Ipsilateral traumatic supracondylar femoral and proximal tibial fractures following total knee replacement: a case report

Repair of supracondylar femur fracture and unilateral knee replacement at the same surgery

In patients who are candidates for a total knee arthroplasty and suffer a periarticular fracture of the femur, the arthroplasty may be performed after bony union of the fracture or immediately, in conjunction with the fracture repair. Herein we present the case of a sixty-year-old female with rheumatoid arthritis and a supracondylar fracture of the right femur in whom total knee arthroplasty and retrograde nail insertion were addressed at one surgery; the outcome was favorable. The transverse extraarticular fracture pattern in this patient was advantageous for simultaneous procedures; had the fracture been more comminuted or intraarticular, it might not have been possible to perform both procedures at the same time.

Knee: role and results of allografts

The vast majority of periprosthetic fractures occur as the result of trauma. There are many predisposing factors for these factors, including osteopenia, neurologic disorders, medications, rheumatoid arthritis, previous arthroplasty, and infection. These same factors also increase the likelihood of fracture comminution, and the presence of poor bone quality makes fixation difficult and prone to failure.

The prevention of periprosthetic fractures in total hip and knee arthroplasty

Periprosthetic fractures in total hip and total knee arthroplasty lead to considerable morbidity in terms of component fixation, bone loss, and subsequent function. The management of these fractures is technically demanding and may result in suboptimal fixation owing to poor bone stock. The prevention, early recognition, and appropriate management of such fractures are therefore critical. The pathogenesis of periprosthetic factors is multifactorial. There are a number of intrinsic patient influences such as bone stock, biomechanics, and compliance. There are also a host of extrinsic factors over which the surgeon has more control. The prevention of periprosthetic fractures requires careful preoperative planning and templating, the availability of the necessary expertise and equipment, and knowledge of the potential pitfalls so that these can be avoided both intraoperatively and in follow-up.

Periprosthetic fractures of the tibia associated with total knee arthroplasty

One hundred two periprosthetic tibial fractures associated with total knee arthroplasty were identified in 29 men and 73 women. Eighty-three fractures occurred postoperatively, and 19 occurred intraoperatively. Fractures were classified into four types based on location and proximity to the prosthesis. There were 61 Type I fractures, occurring at the tibial plateau; 22 Type II fractures, occurring adjacent to the prosthetic stem; 17 Type III fractures, occurring distal to the prosthetic stem; and two Type IV fractures, involving the tibial tubercle. Fracture types were additionally classified by whether the prosthesis appeared to be radiographically well fixed (A) or loose (B) at the time of fracture, or whether the fracture occurred intraoperatively (C). The majority of postoperative Types I and II fractures were Types IB and IIB, and these were treated most successfully with revision surgery. Types IIA, IIIA, and IVA fractures were managed successfully by the usual principles of tibial fracture treatment. Type IC fractures usually were managed by intraoperative fixation, Type IIC by bone grafting or external immobilization and weightbearing restrictions, and Type IIIC by conventional fracture management. This classification system provides a guide for determining the appropriate treatment for tibial fractures associated with total knee arthroplasty.

A new method of treatment for periprosthetic supracondylar fractures of the femur for prostheses with a stemmed femoral component

Knee arthroplasty periprosthetic supracondylar fracture of the femur is a well-recognized problem that is likely to be seen more frequently with the increasing number of knee arthroplasties being performed. Treatment of this fracture is difficult. A new method of internal fixation for supracondylar fractures around a stemmed femoral component using a custom-made extension to the femoral stem is described. This technique allowed early mobilization of the patient, with restoration of a good range of movement of the knee and fracture union within 1 year.

Intercondylar distal femoral fracture. An unreported complication of posterior-stabilized total knee arthroplasty

In an attempt to study the incidence of intraoperative femoral intercondylar fractures, two large series of posterior-stabilized total knee arthroplasty (TKA) systems were reviewed. Eight hundred ninety-eight nonconsecutive primary posterior-stabilized TKAs were compared with a second nonconsecutive series of 532 posterior-stabilized TKAs. Unique to the secondary TKA system is an intercondylar sizing guide to aid in verification of the intercondylar resection size. In the initial series, 40 distal femoral intercondylar fractures were noted (rate = 1:22; nondisplaced, 35; displaced, 5). In the secondary series, one displaced distal femoral intercondylar fracture occurred (rate = 1;532). The difference in the rate of fracture between the two populations was statistically significant (P<.001). Intraoperative distal femoral intercondylar fracture represents a potential complication of TKA and can be avoided with careful resection technique and size verification. No change in the postoperative rehabilitation program is required, however, for those patients identified with nondisplaced and intraoperative-stabilized displaced distal femoral intercondylar fractures.

Management of ipsilateral supracondylar femur fractures following total knee arthroplasty

A complete review of the literature revealed 195 fractures in 12 published studies of ipsilateral supracondylar femur fractures occurring about a total knee arthroplasty. This review included general surveys, multicenter studies, and case reports. Based on these studies, the authors divided the fractures into nonoperative and operative treatment groups. The fracture types were also subclassified into nondisplaced (Neer type 1) and displaced (Neer types 2 and 3). Statistical analysis of each type of fracture in terms of the various treatments and clinical outcome was performed. This study revealed satisfactory results in 83% of the patients with nondisplaced fractures that were treated without surgery. In contrast, 64% of all patients with displaced fractures that were treated with or without surgery had satisfactory outcomes. This difference is statistically significant (P < .05). Of the patients with displaced fractures, nonoperative versus operative results were not statistically significant (P < .9) (67% satisfactory vs 61%). A treatment algorithm is proposed based on the above data.