Periprosthetic Fractures after Total Knee Arthroplasties

Introduction The management of periprosthetic fractures is challenging and is guided by the configuration of the fracture, stability of implants and quality of the patient’s bone. This case report discusses the long-term fate of femoral allograft for periprosthetic fracture around a revision knee arthroplasty. Case report We present the operative technique and long-term fate of a bivalved femoral allograft used for the treatment of a periprosthetic fracture around a stemmed femoral component of a revision total knee arthroplasty (TKA) in a patient with rheumatoid arthritis and osteoporosis. Regular radiographic follow-up confirmed incorporation and docking of the allograft. A subsequent ipsilateral femoral neck fracture 4 years after allograft implantation was treated with routine total hip replacement. Conclusion The use of femoral allograft for augmenting fixation of periprosthetic fractures above a TKA is not widely reported, and, at 11 years, this case represents the longest published follow-up above a revision TKA. Our case supports the use of a bivalved total femoral allograft in the treatment of long-bone periprosthetic fractures with poor bone stock. Introduction Data from joint registries indicate an increase in the number of primary and revision knee arthroplasties being performed each year internationally, and the volume of revision knee arthroplasty being performed in the USA alone is expected to increase by 601% between 2005 and 20301. Periprosthetic supracondylar femoral fractures can occur intraoperatively and postoperatively, with an overall incidence of 0.3–2.5% above primary total knee arthroplasties (TKAs)2–7. Estimates of the incidence after revision knee arthroplasty vary greatly from 1.7% to 38%3,6–8, with most reports quoting closer to 2%. Periprosthetic femoral fractures above TKA and revision TKA have historically been associated with high complication rates when treated nonoperatively or with internal fixation4,5,9. Periprosthetic fractures are more common in the elderly population and in females7. Additional risk factors include rheumatoid arthritis, chronic steroid treatment, reduced bone stock, neurological disorders, revision surgery, notching of the anterior cortex of the femur, and in particular poor bone stock3,9–11. Primary osteopenia or secondary to stress shielding around a stemmed revision femoral component further increases the difficulty of achieving good fracture fixation by traditional methods. Whilst the introduction of locked plate technology has revolutionized surgery in the presence of osteoporotic bone12, the use of a combination of cortical femoral allograft and compression plate13 or a bivalved total femoral allograft5,14 may be indicated when a periprosthetic fracture around a well-fixed implant is complicated by deficient bone stock or significant comminution. Unfortunately, there remains insufficient evidence to strongly support the use of a single method of surgical treatment in this complex fracture group. In this case report, we aim to provide further evidence that a bivalved total femoral allograft can be successfully used in the treatment of periprosthetic femoral fractures above/around a well-fixed stemmed revision TKA and that incorporation of the graft with the host femur is possible thereby increasing the patient’s bone stock. This technique can provide a reliable long-term solution in this complex fracture group. Case report One month after primary TKA for valgus arthritis, a 60-year-old lady with polyarticular rheumatoid arthritis and severe osteoporosis re-presented with a sintering fracture of the lateral femoral condyle after a simple stumble. The femoral component was revised to an uncemented stemmed implant, and the lateral femoral condyle was reconstructed with femoral head structural allograft. Three months after discharge, she fell and sustained a spiral periprosthetic fracture around the femoral stem (Figure 1). * Corresponding author Email: gavin.macpherson@nhs.net 1 Department of Orthopaedic Surgery, The Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK 2 Stiftung Orthopadische Universitatsklinik, Schlierbacher Landstrase 200a, 69118 Heidelberg, Germany 3 Orthopadischen Klinik Paulinenhilfe, Diakonie Klinikum Stuttgart, Rosenbergstrasse 38, D-70176 Stuttgart, Germany 4 Endoklinik Hamburg, Holstenstr. 2, 22767 Hamburg, Germany

