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Kriechling P, Bowley ALW, Ross LA, Moran M, Scott CEH. Double plating is a suitable option for periprosthetic distal femur fracture compared to single plate fixation and distal femoral arthroplasty. Bone Jt Open 2024; 5:489-498. [PMID: 38862133 PMCID: PMC11166487 DOI: 10.1302/2633-1462.56.bjo-2023-0145.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2024] Open
Abstract
Aims The purpose of this study was to compare reoperation and revision rates of double plating (DP), single plating using a lateral locking plate (SP), or distal femoral arthroplasty (DFA) for the treatment of periprosthetic distal femur fractures (PDFFs). Methods All patients with PDFF primarily treated with DP, SP, or DFA between 2008 and 2022 at a university teaching hospital were included in this retrospective cohort study. The primary outcome was revision surgery for failure following DP, SP, or DFA. Secondary outcome measures included any reoperation, length of hospital stay, and mortality. All basic demographic and relevant implant and injury details were collected. Radiological analysis included fracture classification and evaluation of metaphyseal and medial comminution. Results A total of 111 PDFFs (111 patients, median age 82 years (interquartile range (IQR) 75 to 88), 86% female) with 32 (29%) Su classification 1, 37 (34%) Su 2, and 40 (37%) Su 3 fractures were included. The median follow-up was 2.5 years (IQR 1.2 to 5.0). DP, SP, and DFA were used in 15, 66, and 30 patients, respectively. Compared to SP, patients treated with DP were more likely to have metaphyseal comminution (47% vs 14%; p = 0.009), to be low fractures (47% vs 11%; p = 0.009), and to be anatomically reduced (100% vs 71%; p = 0.030). Patients selected for DFA displayed comparable amounts of medial/metaphyseal comminution as those who underwent DP. At a minimum follow-up of two years, revision surgery for failure was performed in 11 (9.9%) cases at a median of five months (IQR 2 to 9): 0 DP patients (0%), 9 SP (14%), and 2 DFA (6.7%) (p = 0.249). Conclusion Using a strategy of DP fixation in fractures, where the fracture was low but there was enough distal bone to accommodate locking screws, and where there is metaphyseal comminution, resulted in equivalent survival free from revision or reoperation compared to DFA and SP fixation.
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Affiliation(s)
| | | | - Lauren A. Ross
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Matthew Moran
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Chloe E. H. Scott
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Orthopaedics, University of Edinburgh, Edinburgh, UK
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Wood MJ, Al-Jabri T, Stelzhammer T, Brivio A, Donaldson J, Skinner JA, Barrett D. Distal femoral replacement for the treatment of periprosthetic distal femoral fractures around a total knee arthroplasty: a meta-analysis. Orthop Rev (Pavia) 2024; 16:94574. [PMID: 38666188 PMCID: PMC11043028 DOI: 10.52965/001c.94574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 02/02/2024] [Indexed: 04/28/2024] Open
Abstract
Background Periprosthetic fracture is a rare complication of arthroplasty but can have devastating consequences for the patient and presents a complex surgical challenge. Locking compression plate and retrograde intramedullary nail are both widely accepted surgical fixation techniques for distal femoral periprosthetic fractures around a total knee arthroplasty. Although there is still a need for further high-quality research into both techniques, there is even less literature concerning the use of distal femoral replacement to treat distal femoral periprosthetic fractures. Interest has been piqued in distal femoral replacements for the treatment of distal femoral periprosthetic fractures due to the theoretical advantages of immediate post-operative weight-bearing and lack of dependence on fracture union, but there are still understandably reservations about performing such an extensive and invasive procedure when an accepted alternative is available. This meta-analysis aims to evaluate the current literature to compare the complication rates and return to pre-operative ambulatory status of distal femoral replacement and locking compression plate. Method A literature search was performed to identify articles related to the management of distal femoral periprosthetic fractures around a total knee arthroplasty in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Methodological quality was assessed using the methodological index for non-randomized studies (MINORS) criteria. Articles were reviewed, and data extracted for analysis. Results Five articles met the inclusion criteria, reporting on 345 periprosthetic fractures. The overall rates of complications for distal femoral replacement and locking compression plate were: re-operation (6.1% vs 12.1%), infection (3.0% vs 5.3%), mortality (19.7% vs 19.3%), and return to pre-operative ambulatory status (60.9% vs 71.8%) (respectively). Conclusion This meta-analysis shows no statistically significant difference in the rates of re-operation, infection, mortality or return to pre-operative ambulatory status when comparing distal femoral replacement to locking compression plate.
