Modern Retrograde Intramedullary Nails Versus Periarticular Locked Plates for Supracondylar Femur Fractures After Total Knee Arthroplasty

This study purpose is to analyze outcomes of modern intramedullary (IM) nails with a locked distal screw versus periarticular locking plates for peri-prosthetic supracondylar femur fractures in TKA. Ninety-five consecutive fractures in 91 patients were retrospectively reviewed. Fixation included 29 knees with a retrograde IM nail and 66 periarticular locked plates. Six patients died and 4 were lost to follow-up. There were 2 (9%) nonunions in the IM nail group and 12 non-unions/delayed-unions (19%) in the locked plate group (P = 0.34). A mean of 5.0 distal screws was used in locked plates versus 3.8 distal screws in the IM nails (P < 0.001). Despite a greater quantity of screws in the distal fragment, the failure rate of locked plating was twice that of IM nail fixation.     

Periprosthetic Distal Femur Fracture after Total Knee Arthroplasty: A Systematic Review

This study was designed to itemize and analyze the classification of fracture types and their corresponding outcomes in an attempt to provide a better understanding of the current treatment methods. Two PubMed searches were performed using the words “periprosthetic distal femur fracture” and “periprosthetic supracondylar femur fracture” in studies that were published in the previous 10 years (2004–2014). Data from 41 articlesthat met the general inclusion criteria, were collected and categorized into fracture type and treatment method groupings. Healing outcome and complications were the two parameters used to analyze the data. Treatment techniques were grouped in the following categories: locking plate, non‐locking plate, intramedullary nail/rod, screw, blade plate, cerclage wires, allograft, external fixation, revision arthroplasty, non‐operative, and other. Classification systems by Lewis and Rorabeck, the Association for Osteosynthesis/Orthopedic Trauma Association (AO/OTA), Su et al., Neer et al., Kim et al., Backstein et al., and the Société Française de Chirurgie Orthopédique et Traumatologique were reported. In total 448 fractures were identified, of which Rorabeck type II was the most common fracture studied. The two most successful treatment options for periprosthetic distal femur fractures were locking plate (87%) and intramedullary nail/rod (84%). The most frequent complications associated with periprosthetic distal femur fractures included non/mal/delayed union and the need for revision. Locking plates used to treat Rorabeck type II fractures had a complication rate of 35% and those treated with intramedullary nailing had a higher complication rate of 53%. In conclusion, the most frequent type of periprosthetic distal femur fracture after total knee arthroplasty was Rorabeck type II. The most common treatments for these types of fractures are locked plating and intramedullary nailing, with similar healing rates of 87% and 84%, respectively. However, the complication rate for locked plating was lower than for intramedullary nailing.     

The Outcome and Complications of the Locked Plating Management for the Periprosthetic Distal Femur Fractures after a Total Knee Arthroplasty

Background

The osteosynthesis of the periprosthetic fractures following a total knee arthroplasty (TKA) can be technically difficult with the relatively small satisfactory outcomes and the high complication rates. The purpose of the study is to analyze the mid-term radiological and functional outcomes following the locked plating of the distal femur periprosthetic fractures after a TKA.

Methods

Records of 20 patients with a periprosthetic distal femur fracture following TKA treated by the locked plate osteosynthesis were retrospectively evaluated. The union rate, complications and functional outcome measures were analyzed.

Results

Successful union was achieved in 18 of the 19 patients available for the follow-up. The mean follow-up was 39 ± 10 months. Significant reductions (p < 0.05) in the range of motion and Western Ontario and McMaster Universities Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were evident in the follow-up. Secondary procedures were required in 5 patients to address the delay in union and the reduced knee range of motion. The osteosynthesis failed in 1 patient who underwent a revision TKA.

Conclusions

The satisfactory union rates can be achieved with the locked plate osteosynthesis in the periprosthetic distal femur fractures after TKA. Prolonged rehabilitation coupled with the un-modifiable risk factors can decrease the activity and satisfaction levels, which can significantly alter the functional outcome.     

