Primary total knee arthroplasty for periarticular fractures

doi:10.1016/S0883-5403(03)00280-8

The Journal of Arthroplasty

Volume 18, Issue 8, December 2003, Pages 968-971

https://doi.org/10.1016/S0883-5403(03)00280-8 Get rights and content

Abstract

We present a series of 6 patients with periarticular fractures of the knee that were treated by primary total joint arthroplasty. These fractures around in 6 elderly women, three in the proximal tibia and three in the distal femoral. All the patients had osteoarthritis and osteopenia. In five patients, a hinged total knee arthroplasty was performed, and in one case an unconstrained prosthesis was performed. Cementing techniques were used in all. Postoperatively, immediate mobilization with full weight bearing was initiated. No radiographic or clinical evidence of loosening was seen, and the functional outcome was satisfying. The results suggest that another treatment option for intra-articular distal femoral or intra-articular proximal tibial fractures in elderly patients with severe osteopenia and osteoarthritis is primary total knee arthroplasty. Furthermore, this primary total knee arthroplasty may require some degree of constraint.

Section snippets

Materials and methods

Between February 1996 and July 1999, 6 women who sustained a periarticular knee fracture were treated using primary total joint arthroplasty. All fractures occurred after a simple fall. Three patients had a fracture of the tibial plateau, and 3 patients experienced a distal femoral fracture. The AO system was used to classify the fractures (Table 1) [8]. The average age of the group was 79 years (range, 70–90 years). All patients had pre-existing systemic illnesses including cardiovascular

Results

In all cases, wound healing occurred without complications, and no patients developed superficial or deep infection. The mean inpatient time at the trauma center was 31 days (range, 11–42 days). All patients were encouraged to bear weight as soon after surgery as possible. We did not see any radiographic or clinical evidence of loosening at follow-up evaluation. Regarding the knee score of The Knee Society Clinical Rating System, 2 patients were free of pain and 4 patients reported mild or

Discussion

Nonsurgical and surgical management of intra-articular fractures of the distal femur and proximal tibia in older patients have been reported to have a high complication rate [11]. Schatzker, Norne, and Waddell [12] and Healy and Brooker [5] discussed poor functional results and a high rate of nonunion for distal intraarticular fractures. Open reduction and internal fixation techniques have also been connected with considerable problems in patients over 60 years of age 3, 4. More recently,

Conclusions

Our results suggest that the use of primary total knee arthroplasty with early mobilization and full weight bearing for intra-articular distal femoral fractures or intra-articular proximal tibial fractures in 6 elderly patients with pre-existing systemic illnesses, severe osteopenia, and osteoarthritis is a valuable method.

Acknowledgements

The authors thank V. Roy, MB, for her helpful advice in the preparation of this manuscript.

