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

V-Y Quadricepsplasty for Knee Stiffness Post Total Knee Arthroplasty: A Case Report and Literature Review

Introduction

Knee stiffness post-total knee arthroplasty (TKA) represents a common and challenging complication. Standard treatment protocols primarily include physical therapy, manipulation under anesthesia (MUA), fibrotic tissue release, lysis of adhesions (LOA), and in refractory cases, revision arthroplasty. However, these interventions often show minimal improvement in refractory cases. This report introduces V-Y quadricepsplasty as an innovative approach for addressing knee stiffness post-TKA, particularly in cases unresponsive to MUA and LOA, without any evidence of prosthetic component malposition or failure.

Case Report

We present a case involving a middle-aged woman experiencing persistent knee stiffness post-TKA, unresponsive to both MUA and LOA. Diagnostic evaluations confirmed no malposition or failure of the prosthetic component. The patient underwent a successful V-Y quadricepsplasty, which resulted in significant improvement in her condition.

Conclusion

This case underscores the efficacy of V-Y quadricepsplasty in managing knee stiffness post-TKA, especially in cases where traditional treatments such as MUA and LOA are ineffective and there is no evidence of prosthetic component failure or malposition. This approach potentially offers a new avenue for treatment in similar clinical scenarios.

Total knee arthroplasty and periprosthetic distal femoral fracture: looking beyond the osteoporosis to previous osteoporotic fracture

Osteoporosis increases the risk of periprosthetic distal femoral fractures after TKA, especially in patients with a history of osteoporotic fractures. Therefore, careful assessment and proper treatment of osteoporosis need and the importance of taking osteoporotic medication needs to be recognized by the patients following primary TKA.

PURPOSE

Osteoporosis is a risk factor for fractures, including those of the hip, vertebrae, and distal radius; however, the association between osteoporosis and periprosthetic fractures after total knee arthroplasty (TKA) has not been much investigated. Therefore, we aimed to investigate the association of the presence of systemic osteoporosis with periprosthetic fractures after TKA.

METHODS

This study included 34 patients with periprosthetic fractures following primary TKA and 106 controls matched for age and sex. Bone mineral density was evaluated at the femoral neck, total hip, and lumbar spine using dual X-ray absorptiometry. Medical records were reviewed for age; sex; body mass index; smoking; rheumatoid arthritis, endocrine diseases, and cardiovascular diseases; history of glucocorticoid use; medication for osteoporosis; and history of previous osteoporotic fracture. In addition, anterior femoral notching after TKA was evaluated. Univariable and multivariable logistic regression analysis were used to determine factors associated with periprosthetic fracture.

RESULTS

The prevalence of osteoporosis in the fracture group was higher than that in the control group (61.8% vs. 40.6%, p=0.045). The rate of medication for osteoporosis was significantly low in the fracture group (47.6 % vs 76.7%, p=0.026). History of previous osteoporotic fracture (odds ratio [OR], 9.1; p=0.015) and osteoporosis (OR, 3.6; p=0.013) were significant risk factors for periprosthetic fractures after TKA. Medication for osteoporosis could decrease the risk of periprosthetic fracture (OR 0.3; p=0.020).

CONCLUSION

Osteoporosis is a major risk factor for periprosthetic distal femoral fractures after TKA. Therefore, careful assessment and proper treatment of osteoporosis need and the importance of taking osteoporotic medication needs to be recognized to the patients following primary TKA, especially in patients with a history of osteoporotic fracture.

LEVEL OF EVIDENCE

Prognostic study, level III.

Saw-box osteotomy versus reamer-box osteotomy in posterior stabilized total knee arthroplasty: a retrospective study of an average five year follow-up

PURPOSE

The purpose of this study is to compare the difference of results between two methods of femoral box osteotomy adopted by two designs of posterior stabilized total knee prostheses.

