Enes.Kanlic at ttuhsc
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Jan 19, 2008, 11:16 AM
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[Orthopod] Re: post-nailing fracture: CHANCES... TKA... yes: Distal
Fem. Replacement, Literature
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Dear Alex,
Answer on question:
"I'd like to learn how TKR is performed with a supracondylar fracture
except the target knee problem, even without knee extension
contracture. What type of prosthesis is to be used? THX in advance."
could be summarized AS: it is indicated for elderly patient with (complex) fractures and accompanying severe knee arthritic changes, using distal femoral replacement constrained type of prosthesis. Literature abstracts are down (attempts of proof :-)).
I have attached similar case (knee periprosthetic fractures in rheumatoid patient ... it fits good for both discussed topics this "time around"...:
- locked plates - some bone left - prosthesis stable; and
- distal femur replacing constrained prosthesis - for unstable primary prosthesis with no bone left attached for eventual fixation and healing).
Sincerely,
Enes M. Kanlic, MD, FACS
Professor
http://www.ttuhsc.edu/elpaso/som/Orthopaedics/
Privacy/Confidentiality Notice: This message, including any attachments, is for the sole use of the intended recipient (s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure, or distribution is strictly prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message.
LITERATURE:
J <javascript:AL_get(this,%20'jour',%20'J%20Bone%20Joint%20Surg%20Br.');> Bone Joint Surg Br. 2006 Aug;88(8):1065-70.
Distal femoral fractures treated by hinged total knee replacement in elderly patients.
<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Appleton%20P%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Appleton P, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Moran%20M%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Moran M, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Houshian%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Houshian S, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Robinson%20CM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Robinson CM.
The Edinburgh Orthopaedic Trauma Unit, The New Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh EH16 4SU, UK.
Although the use of constrained cemented arthroplasty to treat distal femoral fractures in elderly patients has some practical advantages over the use of techniques of fixation, concerns as to a high rate of loosening after implantation of these prostheses has raised doubts about their use. We evaluated the results of hinged total knee replacement in the treatment of 54 fractures in 52 patients with a mean age of 82 years (55 to 98), who were socially dependent and poorly mobile. Within the first year after implantation 22 of the 54 patients had died, six had undergone a further operation and two required a revision of the prosthesis. The subsequent rate of further surgery and revision was low. A constrained knee prosthesis offers a useful alternative treatment to internal fixation in selected elderly patients with these fractures, and has a high probability of surviving as long as the patient into whom it has been implanted.
PMID: 16877607 [PubMed - indexed for MEDLINE]
1: Clin <javascript:AL_get(this,%20'jour',%20'Clin%20Orthop%20Relat%20Res.');> Orthop Relat Res. 2004 Aug;(425):101-5.
Primary total knee arthroplasty for complex distal femur fractures in elderly patients.
<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Rosen%20AL%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Rosen AL, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Strauss%20E%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Strauss E.
Insall Scott Kelly Institute for Orthopaedics and Sport Medicine, 10 Union Square East, Suite 3M, New York, NY 10003, USA. andrewrosen@nyc.rr.com
Fractures of the distal femur in the geriatric population are associated with a high incidence of postoperative complications and poor results. Nonunion, loss of fixation, and malunion of these fractures occur with all types of treatment. The postoperative treatment of these patients demands a lengthy period of limited weightbearing that can increase the rate of medical complications. Our experience with these challenging fractures caused us to consider the use of a primary distal femur replacement total knee arthroplasty with the goals of elimination of fracture healing issues, early mobilization, and immediate weightbearing. Twenty-four distal femoral replacement knee arthroplasties were done from July 1998 to January 1999. Reviewed with a mean followup of 11 months, 17 patients (71%) resumed their preoperative level of ambulation. Knee range of motion averaged 1 degree - 103 degrees. No major surgical or significant medical complications were experienced by these patients. Our experiences with this small number of patients have shown that an immediate arthroplasty offers many advantages over open reduction and internal fixation for geriatric patients with poor bone quality, preexisting degenerative joint disease, and medical problems.
PMID: 15292794 [PubMed - indexed for MEDLINE]
1: Injury. <javascript:AL_get(this,%20'jour',%20'Injury.');> 2005 Jan;36(1):163-8.
Stanmore total knee replacement versus internal fixation for supracondylar fractures of the distal femur in elderly patients.
<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Pearse%20EO%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Pearse EO, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Klass%20B%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Klass B, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bendall%20SP%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Bendall SP, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Railton%20GT%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Railton GT.
