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Bilateral stress fracture of the femoral shaft after total knee arthroplasty
The Knee 18 (2011) 354–357
Contents lists available at ScienceDirect
The Knee
Case report
Bilateral stress fracture of the femoral shaft after total knee arthroplasty A case report Hong Chul Lim a, Ji Hoon Bae b,⁎, Ju Won Yi a, Jung Ho Park b a b
Department of Orthopaedic Surgery, Guro Hospital, Korea University College of Medicine, 97 Guro-dong Gil, Guro-Gu, Seoul, Republic of Korea Department of Orthopaedic Surgery, Ansan Hospital, Korea University College of Medicine, Gojan 1-Dong, Danwon-Gu, Ansan-Si,Gyeonggi-Do, Republic of Korea
a r t i c l e
i n f o
Article history: Received 1 February 2010 Received in revised form 4 June 2010 Accepted 16 June 2010 Keywords: Stress fracture Total knee arthroplasty Femur shaft
a b s t r a c t The authors present a case of bilateral stress fracture of the femoral shaft 15 years after total knee arthroplasty. Considerable femoral bowing deformity and varus malposition of the femoral and tibial components after total knee arthroplasty may produce abnormal stresses and lead to stress fracture of the distal femur in the region of greatest curvature. © 2010 Elsevier B.V. All rights reserved.
Stress fractures after TKA occur mainly in patients with considerable deformity of the knee and osteoporosis[1–10]. Increased activity on osteoporotic bone and the changes in loading over the femoral neck due to the corrected axis of the knee after TKA may lead to stress fractures. The majority of stress fractures after TKA involve the femoral neck or the subtrochanteric region [1–9]. Here, we present a case of stress fracture of the femur shaft after total knee arthroplasty, which is the first of its kind to be described in the English literature [10]. 1. Case Report A 73-year-old female patient (height 158 cm, weight 62 kg, body mass index 24.8) with osteoarthritis of both knees underwent bilateral total knee replacement arthroplasty using a cementless posterior cruciate ligament retaining type prosthesis (Anatomic Graduated Components, Biomet, Inc, Warsaw, IN). After surgery, she was able to participate in light activities like walking, housework, or yard work without significant knee pain. However, 13 years later, she presented with a one month history of bilateral thigh pain, which increased with weight bearing but decreased at rest. She was treated with alendronate (Fosamax®) due to a low bone mineral density, which was found at other institution one before the presentation. Physical examinations revealed mild tenderness on the lateral aspect of both mid-thighs. Range of motion was 0 to 120 degrees for the right ⁎ Corresponding author. Department of Orthopaedic Surgery, Ansan Hospital, Korea University College of Medicine, Gojan 1-Dong, Danwon-Gu, Ansan-Si,Gyeonggi-Do, Republic of Korea. Tel.: + 82 31 412 5043; fax: +82 31 487 9502. E-mail address: [email protected] (J.H. Bae). 0968-0160/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.knee.2010.06.002
knee joint and 0 to 125 degrees for the left. Plain radiography showed varus deformity of the right lower extremity with cortical thickening of the right distal femoral shaft (Fig. 1). Mechanical femorotibial angles were 164° on the right side and 170° on the left. Femoral and tibial components were malpositioned in varus on both sides. There were no signs of osteolysis, implant loosening, or subsidence as compared with previous plain radiographs. Under a diagnosis of stress fracture, she was treated with rest and an anti-inflammatory drug, and after 1 month of conservative treatment, she was able to walk without pain. However, 1 year after the first episode of right thigh pain, she again presented with right thigh pain without a history of trauma. On this occasion, pain also increased with weight bearing and decreased at rest, but she was not able to stand on the right lower leg. Physical examinations failed to reveal any sign of infection or implant loosening, and plain radiography showed no change as compared with previous radiographic findings. Cortical thickening of the distal femur was still apparent on the right side with varus alignment of both lower extremity. We again recommended medication and rest, and the patient's symptom subsequently improved. Four months after the second presentation due to right thigh pain, she presented with the same symptom and could not walk without a cane. Plain radiography failed to reveal any pathologic findings, but cortices at the junction of the middle and distal 1/3rd portion of the femur had thickened. Bone scintigraphy showed bilaterally increased uptake at the distal 1/3rd of both femurs, which was more dominant in the right (Fig. 2). The patient was informed that she had a stress fracture and non-weight bearing walking or rest was recommended. However, one month later, she presented with a displaced transverse fracture at the distal one third of right femoral shaft (Fig. 3). She was
H.C. Lim et al. / The Knee 18 (2011) 354–357
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Fig. 1. Anteroposterior lower extremity radiograph showing cortical thickening and a transverse fracture line at the junction of middle and distal diaphysis of the right femur.
