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Crebert MJ, Kasunic D, Karunaratne SR, Alexander KG, Scholtz AC, Boyle RA, Steffens D. Patient-Reported Outcomes and Range of Motion Following Knee Arthroplasty Using a Megaprosthesis in Non-Oncological Patients: A Systematic Review. J Arthroplasty 2024; 39:2633-2644.e4. [PMID: 38754706 DOI: 10.1016/j.arth.2024.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND This review aimed to determine outcomes following megaprostheses in non-oncological indications for knee arthroplasty, including range of motion (ROM) and patient-reported outcome measures of function, pain, and quality of life (QoL). METHODS A search of MEDLINE, Embase, and Cochrane via Ovid and PubMed between January 2003 and June 2023 was conducted. Studies reporting function, pain, ROM, and/or QoL in non-oncological patients who have received knee megaprostheses were included. Studies with sample sizes (n ≤ 5) were excluded. The risk of bias was assessed using the Downs and Black Quality Checklist for Health Care Intervention Studies. Central tendency measures (mean or median) were reported at each time point, and dispersion measures were extracted and reported whenever data were available. RESULTS A total of 30 studies (involving 1,294 megaprostheses) were included. Of which, 14 of 30 studies reviewed patients who had mixed indications; 14 of 30 looked at fracture only; 1 of 30 focused on distal femur nonunion; and 1 of 30 focused on patients who had periprosthetic infections. The average patient follow-up time was 40.1 months (range, 1.0 to 93.5). Most studies presented a high risk of bias (27 of 30), while a few (3 of 30) presented a low risk of bias. Improvements from preoperative baseline were observed in 85.7% of studies that reported baseline and follow-up data for function (12 of 14), 100.0% pain (4 of 4), 90.9% ROM (10 of 11), and 66.6% QoL (2 of 3). CONCLUSIONS Favorable function, pain, ROM, and QoL outcomes following knee megaprostheses in non-oncological patients were observed. Heterogeneity in outcome measures and follow-up periods prevented the pooling of data. Future comparative studies are warranted to enhance the body of evidence relating to knee megaprostheses in non-oncological patients.
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Affiliation(s)
- Mitchell J Crebert
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital and Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia
| | - Daniel Kasunic
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital and Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia
| | - Sascha R Karunaratne
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital and Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia
| | - Kate G Alexander
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital and Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia
| | - Amelia C Scholtz
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital and Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia
| | - Richard A Boyle
- Orthopaedic Surgery Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital and Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia
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Routledge JC, Bashir O, Elbeshbeshy M, Saber AY, Aqil A. Management of Distal Femur Fractures: Replacement Versus Surgical Fixation Versus Conservative Management. Cureus 2023; 15:e45333. [PMID: 37849599 PMCID: PMC10577514 DOI: 10.7759/cureus.45333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2023] [Indexed: 10/19/2023] Open
Abstract
INTRODUCTION Distal femur fractures are a frequently encountered injury, especially among the ageing population. Previous studies have identified that these fractures can be managed with a variety of methods and techniques which has led to an ongoing debate and investigation to decipher the optimal approach to manage these fractures. AIM The purpose of this study was to compare outcomes of patients managed with either distal femur replacements (DFRs), surgical fixation (SF) or conservative management. Outcomes measured included length of hospital stay, readmission rates, 30-day mortality and Oxford Knee Score. METHODS A retrospective review was conducted, of patients admitted with distal femur fractures between June 2020 and October 2022 at Huddersfield Royal Infirmary Hospital. Patients with both native and peri-prosthetic joints were included. All patient's medical data, including imaging and operative records, were reviewed. RESULTS A total of 42 patients were identified. There were six males and 36 females with a mean age of 78 years, a median age of 76 and a range of 35-102 years. Of these fractures, 15 were peri-prosthetic, and 27 were native joints. Of the patients, 30 had an SF, five had a DFR and the remaining seven were conservatively managed. Those managed with an SF had an average length of stay of 18 days, an Oxford score of 24 and two patients were readmitted within 30 days of discharge. For the DFR, the average length of stay was 16 days, an Oxford score of 22 and no patients were readmitted within 30 days. For the conservatively managed patients 21 days, an Oxford score of 25 and two patients were readmitted within 30 days of discharge. There was no 30-day mortality across all groups. CONCLUSIONS From our study, we can conclude that patients who managed with a DFR had the shortest length of stay in a hospital and the lowest readmission rates when compared to alternative management techniques. There was minimal difference found between the Oxford scores between all three groups. This study shows that DFR can be a safe and reliable strategy to manage distal femur fractures. Additional research is required to further compare the outcomes of these different methods of repair.
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Affiliation(s)
- Jamie C Routledge
- Orthopaedics and Trauma, Huddersfield Royal Infirmary, Huddersfield, GBR
| | - Oladimeji Bashir
- Orthopaedics and Trauma, Huddersfield Royal Infirmary, Huddersfield, GBR
| | | | - Ahmed Y Saber
- Orthopaedics and Trauma, Huddersfield Royal Infirmary, Huddersfield, GBR
| | - Adeel Aqil
- Orthopaedics and Trauma, Huddersfield Royal Infirmary, Huddersfield, GBR
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Sambri A, Parisi SC, Zunarelli R, Di Prinzio L, Morante L, Lonardo G, Bortoli M, Montanari A, De Cristofaro R, Fiore M, De Paolis M. Megaprosthesis in Non-Oncologic Settings-A Systematic Review of the Literature. J Clin Med 2023; 12:4151. [PMID: 37373844 DOI: 10.3390/jcm12124151] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 05/31/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Modular megaprostheses (MPs) are commonly used after bone-tumor resection, but they can offer a limb salvage solution in massive bone defects. The aim of this systematic review of the Literature is to provide a comprehensive data collection concerning the use of MPs in non-oncologic cases, and to provide an overview of this topic, especially from an epidemiologic point of view. Three different databases (PubMed, Scopus, and Web of Science) were searched for relevant articles, and further references were obtained by cross-referencing. Sixty-nine studies met the inclusion criteria, reporting on cases of MP in non-oncologic cases. A total of 2598 MPs were retrieved. Among these, 1353 (52.1%) were distal femur MPs, 941 (36.2%) were proximal femur MPs, 29 (1.4%) were proximal tibia MPs and 259 (10.0%) were total femur MPs. Megaprostheses were most commonly used to treat periprosthetic fractures (1158 cases, 44.6%), in particular in the distal femur (859, 74.2%). Overall, complications were observed in 513 cases (19.7%). Type I (soft tissue failures) and type IV (infection) according to the Henderson classification were the most frequent (158 and 213, respectively). In conclusion, patients with severe post-traumatic deformities and/or significant bone loss who have had previous septic complications should be considered as oncologic patients, not because of the disease, but because of the limited therapeutic options available. The benefits of this treatment include relatively short operative times and immediate weight-bearing, thus making MP particularly attractive in the lower limb.
