Locked plating of supracondylar periprosthetic femur fractures

Retrograde intramedullary nail fixation with oblique fixed angle screws versus locking plates in periprosthetic supracondylar fractures after total knee arthroplasty

PURPOSE

Common surgical procedures in the treatment of periprosthetic distal femur fractures (PPFF) include osteosynthesis with fixed angle locking plates (LP) and retrograde intramedullary nails (RIN). This study aimed to compare LPs to RINs with oblique fixed angle screws in terms of complications, radiographic results and functional outcome.

METHODS

63 PPFF in 59 patients who underwent treatment in between 2009 and 2020 were included and retrospectively reviewed. The anatomic lateral and posterior distal femoral angle (aLDFA and aPDFA) were measured on post-surgery radiographs. The Fracture Mobility Score (FMS) pre- and post-surgery, information about perceived instability in the operated leg and the level of pain were obtained via a questionnaire and previous follow-up (FU) examinations in 30 patients (32 fractures).

RESULTS

The collective (median age: 78 years) included 22 fractures treated with a RIN and 41 fractures fixed with a LP. There was no difference in the occurrence of complications (median FU: 21.5 months) however the rate of implant failures requiring an implant replacement was higher in fractures treated with a LP (p = 0.043). The aPDFA was greater in fractures treated with a RIN (p = 0.04). The functional outcome was comparable between both groups (median FU: 24.5 months) with a lower outcome in the post-surgery FMS (p =  < 0.001).

CONCLUSION

Fractures treated with RIN resulted in an increased recurvation of the femur however the rate of complications and the functional outcome were comparable between the groups. The need for implant replacements following complications was higher in the LP group.

Posterior Cruciate Ligament Injury After Retrograde Nailing of Periprosthetic Distal Femur Fractures: A Report of 2 Cases

CASE

A 51-year-old man and 64-year-old woman with bilateral cruciate-retaining total knee arthroplasties (CR-TKAs) who sustained unilateral periprosthetic distal femur fractures above their CR-TKA and experienced knee instability secondary to an iatrogenic posterior-cruciate-ligament (posterior cruciate ligament [PCL]) injury from retrograde intramedullary nailing. Both patients recovered knee stability after undergoing revision surgery.

CONCLUSION

Many CR-TKA designs have sufficient medial-lateral intercondylar distance to place a retrograde nail, femoral components with a relatively posterior transition from the trochlear groove to the intercondylar box will necessitate a nail starting point closer to the PCL origin. This may contribute to iatrogenic postoperative knee instability for patients with CR-TKA designs.

Comparison of radiological and functional results in osteoporotic distal femur fractures operated with single plating, lateral incision, and double plating, anterior paramedial incision: A retrospective study

Treatment of osteoporotic distal femur fractures is often complicated by a high rate of nonunion and varus collapse. For such fractures, lateral plating with lateral incision and double plating with anterior paramedial incision have shown promising results in the recent literature. The hypothesis of this study was that bilateral plating of comminuted distal femur fractures in osteoporotic patients would result in higher union rates and lower revision rates compared to an isolated lateral locking plate. The study included 56 patients (23 males, 33 females) with supracondylar femur fracture. According to the OA/OTA classification, 9 were type A3, 8 were A2, 13 were C1, 16 were C2, and 10 were C3. The mean follow-up period was 12 months, with 29 patients treated using lateral mini-incision, lateral locking plate, and 27 patients treated with anterior paramedial incision, dual plating. The clinical and radiological results were evaluated. The mean duration of radiological union in the studied population was 15 ± 2.1 months (range, 11-21 months) in the single plate group (Group A), and 13.5 ± 2.6 months (range, 9-19 months) in the double plate group (Group B). Mean ROM was 112.3° and flexion contracture 4° in Group A, and ROM 108.3° and flexion contracture 6.7° in Group B. (P = .15). The average Western Ontario and McMaster Universities Arthritis Index (WOMAC) score was 85.6 points in Group A and 83.5 points in Group B (P = .2278). The postoperative anteversion measurement in the operated extremity ranged from -15 to 19 in Group A, and from 5 to 18 in Group B. When the anteversion degrees were compared between the injured and uninjured extremities in the postoperative period, a significant difference was observed within Group A (P = .0018), but no significant difference was observed in Group B (P = .2492). Dual plate fixation using the anterior paramedial approach is an effective operative method for osteoporotic distal femur fractures. This has many advantages such as precise exposure, easy manipulation, anatomic reduction, and stable fixation. However, for surgical indications and medial bone defects > 1 cm, grafting should be performed.

Retrograde Intramedullary Nailing Versus Locked Plating for Extreme Distal Periprosthetic Femur Fractures: A Multicenter Retrospective Cohort Study

OBJECTIVES

To compare clinical and radiographic outcomes after retrograde intramedullary nailing (rIMN) versus locked plating (LP) of "extreme distal" periprosthetic femur fractures, defined as those that contact or extend distal to the anterior flange.

METHODS

DESIGN

Retrospective review.

SETTING

Eight academic level I trauma centers.

PATIENT SELECTION CRITERIA

Adult patients with periprosthetic distal femur fractures at or distal to the anterior flange (OTA/AO 33B-C[VB1]) treated with rIMN or LP.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was reoperation to promote healing or to treat infection (reoperation for elective removal of symptomatic hardware was excluded from this analysis). Secondary outcomes included nonunion, delayed union, fixation failure, infection, overall reoperation rate, distal femoral alignment, and ambulatory status at final follow-up. Outcomes were compared between patients treated with rIMN or LP.

RESULTS

Seventy-one patients treated with rIMN and 224 patients treated with LP were included. The rIMN group had fewer points of fixation in the distal segment (rIMN: 3.5 ± 1.1 vs. LP: 6.0 ± 1.1, P < 0.001) and more patients who were allowed to weight-bear as tolerated immediately postoperatively (rIMN: 45%; LP: 9%, P < 0.01). Reoperation to promote union and/or treat infection was 8% in the rIMN group and 16% in the LP group ( P = 0.122). There were no significant differences in nonunion ( P > 0.999), delayed union ( P = 0.079), fixation failure ( P > 0.999), infection ( P = 0.084), or overall reoperation rate ( P > 0.999). Significantly more patients in the rIMN group were ambulatory without assistive devices at final follow-up (rIMN: 35%, LP: 18%, P = 0.008).

CONCLUSIONS

rIMN of extreme distal periprosthetic femur fractures has similar complication rates compared with LP, with a possible advantage of earlier return to weight-bearing. Surgeons can consider this treatment strategy in all fractures with stable implants and amenable prosthesis geometry, even extreme distal fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment of supracondylar periprosthetic femoral fractures with retrograde intramedullary nailing versus distal femoral plating: A systematic review and meta-analysis of current evidence

BACKGROUND

Supracondylar periprosthetic fractures, when amenable to fixation, can be treated by either retrograde intramedullary nailing (RIMN) or plating. There is paucity of evidence regarding the superiority of one fixation method over the other. This review aims to determine which fixation method leads to better functional outcomes and perioperative complications.

HYPOTHESIS

Superiority of intramedullary nailing in terms of fracture healing and surgical complications when compared to distal femoral plating.

MATERIALS AND METHODS

Using PRISMA guidelines, a systematic search was performed. Studies which reported comparative outcome data following the two interventions were included. Qualitative data analysis and narrative synthesis were reported. Pooled comparisons were conducted when similar quantifiable outcomes were reported in a minimum of three studies.

