Knee arthroplasty for acute fractures around the knee

S2k Guideline for Tibial Plateau Fractures - Classification, Diagnosis, and Treatment

Tibial plateau fractures are mostly complex and surgically demanding joint fractures, which require a comprehensive understanding of the fracture morphology, ligamentous and neurovascular injuries, as well as the diagnostic and therapeutic options for an optimal clinical outcome. Therefore, a standardised and structured approach is required. The success of the treatment of tibial plateau fractures relies on the interdisciplinary cooperation between surgical and conservative physicians in an outpatient and inpatient setting, physical therapists, patients and service providers (health insurance companies, statutory accident insurance, pension providers). On behalf of the German Society for Orthopaedics and Trauma Surgery (DGOU), the German Trauma Society (DGU) and the Society for Arthroscopy and Joint Surgery (AGA), under the leadership of the Fracture Committee of the German Knee Society (DKG), a guideline for tibial plateau fractures was created, which was developed in several voting rounds as part of a Delphi process. Based on the current literature, this guideline is intended to make clear recommendations and outline the most important treatment steps in diagnostics, therapy and follow-up treatment. Additionally, 25 statements were revised by the authors in several survey rounds using the Likert scale in order to reach a final consensus.

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.

[Intra-articular proximal tibia fractures]

The incidence of proximal intra-articular tibial fractures is continuously increasing. In addition to high-energy trauma in young patients, osteoporotic fractures occur more frequently in geriatric patients. After a thorough clinical examination including X‑ray and computed tomography (CT) imaging, consolidation of the soft tissue is followed by surgical treatment to achieve the best possible anatomic reconstruction of the articular surface. Nonanatomic reduction with articular gaps >2.5 mm leads to a significantly increased risk of osteoarthritis. Selection of the surgical approach and planning of the osteosynthesis are based on the fracture morphology and the existing soft tissue damage. In addition to arthroscopically assisted percutaneous procedures, sophisticated osteosynthesis is often necessary, which requires several surgical approaches. In this context, posterior surgical approaches are becoming increasingly more important. Primary knee arthroplasty can also play a role, particularly in older patients.

Distal femur complex fractures in elderly patients treated with megaprosthesis: Results in a case series of 11 patients

BACKGROUND

Surgical treatment of complex fractures of the distal femur in the elderly is controversial. Osteoporosis and pre-existent osteoarthritis are common comorbidities in the elderly which add to the need for early walking and rapid restoration of function and also pose significant obstacles to achievement of satisfactory results with standard fixation techniques. Recently, several authors have suggested that primary arthroplasty could be a viable alternative option to standard fixation techniques in selected patients with complex distal femur fractures.

AIM

To present our experience with 11 cases of distal femur fractures treated with knee arthroplasty and large femoral resection in a population of patients over the age of 85.

METHODS

Data from 11 consecutive patients (10 females, 1 male) presenting with acute intra-articular supracondylar or intercondylar distal femur fractures and with pre-existent primary osteoarthritis who were treated with primary knee arthroplasty were recorded. We collected standard demographic data, comorbidities and patient reported outcomes including Visual Analogical Scale (VAS), Oxford Knee Score (OKS) and Barthel's Index. Post-operative joint range of motion (ROM) and standard radiographic data were also collected.

RESULTS

At a mean follow-up of 23.2 mo, all of the implants were well-positioned and osteointegrated. Furthermore, all the patients were alive and walking either independently or with walking aids. There was a marked improvement in pain (VAS 4.5 postop vs 1.9 at the last follow-up), OKS score (29.5 postop vs 36.81 at the last follow-up), ROM (96.2° postop vs 102° at the last follow-up) and restoration of pre-injury ambulatory status (average Barthel Index 77.3). The radiographic evaluations showed good restoration of the articular geometry. No deaths and no complications were recorded.

CONCLUSION

In conclusion, we believe that knee megaprosthesis in the case of complex fractures of the distal femur is a valid surgical choice. This is particularly true in elderly patients with severe osteoporosis and pre-existing osteoarthritis. It is important to note that this surgery should be performed by surgeons with proven experience in prosthetic hip and knee surgery and that a scrupulous selection of the cases is completed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Shaft Fractures in Patients Requiring Primary or Revision Total Knee Arthroplasty Can Be Successfully Treated with Long-Stemmed Implants without Additional Fixation

The aim of this study was to evaluate the bone union, complication rate, clinical and functional outcomes of long-stemmed total knee arthroplasty (TKA) in patients with periprosthetic femoral or tibial shaft fractures and in patients with femoral or tibial shaft fractures with coexisting advanced knee osteoarthritis (OA). This retrospective study comprised 25 patients who underwent surgery due to tibial or femoral shaft fractures: (1) with coexisting severe knee OA or (2) with a periprosthetic fracture requiring implant exchange. In all cases, fracture stabilization was performed intramedullary with the use of long-stemmed implants without the use of additional fixation material (plates, screws, or cerclage). Bone union was achieved in 22/25 patients (88%). One patient required revision with additional plate stabilization due to non-union, and asymptomatic partial bone union was observed in two cases. The group with periprosthetic fractures demonstrated good clinical (mean 73.1 ± 13.3) and moderate functional (mean 59.2 ± 18.8) outcomes in the Knee Society Scoring system (KSS). In the group with shaft fracture and coexisting OA significantly higher clinical (excellent results, mean 84.1 ± 11; p = 0.03) and functional (good results, mean 76.2 ± 20.6; p = 0.04) results were noted. There were no statistically significant differences in terms of range of motion (ROM) or complication rate between these two groups. One-stage TKA with a long-stemmed implant without the use of additional fixation material is an effective method for the treatment of femoral or tibial shaft fractures in patients who require joint replacement. Despite being technically demanding, the approach yields bone union and moderate to excellent clinical and functional outcomes with a relatively low complication rate.