Navigation-Assisted Total Knee Arthroplasty for the Knee Retaining Femoral Intramedullary Nail, and Distal Femoral Plate and Screws

Proper ligament balancing, restoration of the mechanical axis and component alignment are essential for the success and longevity of a prosthesis. In conventional total knee arthroplasty (TKA), an intramedullary guide is used to improve the alignment. An extramedullary guide can be used in cases of severe femoral bowing or intramedullary nailing but its use is more subjective and relies on the surgeon''s experience. This paper reports two successful cases of navigation-assisted TKA for severe right knee osteoarthritis retaining a femoral intrameullary nail, and left knee osteoarthritis retaining a distal femoral plate.     

Periprosthetic Supracondylar Femoral Fractures Above a Total Knee Replacement: Compatibility Guide for Fixation With a Retrograde Intramedullary Nail

The incidence of total knee arthroplasty (TKA) is increasing, as are periprosthetic supracondylar femoral fractures. Treatment is complex and may involve the use of a retrograde intramedullary femoral nail, and it is essential to know the nail will fit through the femoral prosthesis in line with the intramedullary canal. Knowledge of certain measurements is crucial i.e. minimal intercondylar distance and the position of the notch on the femoral component in relation to the intramedullary canal. A review of TKA prostheses dimensions and their compatibility with a retrograde nail was obtained directly from the manufacturers. A comprehensive data set lists manufacturer, model, size, minimal intercondylar notch distance and position. This will be of practical use when planning the operative management of periprosthetic supracondylar femoral fractures.     

Distal Femoral Arthroplasty for the Treatment of Periprosthetic Fractures After Total Knee Arthroplasty

Periprosthetic fractures after total knee arthroplasty present substantial challenge if associated with poor bone stock, fracture comminution, and loose or damaged components. Revision total knee arthroplasty with distal femoral arthroplasty is often necessary in these injuries. We reviewed 20 patients (22 knees) with a mean age of 69.5 years who underwent revision with distal femoral arthroplasty fracture. Patients were followed for an average of 58.6 months. At the latest follow-up, the mean Knee Society knee and functional score were 82.8 and 40, and the Short Form 36 mean physical functioning and mental functioning scores were 55.8 and 65.6, respectively. There were 10 postoperative complications with 5 patients requiring additional surgery. Distal femoral arthroplasty seems to be a viable option for complex periprosthetic femoral fractures after total knee arthroplasty. However, considering the relatively high rate of complications, this procedure should be reserved for patients where alternative treatments are not possible.     

Retrograde Intramedullary Nailing for Distal Femur Fracture with Osteoporosis

Background

The incidence of distal femur fracture in the elderly has been increasing recently, and commonly occurs with osteoporosis. Retrograde intramedullary nailing has been considered a good surgical option for distal femur fracture. The purpose of the present study was to present our surgical results with retrograde intramedullary nailing for distal femur fractures with osteoporosis.

Methods

Thirteen patients diagnosed with extra-articular distal femur fracture and osteoporosis and managed with retrograde intramedullary nailing were retrospectively reviewed. Cement augmentation was used in four patients, shape memory alloy was used in eight patients and both were used in one patient. All patients were followed up for more than 2 years. Radiologic alignments were scored and Tegner and the Lysholm activity score was used for a functional assessment.

Results

The average time to clinical union was 13 weeks (range, 10 to 15 weeks). In 12 of our cases, the total alignment scores were excellent. At the last follow-up, the mean range of motion was 116° (range, 110° to 125°). The average functional score at postoperative 1 year was 2.6 (range, 1 to 5).

Conclusions

Retrograde intramedullary nailing is a good surgical option for distal femur fracture with osteoporosis. Cement augmentation and shape memory alloy can also be used for added mechanical stability. This surgical technique is very useful for distal femur fracture with osteoporosis as it promotes fracture healing and early rehabilitation.     

Revision Total Knee Arthroplasty for Failure of Primary Treatment of Periprosthetic Knee Fractures

Periprosthetic knee fractures and their complications are expected to increase as the numbers of knee arthroplasties continue to rise. We report our experience with revision knee arthroplasty for failure of primary fracture treatment. Five periprosthetic knee non-unions and 1 mal-union in 6 patients, with ages ranging from 65 to 83 years (average 74.6 years) were treated with revision total knee arthroplasty, and were followed up for 3 to 10 years (average 4.5 years). Union occurred in 8 to 18 weeks (average 12.5 weeks). All patients were ambulatory at the latest follow-up, with a range of motion averaging 84.2° (P = 0.03), and an Oxford Knee Score averaging 35 (P = 0.03). We conclude that union complications of periprosthetic knee fractures can be satisfactorily addressed with revision arthroplasty.     

