TKA periprosthetic fractures

Incidence

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 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.

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

Definition ??

• Neer 3 inches• Culp 9 cm• Sisto15 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.ClinOrthop1985;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

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

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

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 screws

DISADVANTAGES– Can’t contour of titanium plates– More expensive than dynamic plate– Requires special training

CHALLENGE:- Avoid hyperextension & valgus deformity

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

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

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.

• 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 : osteosyntheticreconstruction,+/-revision arthroplasty

Type IV fractures

Periprosthetic Patellar Fractures

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

• If Intact extensor mechansimConservativeTYPE 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 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 achillestendon 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