PATIENTS AND METHODS

Retrospective analysis of the results of two groups of patients operated upon using two primary PS TKA systems, PFC Sigma (DePuy Synthes, Johnson and Johnson®) and Genesis II prosthesis (Smith and Nephew®), with an average of five year follow-up was done. Group 1 included 152 knees in 121 patients and group 2 included 122 knees in 111 patients. The average follow-up period in both groups was five years. The box osteotomy method depends on bone saw in group 1, and bone reamer in group 2.

RESULTS

The KSS score of group 2 was better in the first six months postoperatively. Then, no significant differences were seen in the remaining follow-up visits. The risk of periprosthetic fractures was significantly higher in group 1 (p-value 0.040). Survival analysis showed a significantly shorter time for reoperation in group 1 than in group 2 as described by log-rank test, (p < 0.006).

CONCLUSION

The method of box cutting has an impact on the function and longevity of posterior stabilized primary knee implants. The risk of periprosthetic fractures can be reduced by proper patient selection, decreasing the box sizes, and development of more "controlled" box osteotomy instruments.

Bone Mineral Density is Associated With Adverse Events but not Patient-Reported Outcomes in Total Hip and Knee Arthroplasty

BACKGROUND

Although osteoporosis is common in patients undergoing elective total hip arthroplasty (THA) and total knee arthroplasty (TKA), its impact on postoperative outcomes has been inadequately studied. The purpose of this study was to evaluate the impact of bone mineral density (BMD) on adverse events and patient-reported outcomes in THA and TKA.

METHODS

A series of 1,306 THA and 1,046 TKA patients who had received osteodensitometry were analyzed retrospectively. Rates of readmission, complication, transfusion, and patient-reported outcome were correlated with BMD. Multivariable logistic regression models were used to assess the relationship between osteoporosis and adverse events.

RESULTS

Osteoporosis patients showed higher rates of 90-day readmission (THA: 8.5% versus 4.0%, P = .02; TKA: 8.9% versus 4.4%, P = .04) and transfusion (THA: 6.8% versus 1.2%, P < .001; TKA: 5.4% versus 1.5%, P = .005). After THA, rates of complications requiring intensive care management (5.1% versus 0.7%, P < .001) and rates of medical complications (3.5% versus 0.6%, P = .001) were increased. After TKA, rates of surgical complications (2.8% versus 0.8%, P = .04) were increased. Postoperatively, osteoporosis patients improved to comparable patient-reported outcomes as patients who had normal BMD. Multivariable logistic regression analyses revealed osteoporosis as an independent risk factor for readmissions, complications, and transfusions.

CONCLUSION

Osteoporosis is a risk factor for adverse events after THA and TKA. Affected patients show similar improvement of patient-reported outcome compared to patients who have normal BMD. As osteoporosis is modifiable, a systematic screening of patients scheduled for THA or TKA should be discussed.

Machine Learning for Opportunistic Screening for Osteoporosis and Osteopenia Using Knee CT Scans

PURPOSE

To predict whether a patient has osteoporosis/osteopenia using the attenuation of trabecular bone obtained from knee computed tomography (CT) scans.

METHODS

Retrospective analysis of 273 patients who underwent contemporaneous knee CT scans and dual-energy X-ray absorptiometry (DXA) within 1 year. Volumetric segmentation of the trabecular bone of the distal femur, proximal tibia, patella, and proximal fibula was performed to obtain the bone CT attenuation. The data was randomly split into training/validation (78%) and test (22%) datasets and the performance in the test dataset were evaluated. The predictive properties of the CT attenuation of each bone to predict osteoporosis/osteopenia were assessed. Multivariable support vector machines (SVM) and random forest classifiers (RF) were used to predict osteoporosis/osteopenia.

RESULTS

Patients with a mean age (range) of 67.9 (50-87) years, 85% female were evaluated. Seventy-seven (28.2%) of patients had normal bone mineral density (BMD), 140 (51.3%) had osteopenia, and 56 (20.5%) had osteoporosis. The proximal tibia had the best predictive ability of all bones and a CT attenuation threshold of 96.0 Hounsfield Units (HU) had a sensitivity of .791, specificity of .706, and area under the curve (AUC) of .748. The AUC for the SVM with cubic kernel classifier (AUC = .912) was better than the RF classifier (AUC = .683, P < .001) and better than using the CT attenuation threshold of 96.0 HU at the proximal tibia (AUC = .748, P = .025).

