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Martinez FA, Yuan BJ. Posterior Cruciate Ligament Injury After Retrograde Nailing of Periprosthetic Distal Femur Fractures: A Report of 2 Cases. JBJS Case Connect 2024; 14:01709767-202406000-00004. [PMID: 38579021 DOI: 10.2106/jbjs.cc.23.00510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
CASE A 51-year-old man and 64-year-old woman with bilateral cruciate-retaining total knee arthroplasties (CR-TKAs) who sustained unilateral periprosthetic distal femur fractures above their CR-TKA and experienced knee instability secondary to an iatrogenic posterior-cruciate-ligament (posterior cruciate ligament [PCL]) injury from retrograde intramedullary nailing. Both patients recovered knee stability after undergoing revision surgery. CONCLUSION Many CR-TKA designs have sufficient medial-lateral intercondylar distance to place a retrograde nail, femoral components with a relatively posterior transition from the trochlear groove to the intercondylar box will necessitate a nail starting point closer to the PCL origin. This may contribute to iatrogenic postoperative knee instability for patients with CR-TKA designs.
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Affiliation(s)
- Frank A Martinez
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Brandon J Yuan
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester Minnesota
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2
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Al-Jabri T, Wood MJ, Faddul F, Musbahi O, Bajracharya A, Magan AA, Jayadev C, Giannoudis PV. Periprosthetic Distal Femoral Fractures Around a Total Knee Arthroplasty: a Meta-analysis Comparing Locking compression Plating and Retrograde Intramedullary Nailing. Orthop Rev (Pavia) 2024; 16:91507. [PMID: 38765295 PMCID: PMC10807720 DOI: 10.52965/001c.91507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 12/10/2023] [Indexed: 05/22/2024] Open
Abstract
Purpose The number of total knee replacements (TKRs) performed per year has been increasing annually and it is estimated that by 2030 demand would reach 3.48 million procedures per year in the United States Of America. The prevalence of periprosthetic fractures (PPFs) around TKRs has followed this trend with incidences ranging from 0.3% to 3.5%. Distal femoral PPFs are associated with significant morbidity and mortality. When there is sufficient bone stock in the distal femur and a fracture pattern conducive to fixation, locking compression plating (LCP) and retrograde intramedullary nailing (RIMN) are commonly used fixation strategies. Conversely, in situations with loosening and deficient bone stock, a salvage procedure such as a distal femoral replacement is recognized as an alternative. This meta-analysis investigates the rates of non-union, re-operation, infection, and mortality for LCPs and RIMNs when performed for distal femoral PPFs fractures around TKRs. Method A search was conducted to identify articles relevant to the management of distal femoral PPFs around TKRs in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Articles meeting the inclusion criteria were then assessed for methodological quality using the methodological items for non-randomised studies (MINORS) criteria. Articles were reviewed, and data were compiled into tables for analysis. Results 10 articles met the inclusion criteria, reporting on 528 PPFs. The overall incidence of complications was: non-union 9.4%, re-operation 12.9%, infection 2.4%, and mortality 5.5%. This meta-analysis found no significant differences between RIMN and LCP in rates of non-union (9.2% vs 9.6%) re-operation (15.1% vs 11.3%), infection (2.1% vs 2.6%), and mortality (6.0% vs 5.2%), respectively. Conclusion This meta-analysis demonstrated no significant difference in rates of non-union, re-operation, infection, and mortality between RIMN and LCP and both remain valid surgical treatment options.
