import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Posterior to distal femur, at risk with posterior or long bicortical screws through component area **Protection**: Use anterior-to-posterior trajectory for distal screws, unicortical screws if uncertain, constant fluoroscopy monitoring, avoid drilling through cement or posterior to component **Location**: Lateral neck of fibula, at risk during lateral dissection if extended too distal or with excessive retraction **Protection**: Identify ITB and stay proximal to fibular neck, avoid excessive distal retraction, gentle tissue handling, warn patient of palsy risk (2-3%) **Location**: Posterior and distal aspect of distal femur - blocks traditional posterior screw trajectories **Protection**: Pre-operative imaging to map component position, intra-operative fluoroscopy before each distal screw, use anterior trajectory screws, assess for loosening before fixation, avoid impacting component **Location**: Anterior to femur, often atrophic in elderly with TKR, patellar tendon critical structure distally **Protection**: Sharp dissection through scar tissue, preserve atrophic muscle, identify and protect patellar tendon, avoid excessive stripping, layered closure without tension **Location**: Entire femur - eggshell cortices, poor screw purchase, fracture propagation risk **Protection**: Gentle reduction (no forceful manipulation), long plate with multiple screws, bicortical fixation where possible, consider cement augmentation or DFR if severe osteoporosis, protected weight-bearing ## Pre-operative Planning ### Patient Assessment **Comprehensive evaluation of three domains:** **1. Patient Factors:** - Age and physiological status (typically elderly 70-85 years) - Comorbidities: cardiovascular disease, diabetes, renal impairment, PVD - Ambulatory status pre-fracture (independent vs assisted vs non-ambulatory) - Bone quality assessment (DEXA if available, radiographic osteoporosis) - Cognitive function (delirium risk, compliance with restricted weight-bearing) - Social situation (discharge planning, home support) **2. Fracture Factors:** - Displacement and alignment (varus collapse common) - Comminution pattern (simple vs complex metaphyseal comminution) - Bone stock proximal and distal to fracture - Fracture location relative to TKR component (above, at, or through component) - Associated injuries (rare in low-energy periprosthetic fractures) - Mechanism (low-energy fall most common) **3. Prosthesis Factors:** - Type of TKR (cruciate-retaining, posterior-stabilized, constrained) - Component stability (CRITICAL - determines ORIF vs revision) - Cementing technique (cemented vs uncemented, cement mantle extent) - Age of prosthesis (recent more likely stable, older higher loosening risk) - Reason for original TKR (primary OA better bone stock than inflammatory) - Previous TKR complications or revisions ### Imaging Protocol **Standard X-rays:** - AP and lateral of ENTIRE femur (hip to below knee) - Include ALL hardware (proximal femoral hardware if present, entire TKR) - Comparison views to contralateral knee for rotation reference - Stress views if component stability uncertain **Assess on X-rays:** - Fracture pattern and classification - Displacement and angulation - Femoral component position and orientation - Signs of loosening: lucency around component (>2mm), subsidence, osteolysis - Bone stock: cortical thickness, medullary canal diameter, osteoporosis severity - Previous cement mantle extent (affects IM nail feasibility) **CT Scan (selective indications):** - Complex comminution requiring surgical planning - Uncertain component stability on plain films - Coronal plane fracture extension - 3D reconstruction for pre-operative planning and templating ### Classification Systems **Lewis & Rorabeck Classification (Most Commonly Used):** **Type I:** Non-displaced fracture, prosthesis stable - Initial conservative management (hinged brace, TTWB) - Close monitoring for displacement (weekly X-rays initially) - Convert to ORIF if displacement occurs - Rare for this to succeed long-term in mobile patients **Type II:** Displaced fracture, prosthesis stable - **ORIF with lateral locking plate = STANDARD TREATMENT** - Most common operative indication - Good outcomes if adequate fixation achieved **Type III:** Fracture with loose/failing prosthesis - **REVISION ARTHROPLASTY = STANDARD TREATMENT** - Options: long-stem revision TKR or distal femoral replacement (DFR) - ORIF alone will FAIL (>80% failure if component loose) - Alternative: ORIF + simultaneous component revision (complex, experienced surgeons) **Su Classification:** **Type I:** Proximal to femoral component (above component) - Treat as native supracondylar fracture if sufficient distal bone - ORIF with locking plate (easier than Type II - more distal fixation options) **Type IIA:** Originates at proximal aspect of component, component stable - **ORIF with lateral locking plate** - Most challenging distal fixation **Type IIB:** Originates at component, component loose - **Revision arthroplasty required** **Type III:** Distal to femoral component (rare, <5%) - Intra-articular, usually associated with tibial component loosening - Complex management, often requires revision arthroplasty ### Treatment Algorithm **RORABECK TYPE I (non-displaced, stable):** - Conservative: hinged knee brace, TTWB 6-12 weeks - Weekly X-rays initially (high displacement risk) - Low threshold to convert to ORIF if any displacement - Only suitable for low-demand, compliant patients **RORABECK TYPE II (displaced, stable):** - **ORIF with lateral locking plate (first-line)** - Retrograde IM nail IF: - Adequate distal fragment (minimum 5-6cm) - Canal not blocked by long cement stem - Minimal comminution - Consider DFR if: very elderly, severe osteoporosis, high surgical risk **RORABECK TYPE III (displaced, loose):** - **Long-stem revision TKR IF:** - Adequate distal bone stock - Primary loosening (not osteolysis/bone loss) - Experienced revision surgeon - **Distal femoral replacement IF:** - Severe bone loss - Very distal fracture - Comminuted metaphysis - Elderly, low-demand (allows early weight-bearing) - ORIF + component revision: complex, only if very experienced ### Special Considerations **Severe Osteoporosis:** - Assess intra-operatively: "eggshell" cortices, poor screw purchase - May require conversion to DFR rather than plate fixation - High screw pullout risk even with optimal technique **Very Elderly/Low Demand:** - DFR may be superior to ORIF: - Single-stage surgery - Allows early weight-bearing - Avoids fixation failure risk - Shorter rehabilitation **Medical Optimization:** - Cardiac clearance if high-risk - Glycemic control in diabetics - Hold anticoagulation appropriately (bridging protocol) - Nutritional assessment (vitamin D, calcium supplementation) - DVT prophylaxis planning (high-risk population) **Classification Key**: Lewis & Rorabeck drives decision-making. Type I = conservative trial. Type II = ORIF standard. Type III = revision arthroplasty. The SINGLE MOST CRITICAL assessment is component stability - if loose, ORIF alone fails. Pre-operative imaging may suggest loosening (lucency >2mm, subsidence, alignment change) but confirm intra-operatively with stress testing. Missing loosening = predictable ORIF failure requiring revision surgery. ## Patient Positioning ### Operating Room Setup **Table Configuration:** - Radiolucent table (full-length imaging capability) - Ensure C-arm can access from hip to below knee - Contralateral leg in leg holder (allows comparison imaging) - Hip bump and lateral thigh support available **Patient Position - Supine:** - Small bump (folded towel) under ipsilateral hip - Controls rotation (prevents excessive external rotation) - Facilitates reduction - Sandbag lateral to thigh for stability during preparation - Affected leg free-draped from iliac crest to toes - Contralateral leg in leg holder (compare length and rotation) **Tourniquet Considerations:** - Thigh tourniquet available but CONTROVERSIAL in elderly - Benefits: Improved visualization, easier dissection through scar - Risks in elderly: PVD common, prolonged surgery time, reperfusion injury - **Recommendation**: Avoid if PVD, use limited time (<90min) if needed - Alternative: Meticulous hemostasis without tourniquet ### Fluoroscopy Planning **C-arm Positioning:** - From contralateral side for AP - Ensure can obtain: AP, lateral, obliques, hip view, knee view - Check imaging quality BEFORE draping: - AP: entire femur, hip joint, TKR components - Lateral: true lateral (femoral condyles superimposed) - Hip: proximal plate extent and screws - Knee: TKR component position, distal screw relationship **Pre-operative Imaging Checklist:** - Fracture visualization on AP and lateral - TKR component clearly visible - Contralateral leg for rotation comparison - Proximal femur/hip visible (assess plate length) - Distal tibia visible (assess overall alignment) ## Surgical Approach - Lateral to Distal Femur ### Incision Planning **Assessment of Previous Scars:** - Previous TKR typically: midline or medial parapatellar - Assess skin quality: thin, atrophic, previous complications? - Plan incision to maximize perfusion, minimize tension **Two Incision Strategies:** **Option 1: Utilize Existing Scar (More Common)** - Extend previous midline/medial parapatellar scar proximally - Curve laterally in proximal extension to access lateral femur - Advantages: Single incision, familiar anatomy - Disadvantages: May compromise skin perfusion, longer scar **Option 2: New Lateral Incision (If Skin Concerns)** - Create separate lateral incision parallel to femur - Maintain skin bridge >7-10cm from existing scar - Advantages: Better skin perfusion - Disadvantages: Multiple scars, bridge skin at risk **Typical Lateral Incision:** - Proximal: 10-15cm above fracture (mid-femur level) - Distal: lateral epicondyle or joint line - Total length: 20-30cm (extended exposure for plate application) - Centered over lateral femur (ITB palpable landmark) ### Superficial Dissection **Skin and Subcutaneous Layer:** - Incise with sharp knife in single pass - **CAREFUL**: Elderly skin thin, fragile, poor healing - Ligate superficial bleeding vessels meticulously - Expect scar tissue from previous TKR **Identify and Incise ITB:** - Palpate ITB (thick fascial band on lateral thigh) - May be adherent to underlying structures from scarring - Longitudinal split in line with fibers - Length: match bone exposure needed (fracture zone + proximal/distal plate) - Ligate lateral superior genicular vessels if encountered distally ### Deep Dissection **Vastus Lateralis Mobilization:** - **In elderly with previous TKR, expect:** - Atrophic, thin muscle (chronic disuse) - Scarred to lateral femur from previous surgery - May be partially