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. 2021 Jan 5;23:239–245. doi: 10.1016/j.jor.2020.12.024

Periprosthetic fracture management around total knee arthroplasty

Moritz F Mayr 1,∗, Norbert P Südkamp 1, Lukas Konstantinidis 1
PMCID: PMC7876523  PMID: 33613007

1. Introduction

The number of patients with joint arthroplasty is growing steadily. Among other things, this is related to the fact that the population is continuously increasing and getting older on the one hand, and the other hand the demand for high physical performance even at an advanced age. In 2018, the Endoprostheses Register Germany recorded a total of over 300.000 implantations or revisions of artificial joints. More than 132.000 of these concerned the knee joint. Projections of the working group around Kurtz et al. assume 3.48 million knee arthroplasties in the USA in 2030.1 With the increasing number of implanted artificial joints, the number of typical complications naturally also raises. A major complication with massive socioeconomic consequences is a periprosthetic fracture. While the incidence of periprosthetic fractures is low after primary TKA, the risk increases after revision surgery. Multiple factors must be taken into account when treating a periprosthetic fracture. The basic principles of classical fracture management can rarely be applied directly to periprosthetic fracture management, as the biomechanics and bone healing are significantly altered with an inserted artificial joint. Identifying the cause of the fracture is a key element in determining further therapy. The presence of a prosthetic joint infection, aseptic loosening or a pathological fracture in malignant disease significantly influences the strategy. Since unexpected findings sometimes first manifest themselves intraoperatively, surgical treatment is recommended in a specialized center where both the expertise and the infrastructure for backup strategies are available. In the following article, the different fracture patterns and treatment strategies for the three joint partners of the knee - femur, tibia and patella – around TKA will be examined. The common classifications as well as special features of the different joint partners are also discussed. Furthermore, the own results of fracture treatment at the authors' clinic with a special technique using double plate osteosynthesis with a medial helix plate in periprosthetic femur fracture around TKA will be presented and discussed.

2. Epidemiology

The underlying causes of periprosthetic fractures around TKA are diverse. In addition to age, gender, the time elapsed since implantation and revision surgery also have a relevant influence on the fracture risk.2 In the current literature, the incidence of a periprosthetic fracture after primary TKA is about 2%. In the case of revision surgery, the incidence increases by up to 38% depending on the literature reference. The most common fracture location is the femur, followed by the patella and tibia.3, 4, 5 High-energy trauma is only in rare cases the cause. Often, the fracture is preceded by inadequate trauma or low-energy fracture mechanisms, with general risk factors such as osteoporosis, prosthetic joint infection (PJI) or aseptic loosening of the implants promoting fracture. The further treatment path depends strictly on the underlying risk factor for the fracture. In general, periprosthetic fractures can occur intraoperatively or postoperatively. If intraoperative fractures are detected during implantation, they can usually be treated directly. In the case of postoperative fractures, the cause of the fracture and the fixation of the components must be considered to decide whether the implant can be retained or has to be replaced. The required information can usually be obtained from the detailed medical history and the corresponding diagnostics including puncture of the affected joint.

3. Diagnostics

The exact recording of medical history is of great importance for further treatment decision. If the patient was never free of symptoms in the area of the affected knee joint after TKR, the focus is on PJI, incorrect positioning or selection of components, or intraoperatively missed periprosthetic fractures. If the patient suffers from a malignant disease or osteoporosis, it may be a pathological fracture. The basic radiological diagnosis consists of an x-ray of the affected knee joint in two perpendicular planes (anterior-posterior and lateral) and an axial image of the patella. Any adjacent implants or prostheses of the neighboring joints must also be displayed for further planning. If the pain level and general condition of the patient permits, an x-ray of the whole leg is recorded to identify axial deviations. A comparison with preexisting imaging allows conclusions to be drawn about a loosening of the implants, peri-implant osteolysis and sintering or malposition of the components.6 CT imaging can detect non-displaced and therefore in the x-ray occult fractures or component fractures. Furthermore, it can help to determine the fracture morphology and bone quality. Besides, rotational malposition of the components can be assessed effectively with CT. In direct proximity to inserted implants, the validity of the CT is limited through metal-related interference artifacts. In exceptional cases, the MRI, which is otherwise very susceptible to metal artifacts, can provide valuable additional information about the soft tissue envelope, occult fractures, the bone-prosthesis-interface, and bone cement without x-ray markers using special sequences with low field strengths.7 Performing a DEXA absorptiometry provides information on bone quality. This information should be considered when planning the procedure and selecting implants. If the patient's medical history, imaging, or laboratory diagnostics indicate a PJI, the affected knee joint must be punctured or even biopsied. The detection or exclusion of a PJI is particularly important, as the further procedure significantly depends on it. The description of the specific treatment for periprosthetic fractures around TKA in the following chapters is limited to fractures of non-infectious and non-malignant origin.