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Affiliation(s)
- Talal Al-Jabri
- Orthopaedic Surgery Imperial College London
- Joint Reconstruction Unit Royal National Orthopaedic Hospital NHS Trust
| | - Matthew J Wood
- Joint Reconstruction Unit, Royal National Orthopaedic Hospital
| | - Farah Faddul
- St George's University Hospitals NHS Foundation Trust
| | | | | | | | - Chethan Jayadev
- Joint Reconstruction Unit Royal National Orthopaedic Hospital
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedic Surgery, Leeds General Infirmary
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Fu P, Liang W, Gao Z, Chen G, Fan W. Optimal surgical treatment for periprosthetic distal femoral fractures after total knee arthroplasty: a Bayesian-based network analysis. J Orthop Surg Res 2023; 18:122. [PMID: 36803522 PMCID: PMC9942323 DOI: 10.1186/s13018-023-03586-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 02/07/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND The surgical methods for periprosthetic distal femoral fractures (PDFFs) after total knee arthroplasty included locking compression plate (LCP), retrograde intramedullary nailing (RIMN), and distal femoral replacement (DFR). However, the optimal treatment remains controversial. We performed a network meta-analysis (NMA) to provide the optimal surgical method for PDFFs. MATERIALS AND METHODS Electronic databases, including Embase, Web of Science, Cochrane Library, and PubMed, were searched for studies that compared LCP, RIMN, and DFR for PDFFs. The quality of the included studies was assessed according to the Newcastle-Ottawa scale. Pairwise meta-analysis was performed by Review Manager version 5.4. The NMA was conducted in Aggregate Data Drug Information System software version 1.16.5. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for postoperative complications and reoperations. RESULTS A total of 19 studies and 1198 patients were included, of whom 733 for LCP, 282 for RIMN, and 183 for DFR. Pairwise meta-analysis comparing LCP to RIMN and LCP to DFR showed no significant difference in complications and reoperations except that RIMN had a higher risk of malunion comparing to LCP (OR 3.05; 95% CI 1.46-6.34; P = 0.003). No statistically significant effects were found in the NMA of overall complications, infection, and reoperation. However, results of rank probabilities showed that DFR ranked best in overall complications and reoperation, RIMN ranked best in infection but worst in reoperation, and LCP ranked worst in infection and middle in reoperation. DISCUSSION We found similar complication rate and reoperation rate between LCP, RIMN, and DFR. The results of rank probabilities favored DFR, and further studies with high-level evidence are expected to verify the optimal surgical method for PDFFs. LEVEL OF EVIDENCE Level II; network meta-analysis.
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Affiliation(s)
- Peng Fu
- grid.412676.00000 0004 1799 0784Department of Orthopaedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China ,grid.411870.b0000 0001 0063 8301Department of Orthopaedics, The Second Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Wenwei Liang
- grid.412676.00000 0004 1799 0784Department of Orthopaedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhenzhen Gao
- grid.411870.b0000 0001 0063 8301Department of Clinical Oncology, The Second Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Gang Chen
- grid.411870.b0000 0001 0063 8301Department of Orthopaedics, The Second Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Weimin Fan
- Department of Orthopaedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
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Distal Femoral Replacement versus Operative Fixation for Periprosthetic Distal Femur Fractures: A Systematic Review and Meta-Analysis. J Arthroplasty 2023:S0883-5403(23)00064-5. [PMID: 36738864 DOI: 10.1016/j.arth.2023.01.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/24/2023] [Accepted: 01/24/2023] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Open reduction and internal fixation (ORIF) and distal femoral replacement (DFR) have been utilized in the management of periprosthetic distal femur fractures. At present, much of the literature has been limited to small retrospective series. The purpose of the current investigation was to present the results of pooled data to determine the complication rates associated with ORIF and DFR. METHODS Publications from 2010 to 2020 describing 10 or more periprosthetic distal femur fractures treated with ORIF (ie, single plate, intramedullary nail, and dual fixation) or DFR were included, resulting in 32 publications and 1,258 fractures (977 ORIF and 281 DFR). Occurrence of surgical complications, reoperations, and medical complications were evaluated and compared. RESULTS The rate of surgical complications (ORIF versus DFR, 20.5 versus 14.9%, P = 1.0) and reoperations (12.9 versus 12.5%, P = 1.0) following DFR were similar. However, pooled analyses demonstrated that patients treated with DFR had a higher medical complication rate (ORIF versus DFR, 8.5 versus 23.1%, P = .0006). CONCLUSION ORIF and DFR for the treatment of periprosthetic distal femur fractures have similar surgical complication and reoperation profiles. While this review found an increased rate of medical complication following DFR, there are limitations in quality reporting in the literature, which should be considered when interpreting the study's findings. Failed ORIF can be salvaged with DFR, but the difficulty of this reoperation is dependent on the ORIF technique that was used. With future prospective studies, this review can help guide management of these fractures.