RESULTS

A total of 151 records were generated by the search. Eight studies met the eligibility criteria so were included in the final analysis. The studies comprised a total of 407 cases, with a follow up period ranging from 1 to 15 years. 252 cases were treated with plate fixation and 155 with RIMN. All studies were mitigated by heterogeneity and methodological limitations. The review showed marked variation in descriptive fracture classifications. Narrative data synthesis was conducted. Although guarded by the methodological limitations of individual studies, outcomes showed that mean time to union was equivalent; 5.88 months for RIMN compared to 6.75 months in plating, standardised mean difference=0.28 (95% CI -0.02-0.58). Similarly, no statistically significant differences were reported between RIMN and plating for deep infection (OR:1.41 95%CI 0.40-5.00) and revision surgery (OR: 0.74, 95%CI 0.39-1.41).

DISCUSSION

Clinical outcomes showed a tendency that favours intramedullary nailing; however, generalisation of results was not possible. Future priority must be awarded to higher quality research in the form of a collaborative multicentre observational studies to delineate appropriate major diagnostic categories, ultimately informing a large comparative trial using condition specific validated outcome measures.

LEVEL OF EVIDENCE

III, meta-analysis.

Optimal surgical treatment for periprosthetic distal femoral fractures after total knee arthroplasty: a Bayesian-based network analysis

BACKGROUND

The surgical methods for periprosthetic distal femoral fractures (PDFFs) after total knee arthroplasty included locking compression plate (LCP), retrograde intramedullary nailing (RIMN), and distal femoral replacement (DFR). However, the optimal treatment remains controversial. We performed a network meta-analysis (NMA) to provide the optimal surgical method for PDFFs.

MATERIALS AND METHODS

Electronic databases, including Embase, Web of Science, Cochrane Library, and PubMed, were searched for studies that compared LCP, RIMN, and DFR for PDFFs. The quality of the included studies was assessed according to the Newcastle-Ottawa scale. Pairwise meta-analysis was performed by Review Manager version 5.4. The NMA was conducted in Aggregate Data Drug Information System software version 1.16.5. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for postoperative complications and reoperations.

RESULTS

A total of 19 studies and 1198 patients were included, of whom 733 for LCP, 282 for RIMN, and 183 for DFR. Pairwise meta-analysis comparing LCP to RIMN and LCP to DFR showed no significant difference in complications and reoperations except that RIMN had a higher risk of malunion comparing to LCP (OR 3.05; 95% CI 1.46-6.34; P = 0.003). No statistically significant effects were found in the NMA of overall complications, infection, and reoperation. However, results of rank probabilities showed that DFR ranked best in overall complications and reoperation, RIMN ranked best in infection but worst in reoperation, and LCP ranked worst in infection and middle in reoperation.

DISCUSSION

We found similar complication rate and reoperation rate between LCP, RIMN, and DFR. The results of rank probabilities favored DFR, and further studies with high-level evidence are expected to verify the optimal surgical method for PDFFs.

LEVEL OF EVIDENCE

Level II; network meta-analysis.

Results of Low Distal Femur Periprosthetic Fractures

OBJECTIVES

To compare retrograde intramedullary nail (RIMN) and open reduction internal fixation (ORIF) in very distal periprosthetic distal femur fractures (PDFFs) to determine whether RIMN is an acceptable option for these fractures that are often considered too distal for IMN due to limited bone stock.

DESIGN

Retrospective comparative series.

SETTING

Level 1 trauma center.

PATIENTS

Patients were treated with fracture fixation for a very distal PDFF, defined as the fracture extending to the anterior flange of the implant or distal. Fifty-six patients met inclusion criteria, with 8 excluded for less than 12 months of follow-up.

INTERVENTION

The intervention involved fracture fixation with RIMN or ORIF.

MAIN OUTCOME MEASUREMENTS

The primary outcome was unplanned return to surgery. Secondary outcomes included fracture union, radiographic alignment, visual analog score, and Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference.

RESULTS

The mean follow-up period was 27 months. Twelve patients were treated with ORIF and 36 with RIMN. Twenty-one fractures were at the flange, and 27 extended distal to the flange. There were no differences between fixation methods for reoperation, deep infection, nonunion, malunion, visual analog score pain score, and PROMIS Pain Interference score. The mean PROMIS PF score was higher in the RIMN group compared with that in the ORIF group. There were 5 reoperations in the RIMN group (14%) and 3 in the ORIF group (25%).

CONCLUSIONS

This is the largest series, to the best of our knowledge, of a subset of very distal PDFFs. The results suggest that RIMN may be an acceptable treatment option for these very difficult fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Epicondylar plate fixation of humeral condylar fractures in immature French bulldogs: 45 cases (2014-2020)

OBJECTIVES

The objective of this study was to report outcome and postoperative complications following stabilisation of humeral condylar fractures in skeletally immature French bulldogs with a transcondylar screw combined with locking or hybrid locking plates.

MATERIALS AND METHODS

Medical records from one referral hospital were reviewed to identify skeletally immature French bulldogs with humeral condylar fractures treated with a transcondylar screw and epicondylar locking or hybrid locking plates crossing the distal humeral physis.

RESULTS

Forty-five fractures in 41 different dogs with a mean age of 4 months (range 3.5 to 5) were identified. Six cases had complications: two (4.4%) minor and four (8.9%) major. Short-term clinical outcome was excellent in 35 (77.8%), good in nine (20%) and poor in one (2.2%) case. Forty-one of 45 fractures reached radiographic union without further surgical intervention; the remaining four cases reached union following revision surgery. Long-term owner assessed outcome by telephone interview was graded as excellent in all available cases (26 of 41 dogs).

CLINICAL SIGNIFICANCE

This study suggests that the stabilisation of humeral condylar fractures in skeletally immature French bulldogs with combinations of a transcondylar screw and epicondylar locking or hybrid locking plates crossing the distal humeral physis was safe and led comparable outcomes and complication rates to previous reports.

Fractures of the distal femur in elderly patients: retrospective analysis of a case series treated with single or double plate

Introduction

We evaluated the radiologic and clinical outcomes of a lateral incision single plate with and a single-incision double plating in elderly patients with osteoporotic distal femoral fractures.

Materials and methods

We performed a retrospective study of 82 cases of distal femoral fractures from May 2004 to June 2018. Group A consisted of 42 patients who underwent single-plate fixation. Group B consisted of 40 patients who underwent double-plate fixation. The mean patient age was 77 years (67–87 years) and 76 years (64–86 years) in groups A and B, respectively. All patients were evaluated for procedure duration, time to union, range of knee motion, Lysholm knee score, and presence of complications.

Results

The average procedure time was 81 min (66–92 min) and 110 min (95–120 min) in groups A and B, respectively (p = 0.33). One case in group B required bone grafting after 5 months. The average time to union was 14 weeks (9–19 weeks) and 12.2 weeks (8–19 weeks) (p = 0.63), and the mean range of knee motion was 105° (90–125°) and 110.7° (90°–130°) (p = 0.37) in groups A and B, respectively. There was no significant statistical difference between the two groups in the Lysholm knee score (p = 0.44) and knee society score (p = 0.53).

Conclusion

The clinical and radiological outcomes were similar in the 2 groups. In elderly patients, double plate fixation for distal femoral fractures is an useful method for several advantages such as adequate exposure, easy manipulation, anatomical reduction and stable fixation.