Periprosthetic fractures can be devastating complications after total joint arthroplasty (TJA). The management of periprosthetic fractures is complex, spanning expertise in arthroplasty and trauma. The purpose of this study was to examine and project trends in the operative treatment of periprosthetic fractures in the United States. A large, public and private payer database was queried to capture all International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for periprosthetic femoral and tibial fractures. Statistical models were created to assess trends in treatment for periprosthetic fractures and to predict future surgical rates. An alpha value of 0.05 was used to assess significance. A Bonferroni correction was applied where applicable to account for multiple comparisons. In this study, from 2016 to 2021, 121,298 patients underwent surgical treatment for periprosthetic fractures. There was a significant increase in the total number of periprosthetic fractures. The incidence of periprosthetic hip fractures rose by 38% and that for periprosthetic knee fractures rose by 73%. The number of periprosthetic fractures is predicted to rise 212% from 2016 to 2032. There was a relative increase in open reduction and internal fixation (ORIF) compared with revision arthroplasty for both periprosthetic hip fractures and periprosthetic knee fractures. Periprosthetic fractures are anticipated to impose a substantial health-care burden in the coming decades. Periprosthetic knee fractures are predominantly treated with ORIF rather than revision total knee arthroplasty (TKA), whereas periprosthetic hip fractures are predominantly treated with revision total hip arthroplasty (THA) rather than ORIF. Both periprosthetic knee fractures and periprosthetic hip fractures demonstrated increasing trends in this study. The proportion of periprosthetic hip fractures treated with ORIF relative to revision THA has been increasing. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Periprosthetic distal femoral fractures present significant challenges in management due to high morbidity and mortality rates. We discuss the treatment options based on fracture pattern, location and status of the prosthesis. Surgical treatment is favored over nonoperative management to enable early mobilization and prevent complications. The Rorabeck and Taylor classification system for periprosthetic fractures was used to identify the prosthesis status. For stable prosthesis, fixation method was decided based on the location of the fracture from the flange, level of comminution and bone quality. Well-fixed prosthetic components require internal fixation with locking plates either single or double or retrograde intramedullary interlocking nail. A revision knee replacement could be done in patients with loose prosthesis and good bone stock. Distal femoral replacement was required in patients with loose components and poor bone stock along with fracture. Treatment of osteoporosis is an integral part of the management. We have described a surgical algorithm to be followed based on the above protocol. Treatment of periprosthetic fractures after TKA needs a tailored treatment approach based on factors such as bone quality, prosthesis stability, fracture location, and patient-specific considerations. A personalized strategy ensures optimal outcomes by addressing the unique challenges of each case and balancing the need for stability, mobility, and long-term implant survival.The surgical algorithm we have described helps in managing periprosthetic fractures effectively.

Introduction:Surgical treatment options for periprosthetic fractures (PPF) include internal fixation with plate, intramedullary nailing and revision arthroplasty. We aimed at evaluating the surgical outcomes of patients who we had treated PPF with locking compression plates (LCP).Materials and methods:Twenty patients with PPF after primary total knee arthroplasty (TKA) between 2009 and 2016 were included in to the study. Knee Society Knee Scoring System (KSKSS) was used in the evaluation of radiologic and functional outcomes. There were periprosthetic supracondylar femoral fractures in 15 patients, and that of tibial fractures in 5 patients. For internal fixation, locking compression plate was preferred.Results:The mean age was 69 (range 61 to 78) years and the mean follow-up period was 72.25 (range 24 to 110) months. Union was achieved by 15.8 weeks in all the cases. Superficial infection and implant fracture were each seen in two patients. Revision operations were done to those patients with implant fracture. Mean KSKSS was 81.4 (75-87) and the mean functional score was 78.75 (75-85). Degenerative osteoarthritis patients were found to have higher age values than post-traumatic osteoarthritis patients (p = 0.001). When the union times were compared, it was found that the degenerative osteoarthritis patient group had a significantly shorter union than the post-traumatic osteoarthritis patient group (p = 0.036).Conclusion:Internal fixation with LCP is an effective treatment method in managing of PPF for patients with good bone stock. Rigid fixation should be done with the right surgical technique and an early movement must be initiated so that a good function can be achieved.