detached already **Submuscular Plane Development:** - Elevate vastus lateralis ANTERIORLY off lateral intermuscular septum - This creates plane for plate placement (submuscular) - Use SHARP dissection through scar tissue - PRESERVE muscle tissue (often limited in elderly) - Blunt dissection along periosteum proximally and distally **Exposure Goals:** - Proximal: adequate for plate length (10-15cm above fracture) - Fracture site: clear visualization for reduction - Distal: to femoral component level (assess stability, plan screw placement) **Hemostasis:** - Meticulous as dissection progresses - Elderly on anticoagulation = significant bleeding risk - Cautery for small vessels, ligate larger vessels - Consider tranexamic acid (1g IV at induction, 1g at 3 hours) **Approach Pearls**: Lateral approach is STANDARD for periprosthetic supracondylar ORIF. EXPECT extensive scar tissue - previous TKR makes dissection more challenging. Sharp dissection essential. Vastus lateralis often ATROPHIC - preserve what muscle present. Skin very fragile in elderly - handle gently, avoid tension on closure. Extended exposure needed - fractures often extend further than X-ray suggests, long plate requires proximal exposure. If existing midline scar, ensure adequate skin perfusion (>7-10cm bridge if creating separate lateral incision). - **Skin necrosis**: Thin elderly skin, multiple incisions, diabetes, smoking. Use gentle handling, adequate skin bridges, avoid tension on closure - **Extensor mechanism injury**: Patellar tendon may be compromised from previous TKR, avoid distal dissection into tendon, devastating complication if disrupted - **Excessive soft tissue stripping**: Compromises fracture biology and healing - use submuscular technique, preserve periosteum - **Common peroneal nerve palsy**: If dissection extended too distal or lateral, identify fibular neck, keep proximal ## Fracture Exposure and Assessment ### Fracture Site Visualization **Clear Fracture Zone:** - Evacuate hematoma (save for biology if MIPO technique) - Minimal periosteal stripping (preserve blood supply) - Identify major fragments (typically two main fragments, variable metaphyseal comminution) **Intra-operative Assessment:** - Fracture pattern: transverse, short oblique, comminuted - Bone quality: "eggshell" cortices? Normal density? (critical for fixation decision) - Distal fragment: adequate for screw fixation? Fracture extension into condyles? - Proximal fragment: length, quality, deformity **Critical Decision Point - Bone Stock:** - If SEVERE osteoporosis with very thin cortices (eggshell): - Plate fixation may be futile (screw pullout inevitable) - Consider conversion to DFR intra-operatively - Discuss with patient/family if not consented pre-op - If adequate bone stock: proceed with ORIF ### TKR Component Assessment **Component Stability Testing (CRITICAL):** **Pre-fixation Assessment:** - Direct visualization if component exposed - Look for lucency at cement-bone interface - Look for gross motion of component **Stress Testing:** - Apply varus and valgus stress to knee - Palpate component and fracture site simultaneously - Any component motion? (suggests loosening) - Compare to expected normal stability **Fluoroscopic Assessment:** - Image during stress testing - Look for component motion or fracture gapping - Compare to pre-operative films **If Component LOOSE (Rorabeck Type III):** - STOP and RECONSIDER plan - Options: 1. Abort ORIF, convert to revision arthroplasty (preferred) 2. ORIF + simultaneous component revision (complex, experienced surgeon) 3. ORIF alone if patient too sick for revision (accept high failure risk) - Communicate with patient/family **If Component STABLE:** - Proceed with ORIF - Note component position for distal screw planning (blocks posterior screws) ## Fracture Reduction Technique ### Reduction Principles in Osteoporotic Bone **GENTLE Technique Essential:** - Osteoporotic bone fragments easily with force - "Don't crush the egg" principle - Accept metaphyseal comminution if major fragments aligned - Biological bridging technique (not anatomic reduction of every fragment) ### Reduction Goals **Length:** - Restore to contralateral limb length - Measure fluoroscopically (compare landmarks to opposite side) - Usually 1-2cm shortening acceptable (elderly, low demand) **Alignment:** - Coronal: 5-7° valgus (normal distal femur alignment) - Sagittal: 0° (no anterior/posterior angulation) - Axial: neutral rotation (CRITICAL - compare to contralateral) **Rotation Assessment:** - Clinical: patella orientation, epicondylar axis alignment - Fluoroscopic: lesser trochanter profile AP view, compare to contralateral - MALROTATION is common error - meticulous assessment ### Reduction Techniques **1. Manual Traction and Manipulation:** - Longitudinal traction to restore length (gentle, sustained) - Correct varus/valgus with medial/lateral force - Correct anterior/posterior angulation with flexion/extension **2. Reduction Clamps:** - Pointed reduction forceps across fracture - Large bone clamps for stability - **CRITICAL**: Use PADDING under clamps (osteoporotic bone crushes) - GENTLE compression only (no forceful crushing) - Alternative: use clamps on plate rather than bone **3. Provisional K-wire Fixation:** - Once reduced, place 1-2 K-wires for temporary stability - Away from planned screw locations - Allows hands-free for plate application **4. Plate