Locked compression plating versus retrograde intramedullary nailing in the treatment of periprosthetic supracondylar knee fractures: a systematic review and meta-analysis

Background

Periprosthetic fractures of the distal femur above a total knee arthroplasty (TKA) have traditionally been managed by locking compression plating (LCP). This technique is technically demanding and is associated with high rates of non-union and revision. More recently, retrograde intramedullary nailing (RIMN) has been proposed as an acceptable alternative. This meta-analysis aims to evaluate clinical outcomes in patients with periprosthetic supracondylar femoral fractures who were treated with LCP and RIMN.

Methods

An up-to-date literature search was carried out using the pre-defined search strategy. All studies that met the inclusion criteria were assessed for methodological quality with the Cochrane’s collaboration tool. Operative time, functional score, time-to-union, non-union rates and revision rates were all considered.

Conclusion

Ten studies with a total of 531 periprosthetic fractures were included. This meta-analysis has suggested that there is no significant difference in any of the outcome measures assessed. Further, more extensive literature is required on the subject to draw more robust conclusions.

Effectiveness of circular external fixator in periprosthetic fractures around the knee

Background

The incidence of periprosthetic fractures after total joint arthroplasty (TJA) is rising due to an increasing number of TJAs performed annually and the growing elderly population. In many elderly patients with periprosthetic fractures, the bone strength is lowered due to the deterioration of bone quality and a decrease in bone quantity; rigid fixation of the fracture is difficult. It is a challenging operation for orthopedic surgeons. The usefulness of circular external fixation for periprosthetic fractures has been reported in several case studies. The aim of this study was to investigate the rate of union and complications associated with circular external fixation in periprosthetic fractures around the knee.

Methods

We included 19 patients with periprosthetic femur and tibial fractures who underwent osteosynthesis using a circular external fixator and had at least 2 years of follow-up. All patients had comorbidities and high risks associated with anesthesia. Tourniquets were not used in any of the patients. There were no cases in which the skin incision was placed, and the closed reduction technique was used in all cases.

Results

A 100% union rate was achieved with no serious complications. All fractures healed after a mean time of 14.3 ± 5.2 weeks (range, 8–38 weeks). The walking ability was the same level as before the injury in 13 cases.

Discussion

There are many comorbidities associated with periprosthetic fractures in elderly patients. Double-plate or revision surgery were largely invasive and had high risks associated with anesthesia. Circular external fixation is a feasible and effective treatment option because it provides stable fixation, prompt postoperative mobilization, and has no major complications, especially in elderly patients who are treated for periprosthetic fractures.

Conclusion

Circular external fixation is a safe and reliable method for periprosthetic fractures around the knee in elderly patients.

Level of evidence

Level IV, retrospective case series.

Musculoskeletal Infection in Orthopaedic Trauma: Assessment of the 2018 International Consensus Meeting on Musculoskeletal Infection

Fracture-related infections (FRIs) are among the most common complications following fracture fixation, and they have a huge economic and functional impact on patients. Because consensus guidelines with respect to prevention, diagnosis, and treatment of this major complication are scarce, delegates from different countries gathered in Philadelphia in July 2018 as part of the Second International Consensus Meeting (ICM) on Musculoskeletal Infection. This paper summarizes the discussion and recommendations from that consensus meeting, using the Delphi technique, with a focus on FRIs. A standardized definition that was based on diagnostic criteria was endorsed, which will hopefully improve reporting and research on FRIs in the future. Furthermore, this paper provides a grade of evidence (strong, moderate, limited, or consensus) for strategies and practices that prevent and treat infection. The grade of evidence is based on the quality of evidence as utilized by the American Academy of Orthopaedic Surgeons. The guidelines presented herein focus not only on the appropriate use of antibiotics, but also on practices for the timing of fracture fixation, soft-tissue coverage, and bone defect and hardware management. We hope that this summary as well as the full document by the International Consensus Group are utilized by those who are charged with musculoskeletal care internationally to optimize their management strategies for the prevention and treatment of FRIs.

Equivalent union rates between intramedullary nail and locked plate fixation for distal femur periprosthetic fractures - a systematic review

BACKGROUND

The incidence of periprosthetic fracture following total knee arthroplasty continues to rise as the number of knee arthroplasty procedures increases. Management of periprosthetic fractures can be complex, with locked compression plating (LCP) and intramedullary nailing (IMN) being the most commonly used treatment options. We performed a systematic review to report and compare the clinical and radiographic outcomes of patients treated with intramedullary nail fixation versus plate fixation for periprosthetic fractures of the distal femur.

METHODS

Several databases were screened. Studies evaluating intramedullary nail fixation or locked plate fixation for distal femur periprosthetic fractures were included. Primary and secondary variables as mentioned below, when included, were analyzed and compared.

RESULTS

One prospective comparative study, 9 retrospective comparative studies, and 28 retrospective case series with 1,188 patients were included in this review. No statistically significant differences were found between IMN and LCP when analyzing union rate or time to union. Plating demonstrated a statistically significant decrease in the overall complication rate and reoperation rate when compared with IMN (p<0.003). IMN demonstrated a slightly higher percentage of patients reaching full weight bearing status and a quicker time to full weight bearing (100% and 7.6 weeks) when compared to plating (94% and 15.8 weeks). A higher percentage of patients treated with IMN returned to preinjury activity when compared to those treated with plating (70.8% vs. 61.6%).

CONCLUSIONS

Both intramedullary nail and locked plate fixation offer unique benefits in terms of clinical and radiographic outcomes for treatment of periprosthetic distal femur fractures after total knee arthroplasty. While the standard of care remains controversial, an increase in the recent literature has allowed for better clarification of the significant clinicoradiologic advantages and disadvantages of both popular treatment options.

Periprosthetic fractures about total knee arthroplasty

Periprosthetic fracture after total knee arthroplasty presents a difficult complication for many orthopaedic surgeons. These fractures occur most frequently around the distal femur followed by the patella and then tibia. These fractures are frequently complicated by poor bone quality or compromised bone due to the presence of the implants. Surgical treatment is typically necessary and requires varied techniques of open fixation, intramedullary fixation, or revision arthroplasty. Outcomes of these injuries vary widely. This review aims to describe the epidemiology, classification, treatment options and outcomes for periprosthetic fractures following total knee arthroplasty.

Additional fixation of medial plate over the unstable lateral locked plating of distal femur fractures: A biomechanical study

INTRODUCTION

Lateral locked plating is a standard treatment option for distal femur fractures. However, the unstable conditions after lateral locked plating are increasing. The objective of this study was to investigate the biomechanical strength of additional medial plate fixation over the unstable lateral locked plating of distal femur fractures.

MATERIALS AND METHODS

A distal femur fracture model (AO/OTA 33-A3) was created with osteotomies in the composite femur. Three study groups consisting of 6 specimens each were created for single-side lateral locked plating with 6 distal locking screws (LP-6), single-side lateral locked plating with 4 distal locking screws (LP-4), and additional medial locked plating on LP-4 construct (DP-4). A compressive axial load (10 mm/min) was applied in the failure test. Mode of failure, load to failure, and ultimate displacement were documented.

