Distal femoral fracture during primary total knee arthroplasty

Diagnosis and Management of Intraoperative Periprosthetic Fractures in Primary Total Knee Arthroplasty

Intraoperative periprosthetic fracture is an uncommon but notable complication that can occur during primary total knee arthroplasty. These fractures may occur at various stages during the procedure, including surgical exposure, implant preparation, implant trialing, and final implantation. Management of femoral and tibial fractures necessitates intraoperative recognition, including attentiveness of preoperative patient and surgical risk factors. This comprehensive review article focuses on the patient and surgical risk factors, diagnosis, management, and outcomes related to intraoperative fractures during primary total knee arthroplasty.

Intraoperative Fractures Sustained During Total Knee Arthroplasty: A Critical Analysis Review

» While the occurrence of postoperative periprosthetic fractures around total knee arthroplasties (TKAs) are well reported, little is known about intraoperative fractures that occur during TKA. Intraoperative fractures during TKA can occur in femur, tibia, or patella. It is a rare complication with an incidence of 0.2% to 4.4%.» Risk factors of periprosthetic fractures include osteoporosis, anterior cortical notching, chronic corticosteroid use, advanced age, female sex, neurologic disorders, and surgical technique.» Fractures can potentially occur at any stage of the TKA including exposure, bone preparation, placement of trial components, cementation, insertion of the final components, and seating of the polyethylene insert. Forced flexion during trialing increases the risk for patella fracture, tibial plateau, or tubercle fractures especially when there is under resection of the bone.» Management guidelines for these fractures are lacking with current options being observation, internal fixation, the use of stems and augments, increasing constraint of the prosthesis, implant revision, and modifying the postoperative rehabilitation.» Finally, the outcomes of intraoperative fractures are not well reported in the literature.

Intraoperative Periprosthetic Fractures during primary Total knee arthroplasty: Experience from an Asian high-volume arthroplasty centre

BACKGROUND

Intraoperative periprosthetic fracture (IF) is an under-reported complication in primary total knee arthroplasty (TKA). This study aimed to audit the outcomes and complication rates in patients encountering IF during primary TKA and propose a new classification for its management.

METHODS

A nested case-control study was performed at a tertiary referral hospital where 50 patients encountering IF during primary TKA operated by a single surgeon team between January 2016 to May 2021, were compared with 150 (3:1) age-, gender- and implant-matched patients not encountering IF. Demographic data, risk factors, outcomes and complications of both groups were compared at a minimum follow up of 1 year.

RESULTS

The incidence of IF was 0.45%, with 44 fractures in the femur (88%), six (12%) in the tibia and none in the patella. Medial collateral ligament avulsion fracture (54.54%) in the femur and medial plateau fracture (66.66%) in the tibia were the most common fracture types. At final follow up, the fracture group had higher rates of 90-day re-admissions (8% vs. 2.66%, P = 0.095), deep infection (4% vs. 0.66%, P = 0.15) and revisions (6% vs. 1.33%, P = 0.06). The mean Knee Society Score was not significantly different between the two groups (152.22 ± 9.25 vs. 161.68 ± 11.22, P = 0.642) with union being achieved in all but one patient at a mean duration of 9.6 weeks.

CONCLUSIONS

Patients with severe and fixed deformities have a higher risk for IF. The occurrence of fracture and the complexity of surgery equally contribute to the higher complication rates. Appropriately managed fractures have comparable functional outcomes.

Risk Factors and Preventive Strategies for Perioperative Distal Femoral Fracture in Patients Undergoing Total Knee Arthroplasty

Background and Objectives Perioperative distal femoral fracture is rare in patients undergoing total knee arthroplasty (TKA). In such rare cases, additional fixation might be required, and recovery can be delayed. Several studies have focused on perioperative distal femoral fractures in TKA, but there remains a lack of information on risk factors. The purpose of this study was to investigate risk factors for perioperative distal femoral fractures in patients undergoing TKA and suggest preventive strategies. Materials and Methods: This retrospective study included a total of 5364 TKA cases in a single institution from 2011 to 2022. Twenty-four distal femoral fractures occurred during TKA or within one month postoperatively (0.45%). Patient demographics, intraoperative findings, and postoperative progress were obtained from patient medical records and radiographs. Risk factors for fractures were analyzed using multivariate Firth logistic regression analysis. Results: Although all 24 distal femoral fractures occurred in female patients (24 of 4819 patients, 0.50%), the incidence rate of fracture between male and female patients was not significantly different (p = 0.165). The presence of osteoporosis and insertion of a polyethylene (PE) insert with knee dislocation were statistically significant risk factors (p = 0.009 and p = 0.046, respectively). However, multivariate logistic regression analysis showed that only osteoporosis with bone mineral density (BMD) < -2.8 (odds ratio (2.30), 95% CI (1.03-5.54), p = 0.043) was an independent risk factor for perioperative distal femoral fracture in TKA patients. Conclusions: Our results suggest that osteoporosis with BMD < -2.8 is a risk factor for distal femoral fractures in patients undergoing TKA. In these patients, careful bone cutting, adequate gap balancing, and especially the use of the sliding method for insertion of a PE insert are recommended as preventive strategies.