Primary Versus Secondary Distal Femoral Arthroplasty for Treatment of Total Knee Arthroplasty Periprosthetic Femur Fractures

Current methods of fixing periprosthetic fractures after total knee arthroplasty (TKA) are variable, and include open reduction and internal fixation (ORIF) via plating, retrograde nailing, or revision using standard revision TKA components or a distal femoral arthroplasty (DFA). The purpose of this study is to compare patients who failed plating techniques requiring subsequent revision to DFA to patients who underwent primary DFA. Of the 13 patients (9.2%) who failed primary ORIF, causes included nonunion (53.8%), infection (30.8%), loosening (7.7%), and refracture (7.7%). There were significantly more surgical procedures for ORIF revision to DFA compared to primary DFA. Complications for patients who underwent primary reconstruction with DFAs included extensor mechanism disruption (8.3%), infection (5.6%), and dislocation (2.8%). Primary reconstruction via ORIF is beneficial for preserving bone stock, but primary DFA may be preferred in osteopenic patients, or those at high risk for nonunion.     

Bone Hook Reduction Technique Combined with Lateral Parapatellar Arthrotomy for Periprosthetic Distal Femoral Fractures Following Total Knee Arthroplasty: A Technical Note

ObjectiveTo report a bone hook reduction technique combined with lateral parapatellar arthrotomy for periprosthetic distal femoral fractures following total knee arthroplasty (TKA).MethodsFrom April 2012 to June 2018, a total of 31 knees who underwent this technique for the treatment of periprosthetic distal femoral fractures following TKA were retrospectively reviewed. Through a lateral parapatellar arthrotomy, the vastus lateralis fascia was dissected from the muscle belly to allow anteromedial mobilization of the muscles. With direct visualization of the posteriorly angulated distal fragment, a bone hook was placed on the anterior flange of the femoral component. The hook was then elevated to correct the posteriorly angulated and shortened distal fragment. The coronal and sagittal alignments of the distal segment with the femoral shaft were confirmed using fluoroscopic images, and internal fixation was performed using an anatomically pre‐contoured lateral locked plate. Once the overall length and sagittal plane alignment were restored, the plate was inserted via the previous articular approach. The plate was centered on the femur using anteroposterior and lateral fluoroscopy and then fixed.ResultsA total of 28 patients underwent internal fixation using the bone hook reduction technique combined with lateral parapatellar arthrotomy for the treatment of periprosthetic distal femoral fractures following TKA. The average age at operation was 70.9 years (range, 62–83 years), and the average follow‐up period was 17.5 months (range, 12–48.5 months). Fractures were classified as Su type I (13/28 [46.4%]), type II (11/28 [39.3%]), and type III (4/28 [14.3%]). Bone union was confirmed radiographically in all patients.ConclusionThe bone hook reduction technique is a simple and effective method to reduce the distal fragment in periprosthetic distal femoral fractures following TKA.     

生长期儿童股骨干骨折髓内针内固定的远期观察

作者从1970～1985年收治生长期儿童股骨干骨折305例,其中切开复位髓内针内固定34例(38处股骨骨折),并进行了5～17年的长期随访观察,发现无1例出现术后早期并发症,12例(占33.3％)出现大粗隆发育受阻的晚期并发症。18例(22处股骨骨折)双下肢等长,13例患肢较健侧长0.8～1.4cm平均1.03cm,1例合并有下肢动脉损伤者出现下肢短缩。作者认为无论采用梅花型髓内针内固定,还是三棱型髓内针内固定都是可行的,但梅花型髓内针内固定有出现大粗隆发育受阻的危险。     

Treatment for Periprosthetic Cyst after Total Hip Arthroplasty: Analysis of Six Cases

