summary TKA Periprosthetic Fractures are a complication of knee arthroplasty that may involve the distal femur, the proximal tibia, or the patella. Diagnosis can be made with plain radiographs. CT can be helpful in surgical planning to assess for bone stock. Treatment can be nonoperative or operative depending on location of fracture, implant stability, available bone stock, and patient comorbidities. Epidemiology Anatomic location distal femur periprosthetic fractures proximal tibia periprosthetic fracture patellar fractures Etiology Timing intraoperative medial femoral condyle fracture most common postoperative Risk factors (general) poor bone quality age steroid use rheumatoid arthritis stress-shielding mechanical stress-risers screw holes local osteolysis stiffness neurological disorders epilepsy Parkinson's disease cerebellar ataxia myasthenia gravis polio cerebral palsy Distal Femur Periprosthetic Fractures Incidence 0.3%-2.5% Fracture specific risk factors anterior femoral notching (debatable) mismatch of elastic modulus between metal implant and femoral cortex rotationally constrained components Classification systems Lewis and Rorabeck is most commonly used Neer and Associates (1967) Type I Nondisplaced (<5 mm displacement and/or <5 degrees angulation) Type II Displaced > 1 cm Type IIa Displaced > 1 cm with lateral femoral shaft displacement Type IIb Displaced > 1 cm with medial femoral shaft displacement Type III Displaced and comminuted DiGioia and Rubash (1991) Group I Extra-articular, non-displaced (<5 mm and/or <5 degrees angulation) Group II Extra-articular, displaced (>5 mm and/or >5 degrees angulation) Group III Loss of cortical contact or angulated (10 degrees); may have intercondylar or T-shaped component Chen and Associates Classification (1994) Type I Nondisplaced Type II Displaced and/or comminuted Lewis and Rorabeck Classification (1997) Type I Nondisplaced; component intact Type II Displaced: component intact Type III Displaced; component loose or failing Su and Associates' Classification of Supracondylar Fractures of the Distal Femur Type I Fracture is proximal to the femoral component Type II Fracture originates at the proximal aspect of the femoral component and extends proximally Type III Any part of the fracture line is distal to the upper edge of anterior flange of the femoral component Treatment nonoperative casting or bracing indications nondisplaced fractures with stable prosthesis operative antegrade intramedullary nail indications supracondylar fracture proximal to the femoral component (Su Type I) retrograde intramedullary nail technical considerations at least 2 distal interlocking screws use end cap to lock most distal screw if available femoral component may cause starting point to be more posterior than normal and lead to hyperextension at the fracture site nail must be inserted deep enough (not protrude) to not abrade on patella/patellar component indications intact/stable prosthesis with open-box design to accommodate nail fracture proximal to femoral component (Su Type I) fracture that originates at the proximal femoral component and extends proximally (Su Type II) ORIF with fixed angle device indications intact/stable prosthesis Lewis-Rorabeck II or Su Types I or II (described above) unable to accommodate intramedullary device fracture distal to flange of anterior femoral component (Su Type III) can be combined with retrograde IMN to allow for earlier weight bearing techniques condylar buttress plate (non-locking) does not resist varus collapse locking supracondylar / periarticular plate polyaxial screws allow screws to be directed into best bone before locking into plate, and can avoid femoral component blade plate / dynamic condylar screw difficult to get adequate fixation around PS implants complications nonunion increased risk in plating via extensile lateral approach compared with submuscular approach malunion increased risk with minimally-invasive approach/MIPO revision to a long stem prosthesis indications loose femoral component Lewis-Rorabeck III or Su Type III (described above) with poor bone stock distal femoral replacement indications elderly patients with loose (Su type III) or malpositioned components and poor bone stock advantages immediate weight-bearing decreased operative time of procedure Tibial Periprosthetic Fractures Incidence 0.4%-1.7% Fracture specific risk factors prior tibial tubercle osteotomy component loosening component malposition insertion of long-stemmed tibial components Classification Felix and Associates' Classification of Periprosthetic Fractures of the Tibia Associated with TKA Type I Fracture of tibial plateau Type II Fracture adjacent to tibial stem Type III Fracture of tibial shaft, distal to component Type IV Fracture of tibial tubercle Treatment nonoperative casting or bracing indications nondisplaced fracture with stable prosthesis