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Affiliation(s)
- Matthew J Wood
- Joint Reconstruction Unit Royal National Orthopaedic Hospital
| | | | | | - Angela Brivio
- Trauma and Orthopaedic Surgery King Edward VII Hospital
| | - James Donaldson
- Joint Reconstruction Unit Royal National Orthopaedic Hospital
| | - John A Skinner
- Joint Reconstruction Unit Royal National Orthopaedic Hospital
| | - David Barrett
- Trauma and Orthopaedic Surgery King Edward VII Hospital
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Miettinen S, Sund R, Törmä S, Kröger H. How Often Do Complications and Mortality Occur After Operatively Treated Periprosthetic Proximal and Distal Femoral Fractures? A Register-based Study. Clin Orthop Relat Res 2023; 481:1940-1949. [PMID: 37036391 PMCID: PMC10499103 DOI: 10.1097/corr.0000000000002638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 01/25/2023] [Accepted: 03/07/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND The incidence of periprosthetic femoral fractures is increasing because of an increasing number of primary THAs and TKAs. High rates of complications and mortality are associated with periprosthetic fractures, but few studies have evaluated and compared the population-based incidences of these events after fractures. QUESTIONS/PURPOSES (1) What is the annual incidence of periprosthetic fractures treated with surgery in one hospital district in Finland? (2) How are those incidences changing over time? (3) What is the risk of complications, reoperations, and death after those injuries? METHODS This register-based study evaluated 2259 patients who underwent revision THA or TKA or any surgery for a femoral fracture between January 2004 and December 2016 at the only hospital in our district where these types of operations are performed. During the study period, the diagnosis and operation codes of the operated-on patients varied greatly, and they were somewhat inaccurate. We thus evaluated radiographs of all 2259 patients one by one, and created inclusion and exclusion criteria based on radiologic findings and medical records. Of those, 12% (279 of 2259) had periprosthetic fractures that met the inclusion criteria, and from these, we formed two study groups (periprosthetic proximal femur fractures, n = 171; periprosthetic distal femur fractures, n = 108). Eighty-eight percent (1980 of 2259) of the patients were excluded because they were treated for a condition other than periprosthetic femoral fracture. The follow-up period ended in December 2019 or at the time the patient died. To evaluate the population-based incidence, we drew the number of individuals with THA or TKA in the hospital district from the Finnish Arthroplasty Register and the Finnish Hospital Discharge Register. The characteristics of patients with operatively treated periprosthetic femoral fractures were evaluated in terms of age, gender, fracture type, implant type, and time from the index operation to periprosthetic fracture. The annual incidences of periprosthetic femoral fractures are summarized per 1000 person-years of individuals living with an implanted THA or TKA and per 100,000 individuals per year living in our hospital district. The risks of death, complications, and reoperations were evaluated for both groups, and comparisons were made in terms of patient characteristics. RESULTS The mean annual incidence of operatively treated periprosthetic proximal femur fractures per 1000 people living with THA implants was 2.3 ± 0.9 (95% confidence interval 1.8 to 2.7) per year, and for those with periprosthetic distal femur fractures with TKA implants, it was 1.3 ± 0.6 (95% CI 1.0 to 1.7). There was an increasing trend in the incidence of periprosthetic proximal femur fractures from 1.6 to 3.8 (95% CI 1.8 to 2.8) per 1000 arthroplasties, and it increased from 0.4 to 1.7 (95% CI 2.4 to 4.4) for periprosthetic distal femur fractures between 2004 and 2016. The mean population-based incidence of periprosthetic proximal femur fractures per 100,000 person-years was 5.3 ± 2.2 (95% CI 4.1 to 6.4) per year, and for periprosthetic distal femur fractures, it was 3.4 ± 1.7 (95% CI 2.5 to 4.4). The incidence of periprosthetic proximal femur fractures related to 100,000 person-years increased from 3.2 to 8.9 (95% CI 3.9 to 