treated by closed reduction and internal fixation using a femoral intramedullary nail (Antegrade femoral nail, Synthes, Paoli, PA), and was then able to return to normal daily activities. The radiograph taken at last follow up showed abundant callus formation (Fig. 4). 2. Discussion Stress fractures are caused by either abnormal stress placed on normal bone (fatigue fractures) or by normal stress on abnormal bone (insufficiency fractures), but both fracture types are due to the cumulative effects of repetitive low intensity forces on bone over an extended period of time. Risk factors include repetitive activity, abnormal biomechanical forces, and systemic diseases that weaken bone. In our patient, a considerable femoral bowing deformity and varus alignment of femoral and tibial components after total knee arthroplasty may have produced the abnormal stresses responsible for the stress fracture in the distal femur, where greatest curvature occurs. Pain during weight bearing and localized tenderness are typical symptoms of a stress fracture. Although pain alone is probably not a reliable indicator of impending fracture, and is insufficient in itself to justify prophylactic fixation, recurrent thigh pain after a resolving a stress fracture is the most important indication for surgical stabilization. We did not perform prophylactic fixation in the described case even though she continued to experience recurrent thigh pain, but conservative treatment failed. Over a two-year period, we asked her to reduce activity and recommended that she use a crutch or cane. It is worth making the point that not only does pain interfere with a
patient's quality of life, but that it can result in disuse osteoporosis, which increases the likelihood of a stress fracture. Boden et al[11] classified stress fractures as low or high-risk injuries. Low-risk fractures have a favorable prognosis when treated with activity restriction. In contrast, high-risk stress fractures are prone to delayed union or nonunion, especially if the diagnosis is delayed. Surgical stabilization is often required for high-risk stress fractures. Femoral shaft stress fractures in athletes and military recruits are undoubtedly considered low-risk, because in most cases fractures are not displaced and can be treated nonoperatively. However, in view of the clinical course of the described case, we advocate that femoral shaft stress fractures associated with bowing deformity and varus malalignment after total knee arthroplasty be considered high-risk. Long-term alendronate therapy has been associated with lowenergy subtrochanteric and femoral diaphyseal fractures in recent reports [12–16]. Furthermore, severely suppressed bone turnover has recently been described as a potential complication of long-term alendronate therapy, and to result in increased susceptibility to, and delayed healing of, nonspinal fractures [17]. Although the duration of alendronate therapy was shorter in our patient than in previous reports, there may have been a causal relationship between the use of alendronate and stress fracture development in our patient. We continue to follow the patient closely to determine if discontinuing alendronate and limiting weight bearing is adequate or whether prophylactic fixation should be recommended. We conclude that femoral bowing deformity and varus malalignment of components should be considered high-risk factors of stress fracture. Accordingly, we recommend that stress fractures be afforded
356
H.C. Lim et al. / The Knee 18 (2011) 354–357
Fig. 2. Bone scintigraphy showing bilaterally increased uptake at the distal 1/3 rd of the femur, which was more dominant on the right side.
special attention when a patient that has undergone TKA and has a considerable deformity of the knee complains of thigh pain. 3. Conflict of Interest The authors disclose no financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work. References [1] Fipp G. Stress fractures of the femoral neck following total knee arthroplasty. J Arthroplasty 1988;3:347–50. [2] Hardy DC, Delince PE, Yasik E, Lafontaine MA. Stress fracture of the hip. An unusual complication of total knee arthroplasty. Clin Orthop Relat Res 1992:140–4. [3] Hendel D, Beloosesky Y, Weisbort M. Fracture of the hip after knee arthroplasty–an unusual case with pain in the knee. Acta Orthop Scand 2001;72:194–5. [4] Joshi N, Pidemunt G, Carrera L, Navarro-Quilis A. Stress fracture of the femoral neck as a complication of total knee arthroplasty. J Arthroplasty 2005;20:392–5. [5] Kumm DA, Rack C, Rutt J. Subtrochanteric stress fracture of the femur following total knee arthroplasty. J Arthroplasty 1997;12:580–3. [6] Lesniewski PJ, Testa NN. Stress fracture of the hip as a complication of total knee replacement. Case report. J Bone Joint Surg Am 1982;64:304–6.
