Updated: 9/18/2018

TKA Periprosthetic Fracture

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Review Topic
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Questions
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Evidence
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Cases
3
Techniques
3
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Introduction
  • Categories of TKA periprosthetic fractures
    • location
      • distal femur periprosthetic fractures
      • proximal tibia periprosthetic fracture
      • patellar fractures
    • 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) 
        • 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
  •  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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Technique Guides (3)
Questions (18)

(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? Review Topic

QID: 4863
FIGURES:
1

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

3%

(141/4427)

2

Neglecting to use lag screws and cerclage cables

12%

(517/4427)

3

Locked plating instead of locked antegrade nailing

5%

(227/4427)

4

Use of a titanium plate instead of a stainless steel plate

10%

(456/4427)

5

Use of an extensile lateral approach instead of a submuscular approach

69%

(3063/4427)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

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%

(11/3335)

2

Open reduction and internal fixation with a distal femoral locking plate

91%

(3027/3335)

3

Open reduction and internal fixation with a condylar buttress plate

3%

(116/3335)

4

Distal femoral replacement arthroplasty

3%

(86/3335)

5

Closed reduction and fixation with an antegrade intramedullary nail

2%

(73/3335)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(SAE07HK.94) A 58-year-old woman is seen in the emergency department after falling at home. History reveals that she underwent right total knee arthroplasty 2 years ago. Radiographs are shown in Figures 56a and 56b. What is the most appropriate treatment? Review Topic

QID: 6054
FIGURES:
1

Closed reduction and casting

0%

(0/73)

2

Bed rest and skeletal traction

0%

(0/73)

3

Open reduction and internal fixation

63%

(46/73)

4

Retrograde intramedullary nailing

1%

(1/73)

5

Revision of the femoral component with a stemmed component

36%

(26/73)

N/A

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(SAE07HK.28) Figure 16 shows the radiograph of an otherwise healthy 62-year-old woman who fell. Management should consist of Review Topic

QID: 5988
FIGURES:
1

revision total hip arthroplasty with a cemented femoral component and adjuvant fracture fixation.

17%

(15/90)

2

revision total hip arthroplasty with a cementless femoral component and adjuvant fracture fixation.

71%

(64/90)

3

open reduction and internal fixation of the fracture and retention of the original components.

10%

(9/90)

4

removal of the components, open reduction and internal fixation of the fracture, and delayed replantation of the components when the fracture is healed.

1%

(1/90)

5

resection arthroplasty and internal fixation of the fracture.

1%

(1/90)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(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 Review Topic

QID: 5969
FIGURES:
1

closed reduction and casting for 6 weeks.

1%

(1/107)

2

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

0%

(0/107)

3

open reduction and internal fixation, using two cancellous screws.

4%

(4/107)

4

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

19%

(20/107)

5

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

72%

(77/107)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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(OBQ05.153) All of the following are risk factors for post-operative total knee arthroplasty periprosthetic supracondylar femur fractures EXCEPT: Review Topic

QID: 1039
1

Rheumatoid arthritis

7%

(68/962)

2

Parkinson's disease

8%

(78/962)

3

Chronic steroid therapy

1%

(12/962)

4

Revision knee arthroplasty

4%

(37/962)

5

Male gender

79%

(760/962)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 986
1

Open reduction and internal fixation of the tibia

1%

(32/2181)

2

External fixation

0%

(3/2181)

3

Intramedullary rod fixation

0%

(2/2181)

4

Revision with a long stem tibial component that bypasses the fracture

98%

(2136/2181)

5

Fracture bracing

0%

(5/2181)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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