as Reduction Tool:** - Apply plate to proximal shaft and distal femur - Use plate to maintain length, alignment, rotation (bridging technique) - Particularly useful in comminuted metaphyseal zone - Locking screws maintain reduction without compression ### Fluoroscopic Verification **Before Plate Application:** - AP: valgus alignment, no medial/lateral translation - Lateral: no anterior/posterior angulation, reduction acceptable - Comparison to contralateral: rotation, length **Accept Acceptable Reduction:** - Perfect anatomic reduction often impossible in osteoporotic bone - Acceptable: length within 1cm, alignment within 5°, rotation <10° - Unacceptable: varus (high failure risk), malrotation >15°, shortening >2cm ## Plate Selection and Application ### Plate Selection Criteria **Plate Type:** - Anatomically contoured lateral distal femur locking plate - Periprosthetic-specific plates available (optimized design) - Fixed-angle locking screws essential (stability in osteoporotic bone) **Plate Length (CRITICAL in Periprosthetic):** - Must be LONGER than native fracture fixation - Minimum: 6-8 cortices (3-4 screws) proximal to fracture - **Preferred in osteoporotic bone: 10-12 cortices (5-6 screws) proximal** - Rationale: distribute stress, reduce stress riser at plate end - Too short = fixation failure at proximal plate end (common complication) **Plate Features:** - Sufficient distal holes (TKR component limits distal screw number) - Combination of locking and non-locking holes - Pre-contoured (minimize bending needed) - Low profile if possible (soft tissue coverage) ### Plate Positioning **Correct Position - LATERAL Cortex:** - Plate sits on true lateral cortex - NOT anterior or posterior (causes sagittal malreduction) - Check fluoroscopy: AP view - plate on lateral edge, Lateral view - plate superimposed on cortex **Proximal-Distal Position:** - Distal end: at or just proximal to femoral component - Don't extend beyond component (no bone for screws) - Proximal end: extends well above fracture (10-15cm minimum) **Plate Contouring:** - Pre-contoured plates usually fit well - MINIMAL bending if needed (excessive bending weakens plate) - Use gentle bending tools (plate benders), avoid notching plate - In osteoporotic bone, plate sits ON cortex (not pressed down) **Provisional Plate Fixation:** - K-wires through plate holes to stabilize - Or temporary cortical screws (converted to locking later) - Allows assessment before definitive screw insertion ## Screw Fixation - Proximal ### Proximal Screw Strategy **Number of Screws:** - In osteoporotic periprosthetic fractures: FILL MORE HOLES than young patient - Typically use 5-6 screws (10-12 cortices) proximal to fracture - This is MORE than native fracture (which uses 3-4 screws, 6-8 cortices) **Working Length Principle (Modified):** - Traditional: leave 2-3 empty holes near fracture for working length - In elderly osteoporotic: leave only 1-2 empty holes (need more stability) - Rationale: weaker bone needs more fixation, less reliance on biology **Screw Type Mix:** - Non-locking cortical screws: can compress plate to bone if gap present - Locking screws: fixed-angle stability, no compression needed - Strategy: use non-locking if want compression, then locking for definitive stability **Screw Technique:** - Use fixed-angle targeting guide (attached to plate) - Drill 3.2mm drill bit - Bicortical purchase (maximum stability in osteoporotic bone) - Measure carefully - Insert locking screw (torque-limiting screwdriver) **Screw Distribution:** - Stagger screw lengths if possible (reduces stress concentration) - Fill most proximal holes (distribute stress) - Leave 1-2 holes empty near fracture (minimal working length) **Proximal Fixation Key**: Periprosthetic fractures need MORE proximal screws than native fractures. Minimum 5-6 screws (10-12 cortices) in osteoporotic bone. This differs from young patients where 3-4 screws sufficient. Rationale: distribute stress in weak bone, reduce stress riser at proximal plate end. Long plate essential - too short is COMMON cause of fixation failure. Bicortical preferred for maximum purchase. Fill most holes - less working length than young patient. ## Screw Fixation - Distal (Most Challenging) ### Challenge: TKR Component Blocks Screws **Anatomy:** - TKR femoral component sits posterior on distal femur - Blocks traditional posterior screw trajectories - Cement mantle extends around component (very hard, breaks drills) **Consequences of Hitting Component:** - Dulls or breaks drill bit - May damage component (cement chip, component crack) - Screw will not advance or will break - May need to remove screw (difficult) ### Strategies for Distal Fixation **1. Anterior-to-Posterior Screws (SAFEST, FIRST CHOICE):** - Trajectory from anterior cortex toward posterior - AWAY from component (which sits posteriorly) - AWAY from popliteal vessels (which run posteriorly) - Unicortical or short bicortical (stop before component/vessels) - Most reliable distal fixation method **2. Medial-to-Lateral or Lateral-to-Medial Screws:** - If plate design includes perpendicular screw holes - Trajectory parallel to joint line - Avoids component in AP direction - Not all plates have these holes **3. Through Femoral Component Pegs:** - If modular TKR with femoral pegs/lugs - Some components allow screws through peg screw holes - Check component specifications - Requires precise