6.6), while the incidence of periprosthetic distal femur fractures increased from 1.3 to 4.4 (95% CI 2.4 to 4.8) during the study period. The cumulative incidence of major complications after periprosthetic proximal femur fracture was 8.8% at 1 year (95% CI 5.1% to 13.6%) and 12.3% at 10 years (95% CI 7.5% to 18.4%), and after periprosthetic distal femur fracture, it was 7.4% at 1 year (95% CI 3.5% to 13.4%) and 9.3% at 10 years (95% CI 4.7% to 15.7%). The cumulative incidence of reoperation after periprosthetic proximal femur fracture was 10.5% at 1 year (95% CI 6.5% to 15.7%) and 13.5% at 10 years (95% CI 8.9% to 19.1%), and for periprosthetic distal femur fracture, it was 8.3% at 1 year (95% CI 4.1% to 14.5%) and 13.8% at 10% years (95% CI 7.8% to 21.4%). The cumulative incidence of death after periprosthetic proximal femur fracture was 8.2% at 1 year (95% CI 4.7% to 12.9%) and 47.3% at 10 years (95% CI 38.1% to 55.9%), and after periprosthetic distal femur fractures, it was 14.8% at 1 year (95% CI 8.8% to 22.2%) and 67.8% at 10 years (95% CI 56.3% to 76.9%). CONCLUSION The increased use of THA and TKA has led to an increase in the incidence of operatively treated periprosthetic fractures, which means there will be more revisions in the future. Older age, frailty of these patients, and often-complicated fracture patterns are related to a high rate of complications, reoperations, and mortality. Healthcare systems must prepare for a large increase in revisions for periprosthetic fracture, which are morbid events for patients and costly ones for healthcare systems. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Simo Miettinen
- Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
- Kuopio Musculoskeletal Research Unit, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Reijo Sund
- Kuopio Musculoskeletal Research Unit, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Health and Social Economics Unit, Department of Health and Social Care Systems, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Samuli Törmä
- Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Heikki Kröger
- Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
- Kuopio Musculoskeletal Research Unit, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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Sambri A, Parisi SC, Zunarelli R, Di Prinzio L, Morante L, Lonardo G, Bortoli M, Montanari A, De Cristofaro R, Fiore M, De Paolis M. Megaprosthesis in Non-Oncologic Settings-A Systematic Review of the Literature. J Clin Med 2023; 12:4151. [PMID: 37373844 DOI: 10.3390/jcm12124151] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 05/31/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Modular megaprostheses (MPs) are commonly used after bone-tumor resection, but they can offer a limb salvage solution in massive bone defects. The aim of this systematic review of the Literature is to provide a comprehensive data collection concerning the use of MPs in non-oncologic cases, and to provide an overview of this topic, especially from an epidemiologic point of view. Three different databases (PubMed, Scopus, and Web of Science) were searched for relevant articles, and further references were obtained by cross-referencing. Sixty-nine studies met the inclusion criteria, reporting on cases of MP in non-oncologic cases. A total of 2598 MPs were retrieved. Among these, 1353 (52.1%) were distal femur MPs, 941 (36.2%) were proximal femur MPs, 29 (1.4%) were proximal tibia MPs and 259 (10.0%) were total femur MPs. Megaprostheses were most commonly used to treat periprosthetic fractures (1158 cases, 44.6%), in particular in the distal femur (859, 74.2%). Overall, complications were observed in 513 cases (19.7%). Type I (soft tissue failures) and type IV (infection) according to the Henderson classification were the most frequent (158 and 213, respectively). In conclusion, patients with severe post-traumatic deformities and/or significant bone loss who have had previous septic complications should be considered as oncologic patients, not because of the disease, but because of the limited therapeutic options available. The benefits of this treatment include relatively short operative times and immediate weight-bearing, thus making MP particularly attractive in the lower limb.