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5
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Kerr MS, Young EG, Shaath MK, Avilucea FR, Adigweme OO, Haidukewych GJ. Periprosthetic distal femur fractures treated by retrograde intramedullary nails with a 10-degree distal bend achieve significantly better post-operative radiographic alignment when compared to conventional retrograde nails. Injury 2023; 54:694-697. [PMID: 36428147 DOI: 10.1016/j.injury.2022.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/24/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Periprosthetic distal femur fractures (PPDFFs) are a common complication after total knee arthroplasty (TKA). In the setting of well-fixed TKA components, treatment options include retrograde intramedullary nailing (rIMN) or lateral locked plating. Treatment with rIMN has historically been associated with potential for extension deformity when using conventional nails. We hypothesized that the PPDFFs treated with an intramedullary nail with a specifically designed 10-degree distal bend for periprosthetic fractures would result in improved post-operative sagittal alignment compared to conventional intramedullary nails. MATERIALS AND METHODS The study was conducted at a level-1 trauma center over a 12-year period (2010 - 2022). Patients over the age of 18 who sustained a PPDFF treated with rIMN were identified. The primary outcomes of the study were post-operative coronal and sagittal alignment determined by reviewing post-operative radiographs. RESULTS A total of 50 patients were included. Twenty-three patients were treated with a rIMN with a 10° distal bend. Twenty-seven patients were treated with a rIMN with distal bend of 5° The mean aPDFA for the 10° distal bend group was 81.7° compared to 92.8° in the 5° distal bend group (p<0.001). There were 3/23 (13%) significant sagittal plane deformities the 10° distal bend group compared to 11/27 (41%) in the 5° distal bend group (p = 0.03). There was one patient with a post-operative extension deformity in the 10° distal bend group compared to 11 patients in the 5° distal bend group (p = 0.02). CONCLUSION Retrograde intramedullary nailing of PPDFF with a 10° distal bend results in significantly better alignment in the sagittal plane when compared to a conventional 5° nail. The use of a 5° nail resulted in an extension deformity significantly more frequently. We therefore recommend the utilization of a rIMN with a 10° distal bend when treating PPDFFs. SUMMARY Periprosthetic distal femur fractures are a common complication following total knee arthroplasty. While several studies report on the use of retrograde intramedullary nails in the treatment of periprosthetic distal femur fractures, there are limited reports of the use of a novel retrograde intramedullary nail with a 10° distal bend in the treatment of these injuries. Herein we present a radiographic study comparing coronal and sagittal postoperative alignment following treatment with retrograde intramedullary nails with a 10° distal bend versus conventional retrograde nails with a 5° distal bend.
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Affiliation(s)
- Matthew S Kerr
- Orlando Health Orthopaedic Institute, Florida State College of Medicine, University of Central Florida College of Medicine, 1222 S Orange Ave, 5 Floor, Orlando, FL 32806, United States.
| | - Everett G Young
- Orlando Health Orthopaedic Institute, Florida State College of Medicine, University of Central Florida College of Medicine, 1222 S Orange Ave, 5 Floor, Orlando, FL 32806, United States
| | - M Kareem Shaath
- Orlando Health Orthopaedic Institute, Florida State College of Medicine, University of Central Florida College of Medicine, 1222 S Orange Ave, 5 Floor, Orlando, FL 32806, United States
| | - Frank R Avilucea
- Orlando Health Orthopaedic Institute, Florida State College of Medicine, University of Central Florida College of Medicine, 1222 S Orange Ave, 5 Floor, Orlando, FL 32806, United States
| | - Obinna O Adigweme
- Orlando Orthopaedic Center, University of Central Florida College of Medicine, 25W Crystal Lake Street Suite 200, Orlando, FL 32806, United States
| | - George J Haidukewych
- Orlando Health Orthopaedic Institute, Florida State College of Medicine, University of Central Florida College of Medicine, 1222 S Orange Ave, 5 Floor, Orlando, FL 32806, United States
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Li QW, Wu B, Chen B. Modified fixation for periprosthetic supracondylar femur fractures: Two case reports and review of the literature. World J Clin Cases 2022; 10:12328-12336. [PMID: 36483801 PMCID: PMC9724516 DOI: 10.12998/wjcc.v10.i33.12328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 09/16/2022] [Accepted: 10/26/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Periprosthetic supracondylar femoral fractures (PSFs) present a challenge in terms of optimizing fixation in patients with poor bone quality. Surgical treatment and peri-operative management of PSFs in the elderly remain a burden for orthopedic surgeons. Among different treatment options, locking plate (LP) and retrograde intramedullary nail (RIMN) have shown favorable results. However, reduced mobility and protected weight-bearing are often present in the postoperative older population. With a purpose of allowing for early weight-bearing, a modified nail plate combination (NPC) was redesigned for PSF management.
