Periprosthetic Knee Fractures Research Articles

Fixation or Revision for Periprosthetic Fractures: Epidemiology, New Trends, and Projections in the United States.

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.

Risk and Epidemiology of Periprosthetic Knee Fractures After Primary Total Knee Arthroplasty: A Nationwide Cohort Study

BackgroundPeriprosthetic knee fractures (PPKFs) following total knee arthroplasty (TKA) are uncommon, but potentially serious injuries. We analyze the risk and risk factors for a PPKF in standard primary TKA patients who have osteoarthritis and a minimally (cruciate-retaining TKAs without a femoral box cut) or posterior-stabilized TKA. In addition, we report the risk for patients who have other underlying knee disorders and/or a higher level of TKA constraint. MethodsAll primary TKAs were identified from the Danish National Patient Register and the Danish Knee Arthroplasty Register using data between 1997 and 2022. Subsequent fractures were identified through the International Classification of Diseases diagnosis code, Nordic Medico-Statistical Committee procedure code, or indication for revision TKA. ResultsWe included 120,642 standard primary TKA patients who had 1,659 PPKFs. The cumulated proportions were 0.4% (95% confidence interval (CI) 0.3 to 0.4) at 2 years 0.8% (0.7 to 0.8) at 5 years. At 10 years, the cumulated proportion was 1.7% (1.6 to 1.8), with 1.3% in the femur, 0.2% in the patella, and 0.2% in the tibia. Significant risk factors were (hazard ratio [HR] [95% CI]); ipsilateral hip arthroplasty (2.3 [2.0 to 2.6]); women (2.1 [1.8 to 2.4]), osteoporosis (1.4 [1.2 to 1.7]); age 80+ (1.4 [1.3 to 1.6]), uncemented TKA (1.3 (1.1 to 1.5) and Charlson Comorbidity Index score 3+ (1.4 [1.1 to 1.8]). An additional 22,624 primary TKA patients who had other underlying knee disorders and/or a higher level of implant constraint were included with 633 PPKFs. The 10-year cumulated proportions were 8.3% (95% CI 6.9 to 9.8) when the underlying disorder was a previous fracture, 2.8% (2.2 to 3.5) for rheumatic disorders, and 5.2% (2.6 to 10.6) for osteonecrosis. In patients who had condylar constrained knees, it was 6.9% (5.1 to 9.4), and 12.4% (8.0 to 16.04) for hinges. ConclusionsIn standard primary TKA patients, the 10-year cumulated proportion of PPKFs was 1.7%, and ipsilateral hip arthroplasty, women, osteoporosis, advanced age, uncemented TKA and higher Charlson Comorbidity Index increased the risk. Higher risks were observed in non-osteoarthritis patients and/or patients who had a higher level of TKA constraint.

Interprosthetic and interimplant femoral fractures: is bone strut allograft augmentation with ORIF a validity alternative solution in elderly?

Nowadays orthopedic surgeons have a new challenge to treat the interimplants fractures. Although fixation strategies exist for periprosthetic hip and knee fractures, there is no standard of care regarding the more complex interprosthetic and interimplants fractures. The aim of our study is targeting the focus on the bone strut grafting to avoid the metal hardware failure and to achieve the bone healing in these injuries. A prospective case note review of all interprosthetic or interimplants femoral fractures admitted to our trauma center. There were 11 patients (2 males and 9 females) with a mean age over 85 years old. We treated all the patients by ORIF and medial graft strut allograft to reduce the main complication leading to re-operations and morbidity or mortality is the nonunion or delayed union. The criteria to evaluate the patients during the follow-up were: the survival and complication after the surgery; the objective quality of life measured by Activities of Daily Living Score (ADL). The bone healing was measured by X-rays control as the alignment was measured by radiographic UNION SCORE, and postoperative complications. All the patients reduced their ADL. In the most of cases we had a good x-rays reduction. We had not: No nonunion or Not delayed union. All patients died within 2 years from the surgery but not due by surgical complications. According us, the purpose of this surgery is to limit comorbidities and early mortality not to improve optimal restoration of lower limb function.