RESULTS

All single-side lateral locked plating (LP-4 and LP-6) showed plate bending at the fracture gap, while none of the DP-4 showed plate bending at the fracture gap. Load to failure of DP-4 (mean 5522 N) was 17.1% greater than that of LP-6 (mean 4713.3 N, p < 0.05) and 29.2% greater than that of LP-4 (mean 4273.2 N, p < 0.05). Ultimate displacement of DP-4 (mean 5.6 mm) was significantly lower than that of LP-6 (mean 8.8 mm, p < 0.05) and LP-4 (mean 9.1 mm, p < 0.05).

CONCLUSIONS

Additional fixation of medial plate significantly increased the fracture stability in distal femur fractures fixed with the lateral locked plating. Especially in the clinical situations where sufficient stability cannot be provided at the distal segment, the medial plate may be considered as a useful biomechanical solution to obtain adequate stability for fracture healing.

Femoral Periprosthetic Fractures after Total Knee Arthroplasty: New Surgically Oriented Classification with a Review of Current Treatments

Purpose

As the number of total knee arthroplasties (TKAs) increases, the incidence of femoral periprosthetic fractures after TKA is also increasing. This review aimed to suggest a new surgically oriented classification system for femoral periprosthetic fractures.

Methods

We investigated the classifications, and current treatment trends for femoral periprosthetic fractures after TKA by means of a thorough review of the relevant literature.

Results

Numerous studies reported good results of surgical treatment with modern fixatives including locking compression plates and retrograde intramedullary nails. However, few classifications of femoral periprosthetic fractures reflect the recent developments in surgical treatment.

Conclusions

We recommend that surgical management be considered the first-line treatment for femoral periprosthetic fractures after TKA. Our new classification will help in deciding the surgical treatment option for femoral periprosthetic fractures after TKA.

Single-Incision Double-Plating Approach in the Management of Isolated, Closed Osteoporotic Distal Femoral Fractures

INTRODUCTION

Distal femoral fractures in elderly population had recorded an increase in incidence in the last 2 decades. Lateral distal femoral locking plating is considered one of the best options especially when dealing with comminuted fractures but varus collapse of the medial femoral condyle occurs frequently in patients with osteoporosis. Anatomical reduction of the fracture with stable rigid fixation using double-plating approach allows early mobilization of geriatric population and prevents varus collapse minimizing the comorbidities in such fractures.

PATIENTS AND METHODS

Between September 2014 and January 2017, a prospective study on 23 patients with comminuted osteoporotic distal femoral fractures managed through the double-plating approach through a single parapatellar approach has been conducted. Only osteoporotic geriatric patients with isolated distal femoral fractures were included. Polytraumatized, open fractures, and fracture type 33-A1, 33-A2, and 33-B were excluded. The mean age was 69.6 years (61-80). All patients have been evaluated as regard duration of procedure, time to union, EQ-5D-5L score, the need of autologous bone grafts, range of knee motion, and presence of complications.

RESULTS

The average follow-up was 14.1 months. The majority of fractures were type 33-C2 (13 patients). Average procedure time was 148 minutes (117-193 minutes). Mean EQ-5D-5 L score was 83.8 (72-82). Average time to union was 9 months (3-12 months). Four (17.4%) cases needed autologous bone graft after 6 months. No loss of reduction in any of the cases was evident, although 6 (26%) cases had screw breakage or cutout in one of the plate fixation. Two (8.7%) patient developed superficial wound infection and 1 (4.3%) developed DVT.

DISCUSSION

This study aimed at evaluation of the success of double plating of distal femoral fractures in geriatric population. different fixation methods were studied for reduction and fixation of such a fracture such as external fixation, intramedullary nails and lateral plating. the quality of fracture reduction, functional and radiological outcomes, time to union, the need for bone grafting and complication are the main debatable issues.

CONCLUSION

Single-incision double-plating approach for distal femoral osteoporotic fractures is effective and provides stable construct without reduction loss allowing early rehabilitation. Delayed union and the need for bone graft are the major drawbacks for this technique.

Comparison of Clinical Efficacy of Lateral and Lateral and Medial Double-plating Fixation of Distal Femoral Fractures

The present study was performed to compare the clinical efficacy of lateral plate and lateral and medial double-plating fixation of distal femoral fractures and explore the indication of lateral and medial double-plating fixation of the distal femoral fractures. From March 2006 to April 2014, 48 and 12 cases of distal femoral fractures were treated with lateral plate (single plate) and lateral and medial plates (double plates), respectively. During the surgery, after setting the lateral plate for the distal femoral fractures, if the varus stress test of the knee was positive and the lateral collateral ligament rupture was excluded, lateral and medial double-plating fixation was used for the stability of the fragments. All the patients were followed up at an average period of 15.9 months. The average operation time, the intraoperative hemorrhage and the fracture union time of the two groups were compared. One year after operation, knee function was evaluated by the Kolmert's standard. There was no significant difference in the average operation time, intraoperative hemorrhage, fracture healing time and excellent and good rates of postoperative knee function between two groups. Positive Varus stress test during operation can be an indication for lateral and medial double-plating fixation of distal femoral fractures.

A double-plating approach to distal femur fracture: A clinical study

BACKGROUND

Locked plating is one of the latest innovative options for treating supracondylar femur fractures with relatively low failure rates. Single lateral plating was often found to have a relative higher failure rate. No clinical studies of double-plating distal femur fixation have thus far been reported. The aim of this study is to present our clinical experience with this surgical approach.

PATIENTS AND METHODS

Thirty-two patients (26 females and 6 males, mean age 76 years, range 44-101) were included in the study. Eight of them patients had a periprosthetic stable implant fracture and two patients were treated for a nonunion.

RESULTS

All fractures, excluding one that needed bone grafting and one refracture, healed within 12 weeks. One patient needed bone grafting for delayed union and one patient needed fixation exchange due to femur re-fracture at the site of the most proximal screw. Two patients developed superficial wound infection and one patient required medial plate removal after union due to deep infection.

CONCLUSIONS

Based on these promising results, we propose that the double-plating technique should be considered in the surgeon's armamentarium for the treatment of supracondylar femur fractures, particularly in patients with poor bone quality, comminuted fractures and very low periprosthetic fractures.

Similar outcomes of locking compression plating and retrograde intramedullary nailing for periprosthetic supracondylar femoral fractures following total knee arthroplasty: a meta-analysis

PURPOSE

This meta-analysis was designed to compare clinical outcomes, including knee scale score and nonunion rate, of patients with periprosthetic supracondylar fractures of the distal femur after total knee arthroplasty (TKA) who were treated using locking compression plates and retrograde intramedullary nails.

METHODS

Studies were included in this meta-analysis if they compared clinical outcomes, including operation time, Knee Society Score (KSS), time to union, nonunion rate, and revision rate due to nonunion, in patients who underwent locking compression plate or retrograde intramedullary nail for periprosthetic distal femur fractures following TKA.

RESULTS

Eight studies were included in this meta-analysis. Mean operation time was 11 min shorter (95 % CI -9.56 to 31.33 min; n.s.) and KSS one point higher (95 % CI -8.88 to 11.10; n.s.) with retrograde intramedullary nail than with locking compression plate, but these differences were not statistically significant. The two groups were also similar in mean time to union (0.46 weeks 95 % CI -1.17 to 2.08 weeks; n.s.), the proportion of subjects with nonunion (OR 0.83, 95 % CI 0.26-2.60; n.s.) and the proportion that underwent revision surgery (OR 0.88, 95 % CI 0.32-2.40; n.s.).