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Affiliation(s)
- Andrea Sambri
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Stefania Claudia Parisi
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Renato Zunarelli
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Lorenzo Di Prinzio
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Lorenzo Morante
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Gianluca Lonardo
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Marta Bortoli
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Andrea Montanari
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Roberto De Cristofaro
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Michele Fiore
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Massimiliano De Paolis
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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Corap Y, Brix M, Brandt JR, Emmeluth C, Lindberg-Larsen M. Knee function, quality of life, pain, and living conditions after distal femoral resection knee arthroplasty for non-tumor indications. BMC Musculoskelet Disord 2023; 24:9. [PMID: 36609249 PMCID: PMC9817378 DOI: 10.1186/s12891-022-06104-z] [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: 06/30/2022] [Accepted: 12/19/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Distal femoral resection knee arthroplasty is a limb salvage procedure. The impact of distal femoral resection arthroplasty on patient function and health status is unknown. The aim of this study was to report knee function, quality of life, knee pain, and living conditions after distal femoral resection knee arthroplasty for non-tumor indications. METHODS Of 52 patients (52 knees) undergoing distal femoral resection knee arthroplasty in a single institution between 2012 and 2021, 22 were excluded as 3 patients had ≤90 days follow-up, 6 had died, and 13 declined or were unable to participate for unrelated reasons. Thus, 30 patients were included and interviewed by telephone in March 2021 (mean follow-up 3.5 years after surgery). Patient completed the Oxford Knee Score (0-48, 48 best), EQ-5D-5L, and the Copenhagen Knee ROM, and information on pain and living conditions was obtained. RESULTS The mean age was 67.9 years (SD 13.6), and 21 (70%) were female. Mean total Oxford Knee Score was 29.9 (SD 10.5), mean Copenhagen Knee ROM flexion was 116° (SD 21.6), and mean extension was - 2° (SD10.1). Mobility aids were used by 18 (60%) patients, i.e. a cane (30%), walker (26.7%) or wheelchair (3.3%). Mean EQ-5Dindex score was 0.70 (SD 0.22) and mean EQ-5D VAS score was 55.4 (SD 23.9). Nine (30%) patients used paracetamol or NSAID and 2 (6.7%) used opioids for knee pain. Mean VAS knee pain score was 1.30 (SD 2.2) at rest and 2.8 (SD 3.1) when walking. Most (90%) patients lived in their own home, with only 3 patients in nursing homes. Two-thirds (66.7%) required no home care, 5 (16.6%) received home care 1-2 times over 2 weeks, and 5 (16.6%) every day. CONCLUSION Distal femoral resection knee arthroplasty appears to be a viable treatment option for non-tumor indications. Acceptable patient outcomes were achieved in terms of functional status and quality of life, especially considering treatment alternatives such as femoral amputation.
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Affiliation(s)
- Yasemin Corap
- grid.7143.10000 0004 0512 5013Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Michael Brix
- grid.7143.10000 0004 0512 5013Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Julie R. Brandt
- grid.7143.10000 0004 0512 5013Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Claus Emmeluth
- grid.7143.10000 0004 0512 5013Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Martin Lindberg-Larsen
- grid.7143.10000 0004 0512 5013Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Caines A, Adamczyk A, Mahaffey R, Pickell M. Open Reduction Internal Fixation Versus Distal Femoral Replacement (DFR) for Treatment of OTA/AO 33C Fractures in the Elderly: A Review of Functional Outcomes and Cost Analysis. J Orthop Trauma 2023; 37:14-18. [PMID: 36518063 DOI: 10.1097/bot.0000000000002455] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the economic cost associated with the treatment of OTA/AO 33C fractures in patients older than 65 years of age using open reduction internal fixation (ORIF) or DFR and to assess the perioperative outcomes of elderly patients treated surgically following OTA/AO 33C fractures. DESIGN Retrospective cohort over a 10-year period. SETTING A single level-1 trauma center. PARTICIPANTS AND INTERVENTION Thirty-nine patients 65 or older with OTA/AO 33C fractures who underwent treatment with ORIF (n = 27) or DFR (n = 12) were included. MAIN OUTCOME MEASUREMENTS Direct cost associated with surgical treatment along with LOS, functional outcomes, patient-reported outcomes, and all-cause reoperation. RESULTS Index procedure costs were as follows: DFR: $ 61,259 vs. ORIF: $44,490 (P = 0.056). Five (20%) ORIF patients required revision versus one (8%) in the DFR group. Total cost when including reoperation resulted in DFR being $14,805 more costly, which was not significant. Hospital LOS was similar between groups; however, convalescent LOS was longer in ORIF patients (43.2 vs. 23.1 days, P = 0.02). CONCLUSION This study demonstrates that there is no significant difference in overall cost between ORIF and DFR when all costs are considered. A larger portion of DFR patients were able to mobilize postoperatively, with subacute length of stay being longer in ORIF patients. A multicenter trial is warranted to determine optimal treatment for this complex problem. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Andrew Caines
- Division of Orthopaedic Surgery, The University of Ottawa, The Ottawa Hospital, Ottawa, ON
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6
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Short-term outcomes of periprosthetic compared to native distal femur fractures, a national database study. Arch Orthop Trauma Surg 2023; 143:115-124. [PMID: 34185154 DOI: 10.1007/s00402-021-04000-0] [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: 03/19/2021] [Accepted: 06/14/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Distal femur fractures (DFFx) are highly morbid injuries with a complication rate comparable to hip fractures. Rising rates of total knee arthroplasty (TKA) have led to increasing rates of periprosthetic DFFx (pDFFx). We sought to determine how pDFFx complication rates differed from native DFFx (nDFFx). METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used to identify patients who sustained pDFFx or nDFFx between 2012 and 2018. Patients were further stratified by operative treatment: open reduction internal fixation (ORIF) or distal femur replacement (DFR). Multivariate logistic regression was used to compare 30-day complication rates between pDFFx versus nDFFx and, among pDFFx patients, ORIF versus DFR or revision TKA (rTKA). RESULTS 563 patients with pDFFx and 2259 patients with nDFFx were identified between 2012 and 2018. pDFFx patients had significantly lower rates of ORIF than nDFFx patients (36.4 vs 95.4%, p < 0.001). On multivariate analysis, pDFFx were associated with a higher rate of surgical site complications (OR 2.48, p = 0.009) compared to nDFFx. There were no differences in mortality, reoperations, major complications, rate of blood transfusion, venous thromboembolism and disposition. In patients with pDFFx, patients undergoing DFR/rTKA were more likely to be discharged home versus a rehab facility, compared to those undergoing ORIF (OR 2.62, p < 0.001). CONCLUSIONS In this first large registry study comparing pDFFx and nDFFx, we find similar outcomes between these groups in the first 30 days after surgery. Patients with pDFFx did have higher rates of surgical site complications, including infection and dehiscence. In pDFFx patients, those undergoing DFR were more likely to return home post-operatively.
