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Supracondylar femur fractures above an Insall-Burstein CCK total knee
The Journal of Arthroplasty Vol. 13 No. 4 1998
Case Report Supracondylar Femur Fractures Above an Insall-Burstein CCK Total Knee A New Method of Intramedullary Stem Fixation Randall
S. P e y t o n ,
MD,* and Robert
E. B o o t h ,
Jr, M D t
Abstract: Supracondylar femur fracture above a well-fixed posterior cruciate
substituting prosthesis may not allow the use of standard fixation methods because of the closed nature of the femoral box. The Insall-Burstein Constrained Condylar Knee femoral prosthesis (Zimmer, Warsaw, IN) possesses a closed box and the capability of modular femoral stems. A retrieval device aids the utilization of the modular ability of the femoral prosthesis to gain intramedullary fixation of supracondylar femur fractures above a well-fixed femoral component allowing restoration of alignment, length, preinjury range of motion, and function. K e y words: total knee prosthesis, supracondylar fracture, distal femur fracture, stems, technique, retrieval device.
Supracondylar f e m u r fracture above a total k n e e arthroplasty is a difficult p r o b l e m w h i c h has b e e n successfully treated w i t h i n t r a m e d u l l a r y fixation with excellent results [1-8]. Using i n t r a m e d u l l a r y fixation there has b e e n a 100% healing rate of these fractures as reported in the literature. We report a case w h e r e an i n t r a m e d u l l a r y rod was m a t e d to a m o d u l a r semiconstrained c o m p o n e n t with a closed b o x (Insall-Burnstein II, constrained condylar k n e e prosthesis [IB-II CCK] Zimmer, Warsaw, IN) utilizing a specifically designed retrieval instrument.
in 1979, w h i c h was subsequently revised in August 1993 to an IB-II CCK prosthesis. She was doing well until S e p t e m b e r of 1994, w h e n she fell out of bed as a result of a stroke. In this fall she sustained a right supracondylar periprosthetic femoral fracture above a well-fixed c o m p o n e n t (Fig. l). This fracture was spiral, starting a p p r o x i m a t e l y at the level of the prosthesis and ending in the diaphyseal portion of the f e m u r (Type II according to modified Neer classification) [9,10]. Because of the nature of the prosthesis, a blade plate or condylar screw w e r e discounted options for obtaining distal fixation. Also, because of the closed box nature of the prosthesis, an i n t r a m e d u l l a r y or supracondylar nail was not an option. Preoperatively, k n o w i n g the m o d u l a r capabilities of the CCK, a retrieval tool was m a d e to capture an i n t r a m e d u l l a r y rod connecting it to the existing, well-fixed femoral c o m p o n e n t . The retrieval tool possesses the same threads as the m a n u f a c t u r e r ' s locking screw for the stem, a n d a long thin shaft to go t h r o u g h the locking screw hole in the b o x of the femoral c o m p o n e n t (Fig. 2). At surgery, the fracture
Case Report I A 77-year-old, 5 ft 3 in tall, 200-1b w o m a n previously u n d e r w e n t right total k n e e arthroplasty
From the *Orthopaedic Surgery Practice, Sterling, Virginia; and the ~-Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. Reprint requests: Randall S. Peyton, MD, 46440 Benedict Drive, Suite 107, Sterling, VA 20164. Copyright © 1998 by Churchill Livingstone® 0883- 5403/1304-001653.00/0
473
474
The Journal of Arthroplasty Vol. 13 No. 4 June 1998
Fig. I. Radiographs of case 1, showing periprosthetic supracondylar femur fracture. (A) Anteroposterior view. (B) Lateral view. Fig. 3. Intraoperative photograph of Case 1, with stem in femur proximal to the fracture. a n d the k n e e w e r e exposed t h r o u g h an e x t e n d e d medial parapatellar a p p r o a c h and the f e m u r proxim a l to the fracture was r e a m e d to accept a long, curved, fluted rod that was inserted into the femoral canal p r o x i m a l to the fracture (Fig. 3). By guiding the retrieval tool t h r o u g h the femoral c o m p o n e n t up to the fracture site a n d screwing into the m o d u lar long curved fluted stem, the s t e m was "captured" (Fig. 4). The c a p t u r e d s t e m is t h e n pulled t o w a r d the femoral c o m p o n e n t , a n d gently but firmly the stem is seated into the Morse taper of the femoral c o m p o nent. Once the s t e m is seated, the retrieval tool is unscrewed, a n d the standard locking screw is placed to secure the s t e m to the f e m o r a l c o m p o n e n t . With the fracture stabilized, Dall-Miles ( H o w m e d i c a , Rutherford, N e w Jersey) cables w e r e placed a r o u n d the femoral fracture for s u p p l e m e n t a l fixation a n d additional rotational stability. A t o u r n i q u e t was not used because of the size of the patient and the location of the fracture. After surgery she was treated w i t h c o n t i n u o u s passive motion, active-assisted physical therapy, a n d partial weight-bearing, w h i c h progressed to full weightbear-
Fig. 2. Peyton retrieval device.