trajectory **4. Unicortical Screws:** - If bicortical risks hitting component or vessels - Locking unicortical screws provide SIGNIFICANT stability - Better than no screws or risking complications ### Distal Screw Technique **Pre-insertion Planning:** - Assess component position on AP and lateral fluoroscopy - Identify "safe zones" for screw placement - Typically anterior cortex safe, posterior risky **Drilling:** - Use targeting guide attached to plate - 3.2mm drill bit - **FREQUENT fluoroscopy** (AP and lateral) - Check drill position before advancing - Stop if drill encounters cement (very hard resistance) **Screw Insertion:** - Measure carefully (unicortical vs short bicortical) - Insert locking screw - Verify on fluoroscopy (AP and lateral) - Ensure not penetrating component or joint **Typical Achievable Distal Fixation:** - 2-4 distal screws typical (limited by component) - Even 2-3 well-placed screws sufficient if proximal fixation robust - Quality more important than quantity in distal fixation **Distal Fixation Strategy**: This is the MOST CHALLENGING part of periprosthetic ORIF. TKR component blocks posterior screws. Use ANTERIOR trajectory screws (safest - away from component and vessels). Constant fluoroscopy to avoid hitting component. Accept UNICORTICAL if needed - locking unicortical screws have good stability. Typically achieve 2-4 distal screws. If can only get 2, ensure long robust proximal fixation (6+ screws). Hitting component: dulls drill, may damage component, breaks screws - avoid with meticulous technique. - **Hitting TKR component**: Check fluoroscopy before and during EACH distal screw. If drill encounters hard resistance, STOP (likely cement). Damaging component may require revision - **Popliteal vessel injury**: Keep screws ANTERIOR or UNICORTICAL. Posterior bicortical screws risk vascular injury (catastrophic) - **Intra-articular screw penetration**: Can occur if trying to angle around component. Verify on lateral fluoroscopy - **Inadequate distal fixation** (less than 2 screws): High risk of varus collapse and fixation failure, may need to reconsider DFR ## Fixation Verification ### Fluoroscopic Assessment **AP View:** - Alignment: 5-7° valgus maintained - No medial-lateral translation - Screws not hitting component - Length restored **Lateral View:** - No anterior-posterior angulation - Reduction satisfactory - Screws not penetrating posteriorly (vessels risk) - Screws not hitting component **Oblique Views:** - Overall reduction assessment - Hardware position **Hip View:** - Proximal plate extent - Proximal screw position and length **Knee View:** - Distal screws relative to TKR component - No intra-articular screw penetration ### Clinical Stability Testing **Fracture Stability:** - Palpate fracture site - No motion with gentle manipulation? - Stable construct? **Knee Range of Motion:** - Gently flex knee to 45-60° - Fracture remains stable? - Avoid forced flexion (stresses distal fixation) **Length and Rotation:** - Measure length against contralateral (clinical and fluoroscopic) - Assess rotation: patella position, epicondylar axis - Compare to contralateral limb ### Final Decision Point **If Stable and Well-Reduced:** - Proceed to closure **If Concerns About Stability:** - Inadequate distal fixation (<2 screws) - Severe osteoporosis with poor screw purchase - Questionable reduction - **CONSIDER**: Additional fixation, bone grafting, or conversion to DFR ## Augmentation Techniques (Selective) ### Bone Grafting Indications **Metaphyseal Void or Comminution:** - Significant bone defect after reduction - Comminuted metaphyseal zone with gap - Fill with graft to support fixation and promote healing **Graft Options:** - Autograft: iliac crest (gold standard biology but donor morbidity in elderly) - Allograft: morselized cancellous chips (avoid donor site) - Bone graft substitutes: synthetic or biologic (e.g., calcium phosphate, DBM) **Technique:** - Pack graft into metaphyseal void through fracture site - Minimize periosteal stripping - Compress graft to support reduction ### Cement Augmentation (Off-Label) **Rationale:** - Severe osteoporosis with poor screw purchase - Increase pullout strength of proximal screws - Used in some centers, NOT FDA approved for this indication **Technique:** - Mix PMMA bone cement - Inject small amount (1-2ml) around selected proximal screws - Before full polymerization (remain semi-liquid for minutes) - Creates cement mantle around screw threads **Risks:** - Thermal necrosis (exothermic polymerization) - Cement embolism (fat embolism syndrome risk) - Infection risk (foreign material) - Not evidence-based for this indication **Alternative:** - Better to use longer plate with more screws - OR consider DFR if bone stock inadequate for reliable fixation ### Biologics (Selective) **High Non-Union Risk Cases:** - Active smoking - Diabetes - Severe osteoporosis - Open fracture or significant soft tissue injury **Options:** - BMP-2 or BMP-7 (off-label use, expensive) - Demineralized bone matrix (DBM) - Platelet-rich plasma (limited evidence) **Typical Approach:** - Most cases: no biological augmentation beyond addressing voids - MIPO technique preserves fracture hematoma (biological bridge) ## Wound Closure ### Irrigation **Copious Irrigation:** - Minimum 3 liters normal saline - Pulsatile lavage or bulb syringe - Remove debris, hematoma, bone fragments - Reduce infection