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7
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Aebischer AS, Hau R, de Steiger RN, Holder C, Wall CJ. Distal femoral arthroplasty for native knee fractures : results from the Australian Orthopaedic Association National Joint Replacement Registry. Bone Joint J 2022; 104-B:894-901. [PMID: 35775178 DOI: 10.1302/0301-620x.104b7.bjj-2021-1136.r3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIMS The aim of this study was to investigate the rate of revision for distal femoral arthroplasty (DFA) performed as a primary procedure for native knee fractures using data from the Australian Orthopaedic Association National Joint Arthroplasty Registry (AOANJRR). METHODS Data from the AOANJRR were obtained for DFA performed as primary procedures for native knee fractures from 1 September 1999 to 31 December 2020. Pathological fractures and revision for failed internal fixation were excluded. The five prostheses identified were the Global Modular Arthroplasty System, the Modular Arthroplasty System, the Modular Universal Tumour And Revision System, the Orthopaedic Salvage System, and the Segmental System. Patient demographic data (age, sex, and American Society of Anesthesiologists grade) were obtained, where available. Kaplan-Meier estimates of survival were used to determine the rate of revision, and the reasons for revision and mortality data were examined. RESULTS The AOANJRR identified 153 primary DFAs performed for native knee fractures in 151 patients during the study period, with 63.3% of these (n = 97) performed within the last five years. The median follow-up was 2.1 years (interquartile range 0.8 to 4.4). The patient population was 84.8% female (n = 128), with a mean age of 76.1 years (SD 11.9). The cumulative percent revision rate at three years was 10%. The most common reason for revision was loosening, followed by infection. Patient survival at one year was 87.5%, decreasing to 72.8% at three years postoperatively. CONCLUSION The use of DFA to treat native knee fractures is increasing, with 63.3% of cases performed within the last five years. While long-term data are not available, the results of this study suggest that DFA may be a reasonable option for elderly patients with native knee fractures where fixation is not feasible, or for whom prolonged non-weightbearing may be detrimental. Cite this article: Bone Joint J 2022;104-B(7):894-901.
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Affiliation(s)
| | - Raphael Hau
- Eastern Health Clinical School, Monash University, Melbourne, Australia.,Department of Surgery, University of Melbourne, Northern Medical School, Melbourne, Australia
| | - Richard N de Steiger
- Department of Surgery, Epworth Healthcare, University of Melbourne, Melbourne, Australia.,Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia
| | - Carl Holder
- South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia
| | - Christopher J Wall
- Department of Orthopaedics, Toowoomba Hospital, Toowoomba, Australia.,School of Medicine Rural Clinical School, University of Queensland, Toowoomba, Australia
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Aebischer AS, Hau R, de Steiger RN, Holder C, Wall CJ. Distal Femoral Replacement for Periprosthetic Fractures After TKA: Australian Orthopaedic Association National Joint Replacement Registry Review. J Arthroplasty 2022; 37:1354-1358. [PMID: 35271977 DOI: 10.1016/j.arth.2022.02.115] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/23/2022] [Accepted: 02/28/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Distal femoral replacement (DFR) is a potential treatment option following periprosthetic fracture (PPF) of a total knee arthroplasty (TKA). However, there is limited literature regarding implant survivorship and complication rates. The aim of this study was to examine patient demographics and trends in usage, implant survivorship and modes of failure, and patient mortality following DFR for PPF captured by a national joint replacement registry. METHODS A retrospective registry review was performed using data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). In total, 306 DFR were performed for PPF of a known primary TKA. Eighty-five percent of patients were female, and the mean age was 76.4 years. Kaplan-Meier estimates of implant and patient survivorship were performed. RESULTS The number of DFR performed for PPF has doubled over the past five years. The cumulative percent second revision rate at six years was 12%. The most common indications for revision were infection (37%) and aseptic loosening (33%). Patient survivorship after DFR was 97% and 83% at five and ten years, respectively. CONCLUSION A national registry review has identified the increasing prevalence of DFR for PPF after primary TKA and demonstrated implant survivorship of 88% at midterm follow-up. Surgeons may consider DFR as an acceptable and durable treatment option. LEVEL OF EVIDENCE Level III - Case Series.
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Affiliation(s)
| | - Raphael Hau
- Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia; Department of Surgery, University of Melbourne, Northern Medical School, Epping, Victoria, Australia
| | - Richard N de Steiger
- Department of Surgery, Epworth Healthcare, University of Melbourne, Richmond, Australia; Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia
| | - Carl Holder
- MBiostat, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia
| | - Christopher J Wall
- Department of Orthopaedics, Toowoomba Hospital, Toowoomba, Australia; School of Medicine Rural Clinical School, University of Queensland, Toowoomba, Australia
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Barzen S, Buschbeck S, Hoffmann R. [Distal femoral fractures]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 125:507-517. [PMID: 35725933 DOI: 10.1007/s00113-022-01197-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 06/15/2023]
Abstract
CLINICAL ISSUE Fractures of the distal femur represent rare but serious injuries with a high 1‑year mortality. An increasingly older patient population requires adapted treatment concepts. STANDARD TREATMENT PROCEDURE Surgical treatment using angular stable plating and retrograde nailing is the standard procedure. Conservative treatment is only indicated in cases of low demands and high perioperative risks of the patient. TREATMENT INNOVATIONS Primary double plate osteosynthesis and primary implantation of a distal femoral replacement represent new treatment procedures and show promising initial results in the collective of geriatric patients. DIAGNOSTIC WORK-UP Conventional radiographs in 2 planes and computed tomography with multiplanar and 3D reconstructions should be performed to enable an adequate assessment of the indications and treatment planning. PERFORMANCE Nonunion rates of plate and nail osteosyntheses range from 4% to 10%. No significant differences in long-term results can be observed. The results regarding double plate osteosynthesis and distal femoral replacement so far do not show any disadvantages compared to the existing procedures but there is still insufficient data for general recommendations. ASSESSMENT Complex fractures with extensive reconstructive procedures and treatment by distal femoral replacement should be performed in specialized centers. PRACTICAL RECOMMENDATIONS The gold standard is still surgical treatment by means of minimally invasive angular stable plate or retrograde nail osteosynthesis. Complex fracture forms require individual treatment planning considering all currently available treatment options.