ing. The fracture had radiographic evidence of u n i o n at a p p r o x i m a t e l y I0 w e e k s a n d a l i g n m e n t r e m a i n e d excellent (Fig. 5). Range of m o t i o n of the k n e e was 0 ° - I 1 5 ° at 2-year follow-up, a l t h o u g h there was mild right-sided w e a k n e s s secondary to the stroke.
Case Report 2 An 80-year-old, 5 ft 2 in. tall, I 7 5 - p o u n d w o m a n previously u n d e r w e n t left total k n e e arthroplasty w h i c h was s u b s e q u e n t l y revised in N o v e m b e r of 1992 to an IB-II CCK prosthesis with a femoral stem. She did well regaining painless m o t i o n in the
Fig. 4. Model demonstrating retrieval tool (on the right) capturing the stem through the knee and guiding it to the Morse taper.
Intramedullary Stem Fixation
•
Peyton and Booth
475
Fig. 5. Postoperative radiographs of Case i, showing healing and maintenance of length and alignment. (A) Anteroposterior view. (B) Lateral view.
knee, but c o m p l a i n e d of mild anterior thigh pain in M a r c h 1995. A b o n e scan was ordered, but before this was done she h a d a m i n i m a l fall and suffered a fracture at the tip of the f e m o r a l s t e m (Fig. 6). Again, k n o w i n g the m o d u l a r capabilities of the CCK femoral c o m p o n e n t the fracture was exposed a n d the previous s t e m was r e m o v e d retrograde t h r o u g h the fracture using the retrieval tool. Bone at the p r o x i m a l tip of the rod required burring to w i d e n the canal to allow passage of the larger Morse taper portion of the rod. After r e m o v i n g the locking screw, the retrieval tool was screwed into the existing stem. With a gentle tap on the retrieval tool, the s t e m was loosened f r o m the Morse taper and p u s h e d retrograde out the fr~icture site. The femoral canal p r o x i m a l to the fracture was r e a m e d to accept a long curved fluted rod, a n d the retrieval tool utilized to
capture a n d guide it into a seated position on the Morse taper of the femoral c o m p o n e n t . The stem was t h e n secured w i t h the standard fixation screw. Allograft b o n e was placed over the fracture site a n d Dall-Miles cables w e r e placed a r o u n d the strut allograft for s u p p l e m e n t a l fixation a n d additional rotational stability. After surgery the same t h e r a p y protocol was utilized as in the first case. Union was achieved at a p p r o x i m a t e l y 12 weeks, and alignment was well m a i n t a i n e d (Fig. 7). Range of m o t i o n was 5°-1 I0 ° at 1 8 - m o n t h follow-up.
Discussion Supracondylar l e m u r fractures above total k n e e arthroplasty have been associated with trauma, notch-
476
The Journal of Arthroplasty Vol. 13 No. 4 June 1998
Fig. 6. Radiographs of Case 2, showing periprosthetic femur fracture. (A) Anteroposterior view. (B) Lateral view.
t h a n 1 cm of shortening are the accepted criteria for treating these fractures [ l 0]. Nonoperative methods of t r e a t m e n t have the risk of malalignment, malunion, n o n u n i o n , and decreased range of motion [ 12,18]. There are also systemic risks to keeping the elderly in bed such as thrombophlebitis, pulmo-
ing of the anterior femoral cortex [ll-15], revision surgery [12-15], r h e u m a t o i d arthritis [13, I4], osteoporosis [11-13, 16], osteolytic defects [I7], n e u r o logic disorders {l 1], and stress risers from screw holes [13]. Fracture union, m a i n t e n a n c e of alignm e n t and preoperative range of motion, and less
B
Fig. 7. Radiographs of Case 2, at 2 years after surgery, showing healing and maintenance of alignment. (A) Anteroposterior view. (B) Lateral view.