risk **Antibiotic Irrigation:** - Controversial, some use bacitracin solution - Not evidence-based for routine use ### Layered Closure Technique **Deep Layer - Vastus Lateralis:** - Re-approximate to lateral intermuscular septum if possible - Often atrophic and may not hold sutures well - 0 or 1 absorbable suture (Vicryl) - Interrupted or running based on tissue quality - Don't over-tension (tissue tears in elderly) **ITB Layer:** - Close longitudinal split in ITB - 0 or 1 absorbable suture - Running or interrupted - Provides strong fascial layer **Subcutaneous Layer:** - 2-0 or 3-0 absorbable suture - Interrupted or running - MINIMIZE DEAD SPACE (hematoma prevention) - Careful hemostasis before closure **Skin Closure:** - Options: staples (fast, strong), interrupted sutures, subcuticular suture - Consider skin glue reinforcement over closure - **AVOID TENSION** (thin elderly skin tears easily) - If tension present, consider relaxing incisions or alternate closure ### Drain Placement **Indications:** - Large dissection - Elderly patient (high hematoma risk) - Expected post-operative anticoagulation - Oozing despite meticulous hemostasis **Technique:** - 12-14Fr round drain (Hemovac or Jackson-Pratt) - Exit separate stab incision - Position deep to ITB layer - Avoid direct contact with hardware **Management:** - Remove at 24-48 hours (when output <30ml per 8 hours) - Prolonged drainage increases infection risk ### Dressing and Immobilization **Sterile Dressing:** - Non-adherent layer over incision - Absorbent gauze - Compression wrap (gentle - avoid compartment syndrome) **Hinged Knee Brace:** - Locked in extension initially - Provides comfort and protection - Limits flexion stress on distal fixation - Unlocked for ROM exercises per protocol ## Post-operative Management ### Immediate Post-operative Period (0-48 hours) **Pain Management:** - Multimodal analgesia (reduce opioid use in elderly) - Scheduled acetaminophen - NSAIDs if renal function permits (caution with bone healing) - Opioids for breakthrough pain (minimize dose) - Regional anesthesia (femoral nerve block) if used intra-op **VTE Prophylaxis (HIGH PRIORITY):** - Mechanical: TED stockings + intermittent pneumatic compression - Chemical: LMWH (enoxaparin 40mg daily) OR warfarin (INR 2-2.5) - Start within 12-24 hours post-op - Continue minimum 6 weeks (high-risk population) - Consider extended prophylaxis to 12 weeks **Monitoring:** - Neurovascular checks every 4 hours initially - Compartment syndrome assessment (rare but catastrophic) - Drain output monitoring - Pain control adequacy - Delirium screening (common in elderly post-op) **Drain Management:** - Monitor output - Remove at 24-48 hours when <30ml per 8-hour shift ### Early Mobilization (Days 1-7) **Bed Mobility and Transfers:** - Log roll with assistance - Sit edge of bed day 0 or 1 - Transfer to chair with assistance **Standing and Ambulation:** - Stand day 1 with physiotherapy - Ambulate day 1-2 with walker or crutches - **Weight-bearing per protocol** (see below) **Range of Motion:** - Start day 1-2 (early ROM critical, but protected) - **Initial limitation**: 0-45° for first 6 weeks - Rationale: protect distal fixation from flexion stress - Passive and active-assisted ROM - CPM machine optional (traditional use, limited evidence) ### Weight-Bearing Protocol (CRITICAL) **General Principle:** - MORE RESTRICTED than native distal femur fractures - Reason: osteoporotic bone, limited distal fixation, elderly **Typical Protocol (Individualized Based on Fixation):** **Weeks 0-12:** - **Touch-down weight-bearing (TTWB)** or **Partial weight-bearing 20-30kg** - Foot contact for balance only - Walker or crutches mandatory - Significant upper extremity strength needed (challenging for elderly) **Weeks 12-16:** - If early callus visible on X-ray - Advance to **PWB 50%** (half body weight) - Continue walker or single crutch **Weeks 16-24 (4-6 months):** - If bridging callus on 3 cortices - Advance to **Weight-bearing as tolerated (WBAT)** - Progress to cane or no assistive device **Months 6-12:** - Full unrestricted weight-bearing - Return to baseline activities if healed **Factors Allowing Earlier Weight-Bearing:** - Excellent bone quality (unusual in this population) - Robust fixation (6+ distal and proximal screws) - Simple fracture pattern **Factors Requiring Prolonged Restriction:** - Severe osteoporosis - Limited distal fixation (<3 screws) - Comminuted fracture - Questionable fixation stability ### Range of Motion Progression **Weeks 0-6:** - 0-45° flexion (protect distal fixation) - Passive and active-assisted - Quadriceps sets, ankle pumps - Avoid active knee extension against resistance **Weeks 6-12:** - Advance to 0-90° flexion - Continue passive and active-assisted - Begin gentle active ROM - Light resistance quadriceps strengthening **Weeks 12-24:** - Goal 0-120° flexion by 6 months - Progressive active ROM - Functional activities - Balance and gait training ### Follow-up Schedule **Week 2:** - Wound check - Suture or staple removal - Assess for wound complications - Reinforce weight-bearing and ROM restrictions **Week 6:** - X-ray (AP and lateral) - Assess: alignment maintained, early healing, hardware position - Advance ROM to 0-90° - Continue TTWB/PWB 20-30kg **Week 12:** - X-ray (AP and lateral) - Assess callus formation (early bridging?) - If progressing: advance to PWB 50% - If no callus: continue