Intraoperative Fractures of the Tibia and Femur in Knee Revision Surgery

Intra-operative fractures in knee revision surgery are relatively rare and have not been well studied. They may occur during joint exposition, removal of the prosthesis or cement, or implantation of trial or original components. The fractures affect both the metaphyseal area and diaphysis of the tibia and femur. Tibial fractures are slightly more common than femur fractures. On the femur, the medial condyle is most frequently affected, followed by the femur diaphysis. The use of non-cemented stems is associated with a greater risk of intra-operative diaphyseal fractures than that of cemented stems. Overall, women and patients with an osteopenic bone structure have a higher risk of fractures. It is common that fractures are diagnosed post-operatively. In these cases, conservative therapy may be successful, depending on the stability of the prosthesis and bones. The most common surgical fixation options are cerclages and screws, followed by stem extensions for bridging the fracture. Plate fixation or use of strut grafts are also sensible therapy options. Overall, intraoperative fractures have a high healing potential with stable and good joint function. The revision rate is still 15%, which is most often caused by peri-prosthetic infection.

A Review of Periprosthetic Tibial Fractures: Diagnosis and Treatment

Periprosthetic fracture occurring during or after total knee arthroplasty is a rare injury. Literature concerning periprosthetic tibial factures is sparse, and there is limited guidance for evidence-based management. This review aims to provide readers with an overview of the epidemiology, risk factors, and classification of these fractures. Management includes nonoperative treatment of nondisplaced fractures, fixation for those with stable implants, and revision for those with loose implants.

Intraoperative Femoral Condyle Fracture during Bone Preparation in a Cruciate-retaining Primary Total Knee Arthroplasty

Introduction

Intraoperative fracture in revision knee arthroplasty is commonly described. Intraoperative fracture during primary total knee arthroplasty (TKA) is a significant yet infrequently reported complication. The literature about intraoperative fractures during primary TKA is limited. It is usually seen in posterior-stabilized prosthesis during primary TKA, however, its occurrence in cruciate-retaining (CR) primary TKA is rarely reported.

Case Report

The authors describe a unique case of intraoperative medial femoral condyle fracture in primary CR TKA during bone preparation. The fracture was managed successfully by fixation with a 3.5 mm screw followed by cemented primary CRTKA. Bony union was achieved with a good clinical outcome as shown by the Knee Society Knee Score of 86 and a Function Score of 90 without any signs of prosthesis failure/loosening at 2 years' follow-up.

Discussion

Careful pre-operative evaluation and planning are necessary for patients with risk factors to avoid poor outcome. A stable internal fixation abiding the standard principles of fracture fixation and arthroplasty is needed to achieve a satisfactory functional and radiographic outcome, thus avoids early prosthetic failure.

Outcomes of Stemmed versus Un-Stemmed Varus-Valgus Constrained Components in Primary Total Knee Arthroplasty

Purpose

The necessity of stemmed components when performing a varus-valgus constrained (VVC) primary total knee arthroplasty (TKA) is unclear. The purpose of this study is to compare the outcomes of primary VVC TKA with and without stems at a minimum of two years.

Methods

Patients in our prospectively collected database with primary VVC TKAs were identified. Patient demographics, prosthesis data, time in vivo, characteristics of revision, and radiographs and PROMs were compared between the stemmed and un-stemmed cohorts.

Results

Sixty-five patients with 69 primary VVC TKAs were identified; 17 were implanted with stems and 52 without stems. Five of the stemmed TKAs (5/17) required revision at 15.1 years, while only one of the un-stemmed TKA (1/52) required a revision at 21.6 years (p=0.003) for aseptic loosening. Of the 5 stemmed TKAs requiring revision, 3 were for aseptic loosening and 2 were for PPJI. The un-stemmed cohort had a significantly higher final total KSS (p=0.048).

Conclusion

There was no increase in aseptic loosening or revision surgery in patients with non-stemmed primary VVC TKA compared to those with stemmed VVC TKA at mid-term follow-up. Utilizing non-stemmed TKA with VVC in appropriate cases is safe and may reduce cost, shorten operative time, and preserve bone-stock.

Intra-operative fractures in primary total knee arthroplasty - a systematic review

BACKGROUND

One of the rare complications of primary total knee arthroplasty is intra-operative fracture. Intra-operative fracture during revision knee arthroplasty has been well-documented but there is limited literature on fractures occurring during primary knee arthroplasty. We conducted a systematic review of the literature to compare and contrast the various studies to clearly define the predisposing factors, incidence, and characteristics of the fracture itself and to arrive at a consensus on the management and prevention of intra-operative fractures during primary knee arthroplasty.

METHODS

The PubMed/Medline, Cochrane, Scopus and Embase databases were searched using keywords "intra-operative fracture", "distal femoral fracture", "tibial fracture", "patella fracture" and "primary total knee arthroplasty". A total of 158 articles were retrieved and after further filtration and exclusion processing, 10 articles that evaluated intra-operative fractures in primary total knee arthroplasty were included for the review.

RESULTS

The reported incidence of intra-operative fractures varied from 0.2% to 4.4%. A higher incidence in female patients with a male to female ratio of 0.4 was reported. Posterior stabilized (PS) total knee arthroplasty was associated with higher risk of intra-operative femoral fractures by many authors in this review. Timing of occurrence and location of the intra-operative fractures can vary widely, with femoral fractures occurring more commonly during bone preparation, trialing and impaction of the final implant and tibial fractures occurring during preparation for the tibial keel and impaction of the tibial component.

CONCLUSIONS

Intra-operative fractures during primary total knee arthroplasty are rare with higher risk associated with osteoporosis, rheumatoid arthritis, advanced age, female gender, chronic steroid use, metabolic bone disorders, PS type of femoral implant and difficult surgical exposure of the knee joint due to severe deformities. A plethora of management options have been utilized according to surgeon preference. Standard principles of fracture fixation and arthroplasty principles should be followed to achieve stable internal fixation and any unstable fracture site should be bypassed with the utilization of stemmed components. Satisfactory radiographic and functional outcome can be expected with appropriate treatment.

Intraoperative femoral condyle fracture in primary total knee arthroplasty - a case-control study in Asian population

PURPOSE

Intraoperative femoral condyle fracture is a significant but rarely reported complication during primary total knee arthroplasty (TKA). This is the first study to identify the incidence, risk factors, location and outcome of these fractures in an Asian population with modern posterior-stabilized (PS) TKA.

MATERIALS AND METHODS

We reviewed 2682 consecutive primary TKAs performed between 2011 and 2017 in a single centre; 23 femoral condyle fractures were identified and analysed.

RESULTS

Fractures were managed conservatively with screw fixation or revision arthroplasty. Mean follow up was 3.0 years (range 3 months to 5.9 years). All patients achieved bone union and good functional outcome. The mean Knee Society Knee score was 89.4 (range 71-100) and the function score was 80.2 (range 60-95) at a mean of 3.0 years post-operation. Bilateral surgery was found to be a significant risk factor for femoral condyle fracture, while there was a higher trend of fracture in female patients and Stryker articular surface mounted (ASM) navigation.

CONCLUSIONS

Intraoperative fracture is not uncommon with modern PS TKA. Postulated risk factors for fracture were discussed. Early identification of risk factors and a rigorous surgical technique may reduce risk of fracture. A good functional result was expected after proper treatment.

Management of periprosthetic fracture following total knee arthroplasty- a retrospective study to decide when to fix or when to revise?

PURPOSE

Periprosthetic fractures around total knee arthroplasty are relatively rare complication comprises to 0.3-2.5%. But these injuries are often complex and challenging for the surgeons due to ageing population in conjunction with severe osteoporosis. The management option varies from conservative to internal fixation or revision surgery. Thus this study was conducted to analyze the results of various methods of treatment of periprosthetic fractures following TKA and to form the optimal treatment guidelines for fixation or revision.

MATERIAL AND METHODS

51 cases diagnosed with periprosthetic fracture were enrolled and underwent surgical intervention. Type of primary prosthesis, interval between TKA and periprosthetic fracture, type of fracture, prosthesis stability and mode of fixation of fracture, any revision surgery and complication were noted.

RESULTS

The mean age of all patients was 65.89 years. The mean interval between the index surgery and periprosthetic fracture was 6 years (Range 2 months to 10 years) in male and 18.5 months (Range 4 days to 7 years) in female. 44 (86%) fractures were femoral, 4 (8%) fractures were tibial and 3 (6%) fractures were of patella. The mean knee society score (KSS) & oxford knee score (OKS) were found to be good for revision group as compared to the fixation group at final follow up.

CONCLUSION

In presence of poor bone stock, far distal fracture configuration, comminution, severe osteoporosis, difficulty in achieving stability with plates & old age-revision TKA is a viable option with stemmed components.

Distal Femoral Replacement Following an Intraoperative Periprosthetic Fracture in a Patient with Prior Bone Mulch ACL Reconstruction

Periprosthetic distal femur fractures can be treated nonoperatively, with open reduction and internal fixation or with more constrained prostheses. Distal femoral replacement is typically a last resort treatment option for comminuted periprosthetic or osteoporotic distal femoral fractures in patients with poor bone stock or resistant nonunions. We report the case of a 54-year-old female with a remote history of bone mulch ACL reconstruction who sustained an intraoperative comminuted bicondylar distal femur fracture during a primary total knee arthroplasty. This patient was treated with a distal femoral replacement and successfully returned to her preoperative function.

Periprosthetic fractures: epidemiology and current treatment

Periprosthetic fractures are becoming increasingly frequent due to aging population and growing number of total joint replacements involving joints different from hip and knee, such as shoulder and elbow. The treatment of these fractures still represents one of the major challenges for the orthopedic surgeon. Despite all efforts to understand and treat these patients, high rate of failure and mortality are still reported. In this review, the epidemiology of periprosthetic fractures, risk factors and results of surgical treatment are disclosed. Moreover, we propose a treatment algorithm based on the findings of the New Unified Classification System.