[7] McElwaine JP, Sheehan JM. Spontaneous fractures of the femoral neck after total replacement of the knee. J Bone Joint Surg Br 1982;64:323–5. [8] Palance Martin D, Albareda J, Seral F. Subcapital stress fracture of the femoral neck after total knee arthroplasty. Int Orthop 1994;18:308–9. [9] Rawes ML, Patsalis T, Gregg PJ. Subcapital stress fractures of the hip complicating total knee replacement. Injury 1995;26:421–3. [10] Niimi R, Hasegawa M, Sudo A, Uchida A. Unilateral stress fracture of the femoral shaft combined with contralateral insufficiency fracture of the femoral shaft after bilateral total knee arthroplasty. J Orthop Sci 2008;13:572–5. [11] Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Am J Sports Med 2001;29:100–11. [12] Ali T, Jay RH. Spontaneous femoral shaft fracture after long-term alendronate. Age Ageing 2009;38:625–6. [13] Capeci CM, Tejwani NC. Bilateral low-energy simultaneous or sequential femoral fractures in patients on long-term alendronate therapy. J Bone Joint Surg Am 2009;91:2556–61. [14] Ing-Lorenzini K, Desmeules J, Plachta O, Suva D, Dayer P, Peter R. Low-energy femoral fractures associated with the long-term use of bisphosphonates: a case series from a Swiss university hospital. Drug Saf 2009;32:775–85. [15] Neviaser AS, Lane JM, Lenart BA, Edobor-Osula F, Lorich DG. Low-energy femoral shaft fractures associated with alendronate use. J Orthop Trauma 2008;22:346–50. [16] Vasikaran SD. Association of low-energy femoral fractures with prolonged bisphosphonate use: a case–control study. Osteoporos Int 2009;20:1457–8. [17] Odvina CV, Zerwekh JE, Rao DS, Maalouf N, Gottschalk FA, Pak CY. Severely suppressed bone turnover: a potential complication of alendronate therapy. J Clin Endocrinol Metab 2005;90:1294–301.
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Fig. 4. Anteroposterior and lateral radiographs of the right femur at 7 months after intramedullary nail fixation showing callus formation and a visible fracture line at the anterolateral cortex. Fig. 3. Anteroposterior radiograph of the right femur showing a displaced transverse fracture.
Contents lists available at ScienceDirect
The Knee
Case report
Bilateral stress fracture of the femoral shaft after total knee arthroplasty A case report Hong Chul Lim a, Ji Hoon Bae b,⁎, Ju Won Yi a, Jung Ho Park b a b
Department of Orthopaedic Surgery, Guro Hospital, Korea University College of Medicine, 97 Guro-dong Gil, Guro-Gu, Seoul, Republic of Korea Department of Orthopaedic Surgery, Ansan Hospital, Korea University College of Medicine, Gojan 1-Dong, Danwon-Gu, Ansan-Si,Gyeonggi-Do, Republic of Korea
a r t i c l e
i n f o
Article history: Received 1 February 2010 Received in revised form 4 June 2010 Accepted 16 June 2010 Keywords: Stress fracture Total knee arthroplasty Femur shaft
a b s t r a c t The authors present a case of bilateral stress fracture of the femoral shaft 15 years after total knee arthroplasty. Considerable femoral bowing deformity and varus malposition of the femoral and tibial components after total knee arthroplasty may produce abnormal stresses and lead to stress fracture of the distal femur in the region of greatest curvature. © 2010 Elsevier B.V. All rights reserved.