Periprosthetic fractures may occur intraoperatively or postoperatively. The incidence of is approximately 0.6% in primary and 2.4% in revision total hip arthroplasty. Predisposing factors include stress risers, osteolysis, osteopoenia, singly or in combination. Focusing on postoperative fractures, this paper provides a management algorithm. If the fracture is stable, conservative treatment is appropriate. If the fracture is not stable, one needs to determine whether the prosthesis is loose or not. If the prosthesis is loose, further management will depend on the quality of the bone stock. Good bone stock will allow revision with a long stem or impaction grafting, while poor bone stock will require extensive allografting. Similarly, the adequacy of the bone stock determines the management regime if the pros-thesis is not loose. In the presence of good bone stock, it is usually possible to carry out open reduction and internal fixation. Poor bone stock requires bicortical onlay allografting. From 1994 to 1998 36 periprosthetic fractures, 14 with stable implants and 22 with unstable, were treated. The stable implants were treated with Dall Miles plates, fixed with cables and crimp-sleeves, bicortical screws distal to the fracture and unicortical screws proximally. The fracture united in 11 hips, two of which subsequently required prosthetic revision for femoral loosening. In one hip the fixation failed with fracture of the cables. Despite other adverse reports, this type of system is recommended for fixation of periprosthetic fractures where the prosthesis is stable. The 22 periprosthetic fractures with unstable implants were treated using the Bicontact long stem revision implant. Two distal interlocking screws provided early rotational and axial stability, and 14 patients had additional allografting. Radiological evidence of fracture healing was apparent in all cases. One prosthesis subsided by more than 5 mm with fracture of the interlocking screws. Cementless long stem revision is the treatment of choice for periprosthetic fractures associated with a loose implant. To ensure successful outcome it is necessary to determine the extent of the fracture, to assess fracture stability and to appreciate the available and appropriate treatment options. It is necessary to ‘be prepared’: these are challenging problems and the final decision often hinges on intraoperative findings.

PHILOS plating of periprosthetic humeral shaft fracture after onlay-type reverse total shoulder arthroplasty: a case report

The incidence of periprosthetic fractures after total knee arthroplasty is continuously rising because of an increasing number of knee joint replacements and an enhanced survivorship of the elderly population after knee arthroplasty. The purpose of this study was to analyze the practicability and effectiveness of the various treatment methods for management of periprosthetic fractures after total knee arthroplasty, and to determine the clinical and radiographic long-term results of patients following surgical and nonoperative treatment of these injuries. We reviewed the clinical and radiographic records of 41 patients (31 women and 10 men; average age, 78.6 years) with periprosthetic fractures after total knee arthroplasty between 1992 and 2008. Thirty-seven patients showed a periprosthetic fracture of the distal femur, and four patients had a periprosthetic proximal tibial fracture. Thirty-six patients underwent operative stabilization by plate fixation (n = 18), intramedullary nailing (n = 15) or revision arthroplasty (n = 3), and five patients were treated nonoperatively by long-term cast immobilization. Twenty-eight patients returned to their preinjury activity level and were satisfied with their clinical outcome. In 10 patients, we saw a relevant decrease of knee function and severe limitations in gait and activities of daily living. Three patients died related to surgery. Successful fracture healing within 6 months was achieved in 33 (87%) of 38 patients. Failures of reduction or fixation occurred in 8 (21%) of 38 patients. Reoperation due to technical failures was necessary in three patients. Compared with current data in literature, we had a satisfactory outcome in following individualized treatment of periprosthetic fractures after knee joint replacement. Referring to the wide field of treatment options and high rates of complications, periprosthetic femoral fractures around the knee commonly constitute a challenging problem for the treating surgeons and require an adequate analysis of fracture etiology and a corresponding transfer into an individual treatment concept.

Intramedullary Fibular Strut Allograft and a Small Fragment Nonlocking T-plate for Periprosthetic Lateral Femoral Condyle Fracture: A Case Report

Summary. Periprosthetic fractures around total knee arthroplasty (TKA) are difficult to treat due to complex fracture morphology, high proportions of injuries associated with osteopenia, and the variability of injury patterns. Periprosthetic fractures associated with TKA are defined as fractures around the knee joint (femur, tibia, or patella) occurring within 5 cm of the intramedullary stem of the prosthesis or 15 cm of the joint. The incidence is estimated to be between 0.3% and 2.5% after primary TKA and up to 28% after revision TKA. There are several surgical and nonsurgical risk factors associated with postoperative periprosthetic fractures. Distal femoral periprosthetic fractures following TKA are the most common and reported to occur in 0.2–1.8% of patients after primary TKA. Tibial periprosthetic fractures have a reported prevalence of 0.07–0.1% in primary and 0.36% in revision knee arthroplasties. Patella fractures are the second most common periprosthetic fractures following TKA, with prevalence ranging from 0.68% to 1.19%, and are usually associated with a resurfaced patella. Several classification systems of periprosthetic fractures around TKA have been published and some treatment recommendations have been provided. However, most systems are subject to criticism and use different classification systems for the tibia, patella, and the femur.A variety of treatment methods are available for periprosthetic fractures. Conservative treatment can include protected weight bearing, splinting, or traction. Surgical treatment commonly involves closed intramedullary nailing or open reduction and internal fixation by plates. In cases of significant bone loss, a revision TKA may be indicated. In general, treatment must be guided based on the stability of the implant and the remaining bone quality, as determined by the presence of osteolysis and the location of the fracture.