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Affiliation(s)
- Andrea Sambri
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Stefania Claudia Parisi
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Renato Zunarelli
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Lorenzo Di Prinzio
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Lorenzo Morante
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Gianluca Lonardo
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Marta Bortoli
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Andrea Montanari
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Roberto De Cristofaro
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Michele Fiore
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Massimiliano De Paolis
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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Scott CEH, Yapp LZ, Howard T, Patton JT, Moran M. Surgical approaches to periprosthetic femoral fractures for plate fixation or revision arthroplasty. Bone Joint J 2023; 105-B:593-601. [PMID: 37259633 DOI: 10.1302/0301-620x.105b6.bjj-2022-1202.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Periprosthetic femoral fractures are increasing in incidence, and typically occur in frail elderly patients. They are similar to pathological fractures in many ways. The aims of treatment are the same, including 'getting it right first time' with a single operation, which allows immediate unrestricted weightbearing, with a low risk of complications, and one that avoids the creation of stress risers locally that may predispose to further peri-implant fracture. The surgical approach to these fractures, the associated soft-tissue handling, and exposure of the fracture are key elements in minimizing the high rate of complications. This annotation describes the approaches to the femur that can be used to facilitate the surgical management of peri- and interprosthetic fractures of the femur at all levels using either modern methods of fixation or revision arthroplasty.
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Affiliation(s)
- Chloe E H Scott
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Orthopaedics, The University of Edinburgh, Edinburgh, UK
| | - Liam Z Yapp
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Tom Howard
- Royal Victoria Hospital, Kirkcaldy, Fife, UK
| | - James T Patton
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Matthew Moran
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
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Fu P, Liang W, Gao Z, Chen G, Fan W. Optimal surgical treatment for periprosthetic distal femoral fractures after total knee arthroplasty: a Bayesian-based network analysis. J Orthop Surg Res 2023; 18:122. [PMID: 36803522 PMCID: PMC9942323 DOI: 10.1186/s13018-023-03586-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 02/07/2023] [Indexed: 02/23/2023] Open
Abstract
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.
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Affiliation(s)
- Peng Fu
- grid.412676.00000 0004 1799 0784Department of Orthopaedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China ,grid.411870.b0000 0001 0063 8301Department of Orthopaedics, The Second Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Wenwei Liang
- grid.412676.00000 0004 1799 0784Department of Orthopaedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhenzhen Gao
- grid.411870.b0000 0001 0063 8301Department of Clinical Oncology, The Second Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Gang Chen
- grid.411870.b0000 0001 0063 8301Department of Orthopaedics, The Second Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Weimin Fan
- Department of Orthopaedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
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Clement ND, Avery P, Mason J, Baker PN, Deehan DJ. First-time revision knee arthroplasty using a hinged prosthesis : temporal trends, indications, and risk factors associated with re-revision using data from the National Joint Registry for 3,855 patients. Bone Joint J 2023; 105-B:47-55. [PMID: 36587261 DOI: 10.1302/0301-620x.105b1.bjj-2022-0522.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
AIMS The aim of this study was to identify variables associated with time to revision, demographic details associated with revision indication, and type of prosthesis employed, and to describe the survival of hinge knee arthroplasty (HKA) when used for first-time knee revision surgery and factors that were associated with re-revision. METHODS Patient demographic details, BMI, American Society of Anesthesiologists (ASA) grade, indication for revision, surgical approach, surgeon grade, implant type (fixed and rotating), time of revision from primary implantation, and re-revision if undertaken were obtained from the National Joint Registry data for England, Wales, Northern Ireland, and the Isle of Man over an 18-year period (2003 to 2021). RESULTS There were 3,855 patient episodes analyzed with a median age of 73 years (interquartile range (IQR) 66 to 80), and the majority were female (n = 2,480, 64.3%). The median time to revision from primary knee arthroplasty was 1,219 days (IQR 579 to 2,422). Younger age (p < 0.001), decreasing ASA grade (p < 0.001), and indications for revision of sepsis (p < 0.001), unexplained pain (p < 0.001), non-polyethylene wear (p < 0.001), and malalignment (p < 0.001) were all associated with an earlier time to revision from primary implantation. The median follow-up was 4.56 years (range 0.00 to 17.52), during which there were 410 re-revisions. The overall unadjusted probability of re-revision for all revision HKAs at one, five, and ten years after surgery were 2.7% (95% confidence interval (CI) 2.2 to 3.3), 10.7% (95% CI 9.6 to 11.9), and 16.2% (95% CI 14.5 to 17.9), respectively. Male sex (p < 0.001), younger age (p < 0.001), revision for septic indications (p < 0.001) or implant fracture (p = 0.010), a fixed hinge (p < 0.001), or surgery performed by a non-consultant grade (p = 0.023) were independently associated with an increased risk of re-revision. CONCLUSION There were several factors associated with time to first revision. The re-revision rate was 16.2% at ten years; however, the risk factors associated with an increased risk of re-revision could be used to counsel patients regarding their outcome.Cite this article: Bone Joint J 2023;105-B(1):47-55.
