Rev. bras. ortop. vol.51 número5

r e v b r a s o r t o p . 2016;51(5):606–609

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Case

Report

Bilateral

distal

femoral

fracture

after

total

knee

arthroplasty

夽

Fabrício

Bolpato

Loures

_,

_Jorge

_Rafael

_Wenck

_Motta,

Rodrigo

Sattamini

Pires

e

Albuquerque,

João

Maurício

Barretto,

Naason

Trindade

Cavanellas

InstitutoNacionaldeTraumatologiaeOrtopedia(Into),CentrodeCirurgiadoJoelho,RiodeJaneiro,RJ,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received12September2015

Accepted20October2015

Availableonline30August2016

Keywords:

Arthroplasty,knee

Femoralfractures

Elderly

a

b

s

t

r

a

c

t

Thenumberoftotalkneearthroplastieshasincreasedexponentiallyandtheirindications

havebeenexpanded.Thisprocedurepresentschallengingcomplicationsfororthopedic

surgeonsthatarepotentiallycatastrophicforpatients.Here,ararecaseofsimultaneous

bilateralperiprostheticfractureofthekneeisreported,withdiscussionofthecausalfactors,

possiblemanagementandprophylaxis.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora

Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Fratura

bilateral

do

fêmur

distal

após

artroplastia

total

do

joelho

Palavras-chave:

Artroplastiadojoelho

Fraturasdofêmur

Idoso

r

e

s

u

m

o

Onúmerodeartroplastiastotaisdojoelhotemaumentadodeformaexponencialesuas

indicac¸õestêmsidoampliadas.Oprocedimentoapresentacomplicac¸õesdesafiadorasao

cirurgiãoortopédicoepotencialmentecatastróficasparaopaciente.Osautoresrelatamum

rarocasodefraturaperiprotéticadojoelho,bilateralesimultâneaediscutemosfatores

causais,aspossíveiscondutaseaprofilaxia.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora

Ltda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Periprostheticfracturesofthekneeareararebutpotentially

devastating complication,1 _{representing a challenge to the}

夽

StudyconductedatInstitutoNacionaldeTraumatologiaeOrtopedia(Into),RiodeJaneiro,RJ,Brazil.

∗ _{Correspondingauthor.}

E-mail:fbolpato@gmail.com(F.B.Loures).

orthopedicsurgeon.2_{Withthegrowthinthenumberoftotal}

knee arthroplasties (TKA)each year, the frequency of this

complicationisincreasing.3_{Theincidencerangesinthe}

lit-eraturefrom0.3%to4.2%forprimaryTKA1,4 _andfrom1.6%

http://dx.doi.org/10.1016/j.rboe.2016.08.018

2255-4971/©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Thisisanopenaccessarticle

rev bras ortop.2016;51(5):606–609

607

Fig.1–RadiographsafterTKAandfixationoftheproximalfemur.

to 38% for revisions.2,4 _{The most common mechanism of}

injuryislow-energytrauma.However,elderlypatientshave

littlehemodynamicreserve,whichincreasesmorbidityand

mortality.2,3_{High-energytraumascanoccurin10%ofcases.}5

Case

report

Female patient, 73 years old, white,retired, withsystemic

hypertension without other conditions, whose main

com-plaint was pain in both knees, worse on the right. She

presentedbilateralvarusknee;radiographicexamination

dis-closedgonarthrosis.Conservative treatmenthadbeen tried

foroverayear,butthepainremainedrefractory.

Sheunderwent TKA on the rightside on November 27,

2006.OnMay25,2008,shesuffered afallfrom ownheight

andwasadmittedforsurgicaltreatmentoftranstrochanteric

fractureontheleftfemur,fixedwithacephalomedullarynail.

OnAugust07,2009,sheunderwentontheleftside.She

pro-gressed without complications in all postoperative periods

andwas placedinoutpatientfollow-up forannual reviews

(Fig.1).

In2015,shesufferedanotherfallfromownheight,resulting

inbilateralsupracondylarfractureofthefemur(Fig.2),

clas-sifiedastypeII_{inaccordancewiththeRorabeckandTaylor}

criteria.6_{Sheunderwentsurgicaltreatmentforsimultaneous}

fixation,withpolyaxiallockingplatesintroducedthroughthe

lateral subvastus approach in order to bridge the fracture

(Fig.3).