CASE SUMMARY In our cases, two elderly osteoporotic female underwent total knee arthroplasty (TKA), and then suffered from low energy trauma onto their knees after falling to the floor. Plain radiographs or computed tomography scans demonstrated oblique or transverse PSFs, both of which occurred at the distal femur above TKA. The modified NPC technique was performed for treatment of PSFs. The patient was made foot flat weight bearing in 1 wk. At 6-mo follow-up, the union was ultimately achieved using modified NPC with satisfactory implant outcomes.
CONCLUSION Neither LP nor RIMN alone may provide adequate support to allow for union in circumstances where the patient has severely osteopenic bone. Therefore, developing a modified implant offer an alternative choice for treating PSFs. These two cases revealed that this technique is a viable option for the geriatric osteoporotic PSFs, offering safe, early weight bearing and favorable clinical outcomes.
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Affiliation(s)
- Qin-Wen Li
- Department of Orthopedics, The People's Hospital of Three Gorges University, The First People's Hospital of Yichang, Yichang 443000, Hubei Province, China
| | - Bin Wu
- Department of Orthopedics, The People's Hospital of Three Gorges University, The First People's Hospital of Yichang, Yichang 443000, Hubei Province, China
| | - Bo Chen
- Department of Orthopedics, The People's Hospital of Three Gorges University, The First People's Hospital of Yichang, Yichang 443000, Hubei Province, China
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Lari A, Kashif S, AlMukaimi A. Arthroscopic Retrograde Intramedullary Nailing of Periprosthetic Fractures After Total Knee Arthroplasty—Technique, Safety, and Outcomes. Arthroplast Today 2022; 17:47-52. [PMID: 36032793 PMCID: PMC9399382 DOI: 10.1016/j.artd.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/14/2022] [Accepted: 07/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background Periprosthetic fractures after total knee arthroplasty are notoriously challenging entities to manage. The 2 major fixation techniques utilized include locking compression plates and retrograde intramedullary nailing. The challenges in obtaining correct entry points in the presence of the superimposing femoral component in retrograde intramedullary nailing often warrants a full knee joint arthrotomy. Thus, the purpose of this first series is to describe the arthroscopy-assisted retrograde intramedullary nailing (ARIN) technique and evaluate clinical results and potential risks and benefits. Methods This was a retrospective review of prospectively collected data obtained from 16 patients treated with the ARIN technique. Data obtained included operative time, size of incision, and intraoperative complications. In the postoperative course, patients were assessed for time to union, functional outcomes using the Knee Society Score, and the presence of complications. Results Nine male and 7 female patients were included with a mean age of 70.8 years. The patients were followed up for a minimum of 24 months. The mean operative time was 86.5 minutes. Union was achieved in all fractures with an average union time of 15.9 weeks. The mean Knee Society Score obtained at 2 years postoperatively was 84.6. No major complications were documented during the follow-up period. None of the cases required conversion to the conventional open technique. Conclusions The ARIN technique has demonstrated results comparable with those from previous resources. Although results from this series suggest that the utilized technique is safe and offers a less invasive approach, direct clinical comparisons in larger scale trials are required.
