Total knee arthroplasty for distal femoral fractures in osteoporotic bone: a systematic literature review

Distal femur fractures in elderly treated with internal fixation or distal femoral replacement - retrospective cohort study on 75 patients assessing functional outcomes, reoperations, and mortality

PURPOSE

This cohort study aimed to describe the functional outcomes, complications, and mortality of patients over 65 with acute distal femur fractures treated with open reduction and internal fixation (ORIF) or distal femoral replacement (DFR).

METHODS

We retrospectively analyzed all patients older than 65, operated consecutively for a distal femur fracture treated with ORIF or DFR. We included 75 patients (9 33A, 5 33B, and 61 33C AO/OTA fractures), 55 treated with ORIF, and 20 with DFR. We used Parker's mobility index (PMI) to assess functional outcomes at 1, 3, and 12 months and study closure. We analyzed complications, reoperations, and mortality at 30 days, one year, and at the end of the study.

RESULTS

The PMI was significantly higher in the DFR group at months 1 (p = 0.023) and 3 (p = 0.032). We found no significant differences between cohorts at one year and the end of follow-up. Postoperative complications were significantly more frequent in the ORIF group (38.10% vs. 10%, p = 0.022). Reoperations were similar in both cohorts (p = 0.98). Mortality at one month was 4% and 20% at one year, and at the end of follow-up, there were no significant differences between groups.

CONCLUSION

The outcomes of this study suggest that DFR offers a faster functional recovery with lower complication rates than those treated with ORIF. Additionally, both options have similar reoperation and mortality rates. Appropriately designed studies are needed to define the best treatment strategy for this type of patient.

Primary Total Knee Arthroplasty for Fractures Around the Knee

Primary arthroplasty for fractures of the femoral neck is a very common procedure and even the gold standard for the geriatric patient. In contrast, primary arthroplasty for perigenicular fractures is a rare event. On the other hand, it can be a therapeutic option, especially for geriatric patients with prior osteoarthritis or complex fractures and severe osteoporosis.The operative procedure can be complex and requires experience in primary and revision arthroplasty as well as suitable implants and good preoperative planning.There are case series reporting primary arthroplasty in a total of approximately 200 cases of both distal femoral and proximal tibial fractures. Complication rates are between 0 and 90% and mostly concern wound healing problems and infections. From a functional point of view, predominantly good results and a range of motion of 100° can be achieved.Primary arthroplasty can be a therapeutic option for selected cases of perigenicular fractures and gives good functional results. The most frequent complications are wound healing problems and infections.

Outcomes of Primary Total Knee Arthroplasty in Fractures Around the Knee in the Elderly: A Systematic Review and Pooled Analysis of 212 Patients Across 11 Studies

BACKGROUND

Treatment of fractures around the knee in the elderly is somewhat controversial with primary total knee arthroplasty (TKA) gaining prominence over the past decade or so, as an alternative for open reduction and internal fixation. The present review was conceptualized to review the published literature and evaluate outcomes of TKA in these patients, and to understand whether this is a viable treatment option for these fractures. We have further tried to identify complications and the challenges faced while performing this surgery.

METHODS

PRISMA guidelines were followed and search was conducted on three databases-PubMed, EMBASE and SCOPUS. Studies evaluating multiple factors related to outcomes and complications in primary TKA performed for fractures around the knee in the elderly were included. Cadaveric studies, conference abstracts, case reports, and any studies that included non-traumatic cases or revision after failed internal fixation, were all excluded.

RESULTS

Eleven studies, published between 2011 and 2021 were included in our review. There was significant female preponderance in the study population (M:F = 1:3). Implants with higher constraint (high post, hinged prosthesis) were frequently required to compensate for ligamentous laxity due to the fractures. On pooled analysis the mean Knee Society Score (KSS) knee score was 84.62 (excellent), and mean knee range of motion was 107.25°. However, the mean KSS function score was 56.71 (poor), which could have been due to co-morbid conditions and pre-operative status. Overall complication rate was 14.6%; surgical site infection was the most commonly reported.

CONCLUSION

There remains limited evidence for the use of TKA as a primary treatment option for these injuries. In the presence of specific conditions, and in expert hands-it may be a viable alternative to osteosynthesis with comparable outcomes. More focused studies are needed to compare the two treatment options and to formulate guidelines.