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Affiliation(s)
- Nick D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Peter Avery
- School of Mathematics, Statistics and Physics, Newcastle University, Newcastle upon Tyne, UK
| | | | - Paul N Baker
- Department of Orthopaedic Surgery, The James Cook University Hospital, Middlesbrough, UK
| | - David J Deehan
- Department of Orthopaedic Surgery, Freeman Hospital, Newcastle upon Tyne, UK
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Fu P, Liang W, Gao Z, Zheng S, Fan W. Comparison of locking compression plate and distal femoral replacement for periprosthetic distal femoral fractures: a retrospective study. J Int Med Res 2022; 50:3000605221133012. [PMID: 36284456 PMCID: PMC9608071 DOI: 10.1177/03000605221133012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To compare the clinical outcomes of locking compression plate (LCP) and distal femoral replacement (DFR) for periprosthetic distal femoral fractures (PDFFs) after total knee arthroplasty. METHODS This retrospective study identified patients with PDFFs in an institutional database between January 2012 and December 2021. Demographic data and clinical outcomes, including postoperative complications, reoperation, 1-year mortality, Knee Society Scores (KSS) and Knee Society Functional Score (KSFS) were analysed. RESULTS In total, 12 patients treated with LCP and six patients treated with DFR were included. There was no significant difference between the LCP and DFR groups in terms of postoperative complications (25.0% versus 33.3%, respectively), reoperation (8.3% versus 0.0%), respectively, 1-year mortality (8.3% versus 16.7%, respectively) or mean ± SD KSS (80.3 ± 8.3 versus 78.0 ± 2.5, respectively). However, the mean ± SD KSFS was significantly better for patients with LCP than for those with DFR (51.8 ± 12.5 versus 37.0 ± 6.7, respectively). CONCLUSION DFR provides similar clinical outcomes compared with LCP for PDFFs. Patients with advanced age may benefit from DFR to allow early weight bearing.
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Affiliation(s)
- Peng Fu
- Department of Orthopaedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
- Department of Orthopaedics, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang Province, China
| | - Wenwei Liang
- Department of Orthopaedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Zhenzhen Gao
- Department of Clinical Oncology, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang Province, China
| | - Song Zheng
- Department of Orthopaedics, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang Province, China
| | - Weimin Fan
- Department of Orthopaedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
- Weimin Fan, Department of Orthopaedics, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, China.
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Makaram NS, Ross LA, Keenan OJ, Magill M, Moran M, Scott CEH. Reliability of current classification systems for periprosthetic distal femur fractures. Injury 2022; 53:3430-3437. [PMID: 35948511 DOI: 10.1016/j.injury.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION This study aims to determine which Periprosthetic Distal Femur Fracture (PDFF) classification system is the most reliable. The secondary aim was to determine which classification system correlated most accurately with the surgical management recommended and delivered. METHODS Between 2011 and 2019, 83 patients with 83 PDFFs that extended to the femoral component of a total knee arthroplasty (TKA) were retrospectively identified from a trauma database. Minimum follow-up was 1 year. Age, BMI, time from TKA, operative management, and Nottingham Hip Fracture Scores were collected, and AP and lateral radiographs used to classify all fractures using seven established classification systems by two observers blinded to management. In patients treated operatively (n = 69), preoperative radiographs were reviewed by two surgeons with expertise in trauma and knee revision who recommended fixation or distal femoral replacement (DFR) requirement. RESULTS Mean age was 80.7 years (SD9.4) and 50 (84.7%) were female. PDFFs occurred at a mean 9.5 years (SD5.2) after primary TKA. Mean follow-up was 3.8 years (SD2.9). Management was fixation in 47, DFR in 22 and non-operative for 14. The Fakler classification demonstrated highest interobserver reliability (ICC=0.948), followed by the Rorabeck (ICC=0.903), UCS (ICC=0.850) and Chen (ICC=0.906). The Neer classification demonstrated weakest agreement (ICC=0.633). Overall accuracy of predicting DFR requirement (as determined by two experts) was highest for the Fakler system (83.9%). Compared with actual management delivered the Rorabeck system was most accurate (94.1%). Multivariate regression demonstrated that the ultimate need for DFR (n = 22) was independently associated with medial comminution (HR 2.66 (1.12-6.35 95%CI), p = 0.027) and fractures distal to the anterior flange and posterior condyle of the femoral component (HR 2.45 (1.13-5.31), p = 0.024). CONCLUSION The Fakler classification showed highest interobserver agreement and was most accurately predictive of the management recommended by two experts. No classification system accurately predicted the fractures that required DFR, and none included medial comminution which was independently associated with DFR requirement. There remains a need for a PDFF classification system that reliably guides operative management of PDFFs.
