An 82-year-old lady with a medical historical past of diabetes mellitus kind 2 (most up-to-date hemoglobin A1c of 10.3%), atrial fibrillation (on apixaban) and hypothyroidism offered to our ED with left thigh ache.
Her surgical historical past was notable for a previous left main complete knee arthroplasty at our establishment 4 years prior. Her knee was beforehand functioning effectively. Nonetheless, 4 months previous to her present presentation, she fell and sustained a left distal periprosthetic femur fracture (Determine 1). This was managed at an out of doors hospital with open discount and inside fixation (ORIF) utilizing a lateral locking plate on the time of her unique damage. Her fracture therapeutic was adopted radiographically thereafter, and it was famous that she had proof of delayed therapeutic of her fracture at 3 months after her ORIF (Determine 2).
Picture: Charles P. Hannon, MD, MBA, and Harold I. Salmons, MD
Supply: Mayo Clinic
The affected person offered to our ED after struggling a sudden onset of ache whereas strolling at dwelling. She may now not bear weight. She denied antecedent ache or trauma. Radiographs had been obtained, and these revealed a brand new periprosthetic femur fracture by means of the prior space of her delayed union with an related fracture and failure of her lateral locking plate (Determine 3).
Supply: Mayo Clinic
On examination, she was alert and comfy with the left decrease extremity in a shortened and externally rotated place. There have been no pores and skin tears or open fractures. There was an apparent deformity in regards to the left thigh. She was in a position to hearth her quadriceps, tibialis anterior, extensor hallucis longus, posterior tibialis, peroneals and gastronemius/soleus muscular tissues. She was sensate to mild contact all through the decrease extremity. She had a heat and well-perfused foot and a palpable dorsalis pedis pulse that was symmetric to her uninvolved contralateral decrease extremity.
Supply: Mayo Clinic
What are the most effective subsequent steps in administration of this affected person?
See reply under.
Revision ORIF with plate and nail assemble
A serum C-reactive protein was collected together with baseline preoperative labs. This was regular, suggesting her fracture and related delayed union had been as a consequence of a mechanical somewhat than infectious trigger. As such, a preoperative aspiration was deferred. She was positioned right into a well-padded knee immobilizer and consented for revision ORIF utilizing an intramedullary nail and lateral plate mixture, with debridement of her nonunion web site.
Revision ORIF
The affected person was positioned supine. A lateral subvastus method incorporating her prior lateral locking plate incision was utilized alongside the distal femur. Care was taken to establish and ligate perforating vessels. Plentiful fracture hematoma was encountered. The damaged lateral plate was recognized and eliminated. At this level, the nonunion web site was visualized and debrided of all fibrinous materials totally. Three cultures had been despatched, which later returned as detrimental for bacterial development. The nonunion web site was debrided till seen osseous bleeding was noticed, and care was taken to keep away from stripping periosteum. The fracture was famous to be cellular and, utilizing a towel bump below the distal section together with a slight valgus power, the fracture was diminished manually to an acceptable place.
At this level, consideration was turned to the intramedullary nail. A 3-cm incision from the inferior pole of the patella to the proximal tibia was created incorporating her prior midline complete knee incision. The scarred paratenon and accompanying patellar tendon had been recognized and cut up longitudinally in step with its fibers. Heavy scissors had been used to bluntly dissect to the anticipated femoral begin level for a retrograde femoral nail. A information pin was inserted, adopted by a gap 12-mm reamer. The ball tip information wire was then inserted to the proximal femur, simply distal to the lesser trochanter. Care was taken to take care of fracture discount through the passing of the information pin and subsequent reaming and nail insertion. A 340-mm nail size was chosen, and reamers had been sequentially administered by means of the diminished fracture web site to a most diameter of 12.5 mm to just accept an 11-mm retrograde femoral nail.
Seen oozing and bleeding had been famous throughout the nonunion web site, with the hopes that this could ship acceptable biology to the realm and help with therapeutic. Beneath biplanar fluoroscopy the retrograde femoral nail was inserted, taking care to take care of discount of the fracture all through this portion of the case. The nail was locked in static mode distally after which impacted into the proximal section in a retrograde method to facilitate additional therapeutic by way of compression throughout the fracture web site. Paying cautious consideration to rotation, the proximal interlock was then applied.
A brand new lateral locking plate was then long-established to bone. A 241-mm plate was chosen and locked distally after first being secured to bone with nonlocking screws. The plate spanned the realm of fracture and nonlocking screws had been applied proximally. The objective of this revision dual-plate assemble was to offer acceptable stability for rapid weight-bearing whereas concomitantly allowing sufficient pressure throughout the fracture web site to advertise osseous union (Determine 4).
Supply: Mayo Clinic
Postoperative rehabilitation
The affected person was permitted to weight-bear as tolerated. Every day supplementation with calcium and vitamin D had been inspired. Deep venous thrombosis chemoprophylaxis was maintained for 30 days, and periprocedural antibiotics within the type of cefazolin had been administered for twenty-four hours. The affected person progressed with bodily remedy within the hospital and was discharged on postoperative day 4.
