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Nonsurgical management of supracondylar fracture above total knee arthroplasty
The Journal of Arthroplasty Vol. 12 No.7 1997
Case Report N o n s u r g i c a l M a n a g e m e n t of S u p r a c o n d y l a r Fracture A b o v e Total K n e e A r t h r o p l a s t y Still the Nineties Option David H. Sochart, FRCS, and Kevin Hardinge, MCh Orth, FRCS
Abstract: Supracondylar fracture of the femur above a total knee arthroplasty has been reported to occur in 0.3-2.5% of all cases. The case of a patient who sustained such a fracture subsequent to a fall and whose fracture was managed without surgery with a good result is reported. There was no evidence of coexisting loosening, osteolysis, or significant wear, and satisfactory bony reduction was achieved, maintaining correct alignment of the prosthetic components. Healing occurred in 3 months, and the patient remains under follow-up evaluation with a painless knee and a range of movement similar to prefracture levels with no evidence of implant loosening. Despite the current enthusiasm for internal fixation of these fractures, a review of the current literature revealed that neither conservative nor operative management has a significant proven advantage, and the treatment of these difficult and uncommon fractures remains challenging. Nonoperative treatment of fractures above well-fixed components can, however, be as successful as surgical intervention, and remains a viable first-line approach. Conservative management also lacks the potential risks of operation, while maintaining the option of later surgical intervention if required. Key words: supracondylar fracture, total knee arthroplasty, nonoperative, reduction/alignment.
philosophies, and the m a n a g e m e n t of these difficult fractures remains challenging. fIirsch et al. reported on 4 cases in 1981 and concluded that n o t c h i n g of the anterior femoral cortex predisposed to later fracture, but that u n i o n occurred satisfactorily following conservative m a n a g e m e n t despite the presence of the prosthesis and c e m e n t [ 1]. Nonsurgical m a n a g e m e n t requires close supervision and these fractures continue to pose a serious challenge to the orthopaedic surgeon. The alternative of surgical m a n a g e m e n t was first recomm e n d e d by Short et al. also in 1981 [2], and various implants and techniques of internal and external fixation have since been used. These operations are
The first reports of supracondy]ar fractures of the f e m u r proximal to total knee arthroplasties (TKAs) emerged at the start of the eighties, with even the authors of the earliest reports divided b e t w e e n conservative and operative m a n a g e m e n t [1,2]. Despite advances in techniques of internal fixation, there has b e e n little difference b e t w e e n the reported results achieved by p r o p o n e n t s of the 2
From The Centre for Hip Surgery, Wrightington Hospital for Joint Disease, Appley Bridge, Wigan, United Kingdom.
Reprint requests: Dr. D. H. Sochart, 7 Woodlea, Walkden Road, Worsley,Manchester, M28 2QJ, United Kingdom. © 1997 Churchill Livingtone Inc.
830
Nonsurgical Management of Supracondylar Fracture often technically demanding, and there continues to be a high rate of associated complications. Because of the relatively u n c o m m o n occurrence of this complication most reported series consist of small n u m b e r s of patients. In general, authors appear to be divided equally b e t w e e n the 2 camps, and we have reviewed the available literature to assess current practice and knowledge of the condition. The aims of both operative and conservative m a n a g e m e n t should be u n i o n of the fracture with correct prosthesis and limb alignment while maintaining c o m p o n e n t fixation and a satisfactory range of m o v e m e n t . Conservative t r e a t m e n t remains the preferred option for the patient with stable, securely fixed implants, but revision TKA is the t r e a t m e n t of choice for those cases with coexisting implant loosening.
Case Report A 63-year-old w o m a n w h o w o r k e d as a parttime secretary u n d e r w e n t simultaneous bila~;eral primary TKAs for osteoarthritis in J a n u a r y 1992. Femoral, tibial, and patellar c o m p o n e n t s were implanted with c e m e n t and 8-ram plastic tibial inserts (Fig. 1). She made an uncomplicated postoperative recovery and had achieved a range of m o v e m e n t of 0 ° - I 0 0 ° by 8 weeks. In October 1993, she fell d o w n a long flight of stairs while on holiday in Spain, and radiographs confirmed an extremely c o m m i n u t e d extra-articular supracondylar fracture (Neer type 2) proximal to the left femoral prosthesis. The components re-
Fig. 1. (A) Postoperative anteroposterior and (B) lateral radiographs of left total knee replacement.