CONCLUSIONS

Opportunistic screening for osteoporosis/osteopenia can be performed using knee CT scans. Multivariable machine learning models are more predictive than the CT attenuation of a single bone.

Periprosthetic patella fractures in total knee replacement and revision surgeries: how to diagnose and treat this rare but potentially devastating complication-a review of the current literature

PURPOSE

Periprosthetic patella fractures (PPPFs) are infrequent but potentially devastating complications after total knee arthroplasty (TKA) and revision TKA (rTKA). These fractures may occur both in resurfaced and un-resurfaced patella. This review summarizes the current literature on PPPFs to help orthopedic surgeons diagnose and treat this uncommon but extremely challenging TKA complication.

METHODS

A comprehensive search was performed in three databases: PubMed, SCOPUS, and EMBASE. All relevant information was retrieved and summarized in this narrative review.

RESULTS

In the studies analyzed, there is a general trend in favor of nonsurgical treatment, except for implant loosening or extensor lag with extensor apparatus disruption, because surgery is often associated with poor clinical outcomes and high complication rates.

CONCLUSION

PPPF is a rare but catastrophic event in TKA and rTKA, occurring mainly in a reconstructed patella. Patient-, implant-, and surgical technique-related factors contribute to its multifactorial etiopathogenesis. Prevention plays a crucial role in reducing the PPPFs rate. Conservative management is the treatment of choice due to high surgery complication rates unless implant loosening, or extensor apparatus disruption occurs.

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.

Cruciate-Retaining Total Knee Arthroplasty: Current Concepts Review

Posterior cruciate-retaining (CR) total knee arthroplasty for osteoarthritis of the knee is a popular implant choice. At present, there is no consensus on whether sacrifice or retention of the posterior cruciate ligament (PCL) offers superior outcomes. This review explores the current literature available on CR total knee arthroplasty (TKA). PubMed was searched by keyword to find relevant articles for inclusion. Additional sources came from article references and joint registry reports. CR design knees have distinct kinematic gait patterns from posterior-stabilizing (PS) knees and exhibit paradoxical anterior femoral movement with less femoral rollback. While CR implants offer less flexion than PS designs, the difference is not clinically detectable as clinical scores are similar in the short and long term. CR implants have better long-term survival compared to PS knees, likely due to lower risk of aseptic loosening. CR total knee arthroplasties also have shorter operating times and lower risk of peri-prosthetic fractures. Because the CR implant is unconstrained, there may be an increased risk of instability compared to PS designs, but the literature is mixed. Overall, the current literature supports the continued use of CR TKAs due to their lower risk of complications, durability, and demonstrated equivalence in function to posterior-substituting models.

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.

Periprosthetic fractures: an unrecognized osteoporosis crisis

Total joint replacement is common and increasing. Many of these patients have low bone mineral density preoperatively, and arthroplasty leads to bone loss. As falls are common before and after arthroplasty, it is unsurprising that periprosthetic fractures, defined as those associated with an orthopedic device, whether a joint replacement or other internal fixation devices, are not rare. These fractures engender morbidity and mortality comparable to osteoporosis-related hip fractures but remain largely unrecognized and untreated by osteoporosis/metabolic bone disease clinicians. Indeed, recent osteoporosis guidelines are silent regarding periprosthetic fractures. The purposes of this clinical review are to briefly describe the epidemiology of arthroplasty procedures and periprosthetic fractures, raise awareness that these fractures are osteoporosis-related, and suggest approaches likely to reduce their occurrence. Notably, bone health evaluation is essential following the occurrence of a periprosthetic fracture to reduce subsequent fracture risk. Importantly, in addition to such secondary fracture prevention, primary prevention, i.e., bone health assessment and optimization prior to elective orthopedic procedures, is appropriate.

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.