4. Treatment

4.1. Distal femur

Periprosthetic fractures around TKA occur most frequently in the distal femur. The incidence is 0.3%–2.5%.6 This area is also particularly at risk due to the large moments of force that occur in the supracondylar region in the context of low-energy trauma. The classification according to Lewis-Rorabeck divides distal femoral fractures into 3 types depending on the degree of dislocation and the fixation of the components (Fig. 1). It is well established in clinical practice.8 Type 1 and 2 fractures imply fixed components and differ only in the degree of dislocation. This subdivision is historically explained since the results of surgical therapy with nonlocking osteosyntheses were inferior to those of conservative treatment. Until the introduction of locking plate systems by the AO Foundation in 2000, the results of plate osteosyntheses in supracondylar periprosthetic femoral fractures were sobering.9, 10, 11, 12 A further milestone was the development of special periprosthetic fracture plates by the AO Foundation in 2005, which met the mechanical and geometric requirements for treating this kind of fractures even better.13 If the locking mechanism is polyaxially, some locking head screws can be placed in the distal fragment without collision with the femoral prosthetic component, even in very distal fractures. It is recommended to insert screws in 8–10 cortices above and below the fracture.3 If an intramedullary implant is present, extra short screws may be inserted monocortically. By using additional modules such as the locking adapting plate, which is screwed onto the plate, it is possible to insert several screws into the bone passing intramedullary implants. Too rigid fixation by plate osteosynthesis should be avoided so as not to compromise bone healing. Load sharing can be improved by using long plates. The screws should not be placed too close to the fracture site to ensure sufficient working length and avoid stress risers.14 Due to the high mechanical load with implants that are already in place, it is recommended to use broad and therefore more stable plates, especially in comminuted fractures to prevent implant failure. If the general condition of the patient allows it, surgical treatment with locking plate osteosynthesis should be performed nowadays, as this reduces complications such as non-union. Postoperative exercise stability can also prevent stiffening of the knee joint since conservative therapy requires the affected extremity to be immobilized across the knee joint for a longer period.15 In principle, retrograde intramedullary nail osteosynthesis is also possible, depending on the prosthesis model and taking into account ipsilateral femoral implants. In recent years, however, it has lost much of its importance as it is inferior to locking plate osteosynthesis concerning stability, non-union and revision procedures. The advantages of intramedullary nailing are the lower invasiveness and the resulting lower infection rate and less blood loss. For a retrograde intramedullary nailing osteosynthesis, several conditions must be given. The femoral component of the TKA must have an open box design and the thickest part of the nail must be able to pass through the open intercondylar space during insertion. For this purpose, the prosthesis model must be known. In this context, it is important to note that the nail diameter is usually given for the part of the nail that is diaphyseal in the area of the isthmus. The distal nail end, which must also fit through the intercondylar space of the prosthesis, usually has a larger diameter. The affected knee joint must be able to be flexed at least 60° for safe nail entry. Very distal fractures are unsuitable for intramedullary nail osteosynthesis because at least 2 locking screws should be placed in the distal fragment.16,17 Retrograde intramedullary nail osteosynthesis for the treatment of periprosthetic distal femoral fractures around TKA should be reserved for situations where there are contraindications for plate osteosynthesis. In all other cases, locking plate osteosynthesis should be preferred.