The present study investigates the pathogenesis of periprosthetic cysts after total hip replacement, and explores appropriate treatment appoaches. Six patients with periprosthetic cysts after total hip arthroplasty were treated at the First Affiliated Hospital of Nanjing Medical University between 2009 and 2014. During surgery, it was found that all cysts communicated with the hip and the hip prosthesis could be seen after cyst excision. Four patients simply underwent cyst excision, and light red liquid was found in the cyst. Among them, radiological examination revealed that a part of the hip prosthesis projected from the bone bed in one case. Postoperative pathology revealed a synovial cyst with inflammatory cell infiltration. Prostheses were loosened in two cases, so cystectomy and revision of the prosthesis were performed at the same time. Among the six patients, polyethylene wear particles could be seen in five patients through a pathological polarizing microscope. Out of the four patients who underwent simple cyst excision, two patients experienced cyst recurrence within 1 year after surgery; however, there was no cyst recurrence in the two patients who underwent cyst excision and revision of the prosthesis. The formation of a periprosthetic cyst after hip replacement is likely to be related to polyethylene wear and undesirable prosthesis position; in addition, when treated by simple cyst excision, the rate of recurrence was higher.     

Corrective Osteotomy of the Distal Femur by Retrograde Nailing

Abstract Objective: Correction of deformities of distal femur by a supracondylar dome or drill hole osteotomy in combination with a retrograde intramedullary nailing as an alternative to the classic technique of osteotomizing with an oscillating saw and internally fixating with a blade plate. In addition, leg length discrepancies can be corrected by the use of a unilateral distraction fixator after correction of axial and torsional deformities. Indications: Multidimensional deformities of the distal femur. Deformities of the distal femur with shortening > 1.5 cm. Deformities of the distal femur in the presence of length discrepancy and torsional deformity of the lower leg. Distal femoral deformities that may later need to be treated with a total knee replacement. Contraindications: State after local bone or soft tissue infections. A condylar bone stock insufficient for purchase of screws for intramedullary locking. Surgical Technique: Knee arthroscopy. Determination of the entry point and direction of insertion of the intramedullary nail in the frontal and sagittal plane. Insertion of the nail up to the level of osteotomy, placement of Schanz screws proximal and distal to the planned osteotomy for later assessment of the degree of correction. Either dome os teotomy or drill hole osteotomy. Correction of axial and torsional malalignments. Advancing of nail and static locking. Optional: for intended callus distraction, mounting of a unilateral distraction fixator. Results: Follow-up after 29 (4–45) months of 18 patients, seven with callus distraction. The goal of correction was reached in 17 patients. Three nonunions and one osteomyelitis healed after surgical revision. The following is a reprint from Operat Orthop Traumatol 2003;15:363–86 and continues the new series of articles at providing continuing education on operative techniques to the European trauma community. Reprint from: Operat Orthop Traumatol 2003;15:363–86 DOI 10.1007/s00064-003-1084-5     

交锁髓内针治疗股骨髁上及髁间粉碎骨折35例

对交锁髓内钉治疗股骨髁上、髁间骨折的指征、方法、疗效及应用中的注意问题进行研究。随访本院11年间用交锁髓内钉固定股骨髁上及髁间骨折的病人,对病人的一般情况、术后并发症及功能恢复等作了分析。35例股骨远端髁上或髁间骨折中31例得到随访(平均27个月),骨折均愈合。采用改良膝关节功能评分,12例(38.7％)优,15例(48.4％)良,4例(12.9％)可,优良率为87.1％。认为股骨远端或髁间粉碎骨折作交锁髓内钉固定,关节面解剖对位,固定牢固、确实,术后能早期功能锻炼,避免了创伤性骨关节炎的发生,疗效满意。     

