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Periprosthetic Fractures around the Knee
Team A-khoula hospitalAhmed Azmy
TKA periprosthetic fractures
S.C # TIBIA # PATELLA #
Key PointsIncidence
Risk Factors
Patient Evaluation
Classifications
Treatment
Complications
0.3% to 2.5%
> 60 yrs old with osteoporotic bones
0.3% – 0.5%
0.6 %
Overall rate center around 1 %.Higher following revision arthroplasty as opposed to primary implantations.
Incidence
Risk factorsI. Patient related:- Rheumatoid arthritis Neurologic disorders Chronic steroid therapy Osteopenia/osteoporosis
II. Surgery related:- 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.
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
Supracondylar periprosthetic femoral
fractures
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.
RORABECK, C.H., TAYLOR, J.W.: Classification of periprosthetic fractures complicating total knee arthroplasty. Orthop. Clin. North Am., 30: 209-214, 1999
Classifications of supracondylar femur periprosthetic fractures
I. Lewis and Rorabeck :
II. Su and associates :-
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.
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.
MITTLMEIER, T., STOCKLE, U., PERKA, C., SCHASER, K.D.: Periprosthetic fractures after total knee joint arthroplasty. Unfallchirurg, 108: 481-495; quiz 496, 2005.
Open reduction and internal fixation
I. Plates and screws:-
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
II. Intramedullary nails: 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
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.
b) Antegrade femoral nailing
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 screwsDISADVANTAGES– Can’t contour of titanium plates– More expensive than dynamic plate– Requires special trainingCHALLENGE:- Avoid hyperextension & valgus deformity
Role Of Revision ArthroplastyIndications: loose prosthesis inadequate bone stock nonunion supracondylar fractures that requires tumor prosthesis.
Requirements:- Surgeons who have the experience and technical support
Tibial Periprosthetic Fractures
Tibia periprosthetic fractures
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.
Felix classification
TreatmentI. Conservative therapy:-
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.
•OSTEOSYNTHESIS +/- REVISION STEM SYSTEMS
Intraoperative # Subtype C
(type I - III)
•Revision arthroplastyLoose tibial implant
(subtype B)ALL TYPES
•Loss of extension function is an indication for : osteosynthetic reconstruction,+/-revision arthroplasty
Type IV fractures
II. Surgical therapy:-
Periprosthetic Patellar Fractures
PERIPROSTHETIC PATELLAR FRACTURESGoldberg 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
• If Intact extensor mechansimConservative TYPE I
• 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 revisionType 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.
TREATMENT
in a systematic study analyzing complications of 415 periprosthetic femur fractures Herrera et al. observed:-
9% pseudarthroses/non-unions4% mechanical complications 3% infections with an overall revision rate, reaching 13%.
complications
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.
Take home message
Thank You