Stress fractures after TKA occur mainly in patients with considerable deformity of the knee and osteoporosis[1–10]. Increased activity on osteoporotic bone and the changes in loading over the femoral neck due to the corrected axis of the knee after TKA may lead to stress fractures. The majority of stress fractures after TKA involve the femoral neck or the subtrochanteric region [1–9]. Here, we present a case of stress fracture of the femur shaft after total knee arthroplasty, which is the first of its kind to be described in the English literature [10]. 1. Case Report A 73-year-old female patient (height 158 cm, weight 62 kg, body mass index 24.8) with osteoarthritis of both knees underwent bilateral total knee replacement arthroplasty using a cementless posterior cruciate ligament retaining type prosthesis (Anatomic Graduated Components, Biomet, Inc, Warsaw, IN). After surgery, she was able to participate in light activities like walking, housework, or yard work without significant knee pain. However, 13 years later, she presented with a one month history of bilateral thigh pain, which increased with weight bearing but decreased at rest. She was treated with alendronate (Fosamax®) due to a low bone mineral density, which was found at other institution one before the presentation. Physical examinations revealed mild tenderness on the lateral aspect of both mid-thighs. Range of motion was 0 to 120 degrees for the right ⁎ Corresponding author. Department of Orthopaedic Surgery, Ansan Hospital, Korea University College of Medicine, Gojan 1-Dong, Danwon-Gu, Ansan-Si,Gyeonggi-Do, Republic of Korea. Tel.: + 82 31 412 5043; fax: +82 31 487 9502. E-mail address: [email protected] (J.H. Bae). 0968-0160/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.knee.2010.06.002
knee joint and 0 to 125 degrees for the left. Plain radiography showed varus deformity of the right lower extremity with cortical thickening of the right distal femoral shaft (Fig. 1). Mechanical femorotibial angles were 164° on the right side and 170° on the left. Femoral and tibial components were malpositioned in varus on both sides. There were no signs of osteolysis, implant loosening, or subsidence as compared with previous plain radiographs. Under a diagnosis of stress fracture, she was treated with rest and an anti-inflammatory drug, and after 1 month of conservative treatment, she was able to walk without pain. However, 1 year after the first episode of right thigh pain, she again presented with right thigh pain without a history of trauma. On this occasion, pain also increased with weight bearing and decreased at rest, but she was not able to stand on the right lower leg. Physical examinations failed to reveal any sign of infection or implant loosening, and plain radiography showed no change as compared with previous radiographic findings. Cortical thickening of the distal femur was still apparent on the right side with varus alignment of both lower extremity. We again recommended medication and rest, and the patient's symptom subsequently improved. Four months after the second presentation due to right thigh pain, she presented with the same symptom and could not walk without a cane. Plain radiography failed to reveal any pathologic findings, but cortices at the junction of the middle and distal 1/3rd portion of the femur had thickened. Bone scintigraphy showed bilaterally increased uptake at the distal 1/3rd of both femurs, which was more dominant in the right (Fig. 2). The patient was informed that she had a stress fracture and non-weight bearing walking or rest was recommended. However, one month later, she presented with a displaced transverse fracture at the distal one third of right femoral shaft (Fig. 3). She was
H.C. Lim et al. / The Knee 18 (2011) 354–357
355
Fig. 1. Anteroposterior lower extremity radiograph showing cortical thickening and a transverse fracture line at the junction of middle and distal diaphysis of the right femur.
treated by closed reduction and internal fixation using a femoral intramedullary nail (Antegrade femoral nail, Synthes, Paoli, PA), and was then able to return to normal daily activities. The radiograph taken at last follow up showed abundant callus formation (Fig. 4). 2. Discussion Stress fractures are caused by either abnormal stress placed on normal bone (fatigue fractures) or by normal stress on abnormal bone (insufficiency fractures), but both fracture types are due to the cumulative effects of repetitive low intensity forces on bone over an extended period of time. Risk factors include repetitive activity, abnormal biomechanical forces, and systemic diseases that weaken bone. In our patient, a considerable femoral bowing deformity and varus alignment of femoral and tibial components after total knee arthroplasty may have produced the abnormal stresses responsible for the stress fracture in the distal femur, where greatest curvature occurs. Pain during weight bearing and localized tenderness are typical symptoms of a stress fracture. Although pain alone is probably not a reliable indicator of impending fracture, and is insufficient in itself to justify prophylactic fixation, recurrent thigh pain after a resolving a stress fracture is the most important indication for surgical stabilization. We did not perform prophylactic fixation in the described case even though she continued to experience recurrent thigh pain, but conservative treatment failed. Over a two-year period, we asked her to reduce activity and recommended that she use a crutch or cane. It is worth making the point that not only does pain interfere with a
patient's quality of life, but that it can result in disuse osteoporosis, which increases the likelihood of a stress fracture. Boden et al[11] classified stress fractures as low or high-risk injuries. Low-risk fractures have a favorable prognosis when treated with activity restriction. In contrast, high-risk stress fractures are prone to delayed union or nonunion, especially if the diagnosis is delayed. Surgical stabilization is often required for high-risk stress fractures. Femoral shaft stress fractures in athletes and military recruits are undoubtedly considered low-risk, because in most cases fractures are not displaced and can be treated nonoperatively. However, in view of the clinical course of the described case, we advocate that femoral shaft stress fractures associated with bowing deformity and varus malalignment after total knee arthroplasty be considered high-risk. Long-term alendronate therapy has been associated with lowenergy subtrochanteric and femoral diaphyseal fractures in recent reports [12–16]. Furthermore, severely suppressed bone turnover has recently been described as a potential complication of long-term alendronate therapy, and to result in increased susceptibility to, and delayed healing of, nonspinal fractures [17]. Although the duration of alendronate therapy was shorter in our patient than in previous reports, there may have been a causal relationship between the use of alendronate and stress fracture development in our patient. We continue to follow the patient closely to determine if discontinuing alendronate and limiting weight bearing is adequate or whether prophylactic fixation should be recommended. We conclude that femoral bowing deformity and varus malalignment of components should be considered high-risk factors of stress fracture. Accordingly, we recommend that stress fractures be afforded
356
H.C. Lim et al. / The Knee 18 (2011) 354–357
Fig. 2. Bone scintigraphy showing bilaterally increased uptake at the distal 1/3 rd of the femur, which was more dominant on the right side.