CONCLUSIONS

Clinical outcomes, including nonunion and revision rates, were similar in patients who underwent locking compression plate and retrograde intramedullary nail fixation for periprosthetic supracondylar femoral fracture following TKA. Orthopaedic surgeons must train to master both the retrograde intramedullary nail and locking compression plate techniques because both approaches can be considered for periprosthetic distal femur fracture after TKA as they have similar clinicoradiologic outcomes.

LEVEL OF EVIDENCE

II.

Periprosthetic knee fractures. A review of epidemiology, risk factors, diagnosis, management and outcome

BACKGROUND AND AIM OF THE WORK

Periprosthetic knee fractures incidence is gradually raising due to aging of population and increasing of total knee arthroplasties. Management of this complication represents a challenge for the orthopaedic surgeon. Aim of the present study is to critically review the recent literature about epidemiology, risk factors, diagnosis, management and outcome of periprosthetic knee fractures.

METHODS

A systematic search of Embase, Medline and Pubmed was performed by two reviewers who selected the eligible papers favoring studies published in the last ten years. Epidemiology, risk factors, diagnostic features, clinical management and outcome of different techniques were all reviewed.

RESULTS

52 studies including reviews, meta-analysis, clinical and biomechanical studies were selected.

CONCLUSIONS

Correct clinical management requires adequate diagnosis and evaluation of risk factors. Conservative treatment is rarely indicated. Locking plate fixation, intramedullary nailing and revision arthroplasty are all valuable treatment methods. Surgical technique should be chosen considering age and functional demand, comorbidities, fracture morphology and location, bone quality and stability of the implant. Given the correct indication all surgical treatment can lead to satisfactory clinical and radiographic results despite a relevant complication rate.

Patterns of Opioid Prescribing for an Orthopaedic Trauma Population

OBJECTIVES

To determine opioid-prescribing practices to the orthopaedic trauma (OT) population at one Level I trauma center.

DESIGN

A retrospective study of discharge prescriptions for adult patients with OT. Prescription details, injury burden, and patient demographics were abstracted for patients from initial injury through a 2-month follow-up.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Adult patients with OT admitted over a 30-day period (n = 110).

INTERVENTION

All discharge and follow-up opioid prescriptions were recorded.

MAIN OUTCOME MEASUREMENTS

Morphine milligram equivalents (MMEs) per day, number of opioid prescriptions, type/dose of medication prescribed.

RESULTS

One hundred thirty-five discharge prescriptions were written for 110 patients with orthopaedic injuries during the review period. All patients received opioids at the time of discharge. The MMEs prescribed at the time of discharge was 114 mg (54-300 mg) for a mean of 7.21 days (2-36.7 days). Although patients with preinjury risk factors were prescribed discharge opioids for a similar duration (7.00 days vs. 7.30 days, P = 0.81) than those without risk factors, they were prescribed significantly more MMEs than those without (130 vs. 108, P < 0.05) and were more likely to receive extended-release and long-acting opioids than those without (42.11% vs. 21.98%).

CONCLUSIONS

Pain management after OT continues to be opioid-centric despite involving a population at risk. Further focus on prescriber and patient education, risk evaluation with mitigation, guideline development, and comprehensive pain management strategies are warranted in the OT population.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Surgical Management of Supracondylar Periprosthetic Femur Fractures

BACKGROUND

Fracture location is an important consideration in managing supracondylar periprosthetic femur fractures. The outcomes of locked plating and intramedullary (IM) nail fixation were therefore compared based on fracture location, being above or at/below the total knee arthroplasty (TKA) flange.

METHODS

Fifty-seven patients were identified from surgical records as being treated for supracondylar periprosthetic femur fracture with either a locking plate (n = 38) or IM nail (n = 19). Based on fracture location, either above or at/below the TKA flange, both groups were assessed for time to full weight bearing, time to radiographic union, number of postoperative complications, subsequent surgery, transfusion requirements, as well as range of motion, pain, and instability at most recent follow-up. Radiographs were reviewed to assess fracture alignment with comparisons made immediately postoperative to most recent.

RESULTS

Mean follow-up for IM nail and locking plate fixation was 13.9 and 15.6 months, respectively. There was no statistical difference between groups in the mean time to fully weight bear, the incidence of postoperative pain, range of motion, use of gait aids, time to full radiographic union, or the overall radiographic alignment of a healed fracture (P > .05). Comparison based on fracture location yielded similar outcomes. Nonunion was only demonstrated in the IM nail cohort, particularly for fractures below the TKA flange (n = 2).

CONCLUSION

The use of either IM nail or locking plate fixation for supracondylar periprosthetic fractures provides comparable clinical outcomes. Caution is recommended in using IM nails for fractures below the flange where limited fixation may increase the risk of nonunion.

Periprosthetic Distal Femur Fracture after Total Knee Arthroplasty: A Systematic Review

This study was designed to itemize and analyze the classification of fracture types and their corresponding outcomes in an attempt to provide a better understanding of the current treatment methods. Two PubMed searches were performed using the words "periprosthetic distal femur fracture" and "periprosthetic supracondylar femur fracture" in studies that were published in the previous 10 years (2004-2014). Data from 41 articlesthat met the general inclusion criteria, were collected and categorized into fracture type and treatment method groupings. Healing outcome and complications were the two parameters used to analyze the data. Treatment techniques were grouped in the following categories: locking plate, non-locking plate, intramedullary nail/rod, screw, blade plate, cerclage wires, allograft, external fixation, revision arthroplasty, non-operative, and other. Classification systems by Lewis and Rorabeck, the Association for Osteosynthesis/Orthopedic Trauma Association (AO/OTA), Su et al., Neer et al., Kim et al., Backstein et al., and the Société Française de Chirurgie Orthopédique et Traumatologique were reported. In total 448 fractures were identified, of which Rorabeck type II was the most common fracture studied. The two most successful treatment options for periprosthetic distal femur fractures were locking plate (87%) and intramedullary nail/rod (84%). The most frequent complications associated with periprosthetic distal femur fractures included non/mal/delayed union and the need for revision. Locking plates used to treat Rorabeck type II fractures had a complication rate of 35% and those treated with intramedullary nailing had a higher complication rate of 53%. In conclusion, the most frequent type of periprosthetic distal femur fracture after total knee arthroplasty was Rorabeck type II. The most common treatments for these types of fractures are locked plating and intramedullary nailing, with similar healing rates of 87% and 84%, respectively. However, the complication rate for locked plating was lower than for intramedullary nailing.

Locked plate versus retrograde intramedullary nail for periprosthetic femur fractures above total knee arthroplasty: a meta-analysis

PURPOSE

Locked plate (LP) and retrograde intramedullary nail (RIN) are the most commonly used treatment options for periprosthetic femur fracture above total knee arthroplasty (TKA). Controversy still exists regarding which is better. Therefore we performed a meta-analysis to compare their clinical results.

METHODS

A comprehensive search was conducted through PubMed, EMBase and the Cochrane Collaboration Library. Six comparative studies (265 patients) were included for the meta-analysis.