Prevalence of osteoporosis and osteopenia in elderly patients scheduled for total knee arthroplasty

INTRODUCTION

Osteoporosis is a common comorbidity in elderly patients with osteoarthritis (OA) and may increase perioperative complications in orthopedic surgery (e.g., component migration, periprosthetic fractures). As there is no investigation of bone mineral density (BMD) in elderly patients prior to total knee arthroplasty (TKA) in Europe, we investigated this issue with a particular focus on a potential treatment gap.

MATERIALS AND METHODS

We assessed the BMD by dual-energy X-ray absorptiometry (DXA) in 109 consecutive elderly patients (age ≥ 70 years) scheduled for TKA. In addition to a detailed assessment of osteoporosis and osteopenia, the influence of clinical risk factors and radiological OA severity on BMD was evaluated using group comparisons and linear regression models. In addition, we analyzed differences in BMD between patients scheduled for TKA vs. total hip arthroplasty (THA).

RESULTS

Of the included 109 patients, 19 patients (17.4%) were diagnosed with osteoporosis and 50 (45.9%) with osteopenia. In the osteoporotic patients, a clinically relevant underdiagnosis concomitant with a serious treatment gap was observed in 95.0% of the patients. Body mass index, OA grade, and glucocorticoid use were identified as independent factors associated with BMD. No differences in BMD were found between the patients scheduled for TKA vs. THA.

CONCLUSIONS

Considering the high prevalence of osteoporosis and osteopenia in elderly patients, DXA screening should be recommended for patients ≥ 70 years indicated for TKA.

Constraint in complex primary total knee arthroplasty: rotating hinge versus condylar constrained implants

INTRODUCTION

Condylar constrained knee arthroplasties (CCKAs) and rotating hinge knee arthroplasties (RHKAs) achieved good outcomes in complex primary total knee arthroplasties (TKAs); however, long-term comparative studies are few. Using an arthroplasty registry, we sought to assess and compare in CCKAs and RHKAs: (1) the intra-operative rates of complications, (2) the survival rates, (3) the reasons for revision, and (4) the adjusted hazard ratios for failure.

MATERIALS AND METHODS

1432 constrained implants in primary TKAs performed for non-oncological indications were included: 703 RHKAs, 729 CCKAs. The two groups were comparable regarding age and gender. Kaplan-Meier curves were used to compare survival rates, multivariate analyses to assess the hazard ratios for failures.

RESULTS

The mean follow-up was 4.1 years (range 0-16.3) for CCKAs and 6.8 years (0-18.1) for RHKAs. The intra/peri-operative complications were similar in both the cohorts, with similar rates of femoral and tibial fractures. 10-year implant survival rates were similar in both the cohorts (91.9%, CI 95% 89.2-93.9% in RHKAs; 93.4%, CI 95% 90.3-95.6% in CCKAs). Periprosthetic infection was the most common reason for revision in the two cohorts, followed by aseptic loosening. Breakage occurred in 3 RHKAs (0.4%). CCKAs and RHKAs had a similar distribution of revision causes. Males aged less than 60 had significantly more failures, regardless the constraint degree. Unstemmed CCKAs significantly failed more than RHKAs and stemmed CCKAs.

CONCLUSIONS

Both modern CCKAs and RHKAs are viable long-term solutions in complex primary TKAs. More failures should be expected in males aged less than 60.

LEVEL OF EVIDENCE

IV, Therapeutic study.

Comparative Analysis of Contemporary Fixed Tibial Inserts: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

Background

Multiple options are available for the tibial insert in total knee arthroplasty (TKA). A systematic review (SR) and network meta-analysis (NMA) to compare available randomized controlled trials (RCTs) could assist with decision making. We aim to show that designs with increased conformity may improve function and satisfaction without an increase in complications though posterior stabilized (PS) inserts will likely have more flexion.

Methods

A search of MEDLINE, EMBASE, and the Cochrane Library was performed. Studies were limited to RCTs evaluating cruciate retaining (CR), PS, anterior stabilized (AS), medial pivot (MP), bicruciate retaining (BR), and bicruciate stabilizing (BCS) inserts. Mean differences (MD) were used for patient reported outcome measures (PROMs) and odds ratios (OR) for reoperation rates and MUA. A systematic review was performed for satisfaction.

