Tips for Managing Periprosthetic Fractures of the Distal Femur
Why is open reduction and internal fixation (ORIF) the gold standard for managing periprosthetic fractures of the distal femur?
Because it works, George J. Haidukewych, MD, told attendees at ICJR’s Advanced Techniques in Total Hip & Total Knee Arthroplasty course, achieving bony union in more than 90% of cases.
These fractures are becoming more common, he said, usually the result of a low-energy injury. The goals of treatment are to:
- Maximize distal fixation
- Promote fracture union
- Heal the fracture in correct alignment, length, and rotation
- Avoid complications
But there are challenges to achieving these goals, including:
- Osteopenic bone with areas of osteolysis
- Short distal fragments
- Obstacles to distal fixation from the femoral component, such as lugs, boxes, and stems
When performing ORIF, surgeons can choose between submuscular locked plating and retrograde nailing with multi-planar, angle-stable locking screws.
Nails have the advantage of being tissue-friendly and mechanically sound, especially in patients with a long area of comminution. Good notch access is essential to avoid malalignment, and, fortunately, most modern implants for total knee arthroplasty allow for this access.
Locked plating can also be successful, because it provides coronal plane stability and allows for percutaneous insertion and very distal fixation. The surgeon can also easily reposition screws if a lug, box, or plate is in the way. And notch access if not required.
The literature gives a slight advantage to nails, Dr. Haidukewych said, but both can achieve the goals of treatment for periprosthetic fractures of the distal femur.
In some cases, though, neither retrograde nailing nor locked plating will be appropriate. For about 10% of patients, Dr. Haidukewych uses a megaprosthesis.
A megaprosthesis allows for full weight-bearing after surgery and early range of motion. There is no fracture to heal, so there’s no concern about non-union. However, a megaprosthesis is very expensive – as high as $40,000 – and the procedure is not a simple operation, requiring expertise to properly position the implant. In addition, use of a megaprosthesis is associated with high rates of complications – 15% in the case of infection – and extensor mechanism problems.
Because of these issues, Dr. Haidukewuch uses a megaprosthesis as a last resort, such as when the patient has severe osteolysis or when ORIF has failed and he’s performing a revision of a periprosthetic non-union.
Click the image above to hear tips and techniques from Dr. Haidukewych on managing a periprosthetic fracture of the distal femur.
George J. Haidukewych, MD, is chief of orthopaedic trauma and adult reconstruction at the Orlando Health Jewett Orthopedic Institute and a professor at the University of Central Florida College of Medicine in Orlando, Florida. He was the course chair for ICJR’s Advanced Techniques in Total Hip & Total Knee Arthroplasty course for senior residents and fellows.
Disclosures: Dr. Haidukewych has disclosed that he owns stock in Revision Technologies; that he receives royalties from DePuy Synthes and Zimmer Biomet; and that he is a paid consultant for ConforMIS, DePuy Synthes, and Zimmer Biomet.