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Affiliation(s)
- S Barzen
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Unfallchirurgie und orthopädische Chirurgie, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland.
| | - S Buschbeck
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Unfallchirurgie und orthopädische Chirurgie, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - R Hoffmann
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Unfallchirurgie und orthopädische Chirurgie, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
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10
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Corap Y, Brix M, Emmeluth C, Lindberg-Larsen M. Patient safety in distal femoral resection knee arthroplasty for non-tumor indications: a single-center consecutive cohort study of 45 patients. BMC Musculoskelet Disord 2022; 23:199. [PMID: 35241040 PMCID: PMC8892708 DOI: 10.1186/s12891-022-05100-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Distal femoral resection knee arthroplasty may be a viable option for several indications other than bone tumors. Resection knee arthroplasty appears to be becoming more common, but patients requiring this type of surgery are often elderly and with high comorbidity. The aim of this study was to report in-hospital complications, readmissions, reoperations, and mortality after distal femoral resection knee arthroplasty for non-tumor indications. METHODS We retrospectively identified a consecutive cohort of 45 knees (45 patients) treated with distal femoral resection knee arthroplasty in a single institution between 2012 and 2021. Indications for surgery were failure of osteosynthesis (8), primary fracture treatment (2), periprosthetic fracture (22), and revision arthroplasty with severe bone loss (13). A major reoperation was defined as a major component exchange procedure or amputation. Mean follow-up was 3.9 years. RESULTS The mean age was 71.3 years (SD 12.3), and 64.4% were female; 8.9% were ASA I, 40% ASA II, and 51% ASA III. Median length of stay was 7 days (range 3-19) with no major in-hospital complications, but 55.6% (n = 25) required blood transfusion. The 90-day readmission rate was 17.8% (n = 8), of which 50% was prosthesis-related. Four patients (8.9%) underwent major reoperation due to infection (n = 2), mechanical failure (n = 1), or periprosthetic fracture (n = 1). The mortality rate was 0% ≤ 90 days and 2.2% ≤1 year. CONCLUSIONS Distal femoral resection knee arthroplasty in this fragile patient population appears to be a viable and safe option considering that it is a limp salvage procedure most cases.
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Affiliation(s)
- Yasemin Corap
- Orthopaedic research unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark. .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Michael Brix
- Orthopaedic research unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Claus Emmeluth
- Orthopaedic research unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Martin Lindberg-Larsen
- Orthopaedic research unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Sobol KR, Fram BR, Strony JT, Brown SA. Survivorship, complications, and outcomes following distal femoral arthroplasty for non-neoplastic indications. Bone Jt Open 2022; 3:173-181. [PMID: 35227074 PMCID: PMC8965790 DOI: 10.1302/2633-1462.33.bjo-2021-0202.r1] [Citation(s) in RCA: 6] [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: 11/23/2022] Open
Abstract
Aims Endoprosthetic reconstruction with a distal femoral arthroplasty (DFA) can be used to treat distal femoral bone loss from oncological and non-oncological causes. This study reports the short-term implant survivorship, complications, and risk factors for patients who underwent DFA for non-neoplastic indications. Methods We performed a retrospective review of 75 patients from a single institution who underwent DFA for non-neoplastic indications, including aseptic loosening or mechanical failure of a previous prosthesis (n = 25), periprosthetic joint infection (PJI) (n = 23), and native or periprosthetic distal femur fracture or nonunion (n = 27). Patients with less than 24 months’ follow-up were excluded. We collected patient demographic data, complications, and reoperations. Reoperation for implant failure was used to calculate implant survivorship. Results Overall one- and five-year implant survivorship was 87% and 76%, respectively. By indication for DFA, mechanical failure had one- and five-year implant survivorship of 92% and 68%, PJI of 91% and 72%, and distal femur fracture/nonunion of 78% and 70% (p = 0.618). A total of 37 patients (49%) experienced complications and 27 patients (36%) required one or more reoperation. PJI (n = 16, 21%), aseptic loosening (n = 9, 12%), and wound complications (n = 8, 11%) were the most common complications. Component revision (n = 10, 13.3%) and single-stage exchange for PJI (n = 9, 12.0 %) were the most common reoperations. Only younger age was significantly associated with increased complications (mean 67 years (SD 9.1)) with complication vs 71 years (SD 9.9) without complication; p = 0.048). Conclusion DFA is a viable option for distal femoral bone loss from a range of non-oncological causes, demonstrating acceptable short-term survivorship but with high overall complication rates. Cite this article: Bone Jt Open 2022;3(3):173–181.
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Affiliation(s)
- Keenan Rhys Sobol
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brianna R Fram
- Department of Orthopedic Surgery and the Rothman Institute of Orthopedics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John T Strony
- Department of Orthopedic Surgery and the Rothman Institute of Orthopedics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Scot A Brown
- Department of Orthopedic Surgery and the Rothman Institute of Orthopedics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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12
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Vitiello R, Ziranu A, Oliva MS, Meluzio MC, Cauteruccio M, Maccauro G, Liuzza F, Saccomanno MF. The value of megaprostheses in non-oncological fractures in elderly patients: A short-term results. Injury 2022; 53:1241-1246. [PMID: 34602244 DOI: 10.1016/j.injury.2021.09.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 09/13/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The management of both hip and distal femur fractures as well as periprosthetic fractures can be challenging for orthopaedic surgeons. The use of megaprosthetic implants could provide substantial advantages in elderly population affected by complex fractures. The aim of the study was to evaluate the effectiveness of megaprosthetic implants for treating hip and distal femur fractures as well as periprosthetic fractures in elderly. MATERIAL AND METHODS From January 1st 2015 to December 31st 2019, patients treated for proximal or distal femoral fractures with severe bone loss or failure of previous surgery were retrospectively reviewed. Patients were divided into two group based on diagnosis: proximal femur fractures (group A) and distal femur fractures (group B). Subsequently, patients underwent hip (group A) or knee (group B) megaprosthesis. Self-assessed questionnaires were administered to all patients pre and postoperatively. Primary outcome was the Activity Daily Living. Secondary outcomes were: Instrumental Activity Daily Living, Short Form-12, Oxford knee or hip score, complications. Charlson score, Harris classification for hip or Anderson Orthopaedic Research Institute score and complication were recorded. All patients underwent a radiological follow up to rule out implant loosening and mobilization. Pre and postoperative functional score comparisons in each group were undertaken. Significance was set p ≤ 0.05. RESULTS Twelve patients were finally included in the study. There were 6 male and 6 females, the mean age was 72,9 years old (± 7,4); the mean BMI was 29,8 points (± 4.5). The mean follow-up was 2.9 years (± 1.4). No differences could be found between pre and postoperative evaluation in each group. No aseptic loosening, dislocation, mobilization or radiolucency were recorded during the follow-up. In group A, two surgical site infections (2/6 patients) and one pneumonia (1/6 patients) were recorded. In group B, two surgical site infections occurred (2/6 patients). All patients were treated by antimicrobial oral therapy with complete regression. CONCLUSION The use of hip and knee megaprosthetic implants in traumatology is a safe and viable option in elderly patients.