Intramedullary Stem Fixation nary embolus, urinary stasis, pressure sores, psychological deterioration, and weakness. Surgical treatm e n t reduces some of the risks of n o n o p e r a t i v e intervention, a l t h o u g h the risk of infection is introduced [19]. Intramedullary fixation has p r o v e n beneficial for supracondylar f e m u r fractures above total knee arthroplasty [1-8]. Also, intramedullary fixation has negated the hardship of revision of a well-fixed, n o n m o d u l a r s t e m m e d femoral c o m p o n e n t and has led to excellent aIignment and functional reults [ 1,2]. Some posterior stabilized knee prostheses have a closed box that does not allow insertion of a retrograde or supracondylar nail. With the m o d u l a r CCK femoral c o m p o n e n t , though, an intramedullary rod can be attached directly to the c o m p o n e n t for stabilizing the fracture. This can be accomplished with a retrieval tool to allow the stem or intramedullary rod to be b r o u g h t into the Morse taper of the m o d u l a r femoral c o m p o n e n t . Revision total knees are associated with a higher incidence of supracondylar fractures, and with the increased n u m b e r of revision surgeries being performed it is logical to expect an increase of supracondylar fractures in this group of patients. The etiology of fractures after revisional surgery is assuredly multifactoriah increased constraint in the component, as pointed out by Culp et al. [11], osteopenia secondary to disease and stress shielding, and decreased vascularity from repeated surgery. Managem e n t of supracondylar f e m u r fractures above a well-fixed total knee arthroplasty presents a difficult problem, since most of these fractures are sustained in elderly osteopenic and debilitated patients. With a semiconstrained femoral c o m p o n e n t of the CCK variety, w h i c h has a p r o m i n e n t and closed femoral box, the ordinary supracondylar nail is not able to be utilized. Also, there is n o t e n o u g h distal bone to allow adequate fixation with a blade plate or condylar screw. Fortunately, by the utilization of a retrieval device, an intramedullary rod can be connected successfully to this type of prosthesis and thereby achieve intramedullary fixation to allow restoration of alignment, length, preinjury range of motion, and function as u n i o n takes place. The cases presented demonstrate the successful stabilization of supracondylar f e m u r fractures above a well-fixed c o m p o n e n t by the addition of a m o d u lar stem t h r o u g h the fracture site. This is a beneficial technique that avoids the morbidity of revisional surgery w h e n other forms of fixation are not possible.
•
Peyton and Booth
477
References 1. Roscoe MW, Goodman SB, Schatzker: Supracondylar fracture of the femur after GUEPAR total knee arthroplasty: a new treatment method. Clin Orthop 241: 221, 1989 2. Sekel R, Newman AS: Supracondylar fractures above a total knee arthroplasty. J Arthroplasty 9:445, 1994 3. Maniar RN, Umlas ME, Rodriguez JA, Ranawat CS: Supracondylar femoral fracture above a PFC posterior cruciate-substituting total knee arthroplasty treated with supracondylar nailing: a unique technical problem. J Arthroplasty 11:637, 1996 4. Ritter MA, Stiver P: Supracondyar fracture in a patient with total knee arthroplasty: a case report. Clin Orthop 193:168, 1985 5. Ritter MA, Keating EM, Faris PM, Meding JB: Rush rod fixation of supracondylar fractures above total knee arthroplasties. J Arthroplasty 10:213, 1995 6. Jabczenski FE Crawford M: Retrograde intramedullary nailing of supracondylar femur fractures