Comparison of morbidity-mortality and functional results between implant exchange and internal fixation by plate for periprosthetic femoral fracture in total knee arthroplasty: A 52-case series

Management of periprosthetic femoral fractures following total knee arthroplasties using locking plates or intramedullary nailing. Comparative study of 567 cases

INTRODUCTION

Proximal femur fractures in elderly patients pose a common problem that requires surgical management. The main objective of this study was to compare the results of treatment by locked plate (LP) and by anterograde (AIN) or retrograde (RIN) intramedullary nailing. The secondary objective was to analyze the complications related to each group. The hypothesis of this study was that the radiological and clinical results of each group were comparable.

MATERIALS AND METHODS

The data of 438 patients from 8 centers were studied retrospectively with 365 LP and 69 cases of intramedullary nailing (49 AIN and 20 RIN). The groups were comparable in terms of mean age (75±2years), mean preoperative Parker score (5.3±0.5) and mean KOOS score (74±2). Most patients lived at home before their fracture [n=375 (86%)]. At follow-up, the joint range of motion, the KOOS and Parker scores, living premises, the time required to regain full weight-bearing, the time required for consolidation as well as the reduction alignment: frontal, sagittal, horizontal.

RESULTS

The average follow-up was: 79±2weeks (65 to 82). The functional and radiological results were comparable, although nailing allowed a faster return to weight-bearing (1±2weeks for nailing versus 7±2weeks for LP, p=0.048) and a better postoperative Parker score (5.5±0.5 for nailing versus 4.7±0.2 for LP, p=0.045). Rotational malalignment in femoral nailing was often in the direction of internal rotation, compared to the LP (p=0.045). Complications were comparable with the exception of mortality, which was more frequent for LP [22.5% in the LP group versus 13% in the nailing group (p=0.045)]. Complications were categorized as: mechanical complications 6.8% of LP, 5.7% of nailing (p>0.05), infections [11% of LP, 5.8% of nailing (p>0.05)], surgical revisions [2% of LP, 10% of nailing (p>0.05)].

DISCUSSION AND CONCLUSION

The hypothesis was refuted. These results show that nailing conferred a faster recovery of weight-bearing, a better Parker score, and is associated with a lower mortality rate. The morbidity rate is comparable between the two techniques. Indeed, when the indication for osteosynthesis by LP or by nailing is made, and both choices are technically justifiable, it would be prudent to favor the technique, which carries the least risk, which in this case is nailing. This conclusion must, however, be taken in to consideration with regard to the reduced number of nailing. A larger series of nailing, particularly retrograde, would be necessary to be able to confirm this last difference between the 2 groups.

LEVEL OF EVIDENCE

IV; comparative retrospective study.

Minimally invasive surgery of femoral periprosthetic fractures increases the rate of consolidation and decreases time to bone healing without a higher rate of complications

BACKGROUND

Knee periprosthetic femoral fractures (KPPFF) are becoming more frequent due to the increasing number of arthroplasties and the aging population, for whom maintaining autonomy and function remains a challenge. The use of locking plates has improved functional results and promoted the development of "minimally invasive" surgical (MIS) approaches. Despite the availability of literature comparing between different types of osteosynthesis for KPPFF, there is a paucity of information available on the complications of osteosynthesis using locking plates, depending on the approach. We therefore carried out a retrospective multicenter study (nine centers: Dijon, Grenoble, Lille, Marseille, Nice, Paris, Saint-Étienne, Strasbourg, Colmar) as part of a Symposium of the French Society of Orthopedic Surgery and Traumatology (SOFCOT). Following osteosynthesis of KPPFF by locking plates carried out by a standard approach or by a minimally invasive approach (MIS), the objectives were: (1) to compare the complications, (2) to evaluate whether the radiological and clinical results (rate and time of consolidation, resumption of weight bearing, lack of reduction, postoperative autonomy) were comparable in the two groups.

HYPOTHESIS

The hypothesis was that performing an MIS approach in these indications does not confer more complications than a standard approach, and rather, the MIS approach offers better functional and radiological results.

MATERIAL AND METHOD

Five hundred and seventy-three patients presented with KPPFF over the periods studied (retrospective series from January 2012 to December 2016, then prospective series from January to December 2019). After applying the inclusion criteria (KPPFF by locking plate) and exclusion criteria (tumor context, infectious, intraoperative fractures, fractures on loose prostheses, other osteosynthesis methods, treatment by prosthetic revision, patients under the age of 18, follow-up less than 1-year, incomplete files), a global series of 306 patients was retained. Two groups were created according to the approach performed: a standard approach group (S, n=228) and a minimally invasive approach group (MIS, n=78). The demographic data of the population were recorded, as was the criteria for autonomy (Parker score, place of living). Postoperative complications were sought (infection, mechanical complication, surgical revision). Finally, the radiological and clinical results were evaluated (rate of, and time to consolidation, resumption of weight bearing, lack of reduction, postoperative autonomy).

RESULTS

The comparison of the two subgroups, S and MIS, found complication rates are comparable in the two groups in terms of infections [S group: n=18 (7.9%), MIS group: n=2 (2.6%)], mechanical complications [S: n=23 (10.1%), MIS: n=2 (2.6%)], and surgical revision [S: n=33 (14.5%), MIS: n=7 (8.9%)], and a lack of difference in postoperative autonomy [Parker; S group: 4.7±2.4 (0-9) vs. MIS group: 5±2, 7 (0-9)]. On the other hand, the time to return to weight bearing was shorter in the MIS group [4.3±3.5weeks (0-12) versus 10.1±10.1weeks (0-110), p<0.001]. The rate of nonunion was lower in the MIS group [n=1 vs. n=20, i.e. 1.7% vs. 11.1% (p=0.031)] and the time to consolidation was shorter [7.5±4.3weeks (6-30) versus 15.2±9.4weeks (5-78) (p<0.001)].

CONCLUSION

Performing an MIS approach in the management of KPPFF by locking plate osteosynthesis does not cause any more complications than a standard approach. In addition, higher consolidation rates can be obtained in shorter periods of time. This study suggests that it proposing osteosynthesis using the MIS approach as a primary surgery is a reasonable choice when treatment using locking plates is chosen for a KPPFF, subject to technical expertise.

LEVEL OF EVIDENCE

III; observational study.

Revision total knee arthroplasty with periprosthetic distal femoral fracture

Treatment strategies for periprosthetic distal femoral fracture depend on the type of fracture, level with respect to the prosthesis, and prosthesis fixation. The usual treatment is internal fixation by nail or locking plate. This can be more difficult when the fracture is close to the joint, is destabilizing the prosthesis or is associated with reduced bone stock, and implant exchange should be considered, depending on the patient's health status. The aim is to obtain the fastest possible recovery while limiting complications and minimizing surgery time for often frail and elderly patients. The present study details the implant revision technique in periprosthetic distal femoral fracture, which requires experience in traumatology and prosthetic revision and material adapted to the situation. LEVEL OF EVIDENCE: V, expert opinion.