Treatment of Periprosthetic Knee Fractures with Plate and Screws and With Retrograde Intramedullary Nail: Indications, Limits and Medium-Term Follow-Up

Periprosthetic knee fracture occur most frequently around the distal femur and are frequently complicated due to poor bone quality and comorbidities. Surgical treatment is typically necessary and requires varied techniques of open fixation, intramedullary fixation, or revision arthroplasty, due to fracture classification. The aim of the study is to report the results obtained in the treatment of periprosthetic knee fractures, comparing the results of two surgical techniques, retrograde intramedullary nail and ORIF with plate and screws. At our institute, a sample of 23 patients with periprosthetic knee fracture were surgically treated. In detail, our patient cohort consisted of 13 women (56.52%) and 10 men (43.48%) with a mean age of 71.91 years (SD ± 12.05) whose mean follow-up was 19.14 months (SD ± 9.90). In terms of treatment, 7 of 23 patients (30.43%) were treated with retrograde Intramedullary Nail (IMN), 2 patients (8.70%) underwent to revision of the prosthesis and 14 patients (60.87%) were treated with plate and screws (ORIF). The clinical evaluation was performed using two different clinical scores as reference, the Lysholm score and the Sanders score. The goal of treatment of periprosthetic knee fractures should be an early mobilization of the patient, in order to reduce the risk of prolonged immobilization, limiting surgical risks. Intramedullary nailing reduces blood loss and provides for shorter surgical times. However, it does not allow an anatomical reduction of the fracture and it is not always possible to achieve, due to the conformation of the prosthetic box. The mean results obtained from the evaluation by Lysholm Score was 58.75 ± 10.46 in group treated with IMN and 63.60 ± 6,82 in the group treated with ORIF. Sanders Functional Evaluation Score was 63.60 ± 6,82 in group treated with IMN and 28.26 ± 6.01 in the groups treated with ORIF. The results obtained are similar to the literature. Student’s t-test showed no statistical significance (p-value >0.05). Fractures healed on average at 4 months. We observed a case of mobilization of the nail. Intramedullary nailing reduces blood loss and provides for shorter surgical times. However, it does not allow an anatomical reduction and it is not always possible to achieve, due to the conformation of the prosthetic box. The ORIF with plate and screws allows an anatomical reduction of the fracture, but involves in greater risks. It appears, therefore, more suitable in relatively young subjects. The reduction and synthesis with MIPO technique appears a good compromise. However, it is not very effective in comminuted and multi-fragmentary fractures.

The Economic Impact of Lower Extremity Periprosthetic Fractures in a Large Hospital System

Periprosthetic fractures (PPFs) place a burden on hospital systems. They occur in older patients with medical comorbidities, as unplanned events requiring technically complex surgeries with expensive implants. The purpose of this study was to describe this patient population and evaluate the economic impact of PPFs on a hospital system. We conducted a retrospective study of PPFs of the hip and knee between 2018 and 2019. Demographics, length of stay (LOS), and discharge disposition were collected. We performed chart and radiographic reviews to determine the fracture classification and type of treatment performed. An analysis of direct inpatient costs was performed and categorized by a fracture type. We identified 213 periprosthetic hip and 151 periprosthetic knee fractures. The mean age of hip patients was 77 years, and 71% were female. The average surgery time was 194minutes, LOS was 5.01 days, and 71% were discharged to a skilled nursing facility (SNF). The mean age of knee patients was 76 years, and 79% were female. The average surgery time was 174minutes, LOS was 5.12 days, and 70% were discharged to a SNF. The median direct cost of hip fractures was $17,108, with Vancouver B2 and B3 costing significantly more at $19,987 and $23,935, respectively (P value <.0001). The median direct cost of knee fractures was $13,713. Type 3 distal femur fractures cost significantly more at $37,445 (P value <.0001). PPFs create a significant economic impact on hospital systems. We stratified the costs of treatment based on the fracture type. Significantly higher costs are associated with injuries requiring revision implants.