RESULTS

No statistically significant differences were found between the LP group and RIN group in terms of six month union rate (OR, 1.19; 95 % CI, 0.52-2.69; P = 0.68), union time (WMD, 0.22; 95 % CI, -0.41 to 0.84; P = 0.50), operation time (WMD, 0.54; 95 % CI, -13.09 to 14.17; P = 0.94) or complication rate (OR, 0.79; 95 % CI, 0.22-2.91; P = 0.73). The LP fixation may have a relatively higher re-operation rate (OR, 5.17; 95 % CI, 1.02-26.27; P = 0.05) compared with RIN. The mean union time was 4.0 months in the LP group and 3.7 months in the RIN group.

CONCLUSION

This meta-analysis found no statistically significant difference in six month union rate, union time, operation time and complication rate between the LP group and RIN group. The RIN fixation may have a potential of lower re-operation rate compared with LP. The mean union time was 4.0 months in the LP group and 3.7 months in the RIN group.

Periprosthetic femur fractures

Successful treatment of periprosthetic femur fractures, like all fractures, requires careful attention to understand the fracture pattern nuances, identifying and executing a rational treatment approach, and providing an appropriate postoperative recovery protocol. Unlike most other fractures, modification of standard techniques is often required to obtain a stable fixation construct, and there is a greater role for revision arthroplasty in the treatment of periprosthetic fractures. Optimal indications for surgical repair versus revision arthroplasty and optimal postoperative weight-bearing protocols remain uncertain. Reported outcomes for patients with periprosthetic femoral shaft fractures are generally good and are relatively consistent. Results for periprosthetic distal femur fractures, however, are less good and more inconsistent. Both periprosthetic femoral shaft and distal femur fractures are associated with relatively high mortality rates, approaching that of patients with hip fractures. This review should provide insight into the current solutions and challenges for the treatment of patients with periprosthetic femur fractures.

The treatment of periprosthetic femur fractures after total knee arthroplasty

Periprosthetic femur fractures after total knee arthroplasty are a rising concern; however, when properly diagnosed, they can be managed nonoperatively or operatively in the form of locking plate fixation, intramedullary nailing, and arthroplasty. The degree of osteoporosis, stability of the femoral implant, and goals of the patient are a few critical variables in determining the ideal treatment. Despite excellent outcomes from each of these operative choices, the risk of nonunion, malunion, instability, and refracture cannot be ignored.

Modern retrograde intramedullary nails versus periarticular locked plates for supracondylar femur fractures after total knee arthroplasty

This study purpose is to analyze outcomes of modern intramedullary (IM) nails with a locked distal screw versus periarticular locking plates for peri-prosthetic supracondylar femur fractures in TKA. Ninety-five consecutive fractures in 91 patients were retrospectively reviewed. Fixation included 29 knees with a retrograde IM nail and 66 periarticular locked plates. Six patients died and 4 were lost to follow-up. There were 2 (9%) nonunions in the IM nail group and 12 non-unions/delayed-unions (19%) in the locked plate group (P = 0.34). A mean of 5.0 distal screws was used in locked plates versus 3.8 distal screws in the IM nails (P < 0.001). Despite a greater quantity of screws in the distal fragment, the failure rate of locked plating was twice that of IM nail fixation.

Systematic review of the treatment of periprosthetic distal femur fractures

OBJECTIVES

To systematically review and compare nonoperative and operative treatments for the management of periprosthetic distal femur fractures adjacent to total knee arthroplasties. Specific operative interventions compared included locked plating, retrograde intramedullary nailing (RIMN), and conventional (nonlocked) plating. Where possible, data were pooled to arrive at summary estimates of treatment effect [odds ratios (ORs) with associated 95% confidence intervals (CIs)].

METHODS

A comprehensive database search (via Pubmed, Medline, Cochrane Database, and the Orthopaedic Trauma Association database) was completed, yielding 44 eligible studies with a total of 719 fractures for analysis. Pertinent outcomes including malunion, nonunion, and the need for secondary surgical procedures were compared statistically.

RESULTS

Both locked plating and RIMN demonstrated significant advantages over nonoperative treatment. Some advantages were also observed when locked plating and RIMN were compared with conventional (nonlocked) plates. Comparison of locked plating and RIMN showed no significant differences with regard to nonunion rates (OR = 0.39, 95% CI = 0.13-1.15; P = 0.09) or rate of secondary surgical procedures (OR = 0.65, 95% CI = 0.31-1.35; P = 0.25). However, RIMN demonstrated a significantly higher malunion rate when compared with locked plating (OR = 2.37, 95% CI = 1.17-4.81; P = 0.02).

CONCLUSIONS

Locked plating and RIMN offer significant advantages over nonoperative treatment and conventional (nonlocked) plating techniques in the management of periprosthetic femur fractures above total knee arthroplasties. Locked plating demonstrated a trend toward increased nonunion rates when compared with RIMN. Malunion was significantly higher with RIMN compared with locked plating.

Periprosthetic supracondylar femoral fractures following total knee arthroplasty: clinical comparison and related complications of the femur plate system and retrograde-inserted supracondylar nail

Background

The purpose of this study is to analyze the clinical results and related complications of the femur plate system (FP) and the retrograde-inserted supracondylar nail (RISN).

Materials and methods

The study included 42 cases of periprosthetic supracondylar femoral fractures (PSF) proximal to posterior stabilized total knee arthroplasty between 2005 and 2009. Twenty-four cases of PSF were treated with the FP, and the other 18 cases were treated with the RISN. This study cohort was divided into subgroups according to the AO classification. We retrospectively compared the clinical results between the FP and RISN group.

Results

There were no significant differences between the two groups in terms of time of clinical union (p = 0.649). In the subgroup analysis, the mean operation time was significantly different only in subgroup A1 (p = 0.03). Complications were seen in 29.2 % (7/24) of patients in the FP group and 27.8 % (5/18) in the RISN group. The age during the index TKA and fracture fixation was a significant risk (p = 0.008) factor for complications between the two groups. No significant differences were found in the other factors between the two groups. The p value for operative time (p = 0.223), immobilization period (p = 0.129), ROM (p = 0.573), KSS (p = 0.379), KSS functional scores (p = 0.310) and time to union (p = 0.649).

Conclusion

Clinical results did not differ according to the treatment methods used. Fixation method and fracture type did not cause an increase in the complication rate, but there was a trend toward higher non-union rates with the FP method and higher re-fracture rate with the RISN method. Noting the fact that only increasing age correlated with an increased complication rate, more careful attention should be paid to elderly patients in terms of both prevention and surgical care.

Level of evidence

Level III, therapeutic study.

Distal femoral replacement for selective periprosthetic fractures above a total knee arthroplasty

BACKGROUND AND AIM

The management of distal femur periprosthetic fractures in the elderly remains a challenge. The aim of this study was to evaluate the results of distal segmental femur replacement as an alternative to fixation in complex distal femoral periprosthetic fractures in elderly patients.

METHODS

Twelve patients were included in this prospective study, with a mean age of 78 years (range 68-90 years); incidentally, all were female. Fractures of the distal femur were classified as per Kim et al.'s classification (Clin Orthop Relat Res 446:167-175, 2006); our series included eight patients with type III and four patients with type II periprosthetic fractures. All 12 patients were treated with segmental distal femur replacement (Zimmer Inc., Warsaw, IN, USA). Nine patients required 90 cm and three patients required 130 cm of distal femur segment with a rotating hinge knee prosthesis.

