Updated: 6/11/2021

TKA Periprosthetic Fracture

0%
Topic
Review Topic
0
0
0%
0%
Flashcards
3
N/A
N/A
Questions
20
0
0
0%
0%
Evidence
31
0
0
0%
0%
Videos / Pods
4
0%
0%
Cases
8
0%
Techniques
3
Topic
Images
https://upload.orthobullets.com/topic/5027/images/key_image.jpg
https://upload.orthobullets.com/topic/5027/images/img_1933.jpg
https://upload.orthobullets.com/topic/5027/images/su1.jpg
https://upload.orthobullets.com/topic/5027/images/su2.jpg
https://upload.orthobullets.com/topic/5027/images/su3.jpg
https://upload.orthobullets.com/topic/5027/images/locking_plate.jpg
https://upload.orthobullets.com/topic/5027/images/nonunion.jpg
https://upload.orthobullets.com/topic/5027/images/intraop.jpg
https://upload.orthobullets.com/topic/5027/images/tibial_ppfx_ap.jpg
https://upload.orthobullets.com/topic/5027/images/tibial_ppfx_lat.jpg
  • 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)
          • 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 Guides (3)
Flashcards (3)
Cards
1 of 3
Questions (20)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
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:
1

Patellectomy

5%

(183/3332)

2

Extensor mechanism allograft

9%

(293/3332)

3

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

5%

(176/3332)

4

Open reduction and internal fixation of the patella fracture

76%

(2539/3332)

5

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

4%

(133/3332)

L 2 B

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
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:
1

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

3%

(165/5287)

2

Neglecting to use lag screws and cerclage cables

12%

(617/5287)

3

Locked plating instead of locked antegrade nailing

6%

(297/5287)

4

Use of a titanium plate instead of a stainless steel plate

10%

(518/5287)

5

Use of an extensile lateral approach instead of a submuscular approach

69%

(3664/5287)

L 3 B

Select Answer to see Preferred Response

(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%

(16/4119)

2

Open reduction and internal fixation with a distal femoral locking plate

90%

(3710/4119)

3

Open reduction and internal fixation with a condylar buttress plate

3%

(141/4119)

4

Distal femoral replacement arthroplasty

3%

(122/4119)

5

Closed reduction and fixation with an antegrade intramedullary nail

3%

(105/4119)

L 1 B

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(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%

(11/647)

2

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

0%

(3/647)

3

open reduction and internal fixation, using two cancellous screws.

5%

(31/647)

4

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

18%

(116/647)

5

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

74%

(477/647)

L 2 E

Select Answer to see Preferred Response

(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%

(96/1405)

2

Parkinson's disease

7%

(104/1405)

3

Chronic steroid therapy

1%

(20/1405)

4

Revision knee arthroplasty

3%

(47/1405)

5

Male gender

80%

(1128/1405)

L 2 D

Select Answer to see Preferred Response

(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%

(35/2699)

2

External fixation

0%

(3/2699)

3

Intramedullary rod fixation

0%

(4/2699)

4

Revision with a long stem tibial component that bypasses the fracture

98%

(2646/2699)

5

Fracture bracing

0%

(5/2699)

L 1 C

Select Answer to see Preferred Response

Evidence (31)
VIDEOS & PODCASTS (6)
CASES (8)
EXPERT COMMENTS (13)
Private Note