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.

2. TKA periprosthetic fractures

3. Incidence
Risk Factors
Patient Evaluation
Classifications
Treatment
Complications

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

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.

12. MITTLMEIER, T., STOCKLE, U., PERKA, C., SCHASER, K.D.: Periprosthetic fractures after total knee joint
arthroplasty. Unfallchirurg, 108: 481-495; quiz 496, 2005.

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

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

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

25. Periprosthetic Patellar
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 mechansimConservative
• Stable implantstension band/screw
• loose implantsTension 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.

29. Take home message