above total knee arthroplasty: a preliminary report of four cases. J Arthroplasty 10:95, 1995 7. McLaren AC, Dupont JA, Schroeber DC: Open reduction internal fixation of supracondylar fractures above total knee arthroplasties using the intramedullary supracondylar rod. Clin Orthop 302:194, 1992 8. MurrelI GAC, Nunley JA: Interlocked supracondylar intramedullary nails for supracondylar fractures after total knee arthroplasty: a new treatment method. J Arthroplasty 10:37, 1995 9. Neer CS II, Grantham SA, Shelton ML: Supracondylar fracture of the adult femur. J Bone Joint Surg [Am] 49:591, 1967 10. DiGioia AM III, Rubash HE: Periprosthetic fractures of the femur after total knee arthroplasty. Clin Orthop 271:135, 1991 11. Culp RW, Schmidt RG, Hanks G, Mak A et al.: Supracondylar fracture of the femur following prosthetic knee arthroplasty. Clin Orthop 222:212, 1987 12. Cain PR, Rubash HE, Wissinger HA, McClain EJ: Periprosthetic femoral fractures following total knee arthroplasty. Clin Orthop 208:205, 1986 13. Merkel KD, Johnson EW Jr: Supracondylar fracture of the femur after total knee arthroplasty. J Bone Joint Surg [Am] 68:29, 1986 14. Aaron RK, Scott R: Supracondylar fracture of the femur after total knee arthroplasty. Clin Orthop 219:136, 1987 15. Figgie MP, Goldberg VM, Figgie HE III, Sobel M: The results of treatment of supracondylar fracture above total knee arthroplasty. J Arthroplasty 5:267, 1990
478
The Journal of Arthroplasty Vol. 13 No. 4 June 1998
16. Nielsen BE Petersen VS, Varmarken JE: Fracture of the femur after knee arthroplasty. Acta Orthop Scand 59:155, 1988 17. Rand JA: Supracondylar fracture of the femur associated with polyethylene wear after total knee arthroplasty. J Bone Joint Surg [Am] 76:1389, 1994
18. Short WH, Hootnick DR, Murray DG: Ipsilateral supracondylar femur fractures following knee arthroplasty. Clin Orthop 158:111, 1981 19. Healy WL, Siliski JM, Incavo SJ: Operative treatment of distal femoral fractures proximal to total knee replacements. J Bone Joint Surg [Am] 75:27, 1993
Case Report Supracondylar Femur Fractures Above an Insall-Burstein CCK Total Knee A New Method of Intramedullary Stem Fixation Randall
S. P e y t o n ,
MD,* and Robert
E. B o o t h ,
Jr, M D t
Abstract: Supracondylar femur fracture above a well-fixed posterior cruciate
substituting prosthesis may not allow the use of standard fixation methods because of the closed nature of the femoral box. The Insall-Burstein Constrained Condylar Knee femoral prosthesis (Zimmer, Warsaw, IN) possesses a closed box and the capability of modular femoral stems. A retrieval device aids the utilization of the modular ability of the femoral prosthesis to gain intramedullary fixation of supracondylar femur fractures above a well-fixed femoral component allowing restoration of alignment, length, preinjury range of motion, and function. K e y words: total knee prosthesis, supracondylar fracture, distal femur fracture, stems, technique, retrieval device.
Supracondylar f e m u r fracture above a total k n e e arthroplasty is a difficult p r o b l e m w h i c h has b e e n successfully treated w i t h i n t r a m e d u l l a r y fixation with excellent results [1-8]. Using i n t r a m e d u l l a r y fixation there has b e e n a 100% healing rate of these fractures as reported in the literature. We report a case w h e r e an i n t r a m e d u l l a r y rod was m a t e d to a m o d u l a r semiconstrained c o m p o n e n t with a closed b o x (Insall-Burnstein II, constrained condylar k n e e prosthesis [IB-II CCK] Zimmer, Warsaw, IN) utilizing a specifically designed retrieval instrument.