operative ORIF indications unstable fracture with stable prosthesis long-stem revision prosthesis indications displaced fractures with loose tibial component Patellar Periprosthetic Fractures Incidence 0.2%-21% in resurfaced patella 0.05% in unresurfaced patella Fracture specific risk factors patellar osteonecrosis asymmetric resection of patella inappropriate thickness of patella implant related central single peg implant uncemented fixation metal backing on patella inset patellar component Classification Goldberg Classification Type I Fracture not involving implant/cement interface or quadriceps mechanism Type II Fracture involving implant/cement interface and/or quadriceps mechanism Type III Type A: inferior pole fracture with patellar ligament rupture Type B: inferior pole fracture without patellar ligament rupture Type IV All types with fracture dislocations Ortiguera and Berry Classification of Postoperative Periprosthetic Patella Fractures Extensor Mechanism Component Type I Intact Stable Type II Disrupted Stable or loose Type IIIa Intact Loose, reasonable bone stock (patellar thickness ≥10 mm) Type IIIb Intact Loose, poor bone stock (<10 mm, marked comminution) Treatment nonoperative casting or bracing in extension indications stable implants with intact extensor mechanism non-displaced fractures operative indications loose patellar component extensor mechanism disruption techniques (indications for each have not been clearly defined) ORIF with or without component revision partial patellectomy with tendon repair patellar resection arthroplasty and fixation total patellectomy
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. TKA Revision Orthobullets Team Recon - High Tibial Osteotomy Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. TKA - Parapatellar Approach Derek T. Bernstein Stephen Incavo Recon - High Tibial Osteotomy Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. TKA - Varus Knee with Anterior Referencing and Gap Balancing Technique Derek T. Bernstein Stephen Incavo Recon - TKA Axial Alignment
QUESTIONS 1 of 23 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ20.121) A 72-year-old female patient presents with left leg pain after tripping over the rug at her home. She underwent a total knee arthroplasty 10 years ago. She reports activity-related pain in the left leg for several months prior to her fall. Figures A-C are her current radiographs. What is the most appropriate treatment for this patient? QID: 215532 FIGURES: A B C Type & Select Correct Answer 1 Cylinder cast and non-weightbearing for 8 weeks 1% (8/1294) 2 ORIF with strut grafting 8% (99/1294) 3 ORIF with intramedullary nail 8% (104/1294) 4 ORIF with revision total knee arthroplasty 75% (972/1294) 5 Proximal tibial replacement 8% (102/1294) L 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ18.222) A 79-year-old man sustains a fall and presents with the injury depicted in Figures A and B. He underwent total knee arthroplasty (TKA) 5 days ago and had been doing well prior to his recent fall. What is the TKA implant design and what is the most appropriate treatment? QID: 213118 FIGURES: A B Type & Select Correct Answer 1 Cruciate-retaining; Open reduction internal fixation with lateral locking plate 10% (234/2337) 2 Cruciate-retaining; Retrograde femoral nail 7% (166/2337) 3 Cruciate-retaining; Open reduction internal fixation with medial locking plate 1% (35/2337) 4 Posterior-stabilized; Open reduction internal fixation with lateral locking plate 74% (1736/2337) 5 Posterior-stabilized; Femoral component revision 6% (147/2337) N/A Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ14.114) A 72-year-old woman sustains a fall onto her knee three years after an uncomplicated total knee replacement. The fracture pattern is seen in Figure A. The operative note reveals that a cemented patellar component was used. On exam, she has a large effusion and an inability to straight leg raise. If the patellar component is well fixed, what is the best treatment option? QID: 5524 FIGURES: A Type & Select Correct Answer 1 Patellectomy 5% (197/3707) 2 Extensor mechanism allograft 9% (319/3707) 3 Revision of the patellar component with cement and bone grafting of any residual defect 5% (186/3707) 4 Open reduction and internal fixation of the patella fracture 77% (2856/3707) 5 Non-operative treatment in a knee brace locked in extension for 6 weeks 4% (137/3707) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.228) A 65-year-old female sustains a periprosthetic supracondylar femur fracture proximal to a well-fixed implant. She undergoes direct reduction and locked plating with a titanium distal femoral locking plate via an extensile lateral approach. At 9 months post-operatively, weightbearing is at 50% and is painful. Examination reveals mild swelling and warmth around the distal incision. Erythrocyte sedimentation rate and C-reactive