Tibial periprosthetic fractures in Total Knee Arthroplasty – A scoping review

BackgroundPeriprosthetic tibial fractures in Total Knee Arthroplasty are much less commonly seen than femoral fractures, and there is a paucity of available literature and management recommendation for these fractures. We aimed to identify the relevant and up-to-date literature on this subject to analyse the incidence, risk factors, and management recommendations.MethodsA literature search was done on the databases of PubMed and SCOPUS using appropriate keywords. All the published literature in the English language was included for this review.ResultsWe included 21 studies comprising 260 tibial periprosthetic fractures (91 intra-operative (35%) and 169 (65%) post-operative or delayed fractures). Only 5.9% of these fractures were managed conservatively. Whereas 98 cases (58%) were managed with open reduction and internal fixation (ORIF) with plating, 19 (11.2%) were managed with revision TKA. Seventeen cases (10%) were managed with minimally invasive percutaneous plate osteosynthesis (MIPPO), and 8 (4.7%) were managed with intramedullary nailing. Less than 6% of cases were managed with other means, viz. megaprosthesis (n = 4), arthrodesis (n = 5), amputation (n = 1), and external fixator (n = 1).ConclusionIntraoperative fractures accounted for one-third of the fractures in our review. A majority of the delayed periprosthetic fractures were treated with surgical intervention. The most preferred surgical treatment method was ORIF of fractures using locking plates (either open or MIPPO). Revision TKA or megaprosthesis was used in cases with the loosened implants in association with the fracture.Level of evidenceIV     

The association between endocrine therapy use and osteoporotic fracture among post-menopausal women treated for early-stage breast cancer in Ontario,Canada

BackgroundThe use of endocrine therapy for early-stage breast cancer, particularly aromatase inhibitor therapy has been associated with an increased risk of osteoporosis and fracture in clinical trials. We sought to validate this observation in real-world practice.MethodsWe used health administrative data collected from post-menopausal women (aged ≥66 years) who were diagnosed with breast cancer and started on adjuvant endocrine therapy from 2005 to 2012. Patients were classified by use of either an aromatase inhibitor or tamoxifen and followed until 2017 for a new diagnosis of an osteoporotic fracture. A multivariable analysis using a Cox proportional hazards model was adjusting for age, medical co-morbidities, medication use and duration of endocrine therapy.ResultsWe identified 12,077 patients of whom 73% were treated with an aromatase inhibitor as compared to 27% with tamoxifen. Our multivariable analysis did not demonstrate any significant difference in the rate of osteoporotic fracture between patients treated with an aromatase inhibitor when compared with tamoxifen [Hazard ratio (HR) = 1.09; 95% confidence interval (CI) = 0.96–1.23, p-value = 0.18]. The 5-year rate of osteoporotic fracture for patients treated with either an aromatase inhibitor or tamoxifen was 7.5% and 6.9%, respectively. A completed sensitivity analysis did observe a decreased risk of fracture associated with tamoxifen usage over time.ConclusionWe could not detect a significant difference in the rate of osteoporotic fracture among patients treated with an aromatase inhibitor versus tamoxifen. Nonetheless, the risk with tamoxifen was numerically lower and significantly decreased when accounting for total duration of endocrine therapy.     

A “closed fracture” with a neighbouring venous ulcer

This is a case report of a 57-year-old lady that sustained a fracture of her distal tibia and fibula. In close proximity to the fracture was a chronic venous ulcer. She was treated as a closed fracture with an intramedullary nail and subsequently developed an infection, requiring further surgery, a prolonged course of antibiotics and 3 months stay in hospital in an attempt to save her leg. Any soft tissue defect close to a fracture should be treated as a source of contamination and infection and should be treated accordingly to avoid significant complications.     

Usefulness of docetaxel as first‐line chemotherapy for metastatic extramammary Paget's disease

In invasive extramammary Paget's disease (EMPD), distant metastases may develop and the condition may become fatal; however, no standardized treatment has been established. Although based on only a few cases, several chemotherapy regimens were reported to be promising. We conducted a multicenter, retrospective study to evaluate the efficacy of docetaxel for metastatic EMPD. We retrospectively collected data on 18 metastatic EMPD patients treated using docetaxel from 1998 to 2012 in 12 institutes in Japan. The following clinical data were collected: tumor response, time to progression, overall survival and adverse effects. Of those, three patients treated combined with S‐1, one patient treated with weekly schedule and one patient treated combined with radiotherapy were excluded from the further analysis. All 13 patients received monthly docetaxel as the first‐line treatment. The average number of treatment cycles was 9.1. Among the 12 patients with a confirmed response, seven (58%) showed a partial response, three (25%) stable disease and two (17%) progressive disease. The disease control rate (partial response + stable disease) was as high as 83%. The time to progression and median overall survival were 7.1 and 16.6 months, respectively. The 1‐year overall survival rate determined by the Kaplan–Meier method was 75.0%. All adverse effects were manageable and no treatment‐related deaths were observed. The high disease control rate and overall survival shown by this study suggest that first‐line use of docetaxel may be a promising treatment for metastatic EMPD. A prospective clinical trial is required to confirm our results.     

胫骨平台后内侧骨折的内固定治疗

目的探讨钢板内固定治疗胫骨平台后内侧骨折的疗效。方法回顾性分析2008年8月至2012年6月在我院行钢板内固定治疗且获得随访的23例胫骨平台后内侧骨折患者的病例资料。所有病例均采用后内侧入路,行钢板内固定治疗,术后进行临床和影像学随访。结果 23例患者均获得随访,随访时间14.0~54.0个月,平均20.2个月。无患者发生血管、神经损伤、内固定松动、断裂等情况。所有骨折均获得愈合,愈合时间为14.0~27.0周,平均17.3周。患者的完全负重时间平均为术后18.2周。骨折愈合后,根据Rasmussen膝关节功能评分标准评定疗效:优15例,良5例,中3例,优良率为87.0%。结论胫骨平台后内侧骨折采用后内侧或内侧入路进行钢板内固定治疗,并发症少,疗效满意。