in 1979, w h i c h was subsequently revised in August 1993 to an IB-II CCK prosthesis. She was doing well until S e p t e m b e r of 1994, w h e n she fell out of bed as a result of a stroke. In this fall she sustained a right supracondylar periprosthetic femoral fracture above a well-fixed c o m p o n e n t (Fig. l). This fracture was spiral, starting a p p r o x i m a t e l y at the level of the prosthesis and ending in the diaphyseal portion of the f e m u r (Type II according to modified Neer classification) [9,10]. Because of the nature of the prosthesis, a blade plate or condylar screw w e r e discounted options for obtaining distal fixation. Also, because of the closed box nature of the prosthesis, an i n t r a m e d u l l a r y or supracondylar nail was not an option. Preoperatively, k n o w i n g the m o d u l a r capabilities of the CCK, a retrieval tool was m a d e to capture an i n t r a m e d u l l a r y rod connecting it to the existing, well-fixed femoral c o m p o n e n t . The retrieval tool possesses the same threads as the m a n u f a c t u r e r ' s locking screw for the stem, a n d a long thin shaft to go t h r o u g h the locking screw hole in the b o x of the femoral c o m p o n e n t (Fig. 2). At surgery, the fracture
Case Report I A 77-year-old, 5 ft 3 in tall, 200-1b w o m a n previously u n d e r w e n t right total k n e e arthroplasty
From the *Orthopaedic Surgery Practice, Sterling, Virginia; and the ~-Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. Reprint requests: Randall S. Peyton, MD, 46440 Benedict Drive, Suite 107, Sterling, VA 20164. Copyright © 1998 by Churchill Livingstone® 0883- 5403/1304-001653.00/0
473
474
The Journal of Arthroplasty Vol. 13 No. 4 June 1998
Fig. I. Radiographs of case 1, showing periprosthetic supracondylar femur fracture. (A) Anteroposterior view. (B) Lateral view. Fig. 3. Intraoperative photograph of Case 1, with stem in femur proximal to the fracture. a n d the k n e e w e r e exposed t h r o u g h an e x t e n d e d medial parapatellar a p p r o a c h and the f e m u r proxim a l to the fracture was r e a m e d to accept a long, curved, fluted rod that was inserted into the femoral canal p r o x i m a l to the fracture (Fig. 3). By guiding the retrieval tool t h r o u g h the femoral c o m p o n e n t up to the fracture site a n d screwing into the m o d u lar long curved fluted stem, the s t e m was "captured" (Fig. 4). The c a p t u r e d s t e m is t h e n pulled t o w a r d the femoral c o m p o n e n t , a n d gently but firmly the stem is seated into the Morse taper of the femoral c o m p o nent. Once the s t e m is seated, the retrieval tool is unscrewed, a n d the standard locking screw is placed to secure the s t e m to the f e m o r a l c o m p o n e n t . With the fracture stabilized, Dall-Miles ( H o w m e d i c a , Rutherford, N e w Jersey) cables w e r e placed a r o u n d the femoral fracture for s u p p l e m e n t a l fixation a n d additional rotational stability. A t o u r n i q u e t was not used because of the size of the patient and the location of the fracture. After surgery she was treated w i t h c o n t i n u o u s passive motion, active-assisted physical therapy, a n d partial weight-bearing, w h i c h progressed to full weightbear-
Fig. 2. Peyton retrieval device.
ing. The fracture had radiographic evidence of u n i o n at a p p r o x i m a t e l y I0 w e e k s a n d a l i g n m e n t r e m a i n e d excellent (Fig. 5). Range of m o t i o n of the k n e e was 0 ° - I 1 5 ° at 2-year follow-up, a l t h o u g h there was mild right-sided w e a k n e s s secondary to the stroke.
Case Report 2 An 80-year-old, 5 ft 2 in. tall, I 7 5 - p o u n d w o m a n previously u n d e r w e n t left total k n e e arthroplasty w h i c h was s u b s e q u e n t l y revised in N o v e m b e r of 1992 to an IB-II CCK prosthesis with a femoral stem. She did well regaining painless m o t i o n in the
Fig. 4. Model demonstrating retrieval tool (on the right) capturing the stem through the knee and guiding it to the Morse taper.