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Affiliation(s)
- Raffaele Vitiello
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Antonio Ziranu
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Maria Serena Oliva
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia.
| | - Maria Concetta Meluzio
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Michele Cauteruccio
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Giulio Maccauro
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Francesco Liuzza
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
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13
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Brodke DJ, Devana SK, Upfill-Brown A, Lee C. Cost-effectiveness of fixation versus arthroplasty for geriatric distal femur fractures. Injury 2022; 53:661-668. [PMID: 34887075 PMCID: PMC10400013 DOI: 10.1016/j.injury.2021.11.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Geriatric distal femur fractures are challenging to treat. The high mortality rate associated with a loss of mobility in this population has led some authors to compare distal femur fractures to femoral neck fractures with respect to the importance of rapidly regaining mobility in the geriatric population. Acute distal femur replacement has been advocated by some as a preferred treatment over internal fixation because arthroplasty may facilitate a more rapid return to a patient's baseline mobility level. The purpose of this study was to systematically review the literature on the costs and outcomes of fixation and arthroplasty in the geriatric distal femur fracture population and to employ decision modeling techniques to generate evidence-based treatment recommendations. METHODS A systematic literature review of clinical studies published since 2000 was conducted to synthesize the available data on outcomes, reoperation rates, and mortality rates after fixation or arthroplasty for distal femur fractures in patients with an average age greater than 70 years. A Markov decision analysis model was created. Costs, health state utilities, reoperation rates, and mortality rates were derived from the systematic literature review and publicly available data. The model was analyzed via probabilistic statistical analysis as well as sensitivity analyses with a willingness-to-pay threshold set at $100,000 per QALY and a 5-year time horizon. RESULTS From a US societal perspective, fixation was associated with a greater quality of life benefit (2.44 QALYs vs. 2.34 QALYs) and lower cost ($25,556 vs. $65,536) compared with distal femur replacement for geriatric distal femur fractures. Probabilistic analysis demonstrated that 82 in 100 model outcomes favored fixation over arthroplasty and 18 in 100 model outcomes favored distal femur replacement. Sensitivity analyses demonstrated that this result was robust to small deviations in the cost and functional outcome variables in the model. CONCLUSION Compared to distal femur replacement, ORIF is likely to be a more cost-effective treatment for distal femur fractures in the geriatric patient population, though this recommendation is tempered by the relatively low quality of evidence available on the comparative functional outcomes of these treatments.
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Affiliation(s)
- Dane J Brodke
- Department of Orthopaedic Surgery, University of California Los Angeles, 10833 Le Conte Ave, Los Angeles, CA 90095, USA
| | - Sai K Devana
- Department of Orthopaedic Surgery, University of California Los Angeles, 10833 Le Conte Ave, Los Angeles, CA 90095, USA
| | - Alexander Upfill-Brown
- Department of Orthopaedic Surgery, University of California Los Angeles, 10833 Le Conte Ave, Los Angeles, CA 90095, USA
| | - Christopher Lee
- Department of Orthopaedic Surgery, University of California Los Angeles, 10833 Le Conte Ave, Los Angeles, CA 90095, USA.
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14
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Onubogu IK, Relwani S, Grewal US, Bhamra JS, Reddy KG, Dhinsa BS. Distal Femoral Replacement as a Primary Treatment Method for Distal Femoral Fractures in the Elderly. Cureus 2021; 13:e18752. [PMID: 34790497 PMCID: PMC8589001 DOI: 10.7759/cureus.18752] [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] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 11/05/2022] Open
Abstract
Distal femoral fractures account for 3-6% of all femoral fractures with a similar demographic as patients suffering from proximal femoral fractures. The mortality risk can be high in such injuries, which has prompted NHS England to extend the scope of the Best Practice Tariff to include all fragility fractures of the femur. Poor bone quality, intra-articular extension, and significant comminution can make these fractures difficult to manage with fixation techniques, while early mobilisation is a key outcome in the treatment of this injury. In this study, a comprehensive literature search was performed based on keywords, and abstracts were reviewed to identify relevant articles. The following factors were analysed: time to surgery, time to full weight-bearing, the average hospital stay, post-operative mobility status, and complications. A total of 233 abstracts were identified using the pre-determined search criteria, and, subsequently, articles were excluded following author review. A total of 10 relevant articles were included in this review, with five used for review and comparison between distal femoral replacement (DFR) and fixation. This resulted in a sample of 200 patients treated with DFR with over 87% ambulatory at follow-up and a re-operation rate of 13.3% compared to 78% and 13.5%, respectively, in those treated with open reduction internal fixation (ORIF) procedure. Despite a limited pool of evidence, the literature suggests that DFR offers an option that potentially allows immediate weight-bearing and leaves most patients ambulatory at follow-up. Although DFR is more costly than other operative techniques, it avoids complications associated with fixation such as non-union and can reduce the risk of further surgery through direct complications or a need for delayed arthroplasty, which is deemed more complex secondary to fixation. Early mobilisation is a key step in reducing morbidity and mortality among this cohort of patients, and a procedure such as DFR should be more widely considered to help achieve this outcome.
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Affiliation(s)
| | - Sanjana Relwani
- Trauma and Orthopaedics, Barts and The London School of Medicine and Dentistry, London, GBR
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15
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Rubinger L, Khalik HA, Gazendam A, Wolfstadt J, Khoshbin A, Tushinski D, Johal H. Very Distal Femoral Periprosthetic Fractures: Replacement Versus Fixation: A Systematic Review. J Orthop Trauma 2021; 35:573-583. [PMID: 33993176 DOI: 10.1097/bot.0000000000002080] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To synthesize all-cause reoperations and complications data as well as secondary clinical and functional outcomes, after the management of very distal femur periprosthetic fractures (vDFPFs) in a geriatric patient population with either a distal femoral locking plate (DFLP) or distal femoral replacement (DFR). DATA SOURCES MEDLINE, Embase, and Web of Science were searched for English language articles from inception to March 16, 2020, in accordance to the PRISMA guidelines. STUDY SELECTION Studies reporting the management of vDFPFs in adults older than 65 years with either a DFLP or DFR were included. To ensure this review solely focused on very distal femoral periprosthetic fractures, only fractures of the following classifications were included: (1) Lewis and Rorabeck type II or III, (2) Su and Associates' Classification of Supracondylar Fractures of the Distal Femur type III, (3) Backstein et al type F2, and/or (4) Kim et al type II or III. DATA EXTRACTION Three reviewers independently extracted data from the included studies. Study validity was assessed using the methodological index for nonrandomized studies (MINORS), a quality assessment tool for nonrandomized controlled studies in surgery. DATA SYNTHESIS Twenty-five studies with 649 vDFPFs were included for analysis. There were 440 knees in the DFLP group (mean age range: 65.9-88.3 years) and 209 knees in the DFR group (mean age range: 71.0-84.8 years). Because of the literature's heterogeneity, the data were qualitatively synthesized. CONCLUSIONS vDFPFs in the elderly treated with DFR underwent fewer reoperations relative to DFLP (0%-45% vs. 0%-77%, respectively). Time to weight-bearing was observably shorter in DFR studies relative to DFLP studies. Functional outcomes and postoperative range of motion indicated a trend for DFLP knees to outperform DFR knees. Future research should include prospective studies and cost-effectiveness evaluations to better understand the utility of DFR for these fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Luc Rubinger
