Periprosthetic fractures around the knee

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

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