protein are normal. Radiographs taken 9 months post-operatively are shown in Figure A. Which of the following may have increased the risk of this complication? QID: 4863 FIGURES: A Type & Select Correct Answer 1 Neglecting to add topical rhBMP-2 on a carrier-scaffold 3% (179/5751) 2 Neglecting to use lag screws and cerclage cables 12% (668/5751) 3 Locked plating instead of locked antegrade nailing 6% (338/5751) 4 Use of a titanium plate instead of a stainless steel plate 10% (553/5751) 5 Use of an extensile lateral approach instead of a submuscular approach 69% (3983/5751) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ13.200) A 62-year-old woman is brought to the emergency room after falling down a flight of stairs. Prior to her fall, she had no knee pain and was a community ambulator without assistance. Intraoperatively, it is determined that the implants are well-fixed. What is the best next treatment step to optimize her quality of life? QID: 4835 FIGURES: A Type & Select Correct Answer 1 Closed reduction and long leg casting at 20 degrees of flexion for 6 weeks, followed by hinged-knee brace for 6 weeks. 0% (17/4524) 2 Open reduction and internal fixation with a distal femoral locking plate 90% (4053/4524) 3 Open reduction and internal fixation with a condylar buttress plate 4% (159/4524) 4 Distal femoral replacement arthroplasty 3% (147/4524) 5 Closed reduction and fixation with an antegrade intramedullary nail 3% (118/4524) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07HK.9) A 75-year-old woman who fell on her right knee now reports pain and is unable to bear weight. History reveals that she underwent total knee arthroplasty on the right knee 6 years ago. Radiographs are shown in Figure 5. Management should now consist of QID: 5969 FIGURES: A Type & Select Correct Answer 1 closed reduction and casting for 6 weeks. 2% (17/899) 2 open reduction and internal fixation, using a locked intramedullary rod. 1% (5/899) 3 open reduction and internal fixation, using two cancellous screws. 4% (35/899) 4 open reduction and internal fixation, using a locked plate and screws. 17% (157/899) 5 open reduction and internal fixation and revision of the femoral component. 75% (674/899) L 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ05.153) All of the following are risk factors for post-operative total knee arthroplasty periprosthetic supracondylar femur fractures EXCEPT: QID: 1039 Type & Select Correct Answer 1 Rheumatoid arthritis 8% (142/1787) 2 Parkinson's disease 7% (128/1787) 3 Chronic steroid therapy 2% (30/1787) 4 Revision knee arthroplasty 3% (58/1787) 5 Male gender 79% (1417/1787) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ05.100) A 73 year-old female underwent total knee arthroplasty 10 years ago. She sustained a proximal tibial shaft periprosthetic fracture after a ground level fall. Radiographs show that the fracture involves the tibial component's stem with loosening of the tibial component. Which of the following is the most appropriate treatment? QID: 986 Type & Select Correct Answer 1 Open reduction and internal fixation of the tibia 1% (41/2956) 2 External fixation 0% (3/2956) 3 Intramedullary rod fixation 0% (5/2956) 4 Revision with a long stem tibial component that bypasses the fracture 98% (2894/2956) 5 Fracture bracing 0% (5/2956) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic
All Videos (11) Podcasts (2) IOEN Vail Arthroplasty Course CoinFlips: TKA Periprosthetic Fracture in 75M Bryan D. Springer Raymond H. Kim Matthew P. Abdel Elizabeth B. Gausden Recon - TKA Periprosthetic Fracture A 12/13/2022 460 views 4.5 (4) Login to View Community Videos Login to View Community Videos ICJR 9th Annual Revision Hip & Knee Course Management of Periprosthetic Fractures after TKA: ORIF vs. Revision - Gwo-Chin Lee, MD Recon - TKA Periprosthetic Fracture 8/2/2022 73 views 0.0 (0) Login to View Community Videos Login to View Community Videos ICJR 9th Annual Revision Hip & Knee Course Management of Patella Fractures after TKA: Classification and Treatment Algorithms - James A. Browne, MD James Browne Recon - TKA Periprosthetic Fracture 8/2/2022 40 views 0.0 (0) Recon⎜TKA Periprosthetic Fracture (ft. Dr. Matt Austin) Team Orthobullets 4 Recon - TKA Periprosthetic Fracture Listen Now 14:14 min 10/18/2019 93 plays 4.0 (1) Recon | TKA Periprosthetic Fracture Recon - TKA Periprosthetic Fracture Listen Now 15:30 min 12/11/2019 297 plays 5.0 (1) See More See Less
IOEN Vail Arthroplasty Course TKA Periprosthetic Fracture in 75M (C102094) Bryan D. Springer Recon - TKA Periprosthetic Fracture A 10/28/2022 6596 47 114 Interprosthetic Femur Fracture in 69F (C102066) Lisa Cannada Recon - TKA Periprosthetic Fracture B 7/2/2022 117 19 0 OhioHealth Grant Medical Center TKA Periprosthetic Fx in 83F (C101856) Travis Jones Sanjay Mehta Recon - TKA Periprosthetic Fracture A 11/19/2021 11167 27 46 See More See Less