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Ponugoti N, Raghu A, Kosy JD, Magill H. A comparison of distal femoral replacement versus fixation in treating periprosthetic supracondylar femur fractures: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2022; 143:3335-3345. [PMID: 36088601 DOI: 10.1007/s00402-022-04603-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 08/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The treatment of periprosthetic femur fractures around a total knee replacement remains a technical challenge for the orthopedic surgeon. Management options include non-operative treatment, plate fixation, intramedullary nailing and distal femur replacement (DFR), with few studies comparing fixation with DFR. This is an up-to-date meta-analysis in the literature to directly compare clinical outcomes between fixation and distal femoral replacement in the treatment of supracondylar periprosthetic femur fractures. METHODS A stratified literature search of the Medline, EMBASE and Cochrane databases was performed. All studies in English language were searched from inception to July 2022. The search was performed with the following MeSH terms: Periprosthetic fracture AND ORIF OR Internal Fixation AND Distal Femur Replacement. The search was conducted using a predesigned search strategy where all eligible literature was critically appraised for methodological quality using the Cochrane collaboration tool. We included Level I, II and III studies comparing fixation with DFR in the treatment of periprosthetic supracondylar femur fractures. Data from eligible studies were extracted by two authors (NP and AR) and a table created which included author, year, sample size, mean age, measured parameters, follow-up period, fracture classification, length of stay (days), mortality rate, revision rate and complication rate. RESULTS The extracted data were pooled for meta-analysis using RevMan® v5.3.5 software (Nordic Cochrane Centre, Copenhagen, Denmark) and forest plots constructed. A p value < 0.05 was considered statistically significant and confidence intervals (CI) set to 95%. A total of six studies were included in the meta-analysis (n = 406). 153 patients underwent distal femur replacement and 253 patients underwent fixation with a mean follow-up time of 71.4 months. The results of this analysis suggest no statistically significant difference in measured outcomes. CONCLUSION The results of this meta-analysis suggest no proven statistically significant difference between DFR and fixation in terms of length of hospital stay, mortality rate, revision rate and complication rate for the treatment of periprosthetic supracondylar femur fractures. Further prospective randomized research may help to define the specific indications for each treatment option which must include fracture configuration. Early functional outcome and cost-effectiveness have yet to be evaluated in the available literature.
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Affiliation(s)
| | - Aashish Raghu
- East and North Hertfordshire NHS Trust, Stevenage, UK
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Gausden EB, Lim PK, Rabonivich A, Shaath MK, Mitchell PM, Hartline B, Achor TS, Warner SJ. Outcomes of periprosthetic distal femur fractures following total knee arthroplasty: Intramedullary nailing versus plating. Injury 2021; 52:1875-1879. [PMID: 34030866 DOI: 10.1016/j.injury.2021.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 05/04/2021] [Accepted: 05/06/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Periprosthetic distal femur fractures (PPDFFs) present a challenge in terms of optimizing fixation in patients with poor bone quality and limited bone stock. The main treatment options include laterally based plating and intramedullary nailing. We hypothesized that treatment of PPDFFs with intramedullary nails would result in improved union rate, fewer complications, and an equivalent rate of malalignment compared to plating. MATERIALS AND METHODS Cases of PPDFFs were identified through a query of our institutional trauma database between 2011-2018. Adult patients (>18 years) were included if they sustained a fracture of the distal femur around a total knee arthroplasty (TKA) that was not initially treated at another institution. The anatomic lateral distal femoral angle (aLDFA) and the anatomic posterior distal femoral angle (aPDFA) were measured on the follow-up radiographs. RESULTS Ninety-seven PPDFFs in 97 patients, with a mean age of 76 years and 74% female were identified. Plating was used in 74 patients (76%) and 23 patients (24%) were treated with intramedullary nailing. Extension deformity in the sagittal plane was more common following intramedullary nailing compared to plating (10/23 nailing versus 10/74 plating) (p=0.002). There were 12 reoperations (12/75, 16%), and the method of fixation was not associated with rate of reoperation (p=0.9). CONCLUSION Intramedullary nailing was associated with an increased risk of malalignment, most commonly an extension deformity, in this series. However, malalignment was not associated with worse outcomes.
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Affiliation(s)
- Elizabeth B Gausden
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 E.70th Street, New York, NY, 10021, USA.
| | - Philip K Lim
- Department of Orthopaedic Surgery, University of California-Irvine, Orange, CA, 92868, USA.
| | - Annat Rabonivich
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, TX, 77005, USA.
| | - M Kareem Shaath
- Department of Orthopaedic Surgery, Orlando Health, Orlando, FL, 32806, USA.
| | - Phillip M Mitchell
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, 73232, USA.
| | - Braden Hartline
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, TX, 77005, USA.
| | - Timothy S Achor
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, TX, 77005, USA.
| | - Stephen J Warner
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, TX, 77005, USA.
