Elsevier

Injury

Volume 42, Issue 11, November 2011, Pages 1368-1371
Injury

Acute primary total knee arthroplasty for peri-articular knee fractures in patients over 65 years of age

https://doi.org/10.1016/j.injury.2011.06.198Get rights and content

Abstract

Peri-articular knee fractures in osteoporotic or osteoarthritic bone present a challenge to fixation, mobilisation or non-operative management. We present a series of 15 proximal tibial and 11 distal femoral fractures treated with total knee arthroplasty at over mean follow-up period of 38.8 months. The mean age of the patients was 80 years. The choice of the implant and level of constraint was determined as per the nature of injury and preference of the surgeon dealing with the fracture. Patients were allowed rapid mobilisation with immediate full weight-bearing. Good clinical results were achieved with fracture healing, sound fixation and well-aligned flexible knees. Mean Knee Society knee score was 90.2; Knee Society function score was 35.5; Oxford Knee score was 39.5; and Short Form (SF)-36 physical function score was 37.3 and mental score 50.6. Good correlation was noted between Knee society knee score and SF-36 physical function score (Pearson's 0.76, p = 0.001), suggesting that generic health would dictate the final function achieved, whilst high knee scores suggest the satisfactory results of the operation. Analogous to arthroplasty for hip fractures, this technique should be considered as a treatment option in elderly peri-articular knee fractures with osteoporosis and/or osteoarthritis.

Introduction

Peri-articular knee fractures in the elderly are difficult to deal with because of poor bone quality, pre-existing arthritis, comminution and osteochondral damage at time of injury.1 A high 1-year mortality rate (22%) and significant decrease in function and quality of life have been noted in frail elderly patients who sustained supracondylar femoral fractures.2 The cause of failure of fixation in this group of patients is not technical failure of the implant but the poor bone quality.3 Failure of fixation after tibial plateau fractures has been associated with advancing age (>60 years) and severe osteoporosis.4 Honkonen5 noted the difficulty in achieving a stable fixation in this group, and the risk of losing the reduction was high despite internal fixation and bone grafting.

Any intervention in this category of patients should ideally allow immediate fracture stability for early mobilisation and early return to pre-injury functional level. Total knee replacement (TKR) is one viable option for this group of patients. We analysed our early results of primary TKR for peri-articular knee fractures with underlying osteoarthritis/osteoporosis in patients above the age of 65 years.

Section snippets

Patients and methods

Between May 2000 and December 2008, 26 patients with peri-articular knee fractures and evidence of osteopenia or arthritis or osteoporosis were treated with primary total knee arthroplasty. Patients were identified from theatre records and operative data obtained from their medical notes. Fractures were classified according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) system. As per hospital protocol, patients were reviewed postoperatively in the clinic and scored according to the

Results

The mean age of the patients at the time of surgery was 80 years (67–92). The mean follow-up was 38.8 months (12–104), with minimum follow-up of 12 months. Left: right knee ratio was 16:10 and the female: male ratio was 25:1. The proximal tibia was fractured in 15 patients and the distal femur in 11 cases. All patients presented after a low-energy injury resulting in the fracture, except one patient who was involved in a road traffic accident. The fracture distribution is as shown in Table 1.

Discussion

TKR for peri-articular knee fractures is not a new concept but is seemingly under reported. We have demonstrated good results in these complex fractures in a challenging group of patients. TKR is a good pain-relieving operation with mean Knee Society knee score of 90.2. However, the overall functional status of these patients remained suboptimum as reflected by low Knee Society function score and SF-36 physical function score. This was possibly because of lower functional ability of this group

Conflict of interest

None.

Funding

None.

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