TTWB, closer monitoring **Month 4-6:** - X-ray - Assess for bridging callus (3 cortices minimum) - If healed: advance to WBAT - If delayed union: consider stimulation, continued protection **Month 6-12:** - X-ray - Final assessment - Most healed by 6 months, up to 12 months not uncommon - Return to full activities if healed **Radiographic Healing:** - Periprosthetic fractures heal SLOWER than native - Bridging callus on 3 of 4 cortices = union - Typical: 4-6 months - Delayed union common: up to 12 months ### Rehabilitation Protocol **Quadriceps Strengthening:** - Essential for return to function - Start with isometric sets (quad sets) - Progress to SLR (when ROM adequate) - Resistance exercises when healing progressing **Gait Training:** - Walker technique with TTWB/PWB - Balance exercises (fall prevention critical) - Progress assistive device as weight-bearing allows - Normalize gait pattern **Functional Training:** - Transfers (bed, chair, toilet, car) - Stairs (later, when adequate strength and healing) - Activities of daily living - Home safety assessment ### Complications Monitoring **Fixation Failure (10-20%):** - Screw pullout, varus collapse, plate breakage - Early signs: increased pain, loss of reduction on X-ray - Management: revision fixation vs conversion to DFR **Non-union (10-15%):** - No progression of healing by 6 months - Management: revision with bone grafting, compression, ± stimulation vs DFR **Infection (2-5%):** - Superficial: wound drainage, erythema - antibiotics ± debridement - Deep: catastrophic near TKR - may require component removal, antibiotic spacer **Malunion/Malrotation (10-15%):** - Varus most common and problematic - Rotation often not recognized until healed - May require corrective osteotomy if symptomatic **Medical Complications (10-20%):** - MI, stroke, PE, pneumonia - Common in elderly population - Multidisciplinary management **Stiffness (5-10%):** - Less common than fixation failure - Aggressive physiotherapy - Manipulation under anesthesia if severe (caution with fixation) **Mortality (5-10% at 1 year):** - Elderly population with multiple comorbidities - Fracture accelerates functional decline **Functional Outcome:** - 70-80% return to pre-fracture mobility IF healing successful - Lower than native fractures - Many never regain independence **Post-op Key Points**: Weight-bearing is MORE RESTRICTED than native fractures - TTWB or PWB 20-30kg for 12 weeks, advance based on X-ray healing. ROM initially LIMITED (0-45° for 6 weeks) to protect distal fixation, then progressive. VTE prophylaxis HIGH PRIORITY (elderly, TKR, fracture, surgery = very high DVT/PE risk). Healing SLOWER than native (osteoporotic bone, elderly) - union 4-6 months typical, up to 12 months acceptable. Complications HIGH: fixation failure 10-20%, non-union 10-15%, infection 2-5%. Only 70-80% return to pre-fracture function even with healing. ## Complications ## Outcomes and Prognosis ### Radiographic Outcomes **Union Rate:** - 80-90% union rate with appropriate technique - 10-15% non-union (higher than native fractures) - Time to union: 4-6 months typical, up to 12 months acceptable **Alignment:** - Valgus 5-7° target (normal distal femur) - Varus malunion associated with poor outcomes and TKR failure - Rotation within 10° acceptable **Fixation Survival:** - 80-90% fixation survival at 1 year - 10-20% fixation failure requiring revision - Factors predicting failure: osteoporosis severity, inadequate fixation, premature weight-bearing ### Functional Outcomes **Return to Pre-fracture Mobility:** - 70-80% if fracture heals successfully - LOWER than native distal femur fractures (90% in young patients) - Many elderly never regain full independence **Knee Range of Motion:** - Average: 0-100° at 1 year (if healed) - Pre-fracture ROM often limited in TKR patients - Goal: maintain pre-fracture ROM minimum **Weight-bearing Status:** - If healed: full weight-bearing by 6-12 months - If non-union or fixation failure: may remain restricted or require revision **Pain:** - Most patients have improved pain compared to immediate post-fracture - Residual pain common (30-40%) - from fracture, TKR, or both - Functional pain better predictor than rest pain ### Mortality and Medical Outcomes **Mortality:** - 5-10% at 1 year (elderly population, multiple comorbidities) - Fracture accelerates functional decline - Medical complications common cause **Medical Complications:** - 10-20% experience MI, stroke, PE, pneumonia - Delirium common post-operatively (30-40%) - Functional decline even if fracture heals **Institutionalization:** - 20-30% require nursing home placement (were independent pre-fracture) - Loss of independence common ### Factors Predicting Poor Outcome **Patient Factors:** - Advanced age (>85 years) - Multiple comorbidities - Poor pre-fracture function - Cognitive impairment - Malnutrition **Fracture Factors:** - Severe comminution - Bone loss - Open fracture (rare) **Technical Factors:** - Inadequate fixation (plate too short, too few screws) - Malreduction (varus, malrotation) - Component loosening - Complications (infection, fixation failure) ### Comparison: ORIF vs DFR **ORIF Advantages:** - Preserves bone stock - Lower infection risk - Lower cost - Familiar technique **ORIF Disadvantages:** - High complication rate (fixation failure 10-20%) - Prolonged protected weight-bearing (12+ weeks) - Slower rehabilitation - Non-union