Fig. 1.

Fig. 1

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Classification of periprosthetic supracondylar fractures around TKA according to Rorabeck.

Type 1 fractures do not have a comminuted zone. The dislocation is a maximum of 5 mm and the axial deviation is a maximum of 5°.18 There is no high degree of instability. The osteosynthesis procedure of choice is a lateral locking plate osteosynthesis. Modern systems can be inserted with an insertion guide via soft tissue sparing approaches in the region of the lateral femur. The proximal screw holes are each accessed through small incisions. This kind of fracture rarely requires direct exposure. A dislocation >5 mm or an axial deviation >5° is referred to as a type 2 fracture. Compared to type 1 fractures, the stability is reduced through the dislocation. In multifragmentary situations and eventually interposed soft tissue, it is often necessary to expose and reduce the fracture. The reduction can then be secured with a cerclage. If the femoral component does not have a box, the distal fixation of the osteosynthesis is usually not affected. Even in the presence of a box (e.g. varus-valgus-constrained or PS-implants) and relatively proximal fracture, a sufficient number of screws can be placed distally. In both cases, the single lateral locking plate osteosynthesis is used. However, if the fracture is far distal and the femoral component has a box or a stem, the distal fixation is significantly compromised. Additional medial plate osteosynthesis is recommended to insert supplemental distal screws and to stabilize the medial column. This increases the stability of the entire osteosynthesis.19,20 Post TKA, the morbidity of the approach for performing additive medial plate osteosynthesis is a challenge for the surgeon since at least two approaches are already present due to the implantation of the prothesis and the insertion of the lateral plate. The iatrogenic trauma of soft tissue should be kept as small as possible to avoid further compromising fracture healing. In this complex situation, the use of a helix plate is a stable and minimally invasive procedure. For this purpose, a straight locking plate is torqued about 90°–120° in the axial direction and then bent according to the anatomy of the individual femur. This plate can now be inserted under the thigh muscles using a small medial approach in the area of the distal femur. The screws can be inserted into the proximal end of the plate through the existing approach of the lateral plate osteosynthesis. It is important to note that the plates do not end at the same level proximally to avoid a stress raiser.21 In the case of a comminuted periprosthetic fracture, the exact anatomical reduction of the individual fragments is not recommended. Fracture-bridging biological osteosynthesis should restore the original length, axis and rotation of the affected femur. In this case, it is also advisable to use a lateral locking plate osteosynthesis with an additional medial helix plate to provide more stability. When selecting the osteosynthesis, any existing implants in the area of the proximal femur should be taken into account. An appropriately large implant-free bone section between proximal and distal implants must be considered. Biomechanically, however, it is more favorable if the implants overlap on a defined area of bone. So-called "kissing implants", in which proximally and distally positioned implants such as intramedullary nails, prosthetic stems or plates only touch but do not overlap, must be avoided since the stress concentration in the junction zone that occurs under load is a predetermined breaking point.22 For the sake of completeness, it should be mentioned that bone grafts were used to support the medial column and thus prevent loss of reduction before the introduction of locking plates.23 Currently, bone grafts are occasionally used in the revision of failed osteosyntheses of periprosthetic fractures.3,13,17 In type 3 fractures, the prosthesis is loose and must be replaced during the revision procedure. If a loosening of the implant cannot be safely ruled out before the operative revision, it is essential that an appropriate revision system is available in the treating institution and that the surgeon has the necessary skills for this procedure. The re-insertion of a surface replacement prosthesis is usually no longer possible due to deficient bone stock. Instead, stemmed revision prostheses are used in this case. Depending on the bone loss, these are fixed or supported in the remnant of the femur with cones and augments. Often the ligamentous apparatus of the knee joint is also affected by the fracture or revision procedure, which is the reason why rotating hinge prostheses are used in this situation. In most cases, the tibial component must also be changed to a stemmed model for reasons of compatibility and stability. If the distal femur has a severe bony defect, the distal femoral replacement arthroplasty is a possible strategy. A major advantage of this procedure is the possibility of full weight-bearing immediately postoperatively. This is of particular benefit to older patients who are unable to maintain postoperative partial weight-bearing. In distal femoral replacement arthroplasty, the force is not applied in the area of the condyles but in the area of the diaphysis. Stress riser in the area of the tip of the stem leads to more frequent fractures. A further disadvantage in addition to the high implant costs is that the origins of the musculus gastrocnemius medialis and lateralis must be detached during the surgical procedure. The implantation of such a modular megaprosthesis is a salvage procedure.24,25

