title: Outcome of periprosthetic distal femoral fractures following knee arthroplasty.
abstract: BACKGROUND
  The majority of periprosthetic fractures around the knee occur at the supracondylar region of the distal femur. Fixation of distal femoral fractures in osteoporotic bone with short segment remains a challenge, especially after total knee arthroplasty (TKA). Internal fixation of these fractures using locking plates has become popular. The purpose of this study was to evaluate a consecutive series of periprosthetic supracondylar femoral fractures treated with locked periarticular plate fixation with regard to surgical procedure, complications and clinical outcome.
  
  
  METHODS
  From two academic trauma centres, 55 consecutive periprosthetic distal femoral fractures (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association, AO/OTA 33) were retrospectively identified as having been treated with locked plate fixation. Of these, 36 fractures in 35 patients (86.1% female) met the inclusion criteria. Patients had an average age of 73.2 years (range 54-95 years). Fixation constructs for plate length and working length were delineated. Nonunion, infection and implant failure were used as complication variables. Demographics were assessed. Outcome was addressed radiographically and clinically according to Kristensen et al.(1) by range of motion and pain.
  
  
  RESULTS
  Twenty-five of 36 fractures (69.4%) healed after the index procedure. Eight of 36 fractures (22.2%) developed a nonunion with three fractures (8.3%) leading to hardware failure. Nine of the 36 patients (25%) were radiographically diagnosed with notching of the anterior femoral cortex. Regarding technical aspects, distance from the anterior flange of the femoral component to fracture was significantly shorter in patients with compared to without anterior notching (t=3.68, p=0.02). Patients who underwent submuscular plate insertion compared to an extensive lateral approach had a reduced nonunion risk (χ(2)=0.05). No difference in infection rate was found for submuscular procedures compared with open procedures (χ(2)=0.85). Range of motion was reduced in most of the patients and 13.5% had a persistent loss of extension of 5°. More than 77% of the patients reported no or only mild pain during the last office visit. Range of motion loss did not influence pain. Successful treatment according to Cain et al.(2) was achieved in 83%. Using Kristensen's(1) criteria, 56% of the knees had acceptable flexion.
  
  
  CONCLUSIONS
  Operative fixation of periprosthetic distal femoral fractures after TKA continues to be challenging. Notching of the anterior femoral cortex should be avoided. Loss of reduction and high failure rates still occur with locked plating and may be related to underlying factors. Indirect reduction and submuscular plate insertion technique reduce nonunion risk.
authors.affiliation: Grand Rapids Medical Education Partners, 1000 Monroe Ave NW, Grand Rapids, MI 49503, USA. Martin.Hoffmann@oamichigan.com
authors.forename: M F
authors.initials: MF
authors.lastname: Hoffmann
authors.forename: C B
authors.initials: CB
authors.lastname: Jones
authors.forename: D L
authors.initials: DL
authors.lastname: Sietsema
authors.forename: S J
authors.initials: SJ
authors.lastname: Koenig
authors.forename: P
authors.initials: P
authors.lastname: Tornetta
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects*; D001860:Bone Plates; D005260:Female; D005264:Femoral Fractures / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery; D005593:Fracture Fixation, Internal / Q000379:methods*; D017102:Fracture Healing; D006801:Humans; D008297:Male; D008875:Middle Aged; D057068:Periprosthetic Fractures / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery; D011859:Radiography; D012189:Retrospective Studies; D016896:Treatment Outcome