•
Sochart and Hardinge
831
m a i n e d well fixed and there was no evidence of wear or osteolysis. She was treated locally in a plaster of Paris posterior mold and returned to the United Kingdom. On her return, the fracture was manipulated u n d e r a general anesthetic and a wellpadded Thomas splint was applied with skin traction and 10 lb. counterweight. Satisfactory reduction was achieved (Fig. 2) and she remained in the hospital for 4 weeks prior to the application of a Thomas ischial bearing caliper to protect the fracture from weight bearing. She was t h e n discharged h o m e and remained mobile with elbow crutches until removal of the caliper 2 m o n t h s later. She continued follow-up evaluation, and at the last appointment, 30 months following fracture, further radiographs were obtained. These confirmed sound union in good position with no angular or rotational deformity, translation, or shortening and no evidence of implant loosening (Fig. 3). She walked well, the knee was pain free, and she had regained a range of m o v e m e n t of 0o-90 °.
Discussion Supracondylar fracture of the f e m u r proximal to a TIQA is an u n c o m m o n complication that is reported to occur in 0.3-2.5% of all cases {3-6], but w h e n encountered, it continues to represent a challenging problem. The fracture is defined as occurring in the distal f e m u r within 15 cm of the joint line or within 5 cm of the most proximal extent of any intramedullary femoral stem [7]. The average patient age at time of fracture is 65-70
832
The Journal of Arthroplasty Vol. 12 No. 7 October 1997
Fig. 2. Comminuted type 2 supracondylar fracture with satisfactory alignment: (A) anteroposterior view, (B) lateral view.
A
years, with a female-to-male p r e d o m i n a n c e ot 4:1 and a ratio of r h e u m a t o i d arthritis to osteoarthritis of 1.3:1 [3,8]. The usual interval b e t w e e n arthroplasty and fracture is reported as 3-4 years [9], with the most frequent m e c h a n i s m of injury being minimal t r a u m a from a fall [10]. Factors that predispose to these fractures include osteopenia and related conditions (rheum a t o i d arthritis, steroid use), w e a r with the presence of endosteolysis, and stress risers f r o m screw
Fig. 3. Radiographs 30 months following fracture showing sound union in good alignment: (A) anteroposterior view, (B) lateral view.
,.1
B
holes [4,11]. Patients w h o have u n d e r g o n e revision TKA and those w i t h neurologic abnormalities are also at increased risk [5,12]. The most comm o n l y cited risk factor is the presence of a n o t c h in the anterior femoral cortex proximal to the prosthesis, especially if it is greater t h a n 3 m m in depth [7,13], and notching has been reported in up to 27% of knee arthroplasties in some series [3]. The patient in this report had n o n e of these associated factors, and the components were well fixed,
Nonsurgical Management of Supracondylar Fracture but she did sustain the fracture during a fall from considerable height. The first reports of this complication emerged at the beginning of the eighties, with Hirsch et al. [1] confirming that the fracture could heal despite the presence of the implant and cement. They advocated conservative management, but in the same year Short et al. were among the first to recomm e n d surgical intervention [2]. Authors remain fairly equally divided b e t w e e n surgical [9,14,15] and conservative [4,12,16] treatment, but because of the u n c o m m o n nature of this complication, most reported series consist of small numbers of patients. The aim of treatment should be a painless knee with return to the prefracture ambulatory status and range of m o v e m e n t in a satisfied patient [8]. Union should be achieved in less than 6 months, with the normal alignment of soundly fixed components maintained [8,10]. These aims were achieved in the reported case, but it has also been stated that if there is significant residual malalignment, t h e n knee function will be impaired and prosthetic loosening will occur in the short term [3,17]. The degree of initial displacement and comm i n u t i o n is i m p o r t a n t in determining t r e a t m e n t and likely outcome, and most series grade the fractures using the Neer classification [18]. Undisplaced extra-articular fractures (type 1) and those with slight displacement (types 2A and B) are most likely to heal successfully with conservative m a n a g e m e n t [3,7,8,14]. Type 3 fractures are severely displaced and are usually associated with greater c o m m i n u t i o n and angulation, with extension of the fracture line to the intercondylar area. A successful o u t c o m e is also more likely if there is less t h a n 15 ° of angulation in b o t h planes [4,12], translation is less t h a n 2 cm, rotational deformity is minimal (< 10°), shortening is less t h a n 1 cm, and tibiofemoral prosthetic alignment is maintained [14,19]. Although the reported fracture was severely c o m m i n u t e d (Figs. 1, 2) the overall alignment and well-fixed c o m p o n e n t s permitted successful treatment, fulfilling all of these criteria. Various m e t h o d s of internal fixation have b e e n advocated including the use of blade, standaid, or condylar screw plates [2,15] or intramedullary devices such as Rush rods [9] and supracondylar nails [6,20]. The ability to introduce an intramedullary nail is also d e p e n d e n t o n the design of the implant and its intercondylar distance, which must be verified prior to operation [6]. Some authors have also described the use of customized allografts, external fixation, primary arthrodesis, and revision arthroplasty [3,21]. This surgery can be technically demanding, with the bone quality
•
Sochart and Hardinge
833
generally being poor and fixation suboptimal [13]. High complication rates have b e e n reported and include infection, failure of fixation, amputation, and perioperative death [4,9]. The disadvantages of conservative m a n a g e m e n t are those of enforced immobility due to traction or splintage, and the average time to u n i o n is reported as 4 m o n t h s [3]. The potential complications include muscle wasting, loss of m o v e m e n t , bed sores, thromboembolism, urinary tract disorders, and psychological deterioration [8]. The potential complications of b o t h conservative and operative m a n a g e m e n t include stiffness and deformity as well as n o n u n i o n and malunion, with varus deformity being c o m m o n even after internal fixation [17]. Early mobilization is r e c o m m e n d e d and has b e e n s h o w n to result in a loss of movem e n t of 7°-10 ° w h e n compared with the prefracture level [4]. Delay in c o m m e n c i n g mobilization has, however, b e e n reported to result in losses of up to 27 ° [12], although Figgie et al. showed no significant difference in the final range of movem e n t b e t w e e n surgically and conservatively managed cases [3]. The overall success rates of the 2 methods of treatment were calculated by Chert et al. using meta-analysis of all the cases reported in the English-language literature [8]. Successful outcome was achieved in 67% of conservatively managed patients and 69% of those w h o u n d e r w e n t surgery. The overall success rate was 83% for type 1 fractures and 64% for type 2. The complication rate in both groups was 30%, with similar rates o f malunion and n o n u n i o n (10% vs 9% and 16% vs 12%); none of the differences were statistically significant. There were, however, higher rates of infection and loss of life or limb in the operative group. In the presence of a loose implant, the best results have undoubtedly been achieved by revision arthroplasty, with a 91% success rate reported [3,8,12]. There remains no single satisfactory m e t h o d of treatment for all these demanding fractures, but in the presence of soundly fixed components, conservative m a n a g e m e n t should remain the first choice, as surgical intervention has been shown to offer no advantage [8]. The fracture pattern and well-fixed components in the case reported made it ideal for conservative m a n a g e m e n t with the expectation of a good result. In the event that fracture reduction and satisfactory alignment prove impossible to maintain, or if the patient is unable to tolerate bed rest, then subsequent surgical m a n a g e m e n t is indicated and will not have been prejudiced. If the prosthesis is loose, revision arthroplasty appears to be the treatm e n t of choice, irrespective of fracture type.