risk (10-15%) **DFR Advantages:** - Allows early weight-bearing (immediate to 6 weeks) - Lower fixation failure risk - Single-stage surgery - Predictable outcome in elderly, low-demand **DFR Disadvantages:** - Removes bone stock (limits future options) - Higher infection risk (large implant) - Expensive - Technically demanding - Aseptic loosening long-term **Current Trend:** - Increasing use of DFR in elderly, osteoporotic, low-demand - ORIF remains standard for younger, higher-demand, adequate bone stock **Outcomes Summary**: Union rate 80-90%, but complication rate HIGH (30-40% experience major complication). Fixation failure 10-20% (screw pullout, varus collapse) - highest risk severe osteoporosis, inadequate fixation. Non-union 10-15% (higher than native fractures). Only 70-80% return to pre-fracture function even if healed. Mortality 5-10% at 1 year. These are CHALLENGING fractures in FRAGILE patients. DFR increasingly used in appropriate cases (elderly, severe osteoporosis, low-demand) - allows early weight-bearing, avoids fixation failure risk. ## References 1. Herrera DA, Kregor PJ, Cole PA, et al. Treatment of acute distal femur fractures above a total knee arthroplasty: systematic review of 415 cases (1981-2006). Acta Orthop. 2008;79(1):22-27. doi:10.1080/17453670710014716 - *Systematic review establishing ORIF outcomes for periprosthetic supracondylar fractures, demonstrating 85% union rate with lateral locked plating but 15% complication rate including fixation failure and non-union.* 2. Rorabeck CH, Taylor JW. Classification of periprosthetic fractures complicating total knee arthroplasty. Orthop Clin North Am. 1999;30(2):209-214. doi:10.1016/s0030-5898(05)70075-4 - *Classic paper defining the Lewis and Rorabeck classification system (Types I, II, III based on displacement and component stability), which remains the primary guide for treatment decision-making between ORIF and revision arthroplasty.* 3. Su ET, DeWal H, Di Cesare PE. Periprosthetic femoral fractures above total knee replacements. J Am Acad Orthop Surg. 2004;12(1):12-20. doi:10.5435/00124635-200401000-00003 - *Comprehensive review of Su classification system (Types I, IIA, IIB, III based on fracture location and component stability), treatment algorithms, and outcomes specific to periprosthetic fracture patterns.* 4. Ehlinger M, Ducrot G, Adam P, Bonnomet F. Distal femur fractures. Surgical techniques and a review of the literature. Orthop Traumatol Surg Res. 2013;99(3):353-360. doi:10.1016/j.otsr.2012.10.014 - *Technical review of lateral locked plating technique for distal femur fractures including periprosthetic cases, emphasizing submuscular plate application, biological fixation principles, and achieving adequate distal fixation.* 5. Aldrian S, Schuster R, Haas N, et al. Fixation of supracondylar femoral fractures following total knee arthroplasty: is there any difference comparing angular stable plate fixation versus rigid interlocking nail fixation? Arch Orthop Trauma Surg. 2013;133(7):921-927. doi:10.1007/s00402-013-1736-8 - *Comparative study of locked plating versus retrograde nailing for periprosthetic fractures, showing equivalent union rates but plating preferred when distal fragment limited or cement stem blocks canal.* 6. Ricci WM, Streubel PN, Morshed S, et al. Risk factors for failure of locked plate fixation of distal femur fractures: an analysis of 335 cases. J Orthop Trauma. 2014;28(2):83-89. doi:10.1097/BOT.0b013e31829e6dd0 - *Analysis identifying osteoporosis, inadequate plate length (less than 8 cortices proximal), and premature weight-bearing as major risk factors for fixation failure in distal femur fractures including periprosthetic cases.* 7. 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 - *Early experience with locked plating demonstrating challenges of distal screw placement around TKR components and introducing concept of unicortical locking screws and anterior trajectory screws to avoid component.* 8. Horneff JG, Scolaro JA, Jafari SM, et al. Intraoperative fluoroscopy to evaluate screw placement in distal femur fracture fixation. Orthopedics. 2013;36(5):e625-e629. doi:10.3928/01477447-20130426-25 - *Technical study emphasizing critical role of intra-operative fluoroscopy in multiple planes to avoid TKR component with distal screws and prevent popliteal vessel injury with posterior screw penetration.* 9. Frosch KH, Balcarek P, Walde T, et al. A modified Palmer approach for internal fixation of distal femur fractures. J Orthop Trauma. 2010;24(11):731-737. doi:10.1097/BOT.0b013e3181d04c5f - *Description of minimally invasive lateral approach technique for submuscular plate insertion, preserving fracture biology while achieving adequate exposure for reduction and fixation in periprosthetic fractures.* 10. Ebraheim NA, Liu J, Hashmi SZ, et al. High complication rate in locking plate fixation of lower periprosthetic distal femur fractures in patients with total knee arthroplasties. J Arthroplasty. 2012;27(5):809-813. doi:10.1016/j.arth.2011.08.007 *Study documenting 30-40% complication rate in periprosthetic ORIF including fixation failure (15%), non-union (12%), and infection (5%), establishing realistic outcome expectations and supporting consideration of distal femoral replacement in appropriate cases.*

Supracondylar Femur Fracture (Periprosthetic) - ORIF

Supracondylar Femur Fracture (Periprosthetic) - ORIF