Periprosthetic knee fractures in an elderly population: open reduction and internal fixation vs distal femur megaprostheses.

The incidence of periprosthetic fractures of distal femur (PPDFFx) after primary total knee arthroplasties is described around 0.3% and 2.5% and it is increasing as the number of patients with total knee arthroplasty continues to arise. surgical options treatments for PPDFFx include fixation in the form of eather Open reduction and internal fixation (ORIF), or retrograde intramedullary nailing (RIMN), or conventional (non locked) plating, or locked plating such as the Less Invasive Stabilization System (LISS), or dynamic condylar screws. In recent years, however, the use of megaprostheses has been increasing. Patients with periprosthetic fractures of distal femur after primary total knee arthroplasties treated with ORIF or with the use of Distal femur replacement (DFR) were retrospectively analyzed in this to evaluate differences in intra-operative blood loss, need of blood trasfusion, weight bearing, range of motion, rate of complications, rate of revision surgery and functional outcome according Oxford Knee Score between two groups. Treatment of Periprosthetic distal femur fracture remains controversial. While ORIF seems to guarantee less percentage of complications and reoperation rate, those treated with megaprosthesis seem to gain better range of motion in a very short post-operative time. In the future it will be necessary to investigate with greater numbers possible advantages and disadvantages of the various treatments in periprosthetic distal femur fractures.

High reoperation and mortality rate after distal femoral replacement for periprosthetic knee fracture in the elderly.

To analyze the outcomes of elderly patients with periprosthetic fractures around the knee operated on with a distal femur replacement (DFR). We performed a retrospective case series study of eleven elderly patients who underwent DFR due to a periprosthetic fracture. Mean follow-up was 30.1months (SD 28.1). Demographic, clinical and radiological data were reviewed. A descriptive analysis and a study of survival were conducted. Then, a comparative analysis between the patients who needed reoperation and did not need reoperation, and the patients who died and the patients who were alive during the follow-up was performed. Mean age was 77.1years (SD 13.9). Reoperation rate was 36%, being infection the most common complication (27%). The risk of reoperation increased with a longer time between fracture and surgery. The 36.4% of patients died during the follow-up. Older age, need of blood transfusion and need of early reoperation were related to a higher risk of mortality. DFR could be a valuable option for knee periprosthetic fractures in elderly patients. However, surgeons should be aware of the high reoperation and mortality rate.

Periprosthetic Knee Fracture with the Left Floating Total Knee and Left Bimalleolar Fracture: A Case Report

Periprosthetic Knee Fracture with the Left Floating Total Knee and Left Bimalleolar Fracture: A Case Report

Current evidence and new challenges in periprosthetic hip and knee fractures

Periprosthetic fractures (PPF) constitute an issue of increasing importance for orthopedic surgeons. With the continuous advancement of less invasive surgery techniques and the progressively ageing population, prosthetic replacement procedures have become routine. PPF are complex conditions that can compromise the outcome of surgery and the patient’s quality of life. However, in some cases, revision surgery is required. In this article we will analyze the epidemiology, risk factors, different classi ications, management, and evolution of treatment of hip and knee periprosthetic fractures.

Cortical strut allografts in salvage revision arthroplasty: Surgical technique and clinical outcomes