Kingston General Hospital, Galsworthy Road, Kingston-upon-Thames, Surrey, UK. YemiPearse@aol.com
BACKGROUND: Supracondylar fractures of the femur in the elderly are difficult to treat. Total knee replacement is often not considered. The aim of this study was to compare the short to medium term outcome of fixation and total knee replacement in medically fit active elderly patients with no pre-existing arthritis in order to determine whether total knee replacement can be an alternative to internal fixation. PATIENTS AND METHODS: In this retrospective study, we included patients who were aged 75 or over with an ASA grade of two or less, walked independently before their injury, and sustained a type A or C supracondylar fracture. Four were treated with internal fixation and six with a cemented Stanmore knee replacement. Patients were reviewed clinically and radiographically a minimum of 6 months after surgery. RESULTS: The advantages of total knee replacement were a greater proportion of patients returned to independent walking, rehabilitation was more rapid, and knee flexion was better. The advantages of internal fixation were a decreased need of blood transfusion, a smaller proportion of patients reported knee pain at follow up, and a better mean Oxford knee score at follow up. Anaesthetic time and level of patient satisfaction at follow up were similar. There were no peri-operative deaths. CONCLUSION: In this preliminary study, total knee replacement was a reasonable alternative to internal fixation for the treatment of supracondylar fractures of the distal femur in elderly.
PMID: 15589936 [PubMed - indexed for MEDLINE]
1: J <javascript:AL_get(this,%20'jour',%20'J%20Arthroplasty.');> Arthroplasty. 2003 Dec;18(8):968-71.
Primary total knee arthroplasty for periarticular fractures.
<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Nau%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Nau T, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Pflegerl%20E%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Pflegerl E, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Erhart%20J%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Erhart J, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Vecsei%20V%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Vecsei V.
University of Vienna Medical School, Trauma Center, Wien, Austria.
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.
PMID: 14658099 [PubMed - indexed for MEDLINE]
1: Rev <javascript:AL_get(this,%20'jour',%20'Rev%20Chir%20Orthop%20Reparatrice%20Appar%20Mot.');> Chir Orthop Reparatrice Appar Mot. 2006 May;92(3):242-7.
[Total knee arthroplasty for recent severe fracture of the proximal tibial epiphysis in the elderly subject]
[Article in French]
<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Nourissat%20G%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Nourissat G, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Hoffman%20E%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Hoffman E, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22H%C3%A9mon%20C%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Hémon C, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Rillardon%20L%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Rillardon L, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Guigui%20P%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Guigui P, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Sautet%20A%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Sautet A.
Service de Chirurgie Orthopédique, Hôpital Saint-Antoine, Paris.
PURPOSE OF THE STUDY: Bone comminution, serious cartilage damage, and the poor mechanical quality of osteoporotic bone create a difficult challenge for osteosynthesis of joint fractures in the elderly subject. Poor results with certain hip, elbow and shoulder fractures have lead certain authors to propose emergency arthroplasty in selected cases. We report our experience with four knee arthroplasties implanted for recent severe fracture of the proximal tibial epiphysis in elderly subjects. MATERIAL AND METHODS: Four independent patients aged over 75 years presented a severe comminutive fracture of the proximal epiphysis of the tibia (Three Schatzker 5, one Schatzker 4). After obtaining the patients' informed consent, early knee arthroplasty was performed. A long-stem cemented tibial piece was used on which the epiphysis was reconstructed. Implants providing support for ligament deficits were used in all cases. Immediate weight-bearing was authorized. RESULTS: Follow-up ranged from two to seven years. The IKS function score (15, 60, 100, 100) depended on the patient's general status. The IKS knee score was excellent for three knees (90, 95, 95), and fair in one (45). Re-operations were not needed in any of the patients. All x-rays showed bone healing with correctly aligned limbs (less than 2 degrees deformation). There were no lucent lines at last follow-up. DISCUSSION: Early arthroplasty for complex fractures of the proximal epiphysis of the tibia is a realistic option. Using a cemented long-stem tibial piece ensures primary stability sufficient for early weight-bearing before bone healing. Use of a constrained prosthesis, or better a hinged prosthesis, can be questioned but avoids the difficulty of ligament balance on an osteoporotic knee with a destroyed joint surface. None of the patients required reoperation and the results in terms of pain were excellent. The overall outcome depends on the general status of the patient.
PMID: 16910606 [PubMed - indexed for MEDLINE]
1: J Orthop Trauma. <javascript:AL_get(this,%20'jour',%20'J%20Orthop%20Trauma.');> 1995 Jun;9(3):231-7.
Total knee replacement including a modular distal femoral component in elderly patients with acute fracture or nonunion.
<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Freedman%20EL%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Freedman EL, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Hak%20DJ%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Hak DJ, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Johnson%20EE%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Johnson EE, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Eckardt%20JJ%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Eckardt JJ.
Department of Orthopaedic Surgery, U.C.L.A. Medical Center 90024, USA.