- Division of Orthopaedic Surgery, Center for Evidence Based Orthopaedics, McMaster University, Hamilton, ON, Canada
| | - Hassaan Abdel Khalik
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Aaron Gazendam
- Division of Orthopaedic Surgery, Center for Evidence Based Orthopaedics, McMaster University, Hamilton, ON, Canada
| | - Jesse Wolfstadt
- Granovsky Gluskin Division of Orthopedic Surgery, Sinai Health System, University of Toronto, Toronto, ON, Canada; and
| | - Amir Khoshbin
- Division of Orthopaedic Surgery, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Daniel Tushinski
- Division of Orthopaedic Surgery, Center for Evidence Based Orthopaedics, McMaster University, Hamilton, ON, Canada
| | - Herman Johal
- Division of Orthopaedic Surgery, Center for Evidence Based Orthopaedics, McMaster University, Hamilton, ON, Canada
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16
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"Use of pedicled corticoperiosteal flap in resistant cases of distal femur non-union: Our learning experience". J Plast Reconstr Aesthet Surg 2021; 75:621-628. [PMID: 34732336 DOI: 10.1016/j.bjps.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 06/04/2021] [Accepted: 09/19/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Nonunion of distal femur is a complex problem with the added burden of poor bone stock, osteopenia, and joint contracture. Various procedures are described ranging from osteosynthesis using auto/allograft, to use of mega prosthesis. Use of vascularized corticoperiosteal flap based on descending genicular artery and superomedial genicular artery is a new technique to provide living vascular graft for the nonunion site. Although few free corticoperiosteal flap reconstructions have been reported in the past for these distal femur nonunions, this flap has seldom been used as a pedicled variety. Through this article, we aimed at highlighting the main obstacles faced while using pedicled corticoperiosteal flap for these patients given its dearth in literature. MATERIALS AND METHODS Five patients of at least two previously failed osteosynthesis for distal femur fracture non-union were selected for performing corticoperiosteal flaps. The intraoperative findings that were both favourable and unfavourable were documented along with the outcome of procedure in the form of callus formation or fracture healing. RESULTS Dissection of the flap was more tedious in these cases than when performed for a different indication in a virgin territory. However, despite the previous trauma resulting in decreased pliability of their vessels, all flaps were viable at the end of procedure with favourable cosmetic and functional outcomes. CONCLUSION Despite the complexities in flap harvest, use of the less morbid and technically easier "Pedicled corticoperiosteal flap" and osteosynthesis along with the auto technique is a worthwhile option for retaining the native joint with favourable outcome in non-unions of distal femur.
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17
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Tibbo ME, Parry JA, Hevesi M, Abdel MP, Yuan BJ. Distal femoral replacement versus ORIF for severely comminuted distal femur fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:959-964. [PMID: 34196820 DOI: 10.1007/s00590-021-03061-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/14/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Distal femoral replacement (DFR) and open reduction and internal fixation (ORIF) are surgical options for comminuted distal femur fractures. Comparative outcomes of these techniques are limited. The aims of this study were to compare implant survivorship, perioperative factors, and clinical outcomes of DFR vs. ORIF for comminuted distal femur fractures. METHODS Ten patients treated with rotating hinge DFRs for AO/OTA 33-C fractures from 2005 to 2015 were identified and matched 1:2 based on age and sex to 20 ORIF patients. Patients treated with DFR and ORIF had similar ages (80 vs. 76 years, p = 0.2) and follow-up (20 vs. 27 months, p = 1.0), respectively. Implant survivorship, length of stay (LOS), anesthetic time, estimated blood loss (EBL), ambulatory status, knee range of motion (ROM), and Knee Society scores (KSS) were assessed at final follow-up. RESULTS Survivorship free from any revision at 2 years was 90% and 65% for the DFR and ORIF groups, respectively (p = 0.59). Survivorship free from any reoperation at 2 years was 90% for the DFR group and 50% for the ORIF group (p = 0.16). Three ORIF patients (15%) went on to nonunion and two went on to delayed union. Mean EBL and LOS were significantly higher for the DFR group: 592 mL vs. 364 mL, and 13 vs. 6.5 days, respectively. Knee ROM (p = 0.71) and KSSs (p = 0.36) were similar between groups. CONCLUSIONS Comminuted distal femur fractures treated with DFR trended toward lower revision and reoperation rates, with similar functional outcomes when compared to ORIF. We noted a trend toward increased EBL and LOS in the DFR group. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Meagan E Tibbo
- Department of Orthopaedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN, 55905, USA
| | - Joshua A Parry
- Department of Orthopaedic Surgery, University of Colorado, 777 Bannock St, Denver, CO, 80204, USA
| | - Mario Hevesi
- Department of Orthopaedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN, 55905, USA
| | - Matthew P Abdel
- Department of Orthopaedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN, 55905, USA
| | - Brandon J Yuan
- Department of Orthopaedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN, 55905, USA.
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18
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Stevens JM, Clement ND, Beckingsale T, Patton JT. Bilateral distal femoral endoprosthesis for trauma. JRSM Open 2020; 11:2054270420970725. [PMID: 33489241 PMCID: PMC7768857 DOI: 10.1177/2054270420970725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In this paper, we describe the outcome of bilateral distal femoral endoprosthesis for the management of acute severe trauma. We also review the literature to ascertain the published functional results of distal femoral endoprosthesis for acute trauma of native knees. In severely comminuted intra-articular fractures, such as those our patient sustained, reconstruction is not always possible, and predictable outcomes can rarely be assured with conviction. Endoprosthesis is an established treatment modality for replacement after resection in limb salvage surgery. In this regard, there is a limited but vital role that endoprosthesis can play in acute complex trauma. We demonstrate a good short-term outcome when bilateral endoprostheses are utilised for complex distal femur trauma.