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Affiliation(s)
- Navnit S Makaram
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, United Kingdom; The University of Edinburgh, Little France Crescent, United Kingdom.
| | - Lauren A Ross
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, United Kingdom
| | - Oisin Jf Keenan
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, United Kingdom
| | - Matthew Magill
- The University of Edinburgh, Little France Crescent, United Kingdom
| | - Matt Moran
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, United Kingdom
| | - Chloe E H Scott
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, United Kingdom; The University of Edinburgh, Little France Crescent, United Kingdom
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10
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Ponugoti N, Raghu A, Kosy JD, Magill H. A comparison of distal femoral replacement versus fixation in treating periprosthetic supracondylar femur fractures: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2022; 143:3335-3345. [PMID: 36088601 DOI: 10.1007/s00402-022-04603-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 08/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The treatment of periprosthetic femur fractures around a total knee replacement remains a technical challenge for the orthopedic surgeon. Management options include non-operative treatment, plate fixation, intramedullary nailing and distal femur replacement (DFR), with few studies comparing fixation with DFR. This is an up-to-date meta-analysis in the literature to directly compare clinical outcomes between fixation and distal femoral replacement in the treatment of supracondylar periprosthetic femur fractures. METHODS A stratified literature search of the Medline, EMBASE and Cochrane databases was performed. All studies in English language were searched from inception to July 2022. The search was performed with the following MeSH terms: Periprosthetic fracture AND ORIF OR Internal Fixation AND Distal Femur Replacement. The search was conducted using a predesigned search strategy where all eligible literature was critically appraised for methodological quality using the Cochrane collaboration tool. We included Level I, II and III studies comparing fixation with DFR in the treatment of periprosthetic supracondylar femur fractures. Data from eligible studies were extracted by two authors (NP and AR) and a table created which included author, year, sample size, mean age, measured parameters, follow-up period, fracture classification, length of stay (days), mortality rate, revision rate and complication rate. RESULTS The extracted data were pooled for meta-analysis using RevMan® v5.3.5 software (Nordic Cochrane Centre, Copenhagen, Denmark) and forest plots constructed. A p value < 0.05 was considered statistically significant and confidence intervals (CI) set to 95%. A total of six studies were included in the meta-analysis (n = 406). 153 patients underwent distal femur replacement and 253 patients underwent fixation with a mean follow-up time of 71.4 months. The results of this analysis suggest no statistically significant difference in measured outcomes. CONCLUSION The results of this meta-analysis suggest no proven statistically significant difference between DFR and fixation in terms of length of hospital stay, mortality rate, revision rate and complication rate for the treatment of periprosthetic supracondylar femur fractures. Further prospective randomized research may help to define the specific indications for each treatment option which must include fracture configuration. Early functional outcome and cost-effectiveness have yet to be evaluated in the available literature.