Fig. 2 shows a summary of the recommended procedures for periprosthetic distal femoral fractures around TKA.

Fig. 2.

Fig. 2

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Treatment algorithm for periprosthetic supracondylar femur fractures around TKA.

4.2. Helix plate

In the hospital of the authors, 4 patients with a periprosthetic fracture around TKA were treated and examined in the time between April 2019 and July 2019 with a lateral locking plate osteosynthesis and an additional medial locking helix plate osteosynthesis. The initial conditions of the patients differed considerably. Due to the already existing implants, it was sometimes difficult to achieve a sufficient number of corticales both proximally and distally. This problem was solved by using the medially inserted helix plate. The postoperative period of partial weight-bearing was 15 weeks on average. In all cases, the fracture consolidated with subsequent full weight-bearing. The average flexion of the affected knee joint was 85°–90° in the examined group. An extension deficit was not detected in any of the patients.

Fig. 3, Fig. 4, Fig. 5, Fig. 6 show x-ray AP-projections pre- and post-operatively of all 4 patients with the diagnosis in the label of the figures.

Fig. 3.

Fig. 3

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86-year-old female patient with interprosthetic refracture Rorabeck 2 due to fracture of the bridging lateral locking plate. Stress riser in the area of kissing stems around THA and stemmed TKA. Status post open reduction and double plate osteosynthesis (lateral plate with attached LAP and medial helix plate).

Fig. 4.

Fig. 4

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84-year-old female patient with periprosthetic fracture Rorabeck 2 around stemmed TKA and severe osteoporosis. Status post open reduction, secured with cerclage and double plate osteosynthesis.

Fig. 5.

Fig. 5

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65-year-old female patient with interprosthetic fracture Rorabeck 2 around THA and stemmed TKA as well as transverse patella fracture. Status post removal of intramedullary cement, vitalized allogenic cancellous bone grafting, open reduction, double plate osteosynthesis and osteosynthesis of the patella using K-wire plus FiberTape tension band.

Fig. 6.

Fig. 6

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93-year-old female patient with severe osteoporosis and very distal periprosthetic femoral fracture Rorabeck 2 around TKA and DHS Status post open reduction and double plate osteosynthesis.

Even though the present study represents a very small group of patients, the application of an additional medial helix locking plate seems to be a successful procedure for complex periprosthetic fractures (e.g. interprosthetic fracture, presence of proximal implants, osteoporosis, non-union or refracture after initial osteosynthesis).