special attention when a patient that has undergone TKA and has a considerable deformity of the knee complains of thigh pain. 3. Conflict of Interest The authors disclose no financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work. References [1] Fipp G. Stress fractures of the femoral neck following total knee arthroplasty. J Arthroplasty 1988;3:347–50. [2] Hardy DC, Delince PE, Yasik E, Lafontaine MA. Stress fracture of the hip. An unusual complication of total knee arthroplasty. Clin Orthop Relat Res 1992:140–4. [3] Hendel D, Beloosesky Y, Weisbort M. Fracture of the hip after knee arthroplasty–an unusual case with pain in the knee. Acta Orthop Scand 2001;72:194–5. [4] Joshi N, Pidemunt G, Carrera L, Navarro-Quilis A. Stress fracture of the femoral neck as a complication of total knee arthroplasty. J Arthroplasty 2005;20:392–5. [5] Kumm DA, Rack C, Rutt J. Subtrochanteric stress fracture of the femur following total knee arthroplasty. J Arthroplasty 1997;12:580–3. [6] Lesniewski PJ, Testa NN. Stress fracture of the hip as a complication of total knee replacement. Case report. J Bone Joint Surg Am 1982;64:304–6.
[7] McElwaine JP, Sheehan JM. Spontaneous fractures of the femoral neck after total replacement of the knee. J Bone Joint Surg Br 1982;64:323–5. [8] Palance Martin D, Albareda J, Seral F. Subcapital stress fracture of the femoral neck after total knee arthroplasty. Int Orthop 1994;18:308–9. [9] Rawes ML, Patsalis T, Gregg PJ. Subcapital stress fractures of the hip complicating total knee replacement. Injury 1995;26:421–3. [10] Niimi R, Hasegawa M, Sudo A, Uchida A. Unilateral stress fracture of the femoral shaft combined with contralateral insufficiency fracture of the femoral shaft after bilateral total knee arthroplasty. J Orthop Sci 2008;13:572–5. [11] Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Am J Sports Med 2001;29:100–11. [12] Ali T, Jay RH. Spontaneous femoral shaft fracture after long-term alendronate. Age Ageing 2009;38:625–6. [13] Capeci CM, Tejwani NC. Bilateral low-energy simultaneous or sequential femoral fractures in patients on long-term alendronate therapy. J Bone Joint Surg Am 2009;91:2556–61. [14] Ing-Lorenzini K, Desmeules J, Plachta O, Suva D, Dayer P, Peter R. Low-energy femoral fractures associated with the long-term use of bisphosphonates: a case series from a Swiss university hospital. Drug Saf 2009;32:775–85. [15] Neviaser AS, Lane JM, Lenart BA, Edobor-Osula F, Lorich DG. Low-energy femoral shaft fractures associated with alendronate use. J Orthop Trauma 2008;22:346–50. [16] Vasikaran SD. Association of low-energy femoral fractures with prolonged bisphosphonate use: a case–control study. Osteoporos Int 2009;20:1457–8. [17] Odvina CV, Zerwekh JE, Rao DS, Maalouf N, Gottschalk FA, Pak CY. Severely suppressed bone turnover: a potential complication of alendronate therapy. J Clin Endocrinol Metab 2005;90:1294–301.
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Fig. 4. Anteroposterior and lateral radiographs of the right femur at 7 months after intramedullary nail fixation showing callus formation and a visible fracture line at the anterolateral cortex. Fig. 3. Anteroposterior radiograph of the right femur showing a displaced transverse fracture.