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Affiliation(s)
- Jarrad M Stevens
- Department of Surgery, St Vincent's Hospital Melbourne, VIC 3065, Australia.,Department of Surgery, Royal Infirmary Edinburgh, Edinburgh EH16 4SA, Scotland
| | - Nick D Clement
- Department of Surgery, Royal Infirmary Edinburgh, Edinburgh EH16 4SA, Scotland.,Department of Surgery, Royal Victoria Infirmary Newcastle, Newcastle upon Tyne NE1 4LP, England
| | - Tom Beckingsale
- Department of Surgery, Royal Victoria Infirmary Newcastle, Newcastle upon Tyne NE1 4LP, England
| | - James T Patton
- Department of Surgery, Royal Infirmary Edinburgh, Edinburgh EH16 4SA, Scotland
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19
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Nucci N, Gazendam A, Gouveia K, Ghert M, Wilson D. Management of infected extremity endoprostheses: a systematic review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:1139-1149. [PMID: 32405759 DOI: 10.1007/s00590-020-02699-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/07/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Endoprosthetic reconstructions have become increasingly common in the setting of significant bone loss. Indications include revision arthroplasty, trauma, and reconstruction in the setting of primary malignancies or bony metastases. Although the use of endoprostheses has several advantages, they carry a high risk of infection. The purpose of this review is to determine the success rates of surgical management of infected endoprostheses. METHODS The authors searched databases for relevant studies and screened in duplicate. Data extracted included overall infection rate, timing of infection, follow-up, isolated pathogen and operative treatment strategy, and subsequent failure rate. The overall quality of the evidence with the Methodological Index for non-randomized studies criteria. RESULTS A total of 16 studies and 647 patients met the inclusion criteria. 400 patients had operative management and reported outcomes. Failure rates of patients undergoing debridement, antibiotics, and implant retention (DAIR) were 55.1%. Failure rates of patients who underwent one-stage revision were 45.5%. Failure rates of patients undergoing two-stage revision were 27.3%. Failure occurred at 31.4 months (range, 0-228) postoperatively. CONCLUSIONS Rates of periprosthetic joint infection remain high in endoprosthetic reconstructions. Although DAIR procedures were found to have a low success rate, they remain a reasonable option in acute infections given the morbidity of staged revisions. There is a lack of comparative data in the current literature and the heterogeneity and low level of evidence does not allow for between group comparisons of results.
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Affiliation(s)
- Nicholas Nucci
- Northern Ontario School of Medicine, Thunder Bay, ON, Canada
| | - Aaron Gazendam
- Division of Orthopaedics, Department of Surgery, Center for Evidence-Based Orthopaedics, St. Joseph's Hospital, McMaster University, Room G522, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada.
| | - Kyle Gouveia
- Michael G. Degroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Michelle Ghert
- Division of Orthopaedics, Department of Surgery, Center for Evidence-Based Orthopaedics, St. Joseph's Hospital, McMaster University, Room G522, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
| | - David Wilson
- Division of Orthopaedics, Department of Surgery, Center for Evidence-Based Orthopaedics, St. Joseph's Hospital, McMaster University, Room G522, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
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20
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Abstract
Distal femur fractures occur in a periarticular fracture pattern and disproportionately afflict an aging population. Although the goals of treatment have not changed, the emergence of new surgical techniques and devices has recently been developed and refined to treat this challenging fracture pattern. Treatment options include open reduction and internal fixation with periarticular locking plates, intramedullary nails, or distal femur replacement. Despite rapid adoption, these modern solutions display a concerning complication rate, specifically from nonunion and malunion. The indications for each of these treatment strategies are not well defined and are the subject of current debate. As with the use of any orthopaedic implant, the knowledge of the strengths and weaknesses of each construct is paramount to successful treatment of these fractures. Recently, as the understanding of the biomechanics of distal femur fracture healing has improved, the literature has demonstrated clinical and theoretical improvements in the outcomes after distal femur fracture repair.
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21
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Angers-Goulet M, Pelet S, Belzile EL, Bédard M. Total knee arthroplasty with distal femoral replacement is associated with an important complication rate. A case series. Knee 2019; 26:1080-1087. [PMID: 31420209 DOI: 10.1016/j.knee.2019.07.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/20/2019] [Accepted: 07/20/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND With the aging population and an increasing number of total knee arthroplasties (TKAs) performed yearly worldwide, revision surgeries for many causes (septic or aseptic loosening, periprosthetic femoral fractures (PDFF), non-unions, malunions) are more frequent and challenging. Distal femoral replacement (DFR) is sometimes the only option to restore knee function and quality of life. DFR in non-oncologic patient is still a rare indication and few reports are published on this topic, with a non-consistent variety of functional results, complication rates and survivorship. METHODS We present a retrospective series of patients who underwent a DFR for a non-oncologic indication between 2010 and 2017. Nineteen patients were available for a full evaluation (clinical and radiological) with a mean follow-up of 48.3 months (range 15-99). Goniometry was performed at the six-week postoperative visit. Complications were reported. Osteolysis and/or signs of aseptic loosening were described using the Knee Society Radiographic Evaluation. Survivorship was calculated for aseptic loosening, infection, and revision for any cause. RESULTS The mean Knee Society Score was good for the pain score (42.2, range 10-50) and fair for the function score (60.6, range 0-100). Four deep infections (21.1%) were successfully treated with mobile parts exchange and debridement. Three patients presented femoral osteolysis ≥5 years after the DFR. Survivorship for aseptic loosening was 100% at four years, 81.8% after five years and 53.3% after eight years. CONCLUSIONS TKA with DFR is a valuable option for patients with a severe bone loss and poor bone quality in the distal femur. DFR restores an acceptable quality of life but is related to an important complication rate.
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Affiliation(s)
- Mathieu Angers-Goulet
- Département de Chirurgie Orthopédique, CHU de Québec - Université Laval, Hôpital de l'Enfant-Jésus, Québec, Canada
| | - Stéphane Pelet
- Département de Chirurgie Orthopédique, CHU de Québec - Université Laval, Hôpital de l'Enfant-Jésus, Québec, Canada; Centre de recherche FRQS du CHU de Québec, Canada
| | - Etienne L Belzile
- Département de Chirurgie Orthopédique, CHU de Québec - Université Laval, Hôpital de l'Enfant-Jésus, Québec, Canada; Centre de recherche FRQS du CHU de Québec, Canada
| | - Martin Bédard
- Département de Chirurgie Orthopédique, CHU de Québec - Université Laval, Hôpital de l'Enfant-Jésus, Québec, Canada.
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22
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Karam J, Campbell P, David M, Hunter M. Comparison of outcomes and analysis of risk factors for non-union in locked plating of closed periprosthetic and non-periprosthetic distal femoral fractures in a retrospective cohort study. J Orthop Surg Res 2019; 14:150. [PMID: 31126333 PMCID: PMC6534870 DOI: 10.1186/s13018-019-1204-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/17/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The primary aim was to compare the outcomes of locked plating of closed distal femur periprosthetic and non-periprosthetic fractures by testing the hypothesis that outcomes would be worse in the periprosthetic group. The secondary aim of this study was to identify risk factors for non-union. METHODS A single-center study over an 8-year period utilizing a retrospective cohort design was performed. Sixty-eight patients with periprosthetic fractures and 57 patients with non-periprosthetic fractures met inclusion criteria for the study. There was a significant difference between groups in mean age (80.1 years periprosthetic vs. 70.9 years non-periprosthetic (p < 0.001)). Statistical analysis between groups was used to assess the outcomes of time to union, incidence of non-union, post-operative functionality, incidence of complications, progression to revision surgery, and mortality. A secondary multivariable analysis was used to assess risk factors for non-union and factors positively associated with union. RESULTS There were no significant differences in outcomes between groups. Union rates were 83.8% (57/68) in the periprosthetic group and 78.9% (45/57) in the non-periprosthetic group (p = 0.648). Comminution was identified as a significant risk factor for non-union (p = 0.005). Use of a submuscular technique had a significant positive association with union (p = 0.006). CONCLUSIONS Outcomes of surgical treatment for periprosthetic and non-periprosthetic distal femur fractures are similar. There is a significant risk of non-union in locked plating of both groups.
