Periprosthetic fractures around total knee replacements can occur in the femur, tibia, or patella. Femur fractures have various classification systems and treatment depends on the specific fracture type, bone quality, and implant stability. Options include open reduction internal fixation with plates or nails, or revision arthroplasty. Tibia fractures also have a classification system and are typically treated with osteosynthesis or revision if the tibial component is loose. Patella fractures also have a classification and treatment involves tension band wiring, osteosynthesis, or revision as needed. Complications can include nonunion, mechanical failures, and infection.
4. Incidence
Overall rate center around 1 %.
Higher following revision arthroplasty as opposed to primary
implantations.
0.3% to 2.5%
> 60 yrs old with
osteoporotic bones
0.6 %
0.3% – 0.5%
5. Risk factors
Rheumatoid arthritis
Neurologic disorders
Chronic steroid therapy
Osteopenia/osteoporosis
In Supracondylar #:
-Anterior femoral notching weakens the anterior femur at the bone-component
interface
In Tibia #:
-Varus positioning and malrotation of the tibial component
In Patella # :
-Axial extremity deformities or malalignment of the prosthesis,
-Extensive resections of the patella with thickness <15 mm
** BURNETT, R.S., BOURNE, R.B.: Periprosthetic fractures of the tibia and patella in total knee
arthroplasty. Instr. Course Lect, 53: 217-235, 2004.
6. Patient evaluation
The history and physical examination:
should focus on prefracture knee symptoms such as pain,
instability, and stiffness
Infection Workup :
In patients with a loose implant or history of prefracture knee
pain.
Medical Optimization
High-quality Radiographs:
stability & periarticular bone stock.
Status of the soft tissues
The neurovascular status
7.
8. Definition ??
• Neer 3 inches
• Culp 9 cm
• Sisto 15 cm
• In Stemmed
component 5 cm
from the proximal end
of the implant
Sisto DJ, Lachiewicz PF, Insall JN: Treatment of
supracondylar fractures following prosthetic
arthroplasty of the knee.Clin
Orthop1985;196:265-272.
9. Classifications of supracondylar femur
periprosthetic fractures
RORABECK, C.H., TAYLOR, J.W.: Classification of periprosthetic fractures complicating total knee arthroplasty.
Orthop. Clin. North Am., 30: 209-214, 1999
10. SU, E.T., DEWAL, H., DI CÉSARE, P.E.: Periprosthetic femoral fractures above total knee replacements.
J. Am. Acad. Orthop. Surg., 12: 12-20, 2004.
11. Treament
GOALS
stable joint
completed fracture healing (within 6 months)
"range of motion" and restored knee function to the level prior to the
trauma.
A functionally favourable result:-
- minimum range of motion of 90°
- shortening < 1 cm
- varus-/valgus-misalignment < 5°,
- minimal change in torsion and ante-/retroflexion < 10°
SU, E.T., DEWAL, H., DI CÉSARE, P.E.: Periprosthetic femoral fractures above
total knee replacements. J. Am. Acad. Orthop. Surg., 12: 12-20, 2004.
13. Open reduction and internal fixation
a) Dynamic Condylar Screw & Fixed Plade :-
-DIFFICULT to OBTAIN STABLE DISTAL FIXATION
-Limited ability to place blade more distally
-Difficult to change alignment
-Possibility of fragmenting periprosthetic bone
b) Condylar buttress plate:-
-no coronal stability
-varus collapse
14. a) Retrograde intramedullary nailing:-
Indications:
-open boxes implants
-sufficient distal bone to allow purchase
with minimum 2 distal locking screws
Advantages
-More stable in medial comminution
than locked plates
-soft tissue–friendly
-minimally invasive
Disadvantages:
-Can not use in typically comminuted,
osteopenic distal bony fragments
15. b) Antegrade femoral nailing
Indications
-sufficiently long distal fragment is present
The main challenge
-obtaining accepted alignment and stable distal fixation.