4.3. Patella

Fractures of the patella around TKA occur in 1.19%. The majority of these periprosthetic fractures happen with an inlaid patellar resurfacing. The proportion of primary TKA with patellar resurfacing in the German Endoprostheses Registry for 2018 was 11.2%. Risk factors include extensive osseous resection when preparing the patella with remaining patella thickness <15 mm, malalignment with (sub)luxation of the patella, devascularization of the patella through lateral release, incorrect positioning of components, use of cementless implants or implants with a single central fixation peg. Since the incorrect positioning of the components plays a major role in the occurrence of periprosthetic patella fractures, radiological diagnostics is of particular importance. To analyze the rotation of the components, a rotational CT of the entire affected leg is recommended. If there is significant malrotation of the femoral or tibial component, new implantation with correct alignment must be performed as part of the fracture management. Periprosthetic patella fractures are rarely caused by direct trauma.5,26 The classification according to Ortiguera and Berry is suitable for decision-making in patella fractures around patellar resurfacing.27 This classification takes into account the condition of the extensor mechanism, the implant fixation, and the bone stock (Fig. 7). In type 1 fractures the extensor mechanism is not affected and the patellar resurfacing is well fixed. As a rule, conservative therapy with initial immobilization in the cast and then a gradual release of flexion can be performed here.28 Type 2 fractures imply an interruption of the extensor apparatus with or without loosening of the patellar component. In this case, reconstruction of the extensor mechanism with osteosynthesis of the patella is required. If the implant is loose, it must be replaced. In type 3 fractures, the patella component is loosened with an intact extensor apparatus. Two subtypes can be distinguished depending on the bone stock after removal of the inserted patella component. Subtype A describes a good bone stock. In general, a remaining patella thickness of 8–12 mm is considered sufficient to replace it with a conventional cemented polyethylene surface.29 If this thickness is not reached, it is possible to implant a biconvex patella component to compensate for the bony deficit. However, the remaining bone stock must have a continuous bony margin for this purpose.30 In cases of pronounced bone loss with poor support of the patella implant, a trabecular metal prosthesis can be used to fill the bony defect and establish good bone contact. The polyethylene component is then fixed to this metal back with cement.31 In subtype B, the remaining bone stock is so deficient that no new patellar resurfacing can be fixed. After removal of the patella component, patelloplasty can be performed to shape the remaining patella. Gullwing osteotomy involves incomplete vertical osteotomy of the patella in its center. The lateral and medial halves are then arranged in a V-shape to each other to create a central ridge that can enter the groove of the femoral component to improve patella tracking and thus extensor function.32 Another option is patella augmentation using autologous bone grafting in a retropatellar tissue flap.33 As the ultimate ratio, there is the possibility of a patellectomy with significant impairment of the stability and biomechanics of the extensor apparatus.5 Fig. 8 summarizes the possible treatment options for periprosthetic patella fractures around TKA with patellar resurfacing.

Fig. 7.

Fig. 7

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Classification of periprosthetic patella fractures around patellar resurfacing and TKA according to Ortiguera and Berry.

Fig. 8.

Fig. 8

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Treatment algorithm for periprosthetic patella fractures around patellar resurfacing and TKA.

4.4. Tibia

Periprosthetic fractures of the proximal tibia around TKA occur rarely and can be classified according to the Felix classification depending on their localization, the stability of the tibial component and the moment of their occurrence. Type 1 fractures are located far proximal, affect only a part of the tibial head and extend to the cranial interface of the tibial component. In type 2 fractures, the fracture line runs along the shaft of the tibial component and in type 3 fractures below it. Periprosthetic fractures affecting the insertion area of the knee joint extensor apparatus are classified as type 4 fractures (Fig. 9). Subtype A describes a stable bony fixation of the tibial plateau. A loose tibial implant is coded with subtype B. Both subtypes A and B imply the postoperative occurrence or detection of the fracture, whereas subtype C describes an intraoperative fracture.34 Local risk factors for the occurrence of a periprosthetic fracture of the proximal tibia include the use of non-cemented implants, prior high tibial osteotomy, malposition of the tibial component, forced compaction of the cancellous bone and impaction of the tibial component during implantation, prior loosening of the components, and cortical impingement in long-stem prostheses. The assessment of the prosthesis fixation is of considerable relevance in the choice of the treatment concept. In case of a loosened tibial component according to subtype B, it is mandatory to change this component, since a single osteosynthesis alone does not provide sufficient stability for the bony fixation of the prosthesis and consequently leads to a dislocation of the component.3 During the revision of the tibial component, larger bone defects that impair the support of the prosthesis are filled with cones or augments. The treatment of periprosthetic tibial fractures of subtype A follows the classic principles of traumatology. Surgical treatment involves reduction with a subsequent plate or screw osteosynthesis. Intraoperative fractures of subtype C can also be treated with osteosynthesis, depending on their level. In type 3C fractures, the fracture can be bridged by the insertion of a longer prosthetic stem and additionally stabilized with plate osteosynthesis. The working group of Haller et al. describes a technique of antegrade intramedullary nail osteosynthesis for diaphyseal type 3 fractures.35 In particular, type 1A and type 1C fractures with small fragments that are not significantly dislocated can be treated conservatively through unloading and immobilization in a femoral cast.15,36 Type 4 fractures describe fractures involving the tibial tuberosity. Depending on the size of the fragment, screw osteosynthesis or plate osteosynthesis may be used.3 Since the extensor apparatus of the knee joint is affected in this type of fracture, the follow-up treatment concept must be adapted accordingly. The flexion of the affected knee joint should initially be limited utilizing an orthesis and then gradually released to minimize tension on the extensor mechanism. Besides, active extension, particularly against resistance, must be avoided for the time of bone healing 6 weeks postoperatively. When planning osteosynthesis for proximal tibial fractures, it should be considered that less soft tissue coverage can be achieved compared to the distal femur. Accordingly, risks such as postoperative wound healing disorders or infections are more pronounced. A summary of recommendations for the treatment of periprosthetic tibial fractures around the TKA is shown in Fig. 10.