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Stamiris D, Gkekas NK, Asteriadis K, Stamiris S, Anagnostis P, Poultsides L, Sarris I, Potoupnis M, Kenanidis E, Tsiridis E. Anterior femoral notching ≥ 3 mm is associated with increased risk for supracondylar periprosthetic femoral fracture after total knee arthroplasty: a systematic review and meta-analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:383-393. [PMID: 33900452 DOI: 10.1007/s00590-021-02989-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 04/18/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Anterior femoral notching (AFN) may be associated with a higher risk for supracondylar periprosthetic fracture (sPPF) after total knee arthroplasty (TKA), although studies have yielded inconclusive results. We aimed to systematically investigate and meta-analyze the best available evidence regarding the association between AFN and the risk of sPPF after TKA. METHODS A comprehensive search of PubMed, Scopus, Mendeley, Google Scholar and Cochrane databases was performed, from conception to February 29, 2020. Data were expressed as odds ratio (OR) with 95% confidence intervals (CI). I2-index was employed for heterogeneity. Newcastle-Ottawa scale was implemented for quality assessment of the included studies. RESULTS Nine studies fulfilled the eligibility criteria, including a total of 3264 patients subjected to TKA. Among them, there were 150 patients who sustained a sPPF. Overall, patients exposed to AFN (AFN group) demonstrated an increased risk for sPPF compared to those not exposed (control group) (OR 3.91, 95% CI 1.22-12.58, p = 0.02; I2 68.52%). Subgroup analysis based on AFN depth with a cut-off value of 3 mm further clarified this association. Patients with AFN ≥ 3mm were at higher risk for sPPF compared to patients with AFN < 3 mm and control group (OR 4.85, 95% CI 2.08-11.33, p = 0.00; I2 0.0%). On the contrary, fracture risk was not significant for patients with AFN < 3 mm compared to the control group (OR 5.0, 95% CI 0.44-56.82, p = 0.19; I2 42.99%). CONCLUSION Patients, exposed to AFN ≥ 3 mm in depth, are at higher risk for sustaining a sPPF.
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Affiliation(s)
- Dimitrios Stamiris
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece. .,Department of Orthopedics, 424 General Military Hospital of Thessaloniki, 56429, Thessaloniki, Greece. .,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Nifon K Gkekas
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Asteriadis
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stavros Stamiris
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Department of Orthopedics, 424 General Military Hospital of Thessaloniki, 56429, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis Anagnostis
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece.,Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lazaros Poultsides
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Sarris
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Michael Potoupnis
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eustathios Kenanidis
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleftherios Tsiridis
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
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11
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Lian X, Zhao K, Chen W, Zhang J, Li J, Meng H, Hou Z, Zhang Y. Application of a double reverse traction repositor in the retrograde intramedullary nailing of distal femur fractures. J Orthop Surg Res 2021; 16:168. [PMID: 33658059 PMCID: PMC7927219 DOI: 10.1186/s13018-021-02324-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 02/22/2021] [Indexed: 11/10/2022] Open
Abstract
Objective The purpose of this prospective study was to introduce the application of a double reverse traction repositor (DRTR) in the retrograde intramedullary nailing (RE-IMN) of AO/OTA 33A distal femur fractures. Patients and methods A total of 27 patients with AO/OTA type 33A distal femur fractures who were admitted from January 2015 to May 2017 to a level I trauma center of a tertiary university hospital were enrolled in this prospective study. A DRTR was used to facilitate RE-IMN for the reduction of distal femur fractures in all patients. The demographic and fracture characteristics, surgical data, postoperative complications, and prognostic indicators of 24 patients were recorded. Results The DRTR helped achieve and maintain the reduction of all distal femur fractures in the present study. All surgeries were conducted by closed reduction, and excellent alignment was observed in the postoperative X-ray images. In the present study, 18 males and 6 females were included, and the average age of all patients was 51.3 years (range, 24–68 years). The mean operation time, intraoperative blood loss, intraoperative fluoroscopy time, and length of postoperative hospital stay were 137 min (range from 80 to 210 min), 320 ml (range from 200 to 600 ml), 28 (from 24 to 33), and 9 days (from 5 to 14 days), respectively. Eleven patients were found to have postoperative deep venous thrombosis before discharge. No cases of wound infection were observed. No cases of nonunion or malunion were observed. The average follow-up duration was 21 months (18–30 months). The average HHS, LKFS, and VAS scores at the 1-year follow-up were 89.9 (86–97), 79.1 (75–87), and 2.1 (from 0 to 5). No complications associated with DRTR were found. Conclusions A DRTR can be successfully applied in the treatment of distal femur fractures with RE-IMN, and it can not only help achieve or maintain the reduction of distal femur fractures with closed methods but also promote fixation with RE-IMN.