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Primary total knee arthroplasty in tibial plateau fractures: Literature review and our institutional experience
2023, Injury
Citation Excerpt :
Age certainly plays a crucial role in the decision-making process. Based on the previous reports, the mean age of patients ranged from 62 to 82 years [9,12–23]. However, other conditions should be examined: general health and cognitive status, bone quality and presence of knee osteoarthritis.
Displaced proximal tibia fractures in the elderly may be very difficult to manage. If osteosynthesis represents the standard of care in the younger patients, in the aged population this solution is controversial because a significant failure rate has been reported after internal fixation. Moreover, osteoarthritis progression following tibial plateau fractures is common, often requiring a subsequent total knee arthroplasty (TKA). In recent years, in order to overcome the fracture healing problems and to allow immediate full weight bearing, primary TKA after tibial plateau fractures in elderly patients has gained popularity.
from 2015 to 2019, 11 tibial plateau fractures in elderly patients with pre-existing osteoarthritis were treated with a primary TKA. Age, gender, mechanism of trauma, pre-operative autonomy level, fractures classification, degree of osteoarthritis and intraoperative data (ligamentous stability and type of implant) were collected. After a mean follow-up of 28 months, Knee Society Score (KSS), post-operative autonomy level and Forgotten Joint Score (FJS) were evaluated. The radiological assessment (signs of loosening, limb axis and patellar height indices) and complications were also recorded.
according to fracture type and ligamentous competence, 6 cases of posterior-stabilized (PS) design and 5 cases of semi-constrained TKA were implanted. At the final follow up, mean KSS knee score was 83±16 and mean KSS functional score was 74±15. Mean pre-operative autonomy level assessed with the Parker scale, was significantly higher than the post-operative one (7.5±1.4 vs 5.6 ± 1.3). Mean FJS was 66 ± 14. No lines of radiolucency or limb malalignment were found at the final radiological follow-up. One major complication was recorded: one acute periprosthetic infection. One patient reported a periprosthetic femoral fracture after 26 months.
Based on our and results and those reported on literature, primary TKA is a suitable option in case of tibial plateau fractures in elderly patients with pre-existing osteoarthritis and poor bone quality, in which osteosynthesis outcome may be poor. Unlike ORIF, primary TKA may allow immediate weightbearing and a faster recovery. Nevertheless, it is a demanding surgery with a significant complications rate and should be reserved for selected patients and experienced surgeons.
Knee Rheumatoid Arthritis With Lateral Tibial Plateau and Tibial Stress Fractures Managed With One-Stage Knee Joint Replacement
2020, Arthroplasty Today
Citation Excerpt :
Ever since, studies have reported good postoperative functional outcomes and return to the preinjury state after acutely managing tibial plateau fractures with knee arthroplasty [20,21]. Most of these studies recommend cemented stemmed constrained prosthesis to provide stability and bypass the fracture; however, the effect of cement on fracture healing has not yet been established [11,20,21]. Bony defects in the proximal tibia can be managed using different types of augments, either wedges or blocks, depending on surgeon experience.
Rheumatoid arthritis (RA) is a chronic systemic disease that causes progressive joint damage, bony defects, and ligament imbalance. These sequelae of RA present major difficulties to surgeons during hip or knee arthroplasty. The presence of coexistent periarticular fractures adds to these difficulties and represents a surgical dilemma. No guidance exists within the literature for the medical and surgical management of complicated cases of RA with coexistent fractures. So far, the evidence has focused on fixation techniques, arthroplasty, and conservative management for periarticular fractures of osteoarthritic joints without significant degeneration of anatomical structures. We report a case of advanced knee RA with associated ipsilateral tibial plateau fracture and a tibial shaft stress fracture that was treated successfully with a single-stage joint replacement procedure. The case study presents a well-planned, single-stage arthroplasty with a lateral parapatellar approach as a management option that allows for early weight-bearing and restoration of function and provides a detailed guide for surgeons when managing similar cases.
Allograft for the treatment of traumatic severe bone loss in the lateral femoral condyle: A case report
2018, Injury
Citation Excerpt :
Functional outcomes are modest and complication rates high [18,19]. Treatment with TKR of an initial fracture is not consistent with the outcome of primary TKR without complications [20,21]. Moreover, due to the considerable bone loss and complex ligamentous instability, there was a strong indication towards a forced revision TKR whose short-term and, above all, long-term results dissuade using the procedure among young individuals.
Open articular fractures are an important issue due to their increasing incidence, along with the rise in motorcycle accidents. Oncology experience with allograft in orthopedics may be extended to cases of traumatic bone loss.
A 37-year-old man with an open fracture of the distal femur and proximal tibia presented a massive bone loss of the lateral femoral condyle after a motorcycle accident. Following Damage Control Surgery, a considerable lateral femoral condyle allograft was used to restore the joint anatomy.
After an intensive rehabilitation program and two subsequent arthroscopic arthrolyses, the patient resumed walking without aids and recovered from stiffness (R.O.M. 0-130°). An MRI performed at median follow-up, revealed a favorable integration of the allograft.
Allografts are a reasonable reconstructive option for young individuals with massive bone loss. An appropriately sized allograft is essential to restore an acceptable function as seen in the herein case.
Primary total knee arthroplasty for acute fracture around the knee