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Affiliation(s)
| | - Aashish Raghu
- East and North Hertfordshire NHS Trust, Stevenage, UK
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11
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Distal femoral replacement or internal fixation for management of periprosthetic distal femur fractures: A systematic review. Knee 2022; 37:121-131. [PMID: 35772245 DOI: 10.1016/j.knee.2022.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 06/12/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The number of periprosthetic fractures above a total knee arthroplasty continues to increase. These fractures are associated with a high risk of morbidity and mortality. Techniques for addressing these fractures include open reduction internal fixation (ORIF) and revision arthroplasty, including distal femoral replacement (DFR). The primary aim of this review is to compare mortality and reoperation rates between ORIF and DFR when used to treat periprosthetic distal femur fractures. METHODS A systematic review including MEDLINE, Embase and Cochrane Library databases was completed from inception to April 10, 2021. Studies including a comparator cohort were meta-analyzed. RESULTS Fourteen studies were identified for inclusion, of which, five had sufficient homogeneity for inclusion in a meta-analysis. 30-day and 2-year mortality was 4.1% and 14.6% in the DFR group. There was no statistically significant difference between ORIF and DFR (log Odds-Ratio (OR) = -0.14, 95 %CI: -0.77 to 0.50). The reoperation rate in the DFR group was 9.3% versus 14.8% for ORIF, with no difference between groups (log OR = 0.10, 95 %CI: -0.59 to 0.79). There was no difference in rates of deep infection (log OR = 0.22, 95 %CI: -0.83 to 1.28). Direct comparison of functional outcomes was not possible, though did not appear significant. CONCLUSION DFR in the setting of periprosthetic distal femur fractures is equivalent to ORIF with respect to mortality and reoperation rate and thus a safe and reliable treatment strategy. DFR may be more reliable in complex fracture patterns where the ability to obtain adequate fixation is difficult.
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12
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Aebischer AS, Hau R, de Steiger RN, Holder C, Wall CJ. Distal Femoral Replacement for Periprosthetic Fractures After TKA: Australian Orthopaedic Association National Joint Replacement Registry Review. J Arthroplasty 2022; 37:1354-1358. [PMID: 35271977 DOI: 10.1016/j.arth.2022.02.115] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/23/2022] [Accepted: 02/28/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Distal femoral replacement (DFR) is a potential treatment option following periprosthetic fracture (PPF) of a total knee arthroplasty (TKA). However, there is limited literature regarding implant survivorship and complication rates. The aim of this study was to examine patient demographics and trends in usage, implant survivorship and modes of failure, and patient mortality following DFR for PPF captured by a national joint replacement registry. METHODS A retrospective registry review was performed using data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). In total, 306 DFR were performed for PPF of a known primary TKA. Eighty-five percent of patients were female, and the mean age was 76.4 years. Kaplan-Meier estimates of implant and patient survivorship were performed. RESULTS The number of DFR performed for PPF has doubled over the past five years. The cumulative percent second revision rate at six years was 12%. The most common indications for revision were infection (37%) and aseptic loosening (33%). Patient survivorship after DFR was 97% and 83% at five and ten years, respectively. CONCLUSION A national registry review has identified the increasing prevalence of DFR for PPF after primary TKA and demonstrated implant survivorship of 88% at midterm follow-up. Surgeons may consider DFR as an acceptable and durable treatment option. LEVEL OF EVIDENCE Level III - Case Series.
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Affiliation(s)
| | - Raphael Hau
- Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia; Department of Surgery, University of Melbourne, Northern Medical School, Epping, Victoria, Australia
| | - Richard N de Steiger
- Department of Surgery, Epworth Healthcare, University of Melbourne, Richmond, Australia; Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia
| | - Carl Holder
- MBiostat, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia
| | - Christopher J Wall
- Department of Orthopaedics, Toowoomba Hospital, Toowoomba, Australia; School of Medicine Rural Clinical School, University of Queensland, Toowoomba, Australia
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13
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Pujol O, Joshi-Jubert N, Nuñez JH, Pijoan J, Castellet E, Minguell J. High reoperation and mortality rate after distal femoral replacement for periprosthetic knee fracture in the elderly. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:911-918. [PMID: 35182239 DOI: 10.1007/s00590-022-03225-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/03/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE To analyze the outcomes of elderly patients with periprosthetic fractures around the knee operated on with a distal femur replacement (DFR). METHODS We performed a retrospective case series study of eleven elderly patients who underwent DFR due to a periprosthetic fracture. Mean follow-up was 30.1 months (SD 28.1). Demographic, clinical and radiological data were reviewed. A descriptive analysis and a study of survival were conducted. Then, a comparative analysis between the patients who needed reoperation and did not need reoperation, and the patients who died and the patients who were alive during the follow-up was performed. RESULTS Mean age was 77.1 years (SD 13.9). Reoperation rate was 36%, being infection the most common complication (27%). The risk of reoperation increased with a longer time between fracture and surgery. The 36.4% of patients died during the follow-up. Older age, need of blood transfusion and need of early reoperation were related to a higher risk of mortality. CONCLUSION DFR could be a valuable option for knee periprosthetic fractures in elderly patients. However, surgeons should be aware of the high reoperation and mortality rate.
