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Modified fixations for distal femur fractures following total knee arthroplasty: a biomechanical and clinical relevance study

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Distal femur fractures adjacent to total knee arthroplasty are a rare yet complex problem. Recently, extramedullary locking plate and retrograde intramedullary nail fixations have become popular options, but the complication rates associated with these procedures are 15–20 %. Modified fixations were assessed in an effort to reduce complications from unstable periprosthetic fractures.

Methods

Using experimental and finite element methods, this study compared the construct behaviours of a locking plate, a retrograde intramedullary nail, and their modifications (a spiral-blade supplemented in an intramedullary nail or a locking plate/allograft hybrid) when subjected to various fracture types, locations, loading conditions, and bony strength. The implanted models were used to assess construct stiffness, fracture micromotion, and implant stress under different osteoporotic conditions. Finally, we collected 40 cases for radiological analysis to indicate the appropriate procedure for treating periprosthetic fractures following total knee arthroplasty.

Results

Regardless of the fracture type, femoral constructs fixed with a conventional or spiral-blade supplemented intramedullary nail exhibited higher axial but lower torsional stiffness than those fixed with a locking plate. Torsional deformation occurred if the lower-positioned fracture had no medial support. The locking plate/allograft construct exhibited the highest stiffness and the least micromotion. A review of 40 clinical cases confirmed the above findings regarding the locking plate/allograft construct.

Conclusion

The spiral-blade supplement of retrograde intramedullary nail and locking plate/allograft modified constructs significantly stabilizes the unstable fractured gaps. The locking plate/allograft is recommended for the periprosthetic fractures with deficient bone stock and severe osteoporosis to improve alignment and healing potentials.

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References

  1. Althausen PL, Lee MA, Finkemeier CG, Meehan JP, Rodrigo JJ (2003) Operative stabilization of supracondylar femur fractures above total knee arthroplasty: a comparison of four treatment methods. J Arthroplasty 18(7):834–839

    Article  PubMed  Google Scholar 

  2. Anakwe RE, Aitken SA, Khan LAK (2008) Osteoporotic periprosthetic fractures of the femur in elderly patients: outcome after fixation with the LISS plate. Injury 39(10):1191–1197

    Article  CAS  PubMed  Google Scholar 

  3. Bong MR, Egol KA, Koval KJ, Kummer FJ, Su ET, Iesaka K et al (2002) Comparison of the LISS and a retrograde-inserted supracondylar intramedullary nail for fixation of a periprosthetic distal femur fracture proximal to a total knee arthroplasty. J Arthroplasty 17(7):876–881

    Article  PubMed  Google Scholar 

  4. Bottlang M, Lesser M, Koerber J, Doornick J, von Rechenberg B, Augat P et al (2010) Far cortical locking can improve healing of fractures stabilized with locking plates. J Bone Joint Surg Am 92(7):1652–1660

    Article  PubMed  PubMed Central  Google Scholar 

  5. Chen AF, Choi LE, Colman MW, Goodman MA, Crossett LS, Tarkin IS (2013) Primary versus secondary distal femoral arthroplasty for treatment of periprosthetic femur fractures after total knee arthroplasty. J Arthroplasty 28(9):1580–1584

    Article  CAS  PubMed  Google Scholar 

  6. Chen SH, Yu TC, Chang CH, Lu YC (2008) Biomechanical analysis of retrograde intramedullary nail fixation in distal femoral fractures. Knee 15(5):384–389

    Article  PubMed  Google Scholar 

  7. Clatworthy MG, Ballance J, Brick GW, Chandler HP, Gross AE (2001) The use of structural allograft for uncontained defects in revision total knee arthroplasty: a minimum five-year review. J Bone Joint Surg Am 83(3):404–411

    PubMed  Google Scholar 

  8. Currall VA, Kulkarni M, Harries WJ (2007) Retrograde nailing for supracondylar fracture around total knee replacement: a compatibility study using the Trigen supracondylar nail. Knee 14(3):208–211

    Article  CAS  PubMed  Google Scholar 

  9. Deshmukh AJ, Thakur RR, Rasquinha VJ, Rodriguez JA (2014) Femoral revision arthroplasty for Su type 3 supracondylar periprosthetic knee fractures. J Knee Surg 28(4):349–354

    Article  PubMed  Google Scholar 

  10. DiGioia AM, Rubash HE (1991) Periprosthetic fractures of the femur after total knee arthroplasty: a literature review and treatment algorithm. Clin Orthop Relat Res 271:135–142

    PubMed  Google Scholar 

  11. Hart RA, Daniels AH, Bahney T, Tesar J, Sales JR, Bay B (2011) Relationship of donor variables and graft dimension on biomechanical performance of femoral ring allograft. J Orthop Res 29(12):1840–1845

    Article  PubMed  Google Scholar 

  12. Henderson CE, Lujan TJ, Kuhl LL, Bottlang M, Fitzpatrick DC, Marsh JL (2011) 2010 mid-America Orthopaedic Association Physician in Training Award: healing complications are common after locked plating for distal femur fractures. Clin Orthop Relat Res 469(6):1757–1765

    Article  PubMed  PubMed Central  Google Scholar 

  13. Heiney JP, Barnett MD, Vrabec GA, Schoenfeld AJ, Baij A, Njus GO (2009) Distal femora fixation: a biomechanical comparison of trigen retrograde intramedullary (I.M.) nail, dynamic condylar screw (DCS), and locking compression plate (LCP). J Trauma 66(2):443–449