Results

27 trials were identified. The NMA showed no difference from a statistical or clinical standpoint for PROMs evaluated. There was a statistical difference for increased flexion for PS knees (3 degrees p 0.04). There were no differences in the MUA or reoperation rates. There was insufficient information to determine if a specific insert improved satisfaction.

Discussion

The results of this NMA show no statistical or clinical difference in PROMs. There was higher flexion for PS knees though the amount was not clinically significant. There was insufficient data for conclusions on patient satisfaction. Therefore, the surgeon should evaluate the clinical situation to determine the best insert rather than choose and insert based on functional scores, patient satisfaction, or complication rates.

Tibial periprosthetic fractures in Total Knee Arthroplasty - A scoping review

Background

Periprosthetic tibial fractures in Total Knee Arthroplasty are much less commonly seen than femoral fractures, and there is a paucity of available literature and management recommendation for these fractures. We aimed to identify the relevant and up-to-date literature on this subject to analyse the incidence, risk factors, and management recommendations.

Methods

A literature search was done on the databases of PubMed and SCOPUS using appropriate keywords. All the published literature in the English language was included for this review.

Results

We included 21 studies comprising 260 tibial periprosthetic fractures (91 intra-operative (35%) and 169 (65%) post-operative or delayed fractures). Only 5.9% of these fractures were managed conservatively. Whereas 98 cases (58%) were managed with open reduction and internal fixation (ORIF) with plating, 19 (11.2%) were managed with revision TKA. Seventeen cases (10%) were managed with minimally invasive percutaneous plate osteosynthesis (MIPPO), and 8 (4.7%) were managed with intramedullary nailing. Less than 6% of cases were managed with other means, viz. megaprosthesis (n = 4), arthrodesis (n = 5), amputation (n = 1), and external fixator (n = 1).

Conclusion

Intraoperative fractures accounted for one-third of the fractures in our review. A majority of the delayed periprosthetic fractures were treated with surgical intervention. The most preferred surgical treatment method was ORIF of fractures using locking plates (either open or MIPPO). Revision TKA or megaprosthesis was used in cases with the loosened implants in association with the fracture.

Level of evidence

IV.

Total knee arthroplasty for acute tibial plateau fractures: a survey amongst 68 Dutch orthopaedic surgeons

In older patients with highly comminuted intra- articular tibial plateau fractures (TPFs), primary total knee arthroplasty (TKA) may be a treatment option. Our aim was to report and rank decisional factors considered by Dutch orthopaedic trauma and knee surgeons that may lead to the decision for TKA as treatment for TPFs. A survey was distributed among 141 experts on traumatology and arthroplasty of the knee. The survey assessed the likelihood of TKA surgery after TPF in various patient and radiological characteristics. The level of experience with this of each responder was also noted. Descriptive statistics were calculated for all items. 141 participants were approached and 68 responded (48.2%). Responders were not more likely to proceed with TKA based on fracture types, impaired mobility, multiple incisions for ORIF, body mass index and ASA classification. However, in patients with pre-existing osteoarthritis (OA) and age ≥ 80 a majority would be more likely to proceed with TKA, with respectively 69.1% and 50.0%. The most strongly considered factors were the presence of pre-existing OA, the age of the patient and the type of fracture, with respectively 55.9%, 51.4% and 42.6% of responders ranking it in their top three most important factors. The study showed that the presence of pre-existing symptomatic OA and age of the patient were valued highest and increased the probability of a TKA in acute TPFs.

Team Approach: Preoperative Management of Metabolic Conditions in Total Joint Replacement

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Total joint arthroplasties (TJAs) of the knee and hip have been considered 2 of the most successful surgical procedures performed to date.

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Frailty is defined as increased vulnerability to adverse outcomes with physiologic stress.

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Preoperative optimization of frailty and metabolic bone conditions, including osteoporosis, vitamin D deficiency, and diabetes, through a multidisciplinary approach can help improve outcomes and minimize costs after TJA.

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.