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Affiliation(s)
- James Karam
- Gosford District Hospital, Central Coast Local Health District, Gosford, NSW 2250 Australia
| | - Paul Campbell
- Gosford District Hospital, Central Coast Local Health District, Gosford, NSW 2250 Australia
| | - Michael David
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308 Australia
| | - Michael Hunter
- Gosford District Hospital, Central Coast Local Health District, Gosford, NSW 2250 Australia
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23
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Hoellwarth JS, Fourman MS, Crossett L, Goodman M, Siska P, Moloney GB, Tarkin IS. Equivalent mortality and complication rates following periprosthetic distal femur fractures managed with either lateral locked plating or a distal femoral replacement. Injury 2018; 49:392-397. [PMID: 29208310 DOI: 10.1016/j.injury.2017.11.040] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 11/23/2017] [Accepted: 11/29/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Management of distal femur fractures above total knee arthroplasty (TKA) remains challenging. Two common surgical options are locked lateral plating (LLP) and distal femoral arthroplasty (DFR). Unfortunately, approximately 30-50% of patients may die within one year of injury, require further surgery, or not regain prior mobility performance. We compared 87 LLP to 53 DFR patients - to our knowledge the largest comparative study - focusing on 90- and 365-day mortality, mobility maintenance, and further surgery. METHODS We performed a retrospective review of patients at least 55 years old who sustained femur fractures near a primary TKA (essentially OTA-33 or Su types 1, 2, or 3) from 2000 to 2015 assigning cohort based on treatment: LLP or DFR. We excluded patients having prior care for the injury, whose surgery was not for fracture (e.g. loosening), or having other surgical intervention (e.g. intramedullary nail). RESULTS Results Cohorts were similar based on body mass index and age adjusted Charlson Comorbidity Index (aaCCI). LLP was more common than DFR for fractures above and at the level of the implant, but similar for fractures within the implant for patients with aaCCI ≥ 5. LLP and DFR had similar mortality at 90 days (9% vs 4%) and 365 days (22% vs 10%), need for additional surgery (9% vs 3%), and survivors maintaining ambulation (77% vs 81%). Patients whose surgery occurred 3 or more days after presentation had similar mortality risk to those whose surgery was before 3days. The mean age of one year survivors was 77 whereas for patients who died it was 85. Neither surgical choice nor aaCCI was associated with increased risk in time to surgery. CONCLUSIONS Fracture location, remaining bone stock, and patient's prior mobility and current comorbidities must guide treatment. Our study suggests that 90- and 365-day mortality, final mobility, and re-operation rate are not statistically different with LLP vs DFR management.
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Affiliation(s)
- Jason S Hoellwarth
- Department of Orthopaedic Surgery, Division of Traumatology, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA, USA.
| | - Mitchell S Fourman
- Department of Orthopaedic Surgery, Division of Traumatology, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA, USA
| | - Lawrence Crossett
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 5230 Centre Avenue, Suite 415, Pittsburgh, PA, 15232, USA, USA
| | - Mark Goodman
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 5230 Centre Avenue, Suite 415, Pittsburgh, PA, 15232, USA, USA
| | - Peter Siska
- Department of Orthopaedic Surgery, Division of Traumatology, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA, USA
| | - Gele B Moloney
- Department of Orthopaedic Surgery, Division of Traumatology, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA, USA
| | - Ivan S Tarkin
- Department of Orthopaedic Surgery, Division of Traumatology, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA, USA
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Wang S, Wu S, You M, Li Q, Zheng F. [One-stage total knee arthroplasty for femoral supracondylar fracture combined with knee osteoarthritis]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2017; 31:1423-1427. [PMID: 29806380 DOI: 10.7507/1002-1892.201707071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To evaluate the effectiveness of one-stage total knee arthroplasty (TKA) for femoral supracondylar fracture combined with knee osteoarthritis. Methods Between January 2012 and March 2015, a total of 19 patients (19 knees) with femoral supracondylar fracture and knee osteoarthritis were treated with one-stage TKA. Of 19 cases, 8 were male and 11 were female with an average age of 69.6 years (range, 60-85 years). The mean body mass index was 22.6 kg/m 2 (range, 22.0-27.5 kg/m 2). The left knee was involved in 13 cases, and the right knee in 6 cases. The causes of femoral supracondylar fracture were falls in 10 cases, traffic accidents in 8 cases, and other injury in 1 case. All fractures were classified as type A according to AO/Association for the Study of Internal Fixation (AO/ASIF) classification. The interval of injury and operation was 4-13 days (mean, 8.6 days). The disease duration of osteoarthritis ranged from 30 to 90 months (mean, 52.6 months). During follow-up, the knee society score (KSS) and the range of motion (ROM) were used to evaluate the knee function; anteroposterior and lateral X-ray films of the knee were used to observe the position of the prosthesis. Results All the incisions healed at the first stage, and there was no early complication such as pulmonary infection, pressure ulcer, and urinary tract infection. All patients were followed up 2-4 years with an average of 2.6 years. The ROM and KSS functional scores and clinical scores were significantly improved at 15 days and 2 years after operation, showing significant differences when compared with those before operation ( P<0.05). There were significant differences in the ROM and KSS functional scores and clinical scores between two time points after operation ( P<0.05). X-ray films showed the fracture bone healing, good alignment, no loosening of prosthesis at 2 years after operarion. Conclusion One-stage TKA for femoral supracondylar fracture combined with knee osteoarthritis can achieve good effectiveness. It can not only reconstruct joint function, but also cure osteoarthritis and fracture at the same time, shorten the healing time, reduce the incidence of related complications.
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Affiliation(s)
- Shangzeng Wang
- Department of Orthopaedics, the Second Affiliated Hospital of Henan University of Traditional Chinese Medicine, Zhengzhou Henan, 450002, P.R.China
| | - Shengchao Wu
- Postgraduate School, Henan University of Traditional Chinese Medicine, Zhengzhou Henan, 450046, P.R.China
| | - Mingcan You
- Postgraduate School, Henan University of Traditional Chinese Medicine, Zhengzhou Henan, 450046, P.R.China
| | - Qiang Li
- Postgraduate School, Henan University of Traditional Chinese Medicine, Zhengzhou Henan, 450046, P.R.China
| | - Fuzeng Zheng
- Department of Orthopaedics, the Second Affiliated Hospital of Henan University of Traditional Chinese Medicine, Zhengzhou Henan, 450002,
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