BackgroundThe aim of this study was to present our clinical outcomes and surgical technique in strut allografts preparation using staggered holes to enhance osteointegration and demineralised bone matrix (DBM) as an adjunct to cortical strut allografts in salvage revision arthroplasty patients. MethodsRetrospective consecutive series of patients who required strut allograft femoral reconstructions with minimum 2 years follow up between 2012 and 2018. Frozen washed irradiated, cortical struts were used and prepared adding 2 mm staggered drill holes along the length of the strut and applying DBM paste on the graft-host interface. Outcome measures included radiographic strut union, graft resorption, infection and complications. Results15 patients included; 3 males and 12 females with median age 72 years (range 60–93). All had significant bony defects (Paprosky III/IV in 12 cases including 3 cases of periprosthetic hip fractures and further 3 cases of periprosthetic knee fractures around revision hinged implants). At final follow up, median 3.8 years (range 2.7–7.2), 14/15 (93.3%) struts had united at a median 6 months (range 5–8), complete incorporation with cortical round-off was seen at median 12 months (range 8–48) in 12/15 (80%) struts, 2/15 (13.3%) show radiographic evidence of proximal minimal graft resorptions although the remainder of the strut had integrated and were asymptomatic. There were no cases of infection. ConclusionsUse of strut allografts helps to reconstruct bone defects, restore bone stock, and provide stable fixation for complex patterns of periprosthetic fractures around hip/knee implants and salvage revision cases with 93.3% union rate at median 6 months.

Periprosthetic fractures of hip and knee–A morbidity and mortality analysis

BackgroundPeriprosthetic fractures (PPF) following total knee (TKA) and hip arthroplasty (THA) have become more common over the years. The aim of the present study was to assess morbidity and mortality following surgery for PPF of hip and knee. Patients and methodsAltogether, 124 patients (mean age: 77 years; 77.4% female) with PPF of the hip (n=97) and knee (n=27), treated between 2005 and 2017 at a level-1 trauma centre, were retrospectively included. In order to assess risk factors for postoperative morbidity, Fine and Gray's model was used to compensate for death as the competing event. Risk factors for mortality were estimated with uni- and multivariate Cox-regression models. ResultsVancouver B2 fractures were most common (n=39; 42.4%), followed by B1 fractures (n=23; 25.0%). Lewis-Rorabeck Type I fractures (n=14; 51.9%) were most frequent in PPF of the knee. Overall complication rates were 44.0% and 29.9% for PPF of the knee and hip, respectively, with three patients having both early and late complications, 25 patients developing early complications and 19 patients undergoing surgery for implant-related, late complications. In the multivariate Fine and Gray model, advanced patient age (HR: 0.956; 95%CI: 0.922-0.991; p=0.014) and prosthesis exchange (vs. ORIF; HR: 0.242, 95%CI: 0.068-0.859; p=0.028) were associated with lower risk of implant-related complications, irrespective of gender (p=0.450) and a surgical delay > 2 days (p=0.411). One- and 5-year overall survival-rates were 97.9% and 93.1%, respectively. Gender, type of fixation (ORIF vs. prosthesis exchange), surgical delay > 2 days, BMI and age at surgery were neither in the univariate, nor multivariate Cox-regression model associated with an increased mortality rate. ConclusionPostoperative morbidity caused by implant-related complications is higher in younger patients and those receiving ORIF. With the statistical approach used, potential underestimation of actual complication rates may have been avoided, taking into account death as the competing event. Despite being based on a retrospective, heterogenous patient collective treated at a level-1 trauma centre, our results indicate that careful planning of the surgical procedure beyond 2 days, taking into consideration both patient's age and activity level, has no negative effect on patient outcome.

Distal femur periprosthetic knee fractures in elderly patients: clinical and radiographic outcome after internal fixation.

Background and aim of the work:The incidence of periprosthetic knee fractures is steadily increasing, especially in the geriatric population. Surgical treatment in these patients must consider the poor bone quality and the risks of general complications related to age and comorbidities. The aim of the present study is to analyze the clinical and radiographic outcome of internal fixation for periprosthetic knee fractures of the distal femur in elderly patients (>75aa).Methods:All patients treated at the Orthopedic and Traumatology Unit of Cattinara Hospital-ASUGI (Trieste, Italy) between September 2014 and September 2019 for distal femur periprosthetic fracture after total knee replacement were included in the study. Mortality, complications, radiographic healing and functional outcomes were retrospectively evaluated. Data collection was conducted by clinical database searching and telephone interview. Results were compared with the literature.Results:The study population included 19 patients, F:M 16:3, mean age 84 years. Plate fixation was used in the majority of cases (90%). One-year mortality was 21.05%. Radiographic healing of the fracture occurred in 92% of cases. Nonetheless, 61% of patients saw a worsening in their functional outcome.Conclusion:Internal fixation is a valuable and safe option for distal femur periprosthetic fracture treatment in the elderly. The significant impact of periprosthetic knee fractures on the medium- to long-term survival and quality of life of the elderly patient is confirmed. (www.actabiomedica.it)

