This article is more than 5 years old. Information may no longer be current.
Surgeon recommends nailing or plating of periprosthetic fractures of the knee
Type 3 fractures can be managed with a constrained insert and stemmed femoral revision implant, which may be done with a tibial component revision.
Click Here to Manage Email Alerts
ORLANDO, Fla., USA — Revision total knee arthroplasty was recommended for Rohrbach type 3 periprosthetic fractures in a presentation at the Current Concepts in Joint Replacement Winter Meeting, here, as was the use of lateral submuscular plating for type 2 fractures and retrograde intramedullary nailing for type 1 fractures.
“Our algorithm is if the prosthesis is loose, obviously we revise,” Jose A. Rodriguez, MD, of Lenox Hill Hospital, in New York City, said. “If the patient is moribund, there is a role for nonoperative treatment, but that role is quite limited. If there is a proximal fracture with good bone stock, we use an intramedullary (IM) nail. If it is a distal fracture with very poor bone stock, we revise, and otherwise our standard treatment is lateral submuscular plating,” he said.
Images: Rodriguez JA
Loose implants
For type 3 fractures where the implant is loose, Rodriguez recommended doing a revision with a constrained insert and stemmed femoral revision prosthesis, with or without a tibial revision. He and his colleagues analyzed nine type 2 fractures and six type 3 fractures treated consecutively. Patients were a mean of 70 years old and the mean follow-up was 4.5 years.
Investigators selected mid-level constraint, which helped “to minimize the effect of epicondylar displacement on subsequent function once the fracture heals,” Rodriguez said.
“The technique included the use of a high-speed burr when the implant was not already loose in order to minimize the additional trauma of a resection,” he said.
All of the fractures united within 5 months and researchers found no malalignment that exceeded 5°. Rodriguez said none of the fractures in this series needed distal femoral replacement or conversion to a hinged knee prosthesis.
“This is the viable option in that it minimizes the risk of nonunion and malunion due to failure of internal fixation and it allows immediate weight bearing and range of motion,” he said.
Options for well fixed implants
According to Rodriguez, there are a variety of treatment options for type 2 displaced periprosthetic fractures, including IM nailing, lateral submuscular plating or revision surgery. He recommended submuscular plating, however, because it yields the most reproducible technique and one he uses because of its excellent healing rate. Citing literature on the subject, Rodriguez said Raab and colleagues reported a 100% healing rate with submuscular plating. Ricci and colleagues had an 86% healing rate and three nonunions with the technique and Deshmukh and colleagues showed a 100% healing rate, despite a 20% malunion rate and 12% complication rate, he noted.
Nailing, not conservative treatment
For type 1 nondisplaced fractures, Rodriguez advised against nonoperative treatment because 15% of patients have increased pain and casting can lead to an average 26° loss of motion. Retrograde IM nailing is his preferred option because it is the “most reproducible,” he said.
In a study presented at the American Association of Hip and Knee Surgeons meeting, Keyes and colleagues compared 96 consecutive periprosthetic knee fractures; 29 knees were treated with retrograde IM nails and 67 knees were treated with a periarticular locked plate. The investigators found two nonunions in the IM nail group and 12 nonunions in the locked plate group.
“They concluded that despite greater fixation of the distal fragment with their locked plating, in their hands, with their techniques, the fixation failure rate was greater by double in the plating group compared with the nailing group,” Rodriguez said. – by Renee Blisard Buddle
- References:
- Deshmukh A. Management of periprosthetic supracondylar fractures with revision arthroplasty. Presented at: EFORT Congress; June 2-5, 2010; Madrid.
- Keyes BJ. Paper #5. Presented at: American Association of Hip and Knee Surgeons Meeting; Nov. 2-4, 2012; Dallas.
- Raab GE. J Arthroplasty. 2005;20(8):984-989.
- Ricci WM. J Orthop Trauma. 2006;20(3):190-196.
- Rodriguez JA. Paper #96. Presented at: Current Concepts in Joint Replacement Winter Meeting; Dec. 12-15, 2012; Orlando, Fla., USA.
- For more information:
- Jose A. Rodriguez, MD, can be reached at Center for Joint Replacement & Reconstruction, North Shore LLJ/Lenox Hill Hospital, 130 E. 77th St., 11th Floor, New York, NY 10075 USA; email: josermd@aol.com.
Disclosure: Rodriguez receives consulting fees from Arthrex for design discussions, and consulting fees and research funds from DePuy, ExacTech, Smith & Nephew and Wright Medical Technology.
Perspective
Back to Top
Jean-Noel A. Argenson, MD
Distal femoral fractures occurring around total knee arthroplasty (TKA) implants are increasing in relation to the implants increased lifetime expectancy. This raises the question of operative treatment in elderly patients since most of these types of fractures are displaced and require surgery. The biggest challenge encountered by orthopaedic surgeons in charge of supracondylar femur fractures following TKA is the question of whether or not the implants are still well fixed or have become loose. The rigid fixation offered by the modern periarticular locking plates inserted through an additional lateral femur approach may balance with the easy, but limited use of intramedullary nails in the absence of implant loosening. When fixation is compromised, the use of a stemmed femoral implant is mandatory in order to bypass the fracture site with equal length material. This will require partial or complete TKA revision, according to the compatibility with the existing tibia component while achieving correct alignment and stability of the knee. Stemmed femoral implants are also indicated in cases of intraoperative fractures occurring during the course of TKA with satisfactory outcome when properly recognized during surgery.
Click Here to Manage Email Alerts