RESULTS

The mean follow up period was 20 months (range 15-28 months), with no major surgical complications reported. The mean duration of hospital stay following surgery was 12 days (range 7-36 days). All patients were mobilising full weight-bearing by day 3. All patients returned to their prior living arrangements. Ten patients returned to their original domicile, with one patient being discharged to a care home requiring minimal ambulatory assistance. The remaining two patients returned to their care homes.

CONCLUSIONS

WOMAC scores improved from the pre-injury state with a mean of 49.62 to 72.54 post-surgery (p-value of 0.0001). The Knee Society scores, possible only following surgery, had a mean value of 72. The mean VAS pain score was 1.75 (0 = no pain to 10 = worst pain ever felt). The average range of knee flexion was from 4° to 89° (range -5° to 110°). The mean SF-36 physical functioning score was 45.64 [range 40.70-48.90; standard deviation (SD) -2.62] and the mean SF-36 mental functioning score was 52.94 (range 45.8-57.70; SD -3.38).

Functional outcome of total knee arthroplasty after periprosthetic distal femoral fracture

A prospective matched cohort study was performed to compare functional outcomes between 28 patients with periprosthetic femoral fractures and 28 with primary total knee arthroplasties (TKA). The mean follow-up was 6.7 years (range, 5-9). Radiographic osteopenia was a predisposing factor, but not notching, body mass index, or preinjury knee scores or motion. At last follow-up, the Knee Society scores, knee motion, Womac, and SF-12 were significantly lower in the fracture group, and were significantly decreased compared to the preinjury status. We found that periprosthetic distal femoral fracture after TKA worsens functional outcomes at the medium term, but arthroplasty complication and survival rates were similar in both groups.

The outcome and complications of the locked plating management for the periprosthetic distal femur fractures after a total knee arthroplasty

Background

The osteosynthesis of the periprosthetic fractures following a total knee arthroplasty (TKA) can be technically difficult with the relatively small satisfactory outcomes and the high complication rates. The purpose of the study is to analyze the mid-term radiological and functional outcomes following the locked plating of the distal femur periprosthetic fractures after a TKA.

Methods

Records of 20 patients with a periprosthetic distal femur fracture following TKA treated by the locked plate osteosynthesis were retrospectively evaluated. The union rate, complications and functional outcome measures were analyzed.

Results

Successful union was achieved in 18 of the 19 patients available for the follow-up. The mean follow-up was 39 ± 10 months. Significant reductions (p < 0.05) in the range of motion and Western Ontario and McMaster Universities Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were evident in the follow-up. Secondary procedures were required in 5 patients to address the delay in union and the reduced knee range of motion. The osteosynthesis failed in 1 patient who underwent a revision TKA.

Conclusions

The satisfactory union rates can be achieved with the locked plate osteosynthesis in the periprosthetic distal femur fractures after TKA. Prolonged rehabilitation coupled with the un-modifiable risk factors can decrease the activity and satisfaction levels, which can significantly alter the functional outcome.

Intramedullary nailing versus locked plate for treating supracondylar periprosthetic femur fractures

The objective of this study was to compare retrograde intramedullary femoral nailing with supracondylar locked screw-plate fixation for the treatment of periprosthetic femur fractures following total knee arthroplasty. Time to union and full weight bearing were the primary study outcomes, with perioperative blood loss, need for transfusion, need for revision surgery, and infection being the secondary outcomes. A retrospective review of 63 patients who sustained Rorabeck Type II periprosthetic femoral fractures was undertaken. Patients were pooled from 3 academic institutions between 2001 and 2009. Patients eligible for the study were identified from the electronic medical record using an IDX query of International Classification of Diseases 9 and Current Procedural Terminology codes for fixation of femur fracture with intramedullary implant or plate and screws. In the series, 35 patients were treated with intramedullary femoral nailing and 28 with a locked screw-plate. The 2 groups were compared for radiographic union at 6, 12, 24, and 36 weeks. At 36 weeks, radiographic union was significantly greater in the locked screw-plate group. Time to full weight bearing was not significantly different. A greater perioperative transfusion rate was observed in the locking plate group, but it also had an overall lower rate of reoperation, for any reason, compared with the intramedullary femoral nailing group. The results support the use of a laterally based locked plate in the treatment of Rorabeck type II distal femur periprosthetic fractures.

Periprosthetic fractures around total knee arthroplasty

INTRODUCTION

The number of total knee arthroplasties performed continues to rise annually and it would be expected that complications, which include periprosthetic fractures, will also therefore become more commonplace. This article reviews the current literature regarding this injury and identifies the treatment principles that enable patients to regain optimal function.

METHODS

A comprehensive search of the Pubmed and Embase™ databases was performed to identify relevant articles. Keywords and MeSH (Medical Subject Headings) terms included in the search strategy were 'periprosthetic fracture(s)', 'femur', 'tibia', 'patella(r)', 'complication(s)', 'failure(s)', 'risk(s)', 'prevalence', 'incidence', 'epidemiology' and 'classification(s)'. The search was limited to all articles published in English and reference lists from the original articles were reviewed to identify pertinent articles to include in this review. A total number of 43 studies were identified.

RESULTS

Common treatment aims have been identified when managing patients with a periprosthetic fracture around total knee arthoplasty. The main criterion that determines which option to choose is the degree of remaining bone stock and the amount of fracture displacement.

CONCLUSIONS

Treatment of a periprosthetic fracture around total knee arthroplasty will either be non-operative, osteosynthesis or revision arthroplasty. It is imperative that a suitable option is chosen and based on the published literature, pathways are outlined to aid the surgeon.

Periprosthetic fractures in the distal femur following total knee replacement: A review and guide to management

The management of distal femoral fractures following a total knee replacement can be complex and requires the equipment, perioperative support and surgical skills of both trauma and revision arthroplasty services. Recent advances in implant technology have changed the management options of these difficult fractures. This article describes the options available and discusses the latest evidence.

Treatment of periprosthetic femoral fractures of the knee

PURPOSE

We report a continuous series of periprosthetic femoral fractures after knee arthroplasty treated with a locking plate. We hypothesize that minimally invasive surgery and immediate weight-bearing improve functional recovery.

METHODS

From June 2002 to December 2008, 15 patients with 16 fractures were treated. Median age was 81 years. The autonomy level according to the mobility score of Parker and Palmer showed a median of 5 (0-9). Osteosynthesis was performed mainly through a minimally invasive approach using a locking compression plate. The rehabilitation protocol consisted of immediate mobilization and, whenever possible, immediate unrestricted weight-bearing.

RESULTS

Five patients died during follow-up, more than 1 year after osteosynthesis. Their results were included. Autonomy and mobility were preserved with a median postoperative score of 4 (0-9) according to Parker and Palmer. The consolidation rate was 93.8%, which was obtained within 10 weeks. There were no mechanical or infectious complications. Fourteen cases were treated with minimally invasive surgery without fracture exposition; the remaining 2 required a slightly more extended approach. Full weight-bearing occurred 10 times; 20-kg partial weight-bearing was advised twice; and on 4 occasions, no weight-bearing was allowed for 6 weeks.

CONCLUSION

Osteosynthesis with a minimally invasive bridge-plating technique is effective in the treatment of periprosthetic, distal femoral fractures without component loosening. Immediate full weight-bearing is possible if certain rules are respected. The surgical management presented herein is beneficial for these challenging fractures, and it may help reduce the complication rate and improve functional outcome.