2018, Orthopaedics and Traumatology: Surgery and Research
Relatively poor results have been reported with open reduction and internal fixation of complex fractures around the knee in elderly osteoporotic patients, and primary total knee arthroplasty (TKA) has been proposed as an alternative solution. While limiting the number of procedures, it meets two prerequisites: (1) to save the patient's life, thanks to early weight-bearing, to limit decubitus complications; and (2) to save knee function and patient autonomy, thanks to early knee mobilization. There are 3 main indications: complex articular fractures in elderly patients with symptomatic osteoarthritis prior to fracture; complex articular fractures of the tibial plateau in elderly patients whose bone quality makes internal fixation hazardous; and major destruction of the distal femur in younger patients. Although admitted in emergency, these patients require adequate preoperative management, including a multidisciplinary approach to manage comorbidities, control of anemia and pain, and assessment and management of vascular and cutaneous conditions. Preoperative planning is crucial, to order appropriate implants and materials that may be needed intraoperatively. Surgical technique is based on the basic principles of revision surgery as regards choice of implant, steps of reconstruction, bone defect management and implant fixation. For complex fractures of the distal femur, primary temporary reduction is a useful “trick”, to determine the level of the joint line and femoral rotation. Complementary internal fixation may be required in case of diaphyseal extension of the fracture and to prevent inter-prosthetic fractures. In the literature, the results of primary TKA for fracture are encouraging and better than for secondary TKA after failure of non-operative treatment or internal fixation, with lower rates of revision and complications, earlier full weight-bearing and better functional results. Loss of autonomy is, however, frequent, and 1-year mortality is high, especially following complex femoral fractures in the elderly.
Distal femur fractures in adults
2017, Orthopaedics and Trauma
Fractures of the distal femur occur in a bimodal age distribution. Many are complicated by intra-articular extension and comminution. Periprosthetic fractures add to the complexity of their management. Open fractures can occur with high energy trauma. Surgical treatment is the standard of care, with fixed angle plate fixation and intramedullary nailing being the most common techniques used. Surgical management can be technically challenging. Complications include malunion, delayed union, non-union and implant failure. Persistent disability and poor clinical outcome often results. Despite the development of modern implants, no clear advantage exists for one particular implant and some poorer outcomes may relate to the surgical technique applied to management. Knowledge and correct application of the principles of fracture management are required to optimize the chance of successful outcome. This article will discuss the epidemiology, anatomy, management and surgical techniques for distal femur fractures and review the evidence for the different surgical options.
Geriatric tibial plateau fractures: Clinical features and surgical outcomes
2016, Journal of Orthopaedic Science
Citation Excerpt :
Some cases of geriatric tibial plateau fractures are associated with advanced arthritis. These difficulties have led several authors to promote the use of TKA in the acute management of these injuries for early weight-bearing, improved results, and avoidance of further procedures [7–9]. It is not easy to clarify the indication for the management of geriatric tibial plateau fractures because there are wide varieties among individuals, such as biological age, pre-injury activity, compliance, bone quality and degree of comminution.
Operative treatment of geriatric tibial plateau fractures is challenging and controversial. There are few studies focusing on the clinical features and operative outcomes of tibial plateau fractures in the elderly. Hence, this study aimed to investigate the clinical features and operative results of these fractures.
Thirty-three displaced tibial plateau fractures in patients >65 years old (mean age: 72.1 years, range: 65–94 years) were treated operatively. We investigated the mechanisms of injury, fracture types according to the Schatzker classification, incidences of soft tissue injury, and postoperative complications. Clinical and radiographic data were analyzed in 23 patients at the last follow-up. The mean follow-up period was 4.0 years (range: 1–13 years). Twenty-one patients were treated with open reduction and internal fixation and evaluated using the Rasmussen clinical and radiologic scores. Two patients with advanced osteoarthritis were treated primarily with total knee arthroplasty and assessed using the Japanese Orthopaedic Association score for the knee osteoarthritis.
Twenty-four patients (72.7%) were injured by low-energy trauma such as a simple fall. Four patients had compartment syndrome and required fasciotomies. Rasmussen clinical and radiologic scores were satisfactory in 85.7% and 81.0% of patients, respectively. Two patients treated primarily with total knee arthroplasty showed no radiologic abnormality, and their Japanese Orthopaedic Association scores were both 70 points.
Geriatric tibial plateau fractures, although mostly due to low-energy trauma, were often accompanied with severe comminution and compartment syndrome. Postoperative results of open reduction and internal fixation for this population were relatively good. Therefore, primary total knee arthroplasty should only be considered for well-selected patients.

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Primary total knee arthroplasty for periarticular fractures☆

Abstract

Section snippets

Materials and methods

Results

Discussion

Conclusions

Acknowledgements

Injury

Injury

Injury

J Arthroplasty

Primary knee arthroplasty for distal femoral fractures in elderly patients

J Bone Joint Surg Br

Cast brace treatment of plateau and bicondylar fractures of the proximal tibia

Clin Orthop

Complications of surgically treated supracondylar fractures

J Trauma

Supracondylar fractures of the femur

Clin Orthop