Distal femoral replacement in periprosthetic fracture around total knee arthroplasty

Periprosthetic fractures after total knee arthroplasty (TKA) are gradually increasing, reflecting extended lifespan, osteoporosis, and the increasing proportion of the elderly during the past decade. Supracondylar periprosthetic femoral fracture is a potential complication after TKA. Generally, open reduction and internal fixation are the conventional option for periprosthetic fracture after TKA. However, the presence of severe comminution with component loosening can cause failure of internal fixation. Although the current concept for periprosthetic fracture is open reduction and internal fixation, we introduce an unusual case of revision arthroplasty using a MUTARS® prosthesis for a comminuted periprosthetic fracture in the distal femur after TKA, with technical tips.

“Floating Total Knee”: Ipsilateral Periprosthetic Fractures of the Distal Femur and Proximal Tibia After Total Knee Arthroplasty

Periprosthetic fractures after total knee arthroplasty may occur in any part of the femur, tibia and patella, and the most common pattern involves the supracondylar area of the distal femur. Supracondylar periprosthetic fractures frequently occur above a well-fixed prosthesis, and risk factors include anterior femoral cortical notching and use of the rotational constrained implant. Periprosthetic tibial fractures are frequently associated with loose components and malalignment or malposition of implants. Fractures of the patella are much less common and associated with rheumatoid arthritis, use of steroid, osteonecrosis and malalignment of implants. Most patients with periprosthetic fractures around the knee are the elderly with poor bone quality. There are many difficulties and increased risk of nonunion after treatment because reduction and internal fixation is interfered with by preexisting prosthesis and bone cement. Additionally, previous soft tissue injury is another disadvantageous condition for bone healing. Many authors reported good clinical outcomes after non-operative treatment of undisplaced or minimally displaced periprosthetic fractures; however, open reduction or revision arthroplasty was required in displaced fractures or fractures with unstable prosthesis. Periprosthetic fractures around the knee should be prevented by appropriate technique during total knee arthroplasty. Nevertheless, if a periprosthetic fracture occurs, an appropriate treatment method should be selected considering the stability of the prosthesis, displacement of fracture and bone quality.