Distal femoral fracture or nonunion in elderly patients with osteopenic bone and coexisting gonarthrosis poses a difficult treatment challenge. Open reduction and internal fixation with or without the use of bone cement may not provide sufficient stabilization, requires a prolonged period of weightbearing restrictions, and does not address preexisting knee arthrosis. We report five patients, three with distal femoral nonunion, two with acute distal femoral fracture, and all with concomitant gonarthrosis treated with total knee replacement including a modular distal femoral component [distal femoral replacement (DFR)]. In this group of patients, modular DFR provided immediate pain relief and allowed early weightbearing and aggressive rehabilitation. We recommend this treatment modality in selected osteopenic elderly patients with difficult distal femoral reconstructive problems and coexisting gonarthrosis.
PMID: 7623176 [PubMed - indexed for MEDLINE]
1: Injury. <javascript:AL_get(this,%20'jour',%20'Injury.');> 2007 Aug;38(8):965-72. Epub 2007 Jun 11.
Management of periprosthetic femur fractures with a first generation locking plate.
<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Fulkerson%20E%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Fulkerson E, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Tejwani%20N%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Tejwani N, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Stuchin%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Stuchin S, <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Egol%20K%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus> Egol K.
Department of Orthopaedic Surgery, Hospital for Joint Diseases, 301 E. 17th St., New York, NY 10003, USA. eric.fulkerson@med.nyu.edu
Periprosthetic femoral fractures associated with well-fixed total hip or total knee prostheses present a challenging management problem as these injuries typically occur in osteoporotic bone. Conventional management entails extensive periosteal stripping to allow for plate fixation. We reviewed a consecutive series of patients who sustained fractures associated with a well fixed total knee prosthesis, a total hip prosthesis, or both. Twenty four patients with a mean age of 69.4 years were included. All patients underwent fixation via percutaneous insertion techniques with a first generation locking plate and screws (LISS--Less Invasive Skeletal Stabilization, Synthes, Paoli, PA). Three patients sustained fractures distal to a well-fixed total hip prosthesis, eighteen fractures occurred above a well-fixed total knee femoral component, and three were interprosthetic. The mean length of time from the index procedure to fracture was 76 months, range (2-172 months). Blood loss was minimal in each case, with a mean operative time of 90 min (range 60-120 min). Twenty one of twenty four went on to unite at a mean 6.2 months (range 3-19 months). Three patients underwent further surgery. One failure of fixation was encountered. Percutaneous fixation is technically demanding as it requires stable fixation without direct visualisation of the fracture site or the entire fixation device. Our results suggest percutaneous fixation with the LISS plate is an effective although technically demanding method of treatment. Complication rates were comparable to existing reports of this treatment method, and appear to be improved over traditional methods of fixation.
PMID: 17561020 [PubMed - indexed for MEDLINE]
Enes M. Kanlic, MD, FACS
Professor
http://www.ttuhsc.edu/elpaso/som/Orthopaedics/
Privacy/Confidentiality Notice: This message, including any attachments, is for the sole use of the intended recipient (s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure, or distribution is strictly prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message.
-----Original Message-----
From: orthopod@googlegroups.com [mailto:orthopod@googlegroups.com] On Behalf Of Alexander Chelnokov
Sent: Friday, January 18, 2008 11:27 PM
To: Kanlic, Enes
Subject: [Orthopod] Re: post-nailing fracture: CHANCES... TKA... yes
Dear Enes,
Friday, January 18, 2008, 2:14:40 AM, you wrote:
KE> EMK: On the x-rays we see severe arthritis, lateral tibial plateau
KE> defect and probable knee instability.
She is an elderly lady with multiple comorbidities.
AFAIR there was no instability. Before the last supracondylar
fracture she was able to walk, no severe pain marked. Her knee was
contractured for about 5 years.
KE> If patient is in good medical health (able to walk and leave
KE> fes more years, and the only limitation is bad knee pain and
KE> instability), with decent soft tissues (no risk of flap necrosis),
Flap recrosis after quad plasty is very likely even in young
patients with best skin conditions. This patient had scars after
previous surgeries particularly over lateral side of the knee abd
distal femur.
KE> than
KE> with one procedure we would solve her fracture, pain and probably
KE> improve the range of motion...
She'd been observed by colleagues from another unit. Even without the
last fracture they didn't plan Judet quad plasty and TKR. I only
helped with the low invasive fracture fixation.
Of course locked plating was discussed, particulary proposed by me
myself to prevent my involvement :-) But colleagues insisted on the
presented nailing because they were familiar with our results, and took
the solution as best choice.
I don't have experience of so massive interventions neither know
somebody around who would perform TKR for arthritis in extra
conditions of acute supracondylar fracture, even if there would be no
other difficulties. We'd prefer to get the fracture healed, then
proceed with joint replacement.
I'd like to learn how TKR is performed with a supracondylar fracture
except the target knee problem, even without knee extension
contracture. What type of prosthesis is to be used? THX in advance.
--
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia
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