Evidence for success with locking plates for fragility fractures

Fixation of fragility fractures with plates and screws often results in loss of fixation and need for revision surgery. Locking plates and screw were introduced to improve fixation of fragility fractures and have been in use for a decade. This review was conducted to compile evidence that locking plates and screws improve fixation of fragility fractures. A search of PubMed was performed to identify biomechanical studies as well as clinical series of fragility fractures treated with locking plates. Biomechanics papers had to use models of osteoporotic bone and had to directly compare locking plates with traditional plates. Clinical studies included case series in which locking plates were applied to elderly patients with fractures of the proximal humerus and periprosthetic distal femur fractures. Most studies are retrospective case series. Locking plates lead to greater stability and higher loads to failure than traditional plates. When applied to proximal humerus fractures, uncomplicated healing occurs in 85% of patients. Constant and Dash scores approach normal values. For distal femoral periprosthetic fractures, union rates of 75% are reported with a malunion rate of 10%. Early evidence suggests that locking plates improve results of treatment of proximal humerus fractures and distal femoral periprosthetic fractures in the elderly. Loss of fixation is associated with failure to achieve stability at the fracture site. Principles of fracture fixation in osteoporotic bone defined prior to the introduction of locking plates should still be applied.

Periprosthetic distal femur fractures: current concepts

Periprosthetic fractures of the distal femur most commonly present as fragility fractures associated with relatively minor trauma. These injuries are often complicated by osteopenia of the distal femur secondary to stress shielding or osteolysis. Effective management of periprosthetic fractures of the distal femur requires knowledge of both fracture fixation techniques and revision arthroplasty. This article reviews the treatment options for these challenging fractures with a particular focus on the management of displaced fractures with a stable prosthesis.

Early results of retrograde expandable nail fixation of 29 distal femoral fractures

The authors retrospectively reviewed 27 consecutive patients with 29 fractures of the distal femur treated with the new retrograde expandable nail. One 10-mm diameter nail that expands to 16 mm was used with the possibility of locking in the condylar area only. Retrieved data included single versus multiple injuries, fracture type, operation time, reaming or nonreaming, hospitalization and healing times, and intra- and postoperative complications. The overall average operation time was 96 (range 40-320) minutes, but only 65 (range 40-120) minutes for isolated fractures. The overall mean hospitalization time was 16 (range 3-40) days, but only 7 (range 4-10) days for isolated fractures. Follow-up continued until fracture healing or for a minimum of 1 year (average 14 months, range 12-24 months). The average clinical union time was 83 (range 43-179) days, and the mean radiographic healing was 87 (range 43-179) days. One patient developed a nonunion that required exchange of the nail to the same device. Another patient underwent hardware removal during a procedure for a torn meniscus. These preliminary results demonstrate satisfactory healing and alignment for the treatment of distal femoral shaft fractures by means of this new device without jeopardizing the knee joint by nail protrusion.

Femoral corrective osteotomy for malunited supracondylar femoral fracture after TKA in a patient with rheumatoid arthritis

This article presents a case of femoral corrective osteotomy for malunited supracondylar femoral fracture after total knee arthroplasty (TKA) in a patient with rheumatoid arthritis. The patient underwent 1-stage bilateral TKA and 2-stage bilateral total hip arthroplasty 17 years prior at our institution. Her fall 10 years before led to a supracondylar femoral fracture that was treated nonoperatively for 3 months and led to malunion. Complaints of mild right knee pain and remarkable varus deformity were observed. On examination, the right knee was not swollen and tender. Range of motion (ROM) of the right knee was 0° to 130°. The patient needed crutches to ambulate. Knee score and function scores, according to the Knee Society clinical rating system, were 65 and 25 points, respectively. Radiographs after malunion showed remarkable varus knee and the femorotibial angle was 197°. At the time of surgery, the components were stable and bone union was completed. Valgus corrective osteotomy of the femur was performed using a retrograde intramedullary nail, with satisfactory results at 10-year follow-up. The patient is able to walk without a cane and has 0° to 130° ROM. Knee and function scores were 88 and 80 points, respectively. Radiographs showed complete bone union and the femorotibial angle was 179° with no loosening of the prostheses. Femoral corrective osteotomy is recommended for malunited supracondylar femoral fracture after TKA.

Management and outcome of periprosthetic fractures after total knee arthroplasty

BACKGROUND

The incidence of periprosthetic fractures after total knee arthroplasty is continuously rising because of an increasing number of knee joint replacements and an enhanced survivorship of the elderly population after knee arthroplasty. The purpose of this study was to analyze the practicability and effectiveness of the various treatment methods for management of periprosthetic fractures after total knee arthroplasty, and to determine the clinical and radiographic long-term results of patients following surgical and nonoperative treatment of these injuries.

METHODS

We reviewed the clinical and radiographic records of 41 patients (31 women and 10 men; average age, 78.6 years) with periprosthetic fractures after total knee arthroplasty between 1992 and 2008. Thirty-seven patients showed a periprosthetic fracture of the distal femur, and four patients had a periprosthetic proximal tibial fracture. Thirty-six patients underwent operative stabilization by plate fixation (n = 18), intramedullary nailing (n = 15) or revision arthroplasty (n = 3), and five patients were treated nonoperatively by long-term cast immobilization.

RESULTS

Twenty-eight patients returned to their preinjury activity level and were satisfied with their clinical outcome. In 10 patients, we saw a relevant decrease of knee function and severe limitations in gait and activities of daily living. Three patients died related to surgery. Successful fracture healing within 6 months was achieved in 33 (87%) of 38 patients. Failures of reduction or fixation occurred in 8 (21%) of 38 patients. Reoperation due to technical failures was necessary in three patients.

CONCLUSIONS

Compared with current data in literature, we had a satisfactory outcome in following individualized treatment of periprosthetic fractures after knee joint replacement. Referring to the wide field of treatment options and high rates of complications, periprosthetic femoral fractures around the knee commonly constitute a challenging problem for the treating surgeons and require an adequate analysis of fracture etiology and a corresponding transfer into an individual treatment concept.

Are extreme distal periprosthetic supracondylar fractures of the femur too distal to fix using a lateral locked plate?

It is unclear whether there is a limit to the amount of distal bone required to support fixation of supracondylar periprosthetic femoral fractures. This retrospective multicentre study evaluated lateral locked plating of periprosthetic supracondylar femoral fractures and compared the results according to extension of the fracture distal with the proximal border of the femoral prosthetic component. Between 1999 and 2008, 89 patients underwent lateral locked plating of a supracondylar periprosthetic femoral fracture, of whom 61 patients with a mean age of 72 years (42 to 96) comprising 53 women, were available after a minimum follow-up of six months or until fracture healing. Patients were grouped into those with fractures located proximally (28) and those with fractures that extended distal to the proximal border of the femoral component (33). Delayed healing and nonunion occurred respectively in five (18%) and three (11%) of more proximal fractures, and in two (6%) and five (15%) of the fractures with distal extension (p = 0.23 for delayed healing; p = 0.72 for nonunion, Fisher's exact test). Four construct failures (14%) occurred in more proximal fractures, and three (9%) in fractures with distal extension (p = 0.51). Of the two deep infections that occurred in each group, one resolved after surgical debridement and antibiotics, and one progressed to a nonunion. Extreme distal periprosthetic supracondylar fractures of the femur are not a contra-indication to lateral locked plating. These fractures can be managed with internal fixation, with predictable results, similar to those seen in more proximal fractures.