BackgroundThe incidence of periprosthetic femoral fractures is increasing because of an increasing number of primary THAs and TKAs. High rates of complications and mortality are associated with periprosthetic fractures, but few studies have evaluated and compared the population-based incidences of these events after fractures.Questions/purposes(1) What is the annual incidence of periprosthetic fractures treated with surgery in one hospital district in Finland? (2) How are those incidences changing over time? (3) What is the risk of complications, reoperations, and death after those injuries?MethodsThis register-based study evaluated 2259 patients who underwent revision THA or TKA or any surgery for a femoral fracture between January 2004 and December 2016 at the only hospital in our district where these types of operations are performed. During the study period, the diagnosis and operation codes of the operated-on patients varied greatly, and they were somewhat inaccurate. We thus evaluated radiographs of all 2259 patients one by one, and created inclusion and exclusion criteria based on radiologic findings and medical records. Of those, 12% (279 of 2259) had periprosthetic fractures that met the inclusion criteria, and from these, we formed two study groups (periprosthetic proximal femur fractures, n = 171; periprosthetic distal femur fractures, n = 108). Eighty-eight percent (1980 of 2259) of the patients were excluded because they were treated for a condition other than periprosthetic femoral fracture. The follow-up period ended in December 2019 or at the time the patient died. To evaluate the population-based incidence, we drew the number of individuals with THA or TKA in the hospital district from the Finnish Arthroplasty Register and the Finnish Hospital Discharge Register. The characteristics of patients with operatively treated periprosthetic femoral fractures were evaluated in terms of age, gender, fracture type, implant type, and time from the index operation to periprosthetic fracture. The annual incidences of periprosthetic femoral fractures are summarized per 1000 person-years of individuals living with an implanted THA or TKA and per 100,000 individuals per year living in our hospital district. The risks of death, complications, and reoperations were evaluated for both groups, and comparisons were made in terms of patient characteristics.ResultsThe mean annual incidence of operatively treated periprosthetic proximal femur fractures per 1000 people living with THA implants was 2.3 ± 0.9 (95% confidence interval 1.8 to 2.7) per year, and for those with periprosthetic distal femur fractures with TKA implants, it was 1.3 ± 0.6 (95% CI 1.0 to 1.7). There was an increasing trend in the incidence of periprosthetic proximal femur fractures from 1.6 to 3.8 (95% CI 1.8 to 2.8) per 1000 arthroplasties, and it increased from 0.4 to 1.7 (95% CI 2.4 to 4.4) for periprosthetic distal femur fractures between 2004 and 2016. The mean population-based incidence of periprosthetic proximal femur fractures per 100,000 person-years was 5.3 ± 2.2 (95% CI 4.1 to 6.4) per year, and for periprosthetic distal femur fractures, it was 3.4 ± 1.7 (95% CI 2.5 to 4.4). The incidence of periprosthetic proximal femur fractures related to 100,000 person-years increased from 3.2 to 8.9 (95% CI 3.9 to 6.6), while the incidence of periprosthetic distal femur fractures increased from 1.3 to 4.4 (95% CI 2.4 to 4.8) during the study period. The cumulative incidence of major complications after periprosthetic proximal femur fracture was 8.8% at 1 year (95% CI 5.1% to 13.6%) and 12.3% at 10 years (95% CI 7.5% to 18.4%), and after periprosthetic distal femur fracture, it was 7.4% at 1 year (95% CI 3.5% to 13.4%) and 9.3% at 10 years (95% CI 4.7% to 15.7%). The cumulative incidence of reoperation after periprosthetic proximal femur fracture was 10.5% at 1 year (95% CI 6.5% to 15.7%) and 13.5% at 10 years (95% CI 8.9% to 19.1%), and for periprosthetic distal femur fracture, it was 8.3% at 1 year (95% CI 4.1% to 14.5%) and 13.8% at 10% years (95% CI 7.8% to 21.4%). The cumulative incidence of death after periprosthetic proximal femur fracture was 8.2% at 1 year (95% CI 4.7% to 12.9%) and 47.3% at 10 years (95% CI 38.1% to 55.9%), and after periprosthetic distal femur fractures, it was 14.8% at 1 year (95% CI 8.8% to 22.2%) and 67.8% at 10 years (95% CI 56.3% to 76.9%).ConclusionThe increased use of THA and TKA has led to an increase in the incidence of operatively treated periprosthetic fractures, which means there will be more revisions in the future. Older age, frailty of these patients, and often-complicated fracture patterns are related to a high rate of complications, reoperations, and mortality. Healthcare systems must prepare for a large increase in revisions for periprosthetic fracture, which are morbid events for patients and costly ones for healthcare systems.Level of EvidenceLevel III, therapeutic study.

Background:Periprosthetic supracondylar femoral fractures following total knee arthroplasty (TKA) are infrequent, but is a devastating complication. The purpose of this study was to evaluate the incidence and outcomes of periprosthetic supracondylar femoral fractures following TKA using nonoperative as well as open reduction and internal fixation (ORIF) techniques.Materials and Methods:Between January 2004 and December 2010, we followed 3,920 operated patients of total knee arthroplasty (TKA) and identified 23 patients with periprosthetic supracondylar fractures. A retrospective analysis of the records of these patients was conducted. Details regarding pre fracture status, treatment offered and the present status were also recorded and analyzed. Time from index arthroplasty to periprosthetic fracture ranged from five days to six years. There were 17 women and 6 men and the average age was 68.26 years (range 52-83 years). Of the 23 patients, 20 patients were treated by operative method, whereas only three patients with relatively undisplaced fractures were treated nonoperatively.Results:The total incidence of periprosthetic fractures in operated cases of TKA was 0.58%. Three patients had infection after surgery. As per radiological assessment, two of three conservatively treated cases had malunion, whereas among 20 cases treated operatively, 16 had primary union with one malunion. Two patients had union after bone grafting, whereas two had nonunion. The average reduction in the knee score after fracture was 20.53%. Twenty one patients were able to achieve limited but independent activity.Conclusions:Desirable results for periprosthetic fractures can be obtained if proper and timely intervention is done, taking into account the other comorbid conditions. However, short duration of followup and small number of patients were major limiting factors in this study.