834
The Journal of Arthroplasty Vol. 12 No. 7 October 1997
References 1. Hirsch D, Bhalla S, Roffman M: Supracondylar fracture of the femur following total knee replacement. J Bone Joint Surg 63A:162, 1981 2. Short WH, Hootnick DR, Murry DG: Ipsilateral supracondylar femur fractures following knee arthroplasty. Clin Orthop 158:111, 1981 3. Figgie M, Goldberg V, Figgie H, Sobel M: The results of treatment of supracondylar fracture above total knee arthroplasty. J Arthroplasty 5:267, 1990 4. Merkel K, Johnson E: Supracondylar fracture in the femur after total knee arthroplasty. J Bone Joint Surg 68A:29, 1986 5. Ritter M , Faris E Keating E: Anterior femoral notching and ipsilateral supracondylar f e m u r fracture in total ,knee arthroplasty. J Arthroplasty 3:185, 1988 6. Rolston L, Christ D, Halpern A e t ah Treatment of supracondylar fractures of the femur proximal to total knee arthroplasty. J Bone Joint Surg 77A:924, 1995 7. DiGioia AM, Rubash HE: Periprosthetic fractures of the femur after total knee arthroplasty. Clin Orthop 271:135, 1991 8. Chen E Mont MA, Bachner RS: M a n a g e m e n t of ipsilateral supracondylar femur fractures following total knee arthroplasty. J Arthroplasty 9:521, 1994 9. Ritter MA, Keating EM, Faris PM, Meding GB: Rush rod fixation of supracondylar fractures above total knee arthroplasties. J Arthroplasty 10:213, 1995 10. Sisto D J, Lachiewicz PE Insall JN: Treatment of supracondylar fractures following prosthetic arthroplasty of the knee. Clin Orthop 196:265, 1985
11. Rand JA: Supracondylar fracture of the femur associated with polyethylene wear after total knee arthroplasty. J Bone Joint Surg 76A:1389, 1994 12. Culp RW, Schmidt G, Hanks et ah Supracondylar fractures of the femur following prosthetic knee arthroplasty. Clin Orthop 222:212, 1987 13. Schatzker J, Lambert DC: Supracondylar fractures of the femur. Clin Orthop i38:77, 1979 14. Bogoch E, Hastings D, Gross A, Gschwend N: Supracondylar fractures of the femur adjacent to resurfacing and Macintosh arthroplasties of the knee in patients with rheumatoid arthritis. Clin Orthop 229:213, 1988 15. Healy W, Siliski J, Incavo S: Operative treatment of distal femoral fractures proximal to knee replacements. J Bone Joint Surg 75A:27, 1993 I6. Delport PH, Van Audekerck R, Martens M, Muller JC: Conservative treatment of ipsilateral supracondylar femoral fracture after total knee arthroplasty. J Trauma 24:864, 1982 17. Cordeiro E, Costa RC, Carrazato JC, Silva J: Periprosthetic fractures in patients with total knee arthroplasties. Clin Orthop 252:182, 1990 18. Neer C, Grantom S, Shelton M: Supracondylar fracture of the adult femur. J Bone Joint Surg 49A:591, 1967 19. Cain PR, Rubash HE, Wissinger HA: Periprosthetic femoral fractures following total knee arthroplasty. Clin Orthop 208:205, 1986 20. Sekel R, N e w m a n AS: Supracondylar fractures above a total knee arthroplasty. J Arthroplasty 9: 445, 1994 21. Murrell GAC, Nunley JA: Interlocked supracondylar intramedullary nails for supracondylar fractures after total knee arthroplasty. J Arthroplasty 10:37, 1995
Case Report N o n s u r g i c a l M a n a g e m e n t of S u p r a c o n d y l a r Fracture A b o v e Total K n e e A r t h r o p l a s t y Still the Nineties Option David H. Sochart, FRCS, and Kevin Hardinge, MCh Orth, FRCS
Abstract: Supracondylar fracture of the femur above a total knee arthroplasty has been reported to occur in 0.3-2.5% of all cases. The case of a patient who sustained such a fracture subsequent to a fall and whose fracture was managed without surgery with a good result is reported. There was no evidence of coexisting loosening, osteolysis, or significant wear, and satisfactory bony reduction was achieved, maintaining correct alignment of the prosthetic components. Healing occurred in 3 months, and the patient remains under follow-up evaluation with a painless knee and a range of movement similar to prefracture levels with no evidence of implant loosening. Despite the current enthusiasm for internal fixation of these fractures, a review of the current literature revealed that neither conservative nor operative management has a significant proven advantage, and the treatment of these difficult and uncommon fractures remains challenging. Nonoperative treatment of fractures above well-fixed components can, however, be as successful as surgical intervention, and remains a viable first-line approach. Conservative management also lacks the potential risks of operation, while maintaining the option of later surgical intervention if required. Key words: supracondylar fracture, total knee arthroplasty, nonoperative, reduction/alignment.