Intramedullary Stem Fixation
•
Peyton and Booth
475
Fig. 5. Postoperative radiographs of Case i, showing healing and maintenance of length and alignment. (A) Anteroposterior view. (B) Lateral view.
knee, but c o m p l a i n e d of mild anterior thigh pain in M a r c h 1995. A b o n e scan was ordered, but before this was done she h a d a m i n i m a l fall and suffered a fracture at the tip of the f e m o r a l s t e m (Fig. 6). Again, k n o w i n g the m o d u l a r capabilities of the CCK femoral c o m p o n e n t the fracture was exposed a n d the previous s t e m was r e m o v e d retrograde t h r o u g h the fracture using the retrieval tool. Bone at the p r o x i m a l tip of the rod required burring to w i d e n the canal to allow passage of the larger Morse taper portion of the rod. After r e m o v i n g the locking screw, the retrieval tool was screwed into the existing stem. With a gentle tap on the retrieval tool, the s t e m was loosened f r o m the Morse taper and p u s h e d retrograde out the fr~icture site. The femoral canal p r o x i m a l to the fracture was r e a m e d to accept a long curved fluted rod, a n d the retrieval tool utilized to
capture a n d guide it into a seated position on the Morse taper of the femoral c o m p o n e n t . The stem was t h e n secured w i t h the standard fixation screw. Allograft b o n e was placed over the fracture site a n d Dall-Miles cables w e r e placed a r o u n d the strut allograft for s u p p l e m e n t a l fixation a n d additional rotational stability. After surgery the same t h e r a p y protocol was utilized as in the first case. Union was achieved at a p p r o x i m a t e l y 12 weeks, and alignment was well m a i n t a i n e d (Fig. 7). Range of m o t i o n was 5°-1 I0 ° at 1 8 - m o n t h follow-up.
Discussion Supracondylar l e m u r fractures above total k n e e arthroplasty have been associated with trauma, notch-
476
The Journal of Arthroplasty Vol. 13 No. 4 June 1998
Fig. 6. Radiographs of Case 2, showing periprosthetic femur fracture. (A) Anteroposterior view. (B) Lateral view.
t h a n 1 cm of shortening are the accepted criteria for treating these fractures [ l 0]. Nonoperative methods of t r e a t m e n t have the risk of malalignment, malunion, n o n u n i o n , and decreased range of motion [ 12,18]. There are also systemic risks to keeping the elderly in bed such as thrombophlebitis, pulmo-
ing of the anterior femoral cortex [ll-15], revision surgery [12-15], r h e u m a t o i d arthritis [13, I4], osteoporosis [11-13, 16], osteolytic defects [I7], n e u r o logic disorders {l 1], and stress risers from screw holes [13]. Fracture union, m a i n t e n a n c e of alignm e n t and preoperative range of motion, and less
B
Fig. 7. Radiographs of Case 2, at 2 years after surgery, showing healing and maintenance of alignment. (A) Anteroposterior view. (B) Lateral view.
Intramedullary Stem Fixation nary embolus, urinary stasis, pressure sores, psychological deterioration, and weakness. Surgical treatm e n t reduces some of the risks of n o n o p e r a t i v e intervention, a l t h o u g h the risk of infection is introduced [19]. Intramedullary fixation has p r o v e n beneficial for supracondylar f e m u r fractures above total knee arthroplasty [1-8]. Also, intramedullary fixation has negated the hardship of revision of a well-fixed, n o n m o d u l a r s t e m m e d femoral c o m p o n e n t and has led to excellent aIignment and functional reults [ 1,2]. Some posterior stabilized knee prostheses have a closed box that does not allow insertion of a retrograde or supracondylar nail. With the m o d u l a r CCK femoral c o m p o n e n t , though, an intramedullary rod can be attached directly to the c o m p o n e n t for stabilizing the fracture. This can be accomplished with a retrieval tool to allow the stem or intramedullary rod to be b r o u g h t into the Morse taper of the m o d u l a r femoral c o m p o n e n t . Revision total knees are associated with a higher incidence of supracondylar fractures, and with the increased n u m b e r of revision surgeries being performed it is logical to expect an increase of supracondylar fractures in this group of patients. The etiology of fractures after revisional surgery is assuredly multifactoriah increased constraint in the component, as pointed out by Culp et al. [11], osteopenia secondary to disease and stress shielding, and decreased vascularity from repeated surgery. Managem e n t of supracondylar f e m u r fractures above a well-fixed total knee arthroplasty presents a difficult problem, since most of these fractures are sustained in elderly osteopenic and debilitated patients. With a semiconstrained femoral c o m p o n e n t of the CCK variety, w h i c h has a p r o m i n e n t and closed femoral box, the ordinary supracondylar nail is not able to be utilized. Also, there is n o t e n o u g h distal bone to allow adequate fixation with a blade plate or condylar screw. Fortunately, by the utilization of a retrieval device, an intramedullary rod can be connected successfully to this type of prosthesis and thereby achieve intramedullary fixation to allow restoration of alignment, length, preinjury range of motion, and function as u n i o n takes place. The cases presented demonstrate the successful stabilization of supracondylar f e m u r fractures above a well-fixed c o m p o n e n t by the addition of a m o d u lar stem t h r o u g h the fracture site. This is a beneficial technique that avoids the morbidity of revisional surgery w h e n other forms of fixation are not possible.