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Affiliation(s)
- Xiaodong Lian
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, PR China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, PR China.,Orthopaedic Research Institution of Hebei Province, Shijiazhuang, Hebei, 050051, PR China
| | - Kuo Zhao
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, PR China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, PR China.,Orthopaedic Research Institution of Hebei Province, Shijiazhuang, Hebei, 050051, PR China
| | - Wei Chen
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, PR China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, PR China.,Orthopaedic Research Institution of Hebei Province, Shijiazhuang, Hebei, 050051, PR China
| | - Junzhe Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, PR China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, PR China.,Orthopaedic Research Institution of Hebei Province, Shijiazhuang, Hebei, 050051, PR China
| | - Junyong Li
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, PR China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, PR China.,Orthopaedic Research Institution of Hebei Province, Shijiazhuang, Hebei, 050051, PR China
| | - Hongyu Meng
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, PR China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, PR China.,Orthopaedic Research Institution of Hebei Province, Shijiazhuang, Hebei, 050051, PR China
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, PR China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, PR China.,Orthopaedic Research Institution of Hebei Province, Shijiazhuang, Hebei, 050051, PR China.,NHC Key Laboratory of Intelligent Orthopaedic Equipment, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, PR China. .,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, PR China. .,Orthopaedic Research Institution of Hebei Province, Shijiazhuang, Hebei, 050051, PR China. .,NHC Key Laboratory of Intelligent Orthopaedic Equipment, The Third Hospital of Hebei Medical University, Shijiazhuang, China. .,Chinese Academy of Engineering, Beijing, 10088, P.R. China.
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12
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Magill H, Ponugoti N, Selim A, Platt J. Locked compression plating versus retrograde intramedullary nailing in the treatment of periprosthetic supracondylar knee fractures: a systematic review and meta-analysis. J Orthop Surg Res 2021; 16:78. [PMID: 33482862 PMCID: PMC7821478 DOI: 10.1186/s13018-021-02222-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 01/11/2021] [Indexed: 01/08/2023] Open
Abstract
Background Periprosthetic fractures of the distal femur above a total knee arthroplasty (TKA) have traditionally been managed by locking compression plating (LCP). This technique is technically demanding and is associated with high rates of non-union and revision. More recently, retrograde intramedullary nailing (RIMN) has been proposed as an acceptable alternative. This meta-analysis aims to evaluate clinical outcomes in patients with periprosthetic supracondylar femoral fractures who were treated with LCP and RIMN. Methods An up-to-date literature search was carried out using the pre-defined search strategy. All studies that met the inclusion criteria were assessed for methodological quality with the Cochrane’s collaboration tool. Operative time, functional score, time-to-union, non-union rates and revision rates were all considered. Conclusion Ten studies with a total of 531 periprosthetic fractures were included. This meta-analysis has suggested that there is no significant difference in any of the outcome measures assessed. Further, more extensive literature is required on the subject to draw more robust conclusions.