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Affiliation(s)
- Oriol Pujol
- Knee Surgery Unit, Orthopedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain. .,Universitat Autónoma de Barcelona, Barcelona, Spain.
| | - Nayana Joshi-Jubert
- Knee Surgery Unit, Orthopedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Jorge H Nuñez
- Knee Surgery Unit, Orthopedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Joan Pijoan
- Knee Surgery Unit, Orthopedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Enric Castellet
- Knee Surgery Unit, Orthopedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Joan Minguell
- Knee Surgery Unit, Orthopedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Universitat Autónoma de Barcelona, Barcelona, Spain
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14
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Keenan OJF, Ross LA, Magill M, Moran M, Scott CEH. Immediate weight-bearing is safe following lateral locked plate fixation of periprosthetic distal femoral fractures. Knee Surg Relat Res 2021; 33:19. [PMID: 34172101 PMCID: PMC8229296 DOI: 10.1186/s43019-021-00097-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 03/29/2021] [Indexed: 12/13/2022] Open
Abstract
PURPOSE This study aimed to determine whether unrestricted weight-bearing as tolerated (WBAT) following lateral locking plate (LLP) fixation of periprosthetic distal femoral fractures (PDFFs) is associated with increased failure and reoperation, compared with restricted weight-bearing (RWB). MATERIALS AND METHODS In a retrospective cohort study of consecutive patients with unilateral PDFFs undergoing LLP fixation, patients prescribed WBAT were compared with those prescribed 6 weeks of RWB. The primary outcome measure was reoperation. Kaplan-Meier and Cox multivariable analyses were performed. RESULTS There were 43 patients (mean age 80.9 ± 11.7 years, body mass index 26.8 ± 5.7 kg/m2 and 86.0% female): 28 WBAT and 15 RWB. There were more interprosthetic fractures in the RWB group (p = 0.040). Mean follow-up was 3.8 years (range 1.0-10.4). Eight patients (18.6%) underwent reoperation. Kaplan-Meier analysis demonstrated no difference in 2-year survival between WBAT (80.6%, 95% CI 65.3-95.9) and RWB (83.3%, 95% CI 62.1-100.0; p = 0.54). Cox analysis showed increased reoperation risk with medial comminution (hazard ratio 10.7, 95% CI 1.5-80; p = 0.020) and decreased risk with anatomic reduction (hazard ratio 0.11, 95% CI 0.01-1.0; p = 0.046). Immediate weight-bearing did not significantly affect the risk of reoperation compared with RWB (relative risk 1.03, 95% CI 0.61-1.74; p = 0.91). CONCLUSIONS LLP fixation failure was associated with medial comminution and non-anatomic reductions, not with postoperative weight-bearing. Medial comminution should be managed with additional fixation. Weight-bearing restrictions additional to this appear unnecessary and should be avoided.
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Affiliation(s)
- Oisin J F Keenan
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.
| | - Lauren A Ross
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Matthew Magill
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Matthew Moran
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Chloe E H Scott
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
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15
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Thompson JW, Haddad FS. Integrated care systems in trauma to elective care: Can we emulate the integration of services in orthopaedic trauma care within elective practice? Bone Jt Open 2021; 2:411-413. [PMID: 34157862 PMCID: PMC8244793 DOI: 10.1302/2633-1462.26.bjo-2021-0113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Joshua W Thompson
- Department of Trauma and Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, London, UK
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, London, UK.,The Bone & Joint Journal, London, UK
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