Dataset Information

Distal Femoral Replacements for Acute Comminuted Periprosthetic Knee Fractures: Satisfactory Clinical Outcomes at Medium-Term Follow-up.

ABSTRACT:

Background

Fracture fixation techniques of comminuted periprosthetic distal femoral fractures have high risk of complications. The aim of this study was to evaluate short- to medium-term outcomes of comminuted periprosthetic distal femoral fractures treated with distal femoral replacements (DFR) at a tertiary arthroplasty unit.

Methods

Retrospective consecutive study of all patients who underwent DFR for periprosthetic fractures with minimum 2-year follow-up between 2010 and 2018. Clinical outcomes, surgical complications, revision for any cause, loosening, Knee Society Score and mortality data were collected at final follow-up.

Results

Thirty patients with average age 81 years (range, 65-90; 6 males and 24 females) were included. All had comminuted fractures (Rorabeck type-2/3). All patients had cemented DFRs. Three patients (10%) with multiple comorbidities died postoperatively. Average time from admission to being fit for discharge was 9 days (range, 3-14). Clinical outcomes and follow-up were available for 27 patients with a median follow-up duration of 4 years (2-13 years). Complication rate was 7.4% with one reoperation, change of polyethylene insert. None of the components have been revised to date. Average Knee Society Score at final follow-up was 78 (range, 57-92) with median arc of motion flexion-extension being 100° (range, 60°-125°).

Conclusions

In our experience, DFRs for comminuted periprosthetic fractures allow immediate mobilization and rehabilitation leading to satisfactory clinical outcomes with low complication rate for this challenging group of patients.

Level of evidence

level IV.

SUBMITTER: Matar HE

PROVIDER: S-EPMC7818597 | biostudies-literature | 2021 Feb

REPOSITORIES: biostudies-literature

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Publications

Distal Femoral Replacements for Acute Comminuted Periprosthetic Knee Fractures: Satisfactory Clinical Outcomes at Medium-Term Follow-up.

Matar Hosam E HE Bloch Benjamin V BV James Peter J PJ

Arthroplasty today 20201225

<h4>Background</h4>Fracture fixation techniques of comminuted periprosthetic distal femoral fractures have high risk of complications. The aim of this study was to evaluate short- to medium-term outcomes of comminuted periprosthetic distal femoral fractures treated with distal femoral replacements (DFR) at a tertiary arthroplasty unit.<h4>Methods</h4>Retrospective consecutive study of all patients who underwent DFR for periprosthetic fractures with minimum 2-year follow-up between 2010 and 2018. ...[more]

PMID: 33521195

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Project description:IntroductionWe hypothesised that the use of a polyaxial locking plate design offers the same clinical benefits as a monoaxial locking plate system following distal femoral osteoporotic/periprosthetic fracture fixation.MethodA multicentre prospective randomised pilot trial was conducted. Inclusion criteria were patients over 60 years with a displaced osteoporotic or periprosthetic distal femoral fracture. Details documented included time to union, complications, reinterventions and functional outcomes according to the Oxford knee score and EuroQol EQ-5D. Analysis of factors influencing an early fracture healing response was performed between those with clear features of radiological callus formation at three months. Statistical analysis was performed using a logistic regression model with multiple covariates assessed for each plate system (1:1 ratio) over a follow-up period of one year.ResultsForty patients (34 females) with a mean age of 77 (60-99) were recruited. Four patients deceased within the first six months. Twenty-five patients united by the six month follow-up. Six more patients progressed to union between six and nine months. Five patients developed non-union (two patients had implant failure; one in each group) and all underwent revision surgery. Malunion was evident in two cases, one with 15° of valgus (monoaxial plate), and one with 12° of recurvatum (polyaxial plate). Between the two plate systems, statistical analysis revealed no significant differences in most of the recorded parameters. Radiological features of early bone healing were present when the surgical approach was smaller (p = 0.015), and when a greater working length of the bridging plate was present (p = 0.016).ConclusionBoth plate systems demonstrated good union rates and limited implant related complications. Good reduction, mechanically sound construct and respect of the local fracture biology was more important than the particular plate design characteristics.