Fig. 9.

Fig. 9

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Classification of periprosthetic tibial fractures around TKA according to Felix.

Fig. 10.

Fig. 10

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Treatment algorithm for periprosthetic tibial fractures around TKA.

5. Conclusion

  • •

    Management of periprosthetic fractures around TKA significantly depends on the cause of the fracture and the fixation of the components

  • •

    Patient's history and preoperative radiological diagnostics provide valuable information in this context

  • •

    If a PJI-related loosening is suspected, a preoperative puncture or biopsy of the affected knee joint is essential

  • •

    The classic principles of fracture treatment can rarely be applied directly to periprosthetic fractures around TKA

  • •

    Due to unexpected intraoperative findings, the surgical treatment should be performed in a specialized center, where both the expertise and infrastructure for backup strategies are available

  • •

    Our study shows good results when using an additive medially placed helix plate to treat complex distal femoral fractures

  • •

    The helix plate can be inserted soft tissue sparing and should be used for complex periprosthetic femoral fractures to increase the overall stability of the osteosynthesis

Declaration of competing interest

None declared.

References

  • 1.Kurtz S., Ong K., Lau E., Mowat F., Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780–785. doi: 10.2106/JBJS.F.00222. [DOI] [PubMed] [Google Scholar]
  • 2.Meek R.M.D., Norwood T., Smith R., Brenkel I.J., Howie C.R. The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement. J Bone Joint Surg Br. 2011;93(1):96–101. doi: 10.1302/0301-620X.93B1.25087. [DOI] [PubMed] [Google Scholar]
  • 3.Ruchholtz S., Tomás J., Gebhard F., Larsen M.S. Periprosthetic fractures around the knee—the best way of treatment. Eur Orthop Traumatol. 2012;4(2):93–102. doi: 10.1007/s12570-012-0130-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Kim K.-I., Egol K.A., Hozack W.J., Parvizi J. Periprosthetic fractures after total knee arthroplasties. Clin Orthop Relat Res. 2006;446:167–175. doi: 10.1097/01.blo.0000214417.29335.19. [DOI] [PubMed] [Google Scholar]
  • 5.Chalidis B.E., Tsiridis E., Tragas A.A., Stavrou Z., Giannoudis P.V. Management of periprosthetic patellar fractures. Injury. 2007;38(6):714–724. doi: 10.1016/j.injury.2007.02.054. [DOI] [PubMed] [Google Scholar]
  • 6.Mittlmeier T., Beck M., Bosch U., Wichelhaus A. Periprosthetic knee fractures. Orthopä. 2015;45(1):54–64. doi: 10.1007/s00132-015-3205-x. [DOI] [PubMed] [Google Scholar]
  • 7.Fritz J., Lurie B., Potter H.G. MR imaging of knee arthroplasty implants. Radiographics. 2015;35(5):1483–1501. doi: 10.1148/rg.2015140216. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Su E.T., DeWal H., Di Cesare P.E. Periprosthetic femoral fractures above total knee replacements. J Am Acad Orthop Surg. 2004;12(1):12–20. doi: 10.5435/00124635-200401000-00003. [DOI] [PubMed] [Google Scholar]
  • 9.Fulkerson E., Tejwani N., Stuchin S., Egol K. Management of periprosthetic femur fractures with a first generation locking plate. Injury. 2007;38(8):965–972. doi: 10.1016/j.injury.2007.02.026. [DOI] [PubMed] [Google Scholar]