philosophies, and the m a n a g e m e n t of these difficult fractures remains challenging. fIirsch et al. reported on 4 cases in 1981 and concluded that n o t c h i n g of the anterior femoral cortex predisposed to later fracture, but that u n i o n occurred satisfactorily following conservative m a n a g e m e n t despite the presence of the prosthesis and c e m e n t [ 1]. Nonsurgical m a n a g e m e n t requires close supervision and these fractures continue to pose a serious challenge to the orthopaedic surgeon. The alternative of surgical m a n a g e m e n t was first recomm e n d e d by Short et al. also in 1981 [2], and various implants and techniques of internal and external fixation have since been used. These operations are
The first reports of supracondy]ar fractures of the f e m u r proximal to total knee arthroplasties (TKAs) emerged at the start of the eighties, with even the authors of the earliest reports divided b e t w e e n conservative and operative m a n a g e m e n t [1,2]. Despite advances in techniques of internal fixation, there has b e e n little difference b e t w e e n the reported results achieved by p r o p o n e n t s of the 2
From The Centre for Hip Surgery, Wrightington Hospital for Joint Disease, Appley Bridge, Wigan, United Kingdom.
Reprint requests: Dr. D. H. Sochart, 7 Woodlea, Walkden Road, Worsley,Manchester, M28 2QJ, United Kingdom. © 1997 Churchill Livingtone Inc.
830
Nonsurgical Management of Supracondylar Fracture often technically demanding, and there continues to be a high rate of associated complications. Because of the relatively u n c o m m o n occurrence of this complication most reported series consist of small n u m b e r s of patients. In general, authors appear to be divided equally b e t w e e n the 2 camps, and we have reviewed the available literature to assess current practice and knowledge of the condition. The aims of both operative and conservative m a n a g e m e n t should be u n i o n of the fracture with correct prosthesis and limb alignment while maintaining c o m p o n e n t fixation and a satisfactory range of m o v e m e n t . Conservative t r e a t m e n t remains the preferred option for the patient with stable, securely fixed implants, but revision TKA is the t r e a t m e n t of choice for those cases with coexisting implant loosening.
Case Report A 63-year-old w o m a n w h o w o r k e d as a parttime secretary u n d e r w e n t simultaneous bila~;eral primary TKAs for osteoarthritis in J a n u a r y 1992. Femoral, tibial, and patellar c o m p o n e n t s were implanted with c e m e n t and 8-ram plastic tibial inserts (Fig. 1). She made an uncomplicated postoperative recovery and had achieved a range of m o v e m e n t of 0 ° - I 0 0 ° by 8 weeks. In October 1993, she fell d o w n a long flight of stairs while on holiday in Spain, and radiographs confirmed an extremely c o m m i n u t e d extra-articular supracondylar fracture (Neer type 2) proximal to the left femoral prosthesis. The components re-
Fig. 1. (A) Postoperative anteroposterior and (B) lateral radiographs of left total knee replacement.
•
Sochart and Hardinge
831
m a i n e d well fixed and there was no evidence of wear or osteolysis. She was treated locally in a plaster of Paris posterior mold and returned to the United Kingdom. On her return, the fracture was manipulated u n d e r a general anesthetic and a wellpadded Thomas splint was applied with skin traction and 10 lb. counterweight. Satisfactory reduction was achieved (Fig. 2) and she remained in the hospital for 4 weeks prior to the application of a Thomas ischial bearing caliper to protect the fracture from weight bearing. She was t h e n discharged h o m e and remained mobile with elbow crutches until removal of the caliper 2 m o n t h s later. She continued follow-up evaluation, and at the last appointment, 30 months following fracture, further radiographs were obtained. These confirmed sound union in good position with no angular or rotational deformity, translation, or shortening and no evidence of implant loosening (Fig. 3). She walked well, the knee was pain free, and she had regained a range of m o v e m e n t of 0o-90 °.