Current Reconstruction Options in Periprosthetic Fractures Around the Knee.

Background:Periprosthetic fractures are a rare complication after total knee arthroplasty (TKA). However, the incidence of these fractures is growing after the increasing number of TKAs performed every year and the progressive aging of the population. In addition, the surgical treatment and peri-operative management of these complications are demanding, representing a challenge for the orthopedic surgeon.Significance:A thorough understanding of these fractures and a correct classification are necessary in order to select the most suitable surgical treatment. The aim of this review was to analyze the epidemiology, classification, diagnosis, surgical treatment, and outcomes of periprosthetic knee fractures in order to give an exhaustive overview.Results:Reduction and internal fixation with locking plates or intramedullary nails represents the preferred option in case of a stable prosthetic implant. Conversely, in case of loose tibial and/or femoral component, implant revision is mandatory. Conservative treatment is rarely indicated.Conclusion:A deep understanding of the characteristics and patterns of periprosthetic knee fractures, and the determination of the stability of the prosthetic implant are necessary in order to establish the correct treatment.

Distal Femoral Replacements for Acute Comminuted Periprosthetic Knee Fractures: Satisfactory Clinical Outcomes at Medium-Term Follow-up

BackgroundFracture fixation techniques of comminuted periprosthetic distal femoral fractures have high risk of complications. The aim of this study was to evaluate short- to medium-term outcomes of comminuted periprosthetic distal femoral fractures treated with distal femoral replacements (DFR) at a tertiary arthroplasty unit.MethodsRetrospective consecutive study of all patients who underwent DFR for periprosthetic fractures with minimum 2-year follow-up between 2010 and 2018. Clinical outcomes, surgical complications, revision for any cause, loosening, Knee Society Score and mortality data were collected at final follow-up.ResultsThirty patients with average age 81 years (range, 65-90; 6 males and 24 females) were included. All had comminuted fractures (Rorabeck type-2/3). All patients had cemented DFRs. Three patients (10%) with multiple comorbidities died postoperatively. Average time from admission to being fit for discharge was 9 days (range, 3-14). Clinical outcomes and follow-up were available for 27 patients with a median follow-up duration of 4 years (2-13 years). Complication rate was 7.4% with one reoperation, change of polyethylene insert. None of the components have been revised to date. Average Knee Society Score at final follow-up was 78 (range, 57-92) with median arc of motion flexion-extension being 100° (range, 60°-125°).ConclusionsIn our experience, DFRs for comminuted periprosthetic fractures allow immediate mobilization and rehabilitation leading to satisfactory clinical outcomes with low complication rate for this challenging group of patients.Level of evidencelevel IV.

Is Timing to Surgery an Independent Risk Factor for Complications Following Operative Treatment of Periprosthetic Lower Extremity Fractures?