  • 10.Cain P.R., Rubash H.E., Wissinger H.A., McClain E.J. Periprosthetic femoral fractures following total knee arthroplasty. Clin Orthop Relat Res. 1986;208:205–214. [PubMed] [Google Scholar]
  • 11.Merkel K.D., Johnson E.W. Supracondylar fracture of the femur after total knee arthroplasty. J Bone Joint Surg Am. 1986;68(1):29–43. [PubMed] [Google Scholar]
  • 12.Herrera D.A., Kregor P.J., Cole P.A., Levy B.A., Jönsson A., Zlowodzki M. Treatment of acute distal femur fractures above a total knee arthroplasty: systematic review of 415 cases (1981–2006) Acta Orthop. 2009;79(1):22–27. doi: 10.1080/17453670710014716. [DOI] [PubMed] [Google Scholar]
  • 13.Wood G.C.A., Naudie D.R., McAuley J., McCalden R.W. Locking compression plates for the treatment of periprosthetic femoral fractures around well-fixed total hip and knee implants. J Arthroplasty. 2011;26(6):886–892. doi: 10.1016/j.arth.2010.07.002. [DOI] [PubMed] [Google Scholar]
  • 14.Graham S.M., Moazen M., Leonidou A., Tsiridis E. Locking plate fixation for Vancouver B1 periprosthetic femoral fractures: a critical analysis of 135 cases. J Orthop Sci. 2013;18(3):426–436. doi: 10.1007/s00776-013-0359-4. [DOI] [PubMed] [Google Scholar]
  • 15.Platzer P., Schuster R., Aldrian S. Management and outcome of periprosthetic fractures after total knee arthroplasty. J Trauma. 2010;68(6):1464–1470. doi: 10.1097/TA.0b013e3181d53f81. [DOI] [PubMed] [Google Scholar]
  • 16.Mittlmeier T., Beck M. Retrograde Verriegelungsmarknagelung bei periprothetischer distaler Femurfraktur nach kondylärem Kniegelenkersatz. Unfallchirurg. 2005;108(6):497–502. doi: 10.1007/s00113-005-0956-6. [DOI] [PubMed] [Google Scholar]
  • 17.Hagel A., Siekmann H., Delank K.-S. Periprosthetic femoral fracture. Dtsch Arztebl Int. 2014:1–7. doi: 10.3238/arztebl.2014.0658. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Rorabeck C.H., Taylor J.W. Classification of periprosthetic fractures complicating total knee arthroplasty. Orthop Clin N Am. 1999;30(2):209–214. doi: 10.1016/s0030-5898(05)70075-4. [DOI] [PubMed] [Google Scholar]
  • 19.Holzman M.A., Hanus B.D., Munz J.W., O'Connor D.P., Brinker M.R. Addition of a medial locking plate to an in situ lateral locking plate results in healing of distal femoral nonunions. Clin Orthop Relat Res. 2016;474(6):1498–1505. doi: 10.1007/s11999-016-4709-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Steinberg E.L., Elis J., Steinberg Y., Salai M., Ben-Tov T. A double-plating approach to distal femur fracture: a clinical study. Injury. 2017;48(10):2260–2265. doi: 10.1016/j.injury.2017.07.025. [DOI] [PubMed] [Google Scholar]
  • 21.Perren S.M., Regazzoni P., Fernandez A.A.D. Biomechanical and biological aspects of defect treatment in fractures using helical plates. Acta Chir Orthop Traumatol Cech. 2014;81(4):267–271. [PubMed] [Google Scholar]
  • 22.Harris T., Ruth J.T., Szivek J., Haywood B. The effect of implant overlap on the mechanical properties of the femur. J Trauma. 2003;54(5):930–935. doi: 10.1097/01.TA.0000060999.54287.39. [DOI] [PubMed] [Google Scholar]