Thepatienthadanuneventfulrecoveryandconsolidation

occurredinthethirdpostoperativemonth(Fig.4).Sheis

cur-rentlyinoutpatientfollow-upandisabletowalkwiththeaid

ofacane.

Discussion

Thenumberofarthroplastieshasbeengrowingexponentially.

IntheUnitedStates,itisestimatedthatthisnumberincreases

by5%each year;this percentageishigher amongpatients

below65yearsofage.3

Despitebeingarelativelyrarecomplication,theincidence

of periprosthetic fractures is also increasing. Meek et al.2

reportedthattheabsolutefrequencyofthiscomplicationhas

doubledinScotlandbetween2001and2007;itisthefourth

causeofTKArevision.4_{Themostfrequentsiteofoccurrence}

isthedistalfemur,followedbythepatellaandproximaltibia.

Theclassicpredisposingfactorsareosteopenia,infection

and osteolysis, female gender, older age, anterior femoral

notching,andrevisionarthroplasty.3 _{However,Singhetal.,}1

inaretrospectivestudyof21,723arthroplasties,foundthat

the onlysignificantfactor forfracture inprimaryTKA was

608

Fig.3–Radiographsoftheimmediatepostoperativeperiod.

patient’sage.Thisincidenceshowedabimodaldistribution:

thefirstpeakwasbelow60years,andthesecond,above80

years.Theseauthorsdiscussedthelikelihoodofamoreactive

lifestyle amongyounger patients generating a higher

ten-sionatthebone-implantinterface.Thisgroupalsoincluded

patientswithinflammatorydiseases;duetothechronicuse

ofcorticosteroids,thesepatientshaveworsebonequality.

Anteriorfemoralnotchingisclassicallydescribedasa

pre-disposingfactortosupracondylarfemoralfracture.Although

biomechanicalstudieshavedemonstratedadecreasein

resis-tance, especially to torsional forces, clinical studies have

foundthisassociationdifficulttoprove.Ritteretal.7_assessed

1,089casesofprimaryTKAandfoundanteriorfemoral

notch-ingin325ofthem(29.8%).Afterameanof5.1yearsfollow-up,

therewere twocasesofsupracondylarfracture,bothinthe

groupwithoutanteriorfemoralnotching.Thepresentpatient

hadasmallanteriorfemoralnotchingintheleftknee,butthe

authorsdonotbelievethereisacausalrelationshiptofracture.

Thetreatmentaimstorestorethepatient’s mobilityand

promotegoodfunctionthroughrecoveryofthelimb’slength,

alignment,androtation. Thestatusofthe implantfixation

shouldbeestablished;incaseofloosening(RorabecktypeIII_),

TKArevisionmustbeperformed.3_FortypeI_andII_fractures,

therearetwofixationoptions:retrogradeintramedullarynail

andlockingplates.Carvalhoetal.5_{reportedacaseofbilateral}

periprostheticfractureofthedistalfemurtreatedwith

retro-gradenail;consolidationoccurredinthefourthmonth.This

typeofnailrequiresaminimumdistalfragmentof2cm,which

wasobservedinCarvalhoetal.’scase,butnotinthepresent.

Althoughretrogradenailspresentadistinctadvantageinthe

preservationofsofttissueandgreaterconsolidationratio,

Her-reraetal.,8_{afterasystematicreviewof415cases,wereunable}

toshowanadvantageofonefixationmethodovertheother.

Inthepresentcase,theauthorsoptedfortheuseof

polyax-ial lockingplate.Thisimplantallowsthepositioningofthe

lockingscrewsata30◦_{angle,leadingtobetterpositioningof}

plateandbetterfixationofthefragments.Furthermore,the

useofretrogradenailwouldgenerateatensionpointwiththe

hipimplant,whichdidnotoccurduetotheoverlappingofthe

plateonthetipofthetrochantericnail.

The periprosthetic fracture is a challenge to the

ortho-pedicsurgeon, consideringtreatment,recovery, andrateof

complications.Althoughtherearefewdataintheliterature,

nonunionprevalencerangesfrom9%to20%;infection,from

rev bras ortop.2016;51(5):606–609

