Original articleTreatment of supracondylar femoral fracture above total knee replacement by custom made hinged prosthesis
Introduction
A supracondylar fracture of the femur following a total knee replacement is a recognised, serious, late complication with a reported incidence of between 0.5 and 2.5% [1], [2], [3]. Various methods of treatment have been employed. Some authors advocate initial conservative treatment, particularly in undisplaced and minimally displaced fractures, with open reduction and internal fixation being employed only after the failure of the initial conservative treatment [3], [4], [5]. Others have recommended early primary internal fixation for all supracondylar fractures above a total knee arthroplasty (TKA), reporting complication rates of only 10–19% with surgery [6], [7]. Other authors reserve internal fixation for displaced supracondylar fractures [8].
Although most supracondylar fractures can be internally fixed, this may be difficult if the bone is extremely porotic or the fracture very low. Good results have been reported using a supracondylar nail [9], but even this may be impossible if there is insufficient distal bone or if a stabilised prosthesis has been used. In such circumstances, revision of a customised prosthesis can provide the solution. In this paper, we wish to report our experience of managing seven patients in this way.
Section snippets
Patients and methods
From January 1994 to August 1996, six women and one man were treated for a supracondylar femoral fracture above a previously inserted total knee replacement (Table 1). The average age of the patients was 78 years (range 69–87 years) and their average weight was 90 kg (range 70–120 kg). The prostheses had been in situ for between 4 weeks and 14 years. The prostheses replaced were five Kinematic, one PFC and one Lubinus patellofemoral replacement. Six fractured after a fall, but one patient (Case
Case no 3
A short, 88 kg, 84-year-old lady had done well following a Kinematic (Howmedica, Newbury, Berkshire, UK) knee replacement 5 years previously. A minor fall resulted in a fracture above the prosthesis. This was internally fixed, and the leg protected in a brace. After 5 months the fixation had clearly failed (Fig. 2) and the patient remained immobile.
A customised endo-rotating hinge was inserted. The patient was a poor rehabilitation prospect, but none the less was walking a little after 7 days
Results (see Table 1)
The average follow-up in these patients was 12 months (a range of 4 months to 2 years). All patients made a rapid post-operative recovery, being mobile with the use of simple walking aids after 7 days, and discharged from hospital, on average, 3 weeks after surgery. Unfortunately the patient who had a tibial pin inserted pre-operatively developed recurrent deep sepsis, requiring the subsequent removal of the prosthesis. At the latest assessment, the six remaining patients have all had a good or
Discussion
A supracondylar fracture above a TKA presents a difficult problem. To maintain good function from the arthroplasty, anatomical fracture alignment with the maintenance of component fixation and a range of movement to 90° is required [10]. Ideally, this should be obtained rapidly, but these goals are difficult to achieve particularly in an elderly group of patients with porotic bone, often with concomittant pathologies, and poor pre-injury mobility.
In stable, undisplaced or minimally displaced
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