Project description:The present study aimed to investigate the prevalence and clinical consequences of occult intra-operative periprosthetic femoral fractures in total hip arthroplasty (THA). Between 2012 and 2017, a total of 113 primary THAs were enrolled. The mean age of the patients was 66.4 ± 7.6 years. We assessed occult intra-operative periprosthetic femoral fractures with the use of computed tomography (CT) and risk factors, including age, sex, body mass index, diagnosis, stem size, and radiographic parameters of proximal femoral geometry were analyzed. We also assessed the differences in thigh pain and stem subsidence and alignment between the patients with and without occult periprosthetic femoral fracture. Occult intra-operative periprosthetic femoral fractures were found in 13 of 113 hips (11.5%). In 9/13 (69.2%) of occult fractures, fracture lines were started from the region below the tip of the lesser trochanter. Six periprosthetic femoral fractures (5.3%) were found during the operation. Out of the five hips that had detected femoral fractures around the lesser trochanter intra-operatively, four hips (80%) showed concurrent occult fractures on different levels. The female sex (P = .01) and canal filling ratio at 7 cm below the tip of the lesser trochanter (P = .01) were significantly different between the patients with and without occult periprosthetic femoral fracture. The sex was significantly associated with an increased risk in predicting an occult intra-operative periprosthetic femoral fracture (odds ratio of male, 0.25 compared with the female; 95% CI, 0.08-0.85; p = .02). There was a significant difference in the incidence of thigh pain between occult fracture group and non-occult fracture group (P < .05). There were no significant differences in stem subsidence and alignment between the patients with and without occult periprosthetic femoral fracture. All 13 cases of occult intra-operative periprosthetic femoral fractures were healed at the final follow-up. Occult periprosthetic femoral fractures are common during a long, trapezoidal, double-tapered cementless femoral stem fixation in primary THA, that CT scans are helpful to identify them, and that these fractures do not adversely affect the implant's survival if a rigid fixation of the implants has been achieved.

Project description:PurposeThe treatment of distal femur fractures with extensive metaphyseal comminution is frequently complicated by high rates of nonunion and varus collapse. Dual plating with lateral and medial locking plates for these types of fractures has shown promising results in the recent literature. We hypothesize that dual plating of comminuted distal femur fractures leads to higher union rates and lower revision rates compared to an isolated lateral locking plate.MethodsA retrospective medical chart review between January 2015 and December 2017 was conducted. Inclusion criteria included patients 18 years of age and older who sustained a complex distal femur fracture (AO/OTA 33-C2/33-C3 or periprosthetic fracture with significant metaphyseal comminution) and at least 6 months of follow up. Patients with simple fracture patterns, alternative fixation methods, and inadequate follow up were excluded. All patients in the single plating group were treated with a lateral distal femoral locking plate using a lateral approach. In the patients treated with dual plating, an extensile parapatellar approach was utilized for fracture reduction and placement of an adjunctive medial plate. Demographic information, fracture types, injury severity score (ISS), medical comorbidities, type of surgical fixation, union rates, complications, knee range of motion, time to follow up, and need for revision surgery were extrapolated from the medical charts for analysis.ResultsTwenty-one patients were included in the study. Thirteen patients underwent single plate fixation and 8 underwent dual plate fixation. There were no significant differences in demographics, number of co-morbidities, fracture classification, or ISS between single and dual plate groups (p > 0.05 for all). There was a statistically significant difference in union rates between the single plate group (6 nonunions, 4 unions, and 3 delayed unions) and the dual plate group, with no nonunions or delayed unions (p = 0.0049). Although not statistically significant, 4 patients treated with single plating underwent revision ORIF, compared to none in the dual plating group (p = 0.13). There were no significant differences in time to follow up, time to full weight bearing, or infection rates (p > 0.1 for all).ConclusionBased on these results, the medial and lateral locked plating technique demonstrates a higher union rate, with possible lower rates of revision surgery, compared to a single lateral plate in highly comminuted distal femur fractures.Level of evidenceLevel 3. Retrospective Cohort Study.