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Affiliation(s)
- Henry Magill
- Orthopaedic Registrar, Chelsea and Westminster Hospital, London, UK.
| | - Nikhil Ponugoti
- Orthopaedic Registrar, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - Amr Selim
- Orthopaedic Registrar, Royal Cornwall Hospital, Truro, UK
| | - James Platt
- Consultant Trauma & Orthopaedic Surgeon, Hillingdon Hospital, London, UK
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13
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Lenz M, Acklin YP, Kasper LA, Mischler D, Varga P, Zderic I, Gehweiler D, Klos K, Gueorguiev B, Stoffel K. Biomechanical evaluation of the docking nail concept in periprosthetic fracture fixation around a stemmed total knee arthroplasty. J Biomech 2020; 115:110109. [PMID: 33257010 DOI: 10.1016/j.jbiomech.2020.110109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 10/02/2020] [Accepted: 10/22/2020] [Indexed: 10/23/2022]
Abstract
Intramedullary femoral nails provide an ideal mechanical axis for periprosthetic fracture fixation. Slotted nails allow a connection to a total knee arthroplasty (TKA) stem. This study aims to compare implant and construct stiffness, interfragmentary movement and cycles to failure between an antegrade slotted femoral nail construct docked to a TKA stem and a distal femoral locking plate in a human periprosthetic femoral fracture model. In eight pairs of fresh-frozen human femora with stalked TKA, a 10 mm transverse osteotomy gap was set simulating a Rorabeck type II, Su type I fracture. The femora were pairwise instrumented with either an antegrade slotted nail coupled to the prosthesis stem, or a locking plate. Cyclic testing with a progressively increasing physiologic loading profile was performed at 2 Hz until catastrophic construct failure. Relative movement at the osteotomy site was monitored by means of optical motion tracking. In addition, four-point bending implant stiffness, torsional implant stiffness and frictional fit of the stem-nail connection were investigated via separate non-destructive tests. Intramedullary nails exhibited significantly higher four-point bending and significantly lower torsional implant stiffness than plates, P < 0.01. Increasing difference between nail and stem diameters decreased frictional fit at the stem-nail junction. Nail constructs provided significantly higher initial axial bending stiffness and cycles to failure (200 ± 83 N/mm; 16'871 ± 5'227) compared to plate constructs (93 ± 35 N/mm; 7'562 ± 1'064), P = 0.01. Relative axial translation at osteotomy level after 2'500 cycles was significantly smaller for nail fixation (0.14 ± 0.11 mm) compared with plate fixation (0.99 ± 0.20 mm), P < 0.01. From a biomechanical perspective, the docking nail concept offers higher initial and secondary stability under dynamic axial loading versus plating in TKA periprosthetic fracture fixation.
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Affiliation(s)
- Mark Lenz
- AO Research Institute Davos, Switzerland; Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Germany.
| | | | - Lena Anna Kasper
- AO Research Institute Davos, Switzerland; Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Germany.
| | | | | | | | | | - Kajetan Klos
- Gelenkzentrum Rhein-Main, Hochheim (Main), Germany.
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14
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Ramavath A, Lamb JN, Palan J, Pandit HG, Jain S. Postoperative periprosthetic femoral fracture around total hip replacements: current concepts and clinical outcomes. EFORT Open Rev 2020; 5:558-567. [PMID: 33072408 PMCID: PMC7528669 DOI: 10.1302/2058-5241.5.200003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The rising incidence of postoperative periprosthetic femoral fracture (PFF) presents a significant clinical and economic burden. A detailed understanding of risk factors is required in order to guide preventative strategies. Different femoral stems have unique characteristics and management strategies must be tailored appropriately. Consensus regarding treatment of PFFs around well-fixed stems is lacking, but revision surgery may provide more predictable outcomes for unstable fracture patterns and fractures around polished taper-slip stems. Future research should focus on implant-related risk factors, treatment of concurrent metabolic bone disease and the use of large endoprostheses.
Cite this article: EFORT Open Rev 2020;5:558-567. DOI: 10.1302/2058-5241.5.200003
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Affiliation(s)
- Ashoklal Ramavath
- Department of Orthopaedic Surgery, Chapel Allerton Hospital, Leeds, UK
| | - Jonathan N Lamb
- Department of Orthopaedic Surgery, Chapel Allerton Hospital, Leeds, UK.,University of Leeds, Leeds, UK
| | - Jeya Palan
- Department of Orthopaedic Surgery, Chapel Allerton Hospital, Leeds, UK
| | - Hemant G Pandit
- Department of Orthopaedic Surgery, Chapel Allerton Hospital, Leeds, UK.,University of Leeds, Leeds, UK
| | - Sameer Jain
- Department of Orthopaedic Surgery, Chapel Allerton Hospital, Leeds, UK
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