Discussion Supracondylar fracture of the f e m u r proximal to a TIQA is an u n c o m m o n complication that is reported to occur in 0.3-2.5% of all cases {3-6], but w h e n encountered, it continues to represent a challenging problem. The fracture is defined as occurring in the distal f e m u r within 15 cm of the joint line or within 5 cm of the most proximal extent of any intramedullary femoral stem [7]. The average patient age at time of fracture is 65-70
832
The Journal of Arthroplasty Vol. 12 No. 7 October 1997
Fig. 2. Comminuted type 2 supracondylar fracture with satisfactory alignment: (A) anteroposterior view, (B) lateral view.
A
years, with a female-to-male p r e d o m i n a n c e ot 4:1 and a ratio of r h e u m a t o i d arthritis to osteoarthritis of 1.3:1 [3,8]. The usual interval b e t w e e n arthroplasty and fracture is reported as 3-4 years [9], with the most frequent m e c h a n i s m of injury being minimal t r a u m a from a fall [10]. Factors that predispose to these fractures include osteopenia and related conditions (rheum a t o i d arthritis, steroid use), w e a r with the presence of endosteolysis, and stress risers f r o m screw
Fig. 3. Radiographs 30 months following fracture showing sound union in good alignment: (A) anteroposterior view, (B) lateral view.
,.1
B
holes [4,11]. Patients w h o have u n d e r g o n e revision TKA and those w i t h neurologic abnormalities are also at increased risk [5,12]. The most comm o n l y cited risk factor is the presence of a n o t c h in the anterior femoral cortex proximal to the prosthesis, especially if it is greater t h a n 3 m m in depth [7,13], and notching has been reported in up to 27% of knee arthroplasties in some series [3]. The patient in this report had n o n e of these associated factors, and the components were well fixed,
Nonsurgical Management of Supracondylar Fracture but she did sustain the fracture during a fall from considerable height. The first reports of this complication emerged at the beginning of the eighties, with Hirsch et al. [1] confirming that the fracture could heal despite the presence of the implant and cement. They advocated conservative management, but in the same year Short et al. were among the first to recomm e n d surgical intervention [2]. Authors remain fairly equally divided b e t w e e n surgical [9,14,15] and conservative [4,12,16] treatment, but because of the u n c o m m o n nature of this complication, most reported series consist of small numbers of patients. The aim of treatment should be a painless knee with return to the prefracture ambulatory status and range of m o v e m e n t in a satisfied patient [8]. Union should be achieved in less than 6 months, with the normal alignment of soundly fixed components maintained [8,10]. These aims were achieved in the reported case, but it has also been stated that if there is significant residual malalignment, t h e n knee function will be impaired and prosthetic loosening will occur in the short term [3,17]. The degree of initial displacement and comm i n u t i o n is i m p o r t a n t in determining t r e a t m e n t and likely outcome, and most series grade the fractures using the Neer classification [18]. Undisplaced extra-articular fractures (type 1) and those with slight displacement (types 2A and B) are most likely to heal successfully with conservative m a n a g e m e n t [3,7,8,14]. Type 3 fractures are severely displaced and are usually associated with greater c o m m i n u t i o n and angulation, with extension of the fracture line to the intercondylar area. A successful o u t c o m e is also more likely if there is less t h a n 15 ° of angulation in b o t h planes [4,12], translation is less t h a n 2 cm, rotational deformity is minimal (< 10°), shortening is less t h a n 1 cm, and tibiofemoral prosthetic alignment is maintained [14,19]. Although the reported fracture was severely c o m m i n u t e d (Figs. 1, 2) the overall alignment and well-fixed c o m p o n e n t s permitted successful treatment, fulfilling all of these criteria. Various m e t h o d s of internal fixation have b e e n advocated including the use of blade, standaid, or condylar screw plates [2,15] or intramedullary devices such as Rush rods [9] and supracondylar nails [6,20]. The ability to introduce an intramedullary nail is also d e p e n d e n t o n the design of the implant and its intercondylar distance, which must be verified prior to operation [6]. Some authors have also described the use of customized allografts, external fixation, primary arthrodesis, and revision arthroplasty [3,21]. This surgery can be technically demanding, with the bone quality