Project description:Optimal acute management of the highly comminuted distal ulna head/neck fracture sustained in conjunction with an unstable distal radius fracture requiring operative fixation is not well established. The purpose of the present study was to determine the clinical, radiographic, and functional outcomes following acute primary distal ulna resection for comminuted distal ulna fractures performed in conjunction with the operative fixation of unstable distal radius fractures. Between 2000 and 2007, 11 consecutive patients, mean age 62 years (range, 30-75) were treated for concomitant closed, comminuted, unstable fractures of the distal radius and ulna metaphysis. All 11 patients underwent distal ulna resection through a separate dorsal ulnar incision with ECU tenodesis following surgical fixation of the distal radius fracture. According to the Q modifier of the Comprehensive Classification of Fractures, there were six comminuted fractures of the ulnar neck (Q3) and five fractures of the head/neck (Q5). Operative fixation of the distal radius fracture included volar plate fixation in four patients and spanning external fixation with supplemental percutaneous Kirschner wires in seven patients. At a mean of 42 months (range, 18-61 months) postoperatively, clinical, radiographic, and wrist-specific functional outcome with the modified Gartland and Werley wrist score were evaluated. At latest follow-up, mean wrist range of motion measured 53 degrees flexion (range, 35-60 degrees), 52 degrees extension (range, 30-60 degrees), 81 degrees pronation (range, 75-85 degrees), and 77 degrees supination (range, 70-85 degrees). Mean grip strength measured 90% of the contralateral, uninjured extremity (range, 50-133%). No patient had distal ulna instability. Final radiographic assessment demonstrated restoration of distal radius articular alignment. According to the system of Gartland and Werley as modified by Sarmiento, there were seven excellent and four good results. No patient has required a secondary surgical procedure. Acute primary distal ulna resection yields satisfactory clinical, radiographic, and functional results in appropriately selected patients and represents a reliable alternative to open reduction and internal fixation when anatomic restoration of the distal ulna/sigmoid notch cannot be achieved. Primary distal ulna resection with distal radius fracture fixation may help avoid secondary procedures related to distal ulna fixation or symptomatic post-traumatic distal radioulnar joint arthrosis.

Project description:BackgroundThe posterior plating technique could be used as a clinical alternative to parallel plating for treating comminuted distal humerus fractures (DHFs) successfully with good clinical results. However, the biomechanical characteristics for posterior fixation are still unclear. The purpose of this study is to evaluate the biomechanical properties of the posterior fixation and to make comparisons between the parallel and the posterior fixation systems.Materials and methodsWe performed a cadaveric biomechanical testing with two posterior plating systems (a posterior two plating and a single posterior pre-contoured Y plating system) and one parallel two plating system to treat AO/OTA type-C2.3 DHFs. Among three groups, we compared construct stiffness, failure strength, and intercondylar width changes after 5000-cycle fatigue loading and failure loads and failure modes after destructive tests in both the axial compression and (sagittal) posterior bending directions. The correlations between construct failure loads and bone marrow density (BMD) were also compared.ResultsIn axial direction, there were no significant differences in the stiffness and failure load between the posterior and the parallel constructs. However, in sagittal direction, the two-plate groups (posterior two plating and parallel plating group) had significant higher stiffness and failure loads than the one-plate group (single posterior Y plating). There was no fixation failure after 5000-cyclic loading in both directions for all groups. Positive correlation was noted between BMD and failure loads on parallel fixation.ConclusionsWe found that when using two plates for treating comminuted DHFs, there were no significant differences in terms of most biomechanical measurements between posterior and parallel fixation. However, the single pre-contoured posterior Y plate construct was biomechanically weaker in the sagittal plane than the parallel and the posterior two-plate constructs, although there was no fixation failure after the fatigue test for all groups regardless of the fixation methods.Level of evidenceBiomechanical study.

Dataset Information

Distal Femoral Replacements for Acute Comminuted Periprosthetic Knee Fractures: Satisfactory Clinical Outcomes at Medium-Term Follow-up.

Background

Methods

Results

Conclusions

Level of evidence

Publications

Distal Femoral Replacements for Acute Comminuted Periprosthetic Knee Fractures: Satisfactory Clinical Outcomes at Medium-Term Follow-up.

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