Disadvantages
-an area of high-stress concentration is created between the
distal end of the nail and the femoral component.
16. Percutaneous Technique of Distal End of the
Femur Using Locked Plating Designs
ADVANTAGES:
– Minimal dissection
– Preserves blood supply
– Rigid internal fixation
– Use with/without cables
– Unicortical screws
– Multiple distal fixation screws
DISADVANTAGES
– Can’t contour of titanium plates
– More expensive than dynamic plate
– Requires special training
CHALLENGE:
- Avoid hyperextension & valgus deformity
17.
18.
19. Role Of Revision Arthroplasty
Indications:
loose prosthesis
inadequate bone stock
nonunion supracondylar fractures that requires
tumor prosthesis.
Requirements:-
Surgeons who have the experience
and technical support
20.
21. Tibia periprosthetic fractures
Felix classification
FELIX, N.A., STUART, M.J., HANSSEN, A.D.: Periprosthetic fractures of the tibia
associated with total knee arthroplasty. Clin. Orthop. Relat. Res., 345: 113-124, 1997.
22. Treatment
Indications:
Intraoperatively stable undisplaced fractures which are and first
seen at the postoperative radiograph
Undisplaced fractures type II.
How ??
an adaptation of the postoperative weight bearing and radiographic
controls
BURNETT, R.S., BOURNE, R.B.: Periprosthetic fractures of the tibia and patella in total knee arthroplasty. Instr.
Course Lect, 53: 217-235, 2004
FELIX, N.A., STUART, M.J., HANSSEN, A.D.: Periprosthetic fractures of the tibia associated with total knee
arthroplasty. Clin. Orthop. Relat. Res., 345: 113-124, 1997.
23. • OSTEOSYNTHESIS +/- REVISION STEM
SYSTEMS
Intraoperative #
Subtype C
(type I - III)
• Revision arthroplasty
Loose tibial implant
(subtype B)
ALL TYPES
• Loss of extension function is an
indication for : osteosynthetic
reconstruction,+/-revision arthroplasty
Type IV fractures
26. PERIPROSTHETIC PATELLAR FRACTURES
Goldberg Classification
GOLDBERG, V.M., FIGGIE, H.E., 3rd, INGLIS, A.E., FIGGIE, M.P., SOBEL, M., KELLY, M., KRAAY, M.: Patellar fracture type
and prognosis in condylar total knee arthroplasty. Clin. Orthop. Relat. Res., 236: 115-122, 1988
27. TREATMENT
TYPE I • If Intact extensor mechansimConservative
• Stable implantstension band/screw
• loose implantsTension band/screw + revision TYPE II
• Type III A fractures with fixed implant are treated
according to guidelines for the management of
patellar tendon ruptures
• Type III B : stable conservative loose revision
Type III
CHALIDIS, B.E.,TSIRIDIS, E., TRAGAS, A.A., STAVROU, Z., GIANNOUDIS, P. V.: Management of periprosthetic patellar
fractures - A systematic review of literature. Injury, 38: 714-724, 2007.
CROSSETT, L.S., SINHA, R.K., SECHRIEST, V.E., RUBASH, H.E.: Reconstruction of a ruptured patellar tendon with achilles
tendon allograft following total knee arthroplasty. J. Bone Jt Surg., 84-A: 1354-1361, 2002.
28. complications
in a systematic study analyzing complications of 415
periprosthetic femur fractures Herrera et al. observed:-
9% pseudarthroses/non-unions
4% mechanical complications
3% infections
with an overall revision rate, reaching 13%.
HERRERA, D.A., KREGOR, P.J., COLE, P.A., LEVY, B.A., JONSSON, A., ZLOWODZKI, M.: Treatment of
acute distal femur fractures above a total knee arthroplasty: systematic review of 415 cases (1981-
2006). Acta Orthop., 79: 22-27, 2008.