•
Sochart and Hardinge
833
generally being poor and fixation suboptimal [13]. High complication rates have b e e n reported and include infection, failure of fixation, amputation, and perioperative death [4,9]. The disadvantages of conservative m a n a g e m e n t are those of enforced immobility due to traction or splintage, and the average time to u n i o n is reported as 4 m o n t h s [3]. The potential complications include muscle wasting, loss of m o v e m e n t , bed sores, thromboembolism, urinary tract disorders, and psychological deterioration [8]. The potential complications of b o t h conservative and operative m a n a g e m e n t include stiffness and deformity as well as n o n u n i o n and malunion, with varus deformity being c o m m o n even after internal fixation [17]. Early mobilization is r e c o m m e n d e d and has b e e n s h o w n to result in a loss of movem e n t of 7°-10 ° w h e n compared with the prefracture level [4]. Delay in c o m m e n c i n g mobilization has, however, b e e n reported to result in losses of up to 27 ° [12], although Figgie et al. showed no significant difference in the final range of movem e n t b e t w e e n surgically and conservatively managed cases [3]. The overall success rates of the 2 methods of treatment were calculated by Chert et al. using meta-analysis of all the cases reported in the English-language literature [8]. Successful outcome was achieved in 67% of conservatively managed patients and 69% of those w h o u n d e r w e n t surgery. The overall success rate was 83% for type 1 fractures and 64% for type 2. The complication rate in both groups was 30%, with similar rates o f malunion and n o n u n i o n (10% vs 9% and 16% vs 12%); none of the differences were statistically significant. There were, however, higher rates of infection and loss of life or limb in the operative group. In the presence of a loose implant, the best results have undoubtedly been achieved by revision arthroplasty, with a 91% success rate reported [3,8,12]. There remains no single satisfactory m e t h o d of treatment for all these demanding fractures, but in the presence of soundly fixed components, conservative m a n a g e m e n t should remain the first choice, as surgical intervention has been shown to offer no advantage [8]. The fracture pattern and well-fixed components in the case reported made it ideal for conservative m a n a g e m e n t with the expectation of a good result. In the event that fracture reduction and satisfactory alignment prove impossible to maintain, or if the patient is unable to tolerate bed rest, then subsequent surgical m a n a g e m e n t is indicated and will not have been prejudiced. If the prosthesis is loose, revision arthroplasty appears to be the treatm e n t of choice, irrespective of fracture type.
834
The Journal of Arthroplasty Vol. 12 No. 7 October 1997
References 1. Hirsch D, Bhalla S, Roffman M: Supracondylar fracture of the femur following total knee replacement. J Bone Joint Surg 63A:162, 1981 2. Short WH, Hootnick DR, Murry DG: Ipsilateral supracondylar femur fractures following knee arthroplasty. Clin Orthop 158:111, 1981 3. Figgie M, Goldberg V, Figgie H, Sobel M: The results of treatment of supracondylar fracture above total knee arthroplasty. J Arthroplasty 5:267, 1990 4. Merkel K, Johnson E: Supracondylar fracture in the femur after total knee arthroplasty. J Bone Joint Surg 68A:29, 1986 5. Ritter M , Faris E Keating E: Anterior femoral notching and ipsilateral supracondylar f e m u r fracture in total ,knee arthroplasty. J Arthroplasty 3:185, 1988 6. Rolston L, Christ D, Halpern A e t ah Treatment of supracondylar fractures of the femur proximal to total knee arthroplasty. J Bone Joint Surg 77A:924, 1995 7. DiGioia AM, Rubash HE: Periprosthetic fractures of the femur after total knee arthroplasty. Clin Orthop 271:135, 1991 8. Chen E Mont MA, Bachner RS: M a n a g e m e n t of ipsilateral supracondylar femur fractures following total knee arthroplasty. J Arthroplasty 9:521, 1994 9. Ritter MA, Keating EM, Faris PM, Meding GB: Rush rod fixation of supracondylar fractures above total knee arthroplasties. J Arthroplasty 10:213, 1995 10. Sisto D J, Lachiewicz PE Insall JN: Treatment of supracondylar fractures following prosthetic arthroplasty of the knee. Clin Orthop 196:265, 1985
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