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Periprosthetic Fractures about the Knee

LXWebb MD

Credits:

Ray White, MD 

Russ Norris, MD

Dan Chan, MD

Dan Dziadozs, MD

Dan Tayag, MD

Lawrence X Webb MDDisclosures (5yrs)

Musculoskeletal Transplant Foundation – Speaker PanelZimmer consultant, serves in education and on surgical panels,

Biocomposites Inc., consultant

Research and Educational Support: Synthes, Zimmer, OREF, NIH, US Dept of Defense

Departmental Laboratory Support: Allergan, Arthroscopy Association of North America, American Society for Surgery of the Hand (ASSH), (AANA), Biomet, Department of Defense, JBJS Resident Journal (OREF), Medtronic, Musculoskeletal Transplant Foundation (MTF), NFL Charities, Omeros, Orthopaedic Research & Education Foundation (OREF), Orthopaedic Trauma Association (OTA), Scoliosis Research Society (SRS), Smith & Nephew, Synthes, Synthes Spine, Wiesler, Mordecai, Wright Medical Technology, Zimmer

Board, Southeastern Fracture Consortium,

Board, Central Georgia Health Network

Chair, OTA Bylaws Committee

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• Distal femur

• Proximal tibia*

• Patella*

* Large series delineating successful strategies isyet to be published

It’s a fracture with something in the way

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• Poor bone (osteoporotic)

• Periarticular location

• Poor protoplasm patients– Healing problems

– Medical issues

• Accurate reduction

• Stable fixation

• Preservation of soft tissues

• Early function

Treatment of acute distal femur fractures above a total knee arthroplasty: systematic review of 415 cases 

(1981‐2006)

• N=415, data from 29 case series

• Nonunion rate 9%, fixation failure rate of 4%, infection rate 3%, revision surgery rate of 13%

• Retrograde nailing associated with a relative risk reduction of 87% (p=0.01) for developing a nonunion and 70% (p=0.03) for requiring revision surgery compared to traditional (nonlocking) plating methods  

Herrera,DA , Kregor, PJ, Cole, PA Acta Orthop 2008 Feb;79(1):22-7

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Treatment of acute distal femur fractures above a total knee arthroplasty: systematic review of 415 cases 

(1981‐2006)

• Pointestimates also suggested risk reductions for locking plates compared to traditional plating.  RRRs for nonunion and revision surgery were also statistically significantly lower for locking plates compared to nonoperative treatment.

Herrera,DA , Kregor, PJ, Cole, PA et al Acta Orthop 2008 Feb;79(1):22-7

Operative Options

• Retrograde Nail

• Dual Plating

• Blade Plate

• Periarticular Locking Plate

Retrograde Nailing with TKR

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• Is there a hole?

• What size?

• Most CR knees will have an open box (11-20mm)

• PS knee frequently do NOT

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Polyaxial Locking Plates

• Enable fixation in small bone segments

• Enable use of screws to reduce fracture and then lock  

(“lag lag lock lock”)

• Can use with both femoral component prosthesis types

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• Polyaxial Locking 

• Ability to place screws around prosthesis/glue

– Wider

– Polyaxial

• Anatomically contoured

• Cable ready

Implant Options that Help

Distractor

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Indirect reduction

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Plate position

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Able to go long,(antecurved)

73 yo female S/P CephlomedullaryIM nailTKA 7 years priorFell at home

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Thank You

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Periprosthetic Tibial Fractures

• 0.4‐1.7%

• Non Displaced, Stable prosthesis: cast or brace

• Displaced, Stable prosthesis: orif

• Unstable prosthesis: prosthesis revision

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1 wk

4 wk

3 mo

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2 mo

5 mo

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Periprosthetic Patella Fractures

• Almost exclusively on the resurfaced patella

• Vascular supply (avn) may be an issue

• Classification:  (Sayeed, 2013) 

– Type1‐ intact extensor mechanism and stable implant  (nonop‐ Cast or brace in extension)

– Type2 complete disruption of ext mechanism + a stable implant 

Sayeed, SA et al J Long Term Eff Med Implants. 2013;23(4):331-6.Patellar fractures following total knee arthroplasty: a review.

Periprosthetic Patella Fractures– Type3

• a a loose implant – with reasonable bone stock

• b  poor bone stock 

--Reserve patellectomy for those with comminution or poor bone stock

* Large series delineating successful strategies is yet to be published