Updated: 2/19/2022

TKA Periprosthetic Fracture

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  • 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
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Questions (21)
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(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:
1

Cruciate-retaining; Open reduction internal fixation with lateral locking plate

11%

(213/2023)

2

Cruciate-retaining; Retrograde femoral nail

8%

(155/2023)

3

Cruciate-retaining; Open reduction internal fixation with medial locking plate

1%

(30/2023)

4

Posterior-stabilized; Open reduction internal fixation with lateral locking plate

73%

(1474/2023)

5

Posterior-stabilized; Femoral component revision

7%

(139/2023)

N/A A

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(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:
1

Patellectomy

5%

(188/3462)

2

Extensor mechanism allograft

9%

(301/3462)

3

Revision of the patellar component with cement and bone grafting of any residual defect

5%

(179/3462)

4

Open reduction and internal fixation of the patella fracture

77%

(2652/3462)

5

Non-operative treatment in a knee brace locked in extension for 6 weeks

4%

(134/3462)

L 2 B

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(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:
1

Neglecting to add topical rhBMP-2 on a carrier-scaffold

3%

(172/5451)

2

Neglecting to use lag screws and cerclage cables

12%

(636/5451)

3

Locked plating instead of locked antegrade nailing

6%

(308/5451)

4

Use of a titanium plate instead of a stainless steel plate

10%

(528/5451)

5

Use of an extensile lateral approach instead of a submuscular approach

69%

(3781/5451)

L 1 B

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(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:
1

Closed reduction and long leg casting at 20 degrees of flexion for 6 weeks, followed by hinged-knee brace for 6 weeks.

0%

(16/4287)

2

Open reduction and internal fixation with a distal femoral locking plate

90%

(3853/4287)

3

Open reduction and internal fixation with a condylar buttress plate

3%

(146/4287)

4

Distal femoral replacement arthroplasty

3%

(131/4287)

5

Closed reduction and fixation with an antegrade intramedullary nail

3%

(115/4287)

L 1 B

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(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:
1

closed reduction and casting for 6 weeks.

2%

(14/744)

2

open reduction and internal fixation, using a locked intramedullary rod.

0%

(3/744)

3

open reduction and internal fixation, using two cancellous screws.

4%

(33/744)

4

open reduction and internal fixation, using a locked plate and screws.

19%

(138/744)

5

open reduction and internal fixation and revision of the femoral component.

74%

(547/744)

L 2 E

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(OBQ05.153) All of the following are risk factors for post-operative total knee arthroplasty periprosthetic supracondylar femur fractures EXCEPT:

QID: 1039
1

Rheumatoid arthritis

7%

(108/1537)

2

Parkinson's disease

7%

(109/1537)

3

Chronic steroid therapy

2%

(24/1537)

4

Revision knee arthroplasty

3%

(50/1537)

5

Male gender

80%

(1236/1537)

L 2 D

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(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
1

Open reduction and internal fixation of the tibia

1%

(37/2791)

2

External fixation

0%

(3/2791)

3

Intramedullary rod fixation

0%

(4/2791)

4

Revision with a long stem tibial component that bypasses the fracture

98%

(2735/2791)

5

Fracture bracing

0%

(5/2791)

L 1 C

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