•
Peyton and Booth
477
References 1. Roscoe MW, Goodman SB, Schatzker: Supracondylar fracture of the femur after GUEPAR total knee arthroplasty: a new treatment method. Clin Orthop 241: 221, 1989 2. Sekel R, Newman AS: Supracondylar fractures above a total knee arthroplasty. J Arthroplasty 9:445, 1994 3. Maniar RN, Umlas ME, Rodriguez JA, Ranawat CS: Supracondylar femoral fracture above a PFC posterior cruciate-substituting total knee arthroplasty treated with supracondylar nailing: a unique technical problem. J Arthroplasty 11:637, 1996 4. Ritter MA, Stiver P: Supracondyar fracture in a patient with total knee arthroplasty: a case report. Clin Orthop 193:168, 1985 5. Ritter MA, Keating EM, Faris PM, Meding JB: Rush rod fixation of supracondylar fractures above total knee arthroplasties. J Arthroplasty 10:213, 1995 6. Jabczenski FE Crawford M: Retrograde intramedullary nailing of supracondylar femur fractures above total knee arthroplasty: a preliminary report of four cases. J Arthroplasty 10:95, 1995 7. McLaren AC, Dupont JA, Schroeber DC: Open reduction internal fixation of supracondylar fractures above total knee arthroplasties using the intramedullary supracondylar rod. Clin Orthop 302:194, 1992 8. MurrelI GAC, Nunley JA: Interlocked supracondylar intramedullary nails for supracondylar fractures after total knee arthroplasty: a new treatment method. J Arthroplasty 10:37, 1995 9. Neer CS II, Grantham SA, Shelton ML: Supracondylar fracture of the adult femur. J Bone Joint Surg [Am] 49:591, 1967 10. DiGioia AM III, Rubash HE: Periprosthetic fractures of the femur after total knee arthroplasty. Clin Orthop 271:135, 1991 11. Culp RW, Schmidt RG, Hanks G, Mak A et al.: Supracondylar fracture of the femur following prosthetic knee arthroplasty. Clin Orthop 222:212, 1987 12. Cain PR, Rubash HE, Wissinger HA, McClain EJ: Periprosthetic femoral fractures following total knee arthroplasty. Clin Orthop 208:205, 1986 13. Merkel KD, Johnson EW Jr: Supracondylar fracture of the femur after total knee arthroplasty. J Bone Joint Surg [Am] 68:29, 1986 14. Aaron RK, Scott R: Supracondylar fracture of the femur after total knee arthroplasty. Clin Orthop 219:136, 1987 15. Figgie MP, Goldberg VM, Figgie HE III, Sobel M: The results of treatment of supracondylar fracture above total knee arthroplasty. J Arthroplasty 5:267, 1990
478
The Journal of Arthroplasty Vol. 13 No. 4 June 1998
16. Nielsen BE Petersen VS, Varmarken JE: Fracture of the femur after knee arthroplasty. Acta Orthop Scand 59:155, 1988 17. Rand JA: Supracondylar fracture of the femur associated with polyethylene wear after total knee arthroplasty. J Bone Joint Surg [Am] 76:1389, 1994
18. Short WH, Hootnick DR, Murray DG: Ipsilateral supracondylar femur fractures following knee arthroplasty. Clin Orthop 158:111, 1981 19. Healy WL, Siliski JM, Incavo SJ: Operative treatment of distal femoral fractures proximal to total knee replacements. J Bone Joint Surg [Am] 75:27, 1993