Unreamed Nailing of Diaphyseal and Metaphyseal Fractures of the Femur

Background: Femoral intramedullary nails with antegrade or retrograde options for insertion and different locking possibilities have extended the indications to include both diaphyseal and metaphyseal fractures. Patients and Methods: A prospective series of 63 patients were treated with three different unreamed nailing and interlocking techniques selected according to the predominant fracture location. Median age of the 30 women and 33 men was 39 (17–97) years. High-energy injuries had occurred in 37 patients. Antegrade nailing and interlocking with standard technique was used in 29 diaphyseal fractures, antegrade nailing and placement of the proximal locking device to the femoral head was performed in eleven proximal fractures with involvement of the intertrochanteric region, and retrograde nailing and standard interlocking was done in 23 mainly distal fractures. Results: We encountered two types of major mechanical complications: angular malalignment and protrusion of the nail into the knee joint following compression in the fracture. Angular malalignment was found in four fractures. One midshaft fracture was fixed in a valgus reduction. Varus malalignment and loss of fixation occurred in two high subtrochanteric fractures after proximal locking with a spiral blade. In another midshaft fracture redisplacement in varus occurred. Compression in the fracture with protrusion of the nail by 2–10 mm into the knee joint following retrograde nailing was observed in six osteoporotic patients. Only two of these patients had significant knee problems. The median time to union – 4 months – did not differ significantly between the fixation groups. Conclusions: Thus, there are still problems after nailing very proximal and distal fractures. Most postoperative complications were seen after retrograde nailing of distal fractures, but the consequences of fixation failure in very proximal fractures were worse. Nevertheless, a protocol that takes advantage of the different options for nail introduction and locking depending on the fracture location seems promising. Received: January 6, 2002; revision accepted: October 8, 2002 Correspondence Address Karl Akke Alberts, MD, PhD, Department of Orthopedics, Karolinska Hospital, 17176 Stockholm, Sweden, Phone (+48/8) 517-70000, Fax -72695, e-mail: akke.alberts@ks.se     

Supracondylar nailing of periprosthetic fractures above total knee arthroplasties

Supracondylar nailing was performed in 10 patients who sustained periprosthetic fractures above total knee arthroplasties. The fractures occurred in women with an average age of 67.4 years (range, 42–92 years). All fractures healed in a satisfactory alignment in an average duration of 13.2 weeks (range, 12–18 weeks). None of the fractures needed bone grafting. There were no cases of wound infections, nonunion or delayed union. All patients achieved satisfactory range of movement of the knee joint and preoperative functional status. Main complications included loosening of a distal screw in one patient and fracture above the short nail following a second injury in another patient. Use of a longer nail where possible and a condylar bolt for distal locking can easily avoid these complications. We conclude that supracondylar nailing, despite some limitations, is a satisfactory method of treatment for a majority of displaced periprosthetic fractures above well-fixed total knee arthroplasties.     

逆行和顺行交锁髓内钉治疗股骨干骨折的比较研究

目的比较逆行和顺行交锁髓内钉治疗股骨干骨折的愈合率和并发症。方法前瞻性地研究应用闭合扩髓交锁髓内钉技术治疗新鲜股骨干骨折72例，其中逆行钉治疗34例，顺行钉治疗38例。所有72例患者均进行了1次以上的随访，随访时间平均19个月（6～31个月）。结果逆行钉组中32例骨折愈合，延迟愈合3例，畸形愈合4例；顺行钉组35例骨折愈合，延迟愈合5例，畸形愈合3例。排除术前即有膝关节疼痛的病例，术后患侧膝关节疼痛者逆行钉组24例，顺行钉组9例；排除术前即有髋关节疼痛的病例，术后患侧髋关节疼痛者逆行钉组1例，顺行钉组6例。结论在骨折愈合方面，两种治疗方法无显著性差异。逆行钉治疗术后有较多的膝关节并发症而顺行钉治疗术后有较多的髋关节并发症。     

Functional Outcome of Total Knee Arthroplasty After Periprosthetic Distal Femoral Fracture

A prospective matched cohort study was performed to compare functional outcomes between 28 patients with periprosthetic femoral fractures and 28 with primary total knee arthroplasties (TKA). The mean follow-up was 6.7 years (range, 5–9). Radiographic osteopenia was a predisposing factor, but not notching, body mass index, or preinjury knee scores or motion. At last follow-up, the Knee Society scores, knee motion, Womac, and SF-12 were significantly lower in the fracture group, and were significantly decreased compared to the preinjury status. We found that periprosthetic distal femoral fracture after TKA worsens functional outcomes at the medium term, but arthroplasty complication and survival rates were similar in both groups.