To identify whether timing to surgery was related to major 30-day morbidity and mortality rates in periprosthetic hip and knee fractures [OTA/AO 3 (IV.3, V.3), OTA/AO 4 (V4)]. Retrospective database review. Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Patients in the NSQIP database with periprosthetic hip or knee fractures between 2007 and 2015. Surgical management of periprosthetic hip and knee fractures including revision or open reduction internal fixation. Major 30-day morbidity and mortality after operative treatment of periprosthetic hip or knee fractures. A total of 1265 patients, mean age 72, including 883 periprosthetic hip and 382 periprosthetic fractures about the knee were reviewed. Delay in surgery greater than 72 hours is a risk factor for increased 30-day morbidity in periprosthetic hip and knee fractures [relative risk = 2.90 (95% confidence interval: 1.74-4.71); P-value ≤ 0.001] and risk factor for increased 30-day mortality [relative risk = 8.98 (95% confidence interval: 2.14-37.74); P-value = 0.003]. Using NSQIP database to analyze periprosthetic hip and knee fractures, delay to surgery is an independent risk factor for increased 30-day major morbidity and mortality when controlling for patient functional status and comorbidities. Although patient optimization and surgical planning are paramount, minimizing extended delays to surgery is a potentially modifiable risk factor in the geriatric periprosthetic lower extremity fracture patient. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk factors of periprosthetic femoral fracture after total knee arthroplasty

Introduction and objectivesPeriprosthetic fractures after primary knee arthroplasty has great importance in our environment due to the increase in their incidence and to the challenge they pose to the surgeon. Multiple factors have been associated with its production. The objective of the study was to identify the risk factors that could influence the appearance of these fractures, which of them are all modifiable and generate a probability prediction model based on these factors. Material and methodsAnalytical, observational, retrospective, unpaired study of 38 cases of periprosthetic femoral knee fractures and 80 controls with knee prostheses. In total, 118 patients, 83 women and 35 men with a mean age of 72.49 years were included in the study. Sociodemographic data, medical history and drug consumption were collected, as well as those related to surgery. A univariate and bivariate analysis of the fracture determining factors was performed, using a logistic regression model to avoid confusion bias. ResultsOf all the factors studied according to the logistic regression model, it was obtained that female sex (OR = 7.6), dementia (OR = 5), motor/Parkinson’s alteration (OR = 19.3) and femoral overcut Previous (OR = 8.6) were factors associated with the increased risk of this type of fractures. ConclusionsThis work allows us to conclude that there are risk factors such as female sex, dementia and Parkinson’s that increase the probability of periprosthetic fracture that are inherent to the patient and are not modifiable. However, there is any other totally modifiable that can be avoided by being demanding and thorough in the surgical technique, such as the anterior femoral overcut.

Periprosthetic fractures around the knee

Periprosthetic fractures of the knee joint are complex injuries and frequently represent a challenge for the surgeon. The aim of this review is to present and discuss the current classification and treatment options for periprosthetic knee fractures. Aselective review of the existing literature on periprosthetic fractures around the knee was performed in PubMed. The various classifications and treatment regimens are discussed with respect to the advantages and disadvantages and from this knowledge a new algorithm was developed. The classifications of periprosthetic fractures have changed in recent years and have been replaced by a uniform fracture classification; however, not only the radiological evaluation of the fractures is crucial to determine the treatment regimen for periprosthetic fractures. A thorough evaluation of the inserted endoprosthesis should be carried out in order to be able to decide between the treatment options of osteosynthesis and revision arthroplasty. Treatment options are available for osteosynthesis and revision arthroplasty that enable a safe treatment of these complex injuries. Periprosthetic fractures of the knee joint are complex injuries, requiring a thorough preoperative planning and an interdisciplinary treatment with trauma and endoprosthetic expertise.

Recurring Peri-Prosthetic Fracture of the Femur Ultimately Managed by Custom-Made Distal Femoral Mega-Prosthesis – A Case Report and Literature Review