At her 6-week follow-up, she had no ache and was ambulating with use of assistive units as wanted. Her radiographs demonstrated proof of early fracture therapeutic and maintained alignment (Determine 5). Her wound had healed effectively.
Supply: Mayo Clinic
Dialogue
Distal femur periprosthetic fractures above well-fixed TKAs are comparatively uncommon however pose a big problem in orthopedic surgical procedure. These fractures usually end result from low-energy trauma in an aged inhabitants, corresponding to a fall, and require cautious consideration of a number of components throughout administration. Therapy includes not solely addressing the fracture itself but in addition contemplating the underlying knee prosthesis, the precise fracture traits, the affected person’s normal well being and bone high quality. The rising longevity of sufferers following TKA means that the incidence of periprosthetic femur fractures will seemingly rise in parallel, with a corresponding want for improved administration methods. Present research estimate the incidence of periprosthetic fractures to be between 1% to 2% of all TKA issues, though different studies counsel the speed could also be as excessive as 3% to five%. These fractures predominantly happen within the aged inhabitants, which necessitates cautious preoperative medical optimization and consideration of fixation methods, particularly given the often-compromised bone inventory on this group.
Surgical procedure is mostly beneficial for displaced fractures, as early mobilization postoperatively is essential to attenuate mortality dangers in aged sufferers. Varied fixation choices have been described within the literature, together with lateral locking plates, dual-plating programs and plate-nail mixtures. The selection of fixation technique relies on cautious analysis of the fracture sample, bone high quality and the extent of involvement of the knee prosthesis. Within the authors’ expertise, intramedullary implants are sometimes favored as a consequence of their load-sharing nature, which facilitates rapid weight-bearing. In instances involving comminution, extra plate fixation could also be vital to offer ample stability. A key consideration throughout preoperative planning is the compatibility of the TKA design with retrograde femoral nails, as the power to cross a nail by means of the open field of the prosthesis can considerably affect the selection of fixation. Reference to current research, such because the work by Daniel E. Gerow, DO, and colleagues, which summarized the compatibility of varied TKA implants with retrograde femoral nail programs, is essential in guiding the surgical decision-making course of.
For fractures extending distally near the joint line, preoperative imaging, notably CT scans, are important in assessing the feasibility of intramedullary fixation. Surgeons should fastidiously consider the interlocking choices for the retrograde femoral nail to make sure that ample fixation could be achieved distally. If interlocking distally isn’t possible, lateral plate fixation could be an appropriate various, notably in instances of easy fractures with out vital instability. Nonetheless, in additional complicated fractures or these involving substantial medial cortical comminution, dual-plate constructs could also be vital to offer enough stabilization. Though devoted distal medial femoral plates can be found, the authors discover {that a} flipped proximal humerus plate can function an efficient and readily accessible answer for medial locking plate fixation in these conditions.
In conclusion, the administration of periprosthetic distal femur fractures above a well-fixed TKA requires a complete, individualized method that considers the affected person’s total well being, bone high quality and the precise traits of the fracture. Early weight-bearing must be a objective within the therapy of aged sufferers, because it has vital advantages by way of restoration and mortality discount. Surgeons should stability the stiffness of the assemble with the suitable pressure required for optimum fracture therapeutic, taking care to make sure compatibility with the prevailing knee prosthesis and addressing any extra challenges posed by complicated fracture patterns.
Key factors:
Distal femur periprosthetic femur fractures provide a problem to the surgeon and portend vital morbidity and mortality danger to the aged affected person.
A cautious consideration of affected person components together with fracture location, morphology and a overview of TKA compatibility for retrograde femoral nailing are paramount.
Whereas a number of choices for surgical fixation have been described, number of the assemble that greatest helps rapid weight-bearing is favored.
References:
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- Bengoa F, et al. J Am Acad Orthop Surg. 2023;doi:10.5435/JAAOS-D-22-00701.
- Gausden EB, et al. Harm. 2021;doi:10.1016/j.damage.2021.05.007.
- Gausden EB, et al. J Arthroplasty. 2024;doi:10.1016/j.arth.2024.04.037.
- Gerow DE, et al. J Orthop Trauma. 2022;doi:10.1097/BOT.0000000000002236.
- Hou Z, et al. J Orthop Trauma. 2012;doi:10.1097/BOT.0b013e31822c050b.
- Konan S, et al. Bone Joint J. 2016;doi:10.1302/0301-620X.98B11.BJJ-2016-0029.R1.
- Kriechling P, et al. Arthroplast At present. 2024;doi:10.1016/j.artd.2024.101456.
- Kurtulu B, et al. Eur Rev Med Pharmacol Sci. 2024;doi:10.26355/eurrev_202404_36032.
- Nasser AAHH, et al. Bone Joint J. 2024;doi:10.1302/0301-620X.106B2.BJJ-2023-0700.R1.
For extra info:
Charles P. Hannon, MD, MBA, and Harold I. Salmons, MD, could be reached on the division of orthopedic surgical procedure on the Mayo Clinic in Rochester, Minnesota. Salmons’s e mail: salmons.harold@mayo.edu.