  • 23.Wang J.-W., Wang C.-J. Supracondylar fractures of the femur above total knee arthroplasties with cortical allograft struts. J Arthroplasty. 2002;17(3):365–372. doi: 10.1054/arth.2002.31077. [DOI] [PubMed] [Google Scholar]
  • 24.Berend K.R., Lombardi A.V., Jr. Distal femoral replacement in nontumor cases with severe bone loss and instability. Clin Orthop Relat Res. 2008;467(2):485–492. doi: 10.1007/s11999-008-0329-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Jassim S.S., McNamara I., Hopgood P. Distal femoral replacement in periprosthetic fracture around total knee arthroplasty. Injury. 2014;45(3):550–553. doi: 10.1016/j.injury.2013.10.032. [DOI] [PubMed] [Google Scholar]
  • 26.Mittlmeier T., Stöckle U., Perka C., Schaser K.D. Periprosthetic fractures after total knee joint arthroplasty. Unfallchirurg. 2005;108(6):481–496. doi: 10.1007/s00113-005-0955-7. [DOI] [PubMed] [Google Scholar]
  • 27.Ortiguera C.J., Berry D.J. Patellar fracture after total knee arthroplasty. J Bone Joint Surg Am. 2002;84(4):532–540. doi: 10.2106/00004623-200204000-00004. [DOI] [PubMed] [Google Scholar]
  • 28.Benkovich V., Klassov Y., Mazilis B., Bloom S. Periprosthetic fractures of the knee: a comprehensive review. Eur J Orthop Surg Traumatol. 2019;30(3):387–399. doi: 10.1007/s00590-019-02582-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Maheshwari A.V., Tsailas P.G., Ranawat A.S., Ranawat C.S. How to address the patella in revision total knee arthroplasty. Knee. 2009;16(2):92–97. doi: 10.1016/j.knee.2008.08.003. [DOI] [PubMed] [Google Scholar]
  • 30.Erak S., Bourne R.B., MacDonald S.J., McCalden R.W., Rorabeck C.H. The cemented inset biconvex patella in revision knee arthroplasty. Knee. 2009;16(3):211–215. doi: 10.1016/j.knee.2008.11.002. [DOI] [PubMed] [Google Scholar]
  • 31.Ries M.D., Cabalo A., Bozic K.J., Anderson M. Porous tantalum patellar augmentation: the importance of residual bone stock. Clin Orthop Relat Res. 2006;452:166–170. doi: 10.1097/01.blo.0000229359.27491.9f. [DOI] [PubMed] [Google Scholar]
  • 32.Gililland J.M., Swann P., Pelt C.E., Erickson J., Hamad N., Peters C.L. What is the role for patelloplasty with gullwing osteotomy in revision TKA? Clin Orthop Relat Res. 2015;474(1):101–106. doi: 10.1007/s11999-015-4363-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Hanssen A.D. Bone-grafting for severe patellar bone loss during revision knee arthroplasty. J Bone Joint Surg Am. 2001;83(2):171–176. doi: 10.2106/00004623-200102000-00003. [DOI] [PubMed] [Google Scholar]
  • 34.Felix N.A., Stuart M.J., Hanssen A.D. Periprosthetic fractures of the tibia associated with total knee arthroplasty. Clin Orthop Relat Res. 1997;(345):113–124. [PubMed] [Google Scholar]
  • 35.Haller J.M., Kubiak E.N., Spiguel A., Gardner M.J., Horwitz D.S. Intramedullary nailing of tibial shaft fractures distal to total knee arthroplasty. J Orthop Trauma. 2014;28(12):e296–e300. doi: 10.1097/BOT.0000000000000096. [DOI] [PubMed] [Google Scholar]
  • 36.Born C.T., Gil J.A., Johnson J.P. Periprosthetic tibial fractures. J Am Acad Orthop Surg. 2018;26(8):e167–e172. doi: 10.5435/JAAOS-D-16-00387. [DOI] [PubMed] [Google Scholar]

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