Patients with peri-prosthetic fractures of the knee comprise a specific cohort demanding a specific set of orthopedic considerations. These fractures are difficult to manage, and essential orthopedic considerations must include patient factors such as age, co-morbid medical conditions, and overall bone quality. Further fracture considerations go beyond fracture displacement, and if present whether a reduction can be achieved, but must also specifically incorporate unique aspects such as prosthetic alignment, the degree of prosthetic fixation, whether there is a prosthetic stem, distal bone stock, and the extensor mechanism. For ease of understanding peri-prosthetic knee fractures are divided into femoral, tibial, and patellar sub-types, each of which has its own specific epidemiology, classification system, and set of well-defined surgical nuances. Of these three major types peri-prosthetic fractures of the femur are the most common surgical subtype encountered. We present a 65-year old male patient who presented to our unit with a neglected right-sided recurrent peri-prosthetic fracture of his femur, post having undergone multiple surgical interventions at another hospital. Our clinical assessment and X-ray investigation of his right knee revealed what we considered to be profound. With complete loss of distal femoral bone stock, gross malunion, and the complex mass of broken hardware noted, our only option was to remove the distal femur and prosthesis and replace these with a custom-made distal femoral mega-prosthesis. Our case report illustrates an extreme example of a peri-prosthetic fracture of the femur, and we compliment this with a review of the topic in general. It is hoped that our case report and review will assist orthopedic surgeons who perform total knee replacement surgery and will, at some point, need to manage this specific complication.

Factores de riesgo en fractura periprotésica femoral tras artroplastia sustitutiva primaria de rodilla

Introduction and objectivesPeriprosthetic fractures after primary knee arthroplasty has great importance in our environment due to the increase in their incidence and to the challenge they pose to the surgeon. Multiple factors have been associated with its production. The objective of the study was to identify the risk factors that could influence the appearance of these fractures, which of them are all modifiable and generate a probability prediction model based on these factors. Material and methodsAnalytical, observational, retrospective, unpaired study of 38 cases of periprosthetic femoral knee fractures and 80 controls with knee prostheses. In total, 118 patients, 83 women and 35 men with a mean age of 72.49 years were included in the study. Sociodemographic data, medical history and drug consumption were collected, as well as those related to surgery. A univariate and bivariate analysis of the fracture determining factors was performed, using a logistic regression model to avoid confusion bias. ResultsOf all the factors studied according to the logistic regression model, it was obtained that female sex (OR = 7.6), dementia (OR = 5), motor/parkinson's alteration (OR = 19.3) and femoral overcut Previous (OR = 8.6) were factors associated with the increased risk of this type of fractures. ConclusionsThis work allows us to conclude that there are risk factors such as female sex, dementia and parkinson's that increase the probability of periprosthetic fracture that are inherent to the patient and are not modifiable. However, there is any other totally modifiable that can be avoided by being demanding and thorough in the surgical technique, such as the anterior femoral overcut.

Risk Factors for Wound Complications After Periprosthetic Fractures.

The number of hip and knee arthroplasties performed annually continues to rise. Revision rates are projected to increase by 137% to 601%, with periprosthetic fractures to be among the leading cause of revision. Wound complications following surgical treatment of periprosthetic fractures are a major source of patient morbidity and health care costs. This study evaluated risk factors for wound healing complications in patients undergoing surgical management of periprosthetic fractures around the hip and knee. This was a retrospective analysis of 67 consecutive lower-extremity periprosthetic hip and knee fracture surgeries. Descriptive data, comorbidities, dressing type, and rates of wound complications treated nonoperatively and operatively were collected. Logistic regression analysis was performed to calculate odds ratios (ORs) of having a wound complication. There was an overall wound complication rate of 22%; the majority of these complications (16%) were treated operatively. On multivariate analysis, prior bariatric surgery (OR, 12.02; 95% confidence interval [CI], 1.24-116.71; P=.03), peripheral vascular disease (OR, 6.84; 95% CI, 1.32-35.39; P=.02), and pulmonary disease (OR, 11.23; 95% CI, 1.85-68.31; P=.01) were all associated with an increased risk of developing a wound complication. Closed-incision negative-pressure therapy was associated with a decreased risk of developing a wound complication (OR, 0.04; 95% CI, 0.00-0.49, P=.01). Surgery to treat hip and knee periprosthetic fractures is associated with a high rate of wound complications. History of bariatric surgery, peripheral vascular disease, and pulmonary disease are all associated with an increased risk of developing a wound complication. Future payment models should reflect this elevated level of complications and risk. [Orthopedics. 2020;43(4):e258-e262.].