    Article  PubMed  Google Scholar 

  14. Herrera DA, Kregor PJ, Cole PA, Levy BA, Jonsson A, Zlowodzki M (2008) Treatment of acute distal femur fractures above a total knee arthroplasty: systematic review of 415 cases (1981–2006). Acta Orthop 79(1):22–27

    Article  PubMed  Google Scholar 

  15. Horneff JG III, Jafari SM, Mirza A, Parvizi J, Mehta S (2013) Intramedullary nailing versus locked plate for treating supracondylar periprosthetic femur fractures. Orthopedics 36(5):561–566

    Article  Google Scholar 

  16. Ito K, Hungerbühler R, Wahl D, Grass R (2001) Improved intramedullary nail interlocking in osteoporotic bone. J Orthop Trauma 15(3):192–196

    Article  CAS  PubMed  Google Scholar 

  17. Jassim SS, McNamara I, Injury Hopgood P (2014) Distal femoral replacement in periprosthetic fracture around total knee arthroplasty. Injury 45(3):550–553

    Article  CAS  PubMed  Google Scholar 

  18. Johnston AT, Tsiridis E, Eyres KS, Toms AD (2012) Periprosthetic fractures in the distal femur following total knee replacement: a review and guide to management. Knee 19:156–162

    Article  PubMed  Google Scholar 

  19. Kassab M, Zalzal P, Azores GMS, Pressman A, Liberman B, Gross AE (2004) Management of periprosthetic femoral fractures after total knee arthroplasty using a distal femoral allograft. J Arthroplasty 19(3):361–368

    Article  PubMed  Google Scholar 

  20. Kim KI, Egol KA, Hozack WJ, Parvizi J (2006) Periprosthetic fractures after total knee arthroplasties. Clin Orthop Relat Res 446:167–175

    Article  PubMed  Google Scholar 

  21. Kolb K, Koller H, Lorenz I, Holz U, Marx F, Grutzner P, Kolb W (2009) Operative treatment of distal femoral fractures above total knee arthroplasty with indirect reduction technique. A long-term follow-up study. Injury 40(4):433–439

    Article  PubMed  Google Scholar 

  22. Koval KJ, Hoehl JJ, Kummer FJ, Simon JA (1997) Distal femoral fixation: a biomechanical comparison of the standard condylar buttress plate, a locked buttress plate and the 95 degree blade plate. J Orthop Trauma 11(7):521–524

    Article  CAS  PubMed  Google Scholar 

  23. Kumar A, Chambers I, Maistrelli G, Wong P (2008) Management of periprosthetic fracture above total knee arthroplasty using intramedullary fibular allograft and plate fixation. J Arthroplasty 23(4):554–558

    Article  PubMed  Google Scholar 

  24. Lujan TJ, Henderson CE, Madey SM, Fitzpatrick DC, Marsh JL, Bottlang M (2010) Locked plating of distal femur fractures leads to inconsistent and asymmetric callus formation. J Orthop Trauma 24(3):156–162

    Article  PubMed  Google Scholar 

  25. Meneghini RM, Keyes BJ, Reddy KK, Maar DC (2014) Modern retrograde intramedullary nails versus periarticular locked plates for supracondylar femur fractures after total knee arthroplasty. J Arthroplasty 29(7):1478–1481

    Article  PubMed  Google Scholar 

  26. Ricci W (2013) Classification treatment of periprosthetic supracondylar femur fractures. J Knee Surg 26(1):9–14

    Article  PubMed  Google Scholar 

  27. Schutz M, Muller M, Krettek C et al (2001) Minimally invasive fracture stabilization of distal femoral fractures with the LISS: a prospective multicenter study. Results of a clinical study with special emphasis on difficult cases. Injury 32(3):48–54

    Article  Google Scholar 

  28. Streubel PN, Gardner MJ, Morshed S (2010) Are extreme distal periprothetic supracondylar fractures of the femur too distal to fix using a lateral locked plate? J Bone Joine Surg Br 92(4):527–534

    Article  CAS  Google Scholar 

  29. Su ET, DeWal H, DiCesare PE (2004) Periprosthetic femoral fractures above total knee replacements. J Am Acad Orthop Surg 12(1):12–20

    Article  PubMed  Google Scholar 

  30. Zlowodzki M, Williamson S, Cole PA, Zardiackas LD, Kregor PJ (2004) Biomechanical evaluation of the less stabilization system, angled blade plate, and retrograde intramedullary nail for the internal fixation of distal femur fractures. J Orthop Trauma 18(8):494–502

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopedics, Buddhist Tzu-Chi General Hospital at Taichung, Tzu-Chi University, Hualien, Taiwan

    Shih-Hao Chen, Tzai-Chiu Yu, Chih-Wei Wang, Chia-Wei Lin & Keng-Chang Liu

  2. Graduate Institute of Medical Mechatronics, Chang Gung University, 259, Wen-Hua 1st RD., Kweishan, Taoyuan, Taiwan

    Ching-Lung Tai

  3. Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan

    Ching-Lung Tai

  4. Department of Orthopedics, Postal Hospital, Taipei, Taiwan

    Chen-Yu Chen

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  1. Shih-Hao Chen
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  2. Ching-Lung Tai
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  3. Tzai-Chiu Yu
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  4. Chih-Wei Wang
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Correspondence to Ching-Lung Tai.

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Chen, SH., Tai, CL., Yu, TC. et al. Modified fixations for distal femur fractures following total knee arthroplasty: a biomechanical and clinical relevance study. Knee Surg Sports Traumatol Arthrosc 24, 3262–3271 (2016). https://doi.org/10.1007/s00167-016-4107-0

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