[Distal femoral fractures in geriatric patients : Does time to surgery affect revision and mortality?]

BACKGROUND

For proximal femoral fractures the time to surgery has been reported to influence the mortality rate. To date, detailed analyses in geriatric patients with distal femoral fractures are not available.

MATERIAL AND METHODS

A monocentric study with retrospective data retrieved from an electronic database was performed. The study included distal femoral fractures with surgical treatment between 2006 and 2017 in patients aged 65 years and older. A total of ten variables were evaluated and two outcome measures were investigated: revision and mortality in relation to time of surgery within 24 h or later. The minimum follow-up was 2 years. For patients who were still alive the Parker score was calculated. The null hypothesis was that time to surgery does not affect revision and mortality.

RESULTS

A total of 57 consecutive patients with 60 fractures and an average age of 82.5 years (65-97 years) were included. Most of the fractures were supracondylar (n = 42). All but three fractures were treated with internal fixation. The revision rate was 17.5% (peri-implant fractures n = 4, infections n = 2, non-union n = 2, impaired wound healing n = 2 and secondary dislocation n = 1). The 1‑year mortality rate was 20%. No significant effects on revision (p = 0.414) and survival rate (log rank 0.175) were observed for patients treated within 24 h or later. After a mean postoperative period of 5.5 years, the mean Parker score for 18 living patients was 5.9.

CONCLUSION

Time to surgery demonstrated no significant effects with respect to revision and mortality. Multicenter studies are absolutely necessary to increase the sample size and statistical power.

Osteoporotic distal femur fractures in the elderly: peculiarities and treatment strategies

Distal femur fractures account for 4-6% of osteoporosis related fractures of the femur in the elderly population. They represent a relevant cause of morbidity and mortality in the geriatric population with a reported 1-year mortality reaching 30%. Non-displaced fractures or even displaced fractures in patients with high operative risk can be treated conservatively. However, operative treatment is the most widely accepted management option for displaced fractures. The advantage resides in early mobilization and weight-bearing, reducing risks related with a prolonged immobilization when compared with conservative treatment. On the other hand, the intrinsic difficulty of fixing an osteoporotic bone is a major concern. The presence of osteosynthesis devices or prosthetic implants in the femur can make the surgical treatment more challenging, sometimes limiting therapeutic options. Aim of the present paper is to review the most recent literature about osteoporotic distal femur fractures in the elderly, including periprosthetic and other hardware related fractures, to highlight current evidence on management options and related results as a guide for the daily clinical practice.

Irreducible Posterolateral Fracture Dislocation of the Knee in an Elderly Patient Treated with Rotating Hinge Total Knee Replacement

Knee dislocation is one of the few real orthopaedic emergencies. It is a serious but relative uncommon injury, representing less than 0.02% of all orthopaedic injuries. Especially posterolateral knee dislocation is much rarer condition that is often missed or misdiagnosed. The main feature of this very rare condition is to be irreducible by closed reduction due to the interposition of soft tissues inside the enlarged medial joint space, such as the medial capsule and retinaculum, vastusmedialis, and medial meniscus. The pathognomonic sign of a posterolateral knee dislocation is the anteromedial distal thigh transverse "pucker" or "dimple sign." We report the case of an 87-year-old man who sustained an irreducible posterolateral fracture dislocation of the knee after being hit by car which has been treated with rotating hinge knee replacement with 1-year of follow-up.

Non-hip/non-vertebral fractures - How to treat best?

Fractures of the extremities in the elderly constitute more than two-thirds of all fragility fractures befalling frail, osteoporotic and sarcopenic patients. Although treatment controversies abound, consensus exists. Upper extremity fractures hinder activities of daily living and are debilitating. Open fractures or displaced fractures will need surgical intervention. Wrist fractures treated operatively allow early use of the hand. Most pelvic fractures are treated conservatively. In the lower extremities, fractures of the long bones, tibia and femur need surgical intervention. Non-displaced fractures around the foot may be treated with immobilisation and avoidance of full weight-bearing. As a rule, fractures take four months for consolidation. Individually tailored solutions are needed for frail patients with comorbidities. Maintaining joint mobility and muscle strength preserves mobility and autonomy. Caring for extremities trauma is team work, involving family and health care providers. Prevention efforts are mandatory.