthroplasty (Fig.1). Fixation of 2 fractures was augmented with bone grafting (structural allografts) owing to deficient bone stock. All 3 patellar fractures were associated with disrupted extensor mechanism with a well-fixed implant (Ortiguera and Berry type 2) and managed with open reduction and internal fixation using tension band wiring (Fig. 2). Both tibial fractures were adjacent to the stem with a loose implant (Felix type 2) and managed with revision arthroplasty. One
(c)
Figure 1 (a) Periprosthetic supracondylar femoral fractures extending distally fixed with (b) locked compression plating or (c) revision arthroplasty.
26
Journal of Orthopaedic Surgery
S Agarwal et al.
of them was strengthened with a proximal tibial lock compression plate (Fig. 3). Postoperatively, active and passive knee physiotherapy was started immediately. Non-weight
bearing mobilisation was allowed for 6 weeks and gradually progressed to full weight bearing, depending on radiographic evidence of bone union. Patients were followed up at 2, 6, and 8 weeks, and then at 3 and 6 months, and yearly thereafter. Coronal alignment of the knee (the angle between the mechanical axes of the tibia and femur) on anteroposterior radiographs was assessed. The fracture was defined as united when callus was visible across at least 3 cortices on both anteroposterior and lateral radiographs. Delayed healing was defined as a fracture united after >6 months without an additional surgical procedure.29 Non-union was defined as a fracture with no features of progressive healing on 3 consecutive radiographs taken at a one-month interval after 6 months of follow up and necessitating an additional procedure.30 Functional outcome was assessed using the Knee Society knee and functional scores. RESULTS
Figure 2 A periprosthetic patellar fracture fixed with tension band wiring.
The mean follow-up was 35 (range, 24–48) months. All fractures healed after a mean time of 15 (range, 12–38) weeks (Table). One patient had delayed union at 38 weeks. Postoperative alignment was satisfactory in all patients except one (with 5º varus). The mean tibiofemoral angle was 4º valgus. The mean range of
Figure 3 A periprosthetic tibial fracture fixed with revision arthroplasty using a long stem and strengthened with a proximal tibial locked compression plate.
Vol. 22 No. 1, April 2014
Periprosthetic fractures after TKA
motion was 98.5º. The mean Knee Society knee score was 85 (range, 75–89) and the functional score was 76 (range, 70–85). One patient developed a superficial infection, which was treated with debridement. No patient had implant failure, loss of reduction, deep infection, deep vein thrombosis, or pulmonary embolism. DISCUSSION Prevention of periprosthetic fractures after TKA is important. Most such fractures are associated with bone loss and implant loosening causing instability around the knee and thus fall. Improvement of bone loss prior to revision arthroplasty can halve the cost of management for such periprosthetic fractures.31 We regularly give bisphosphonates to all patients undergoing TKA to prevent periprosthetic osteolysis.
27
Treatment outcome for periprosthetic fracture is related to the degree of bone loss.32–34 Fixation with periarticular locked compression plates27,35–37 or retrograde intramedullary nails38–40 is superior to cast immobilisation, external fixation, dynamic compression plate fixation, and dynamic condylar screw fixation. We preferred to use periarticular locked compression plates for internal fixation, as using a retrograde intramedullary nail is limited by the narrow or closed intercondylar space of the TKA prosthesis. Enlargement of the notch is often required and may raise concern about 3rd body wear.41 Using a minimally invasive technique, the locked compression plate can be inserted through a small incision into the submuscular periosteal plane, thus minimising damage to the periosteal blood supply and promoting healing. The plate is precontured so it helps in reducing the fracture fragments. Multiple screws are inserted at different
Table Patient characteristics and outcomes Sex/age (years)
Periprosthetic supracondylar femoral fracture F/49
Time Comorbidity from surgery to fracture (months)
21
F/75 F/75 F/67 F/79 F/45 M/68 F/75
47 24 49 14 38 67 24
M/62 F/61 M/75 F/58
33 87 36 49
F/81
48
F/61
39
M/65 Periprosthetic patellar fracture F/67
98
F/55 F/67 Periprosthetic tibial fracture M/85 M/70
25 47
45
39 25
Rheumatoid arthritis, diabetes mellitus Rheumatoid arthritis Hypertension Hypertension Right total hip arthroplasty (THA), diabetes mellitus, hypertension Rheumatoid arthritis, bilateral THA, diabetes mellitus -
Treatment
Time to Range of Knee Func- Followunion motion score tional up (weeks) score (months)
Long leg cast immobilisation
16
05º–90º
75
70
24
Long leg cast immobilisation Locked compression plating Locked compression plating Locked compression plating Locked compression plating Locked compression plating Locked compression plating
14 14 12 12 14 16 14
05º–100º 0º–100º 0º–110º 0º–110º 0º–105º 0º–95º 0º–95º
83 87 89 89 87 85 85
75 80 80 80 85 75 70
34 24 26 36 35 30 36
Locked compression plating Locked compression plating Locked compression plating Locked compression plating
12 14 16 12
0º–110º 0º–100º 0º–100º 0º–110º
89 87 87 89
80 75 75 80
36 24 34 34
Locked compression plating with bone grafting Bilateral THA, avascular necrosis Revision arthroplasty with of left shoulder, hypertension structural bone grafting Hypertension Revision arthroplasty
14
0º–80º
80
75
36
12
0º–95º
87
70
30
-
0º–100º
75
75
29
Tension band wiring
38
05º–110º
80
70
48
Tension band wiring Tension band wiring
12 12
0º–95º 10º–100º
83 80
80 80
48 48
Revision arthroplasty Revision arthroplasty
-
0º–100º 0º–90º
87 85
70 75
32 24
Rheumatoid arthritis, hypertension -
28
Journal of Orthopaedic Surgery
S Agarwal et al.
angles, thus preventing toggling of fracture fragments and varus collapse. Even unicortical purchase is strong enough to secure fracture fragments in the presence of a prosthesis. Traditional plate fixation is prone to varus collapse.42 Fixed angle blade plates or 95º condylar plates can prevent varus collapse, but are difficult to insert in the presence of a prosthesis. In 10 periprosthetic supracondylar femoral fractures internally fixed with conventional plating, the nonunion rate was 50%.43 However, a 100% union rate was achieved in a series of periprosthetic supracondylar femoral fractures fixed with the locking plates, and only one patient needed bone grafting.35 The union rate was 86% in 24 periprosthetic supracondylar femoral fractures fixed with the locking plates.36 Good alignment and early return to previous functional status was achieved after fixation with the locking plates.26 86 to 90% union rates were achieved with most patients returning to their preoperative functional status, with stable prosthesis and good bone stock.42,44 Nonetheless, high complication rates have also been reported.27 There were 2 nonunion, one delayed union, one deep infection, and one implant failure in a series of 18 periprosthetic supracondylar femoral fractures fixed with the locking plates.27 In our study, a 100% union rate was achieved, with excellent alignment with no implant failure. When the supracondylar periprosthetic fracture extends distally to the proximal border of the femoral
component (Su type 3),45 stability of fixation depends on the number of screws that can be placed to hold the small distal fragment. In our series, such cases could be adequately fixed using the locking compression plate. Extreme distal periprosthetic supracondylar fractures can be adequately fixed using a lateral locking plate.46 Periprosthetic patellar fractures are not common. Management options include open reduction and internal fixation with screws or tension band wiring, partial patellectomy, patelloplasty and extensor mechanism reconstruction, and cylindrical cast immobilisation. Most such fractures are associated with a stable implant and intact extensor mechanism,19 and can be managed with immobilisation in a cylindrical cast. With the modern condylar designs of prosthesis, periprosthetic tibial fractures after TKA have become rare. Such fractures are usually associated with a loose implant, deficient bone stock, and instability, and are best managed with revision arthroplasty with an intramedullary nail. In revision arthroplasty, bone defects can be treated with increased resection and component shift, use of bone grafts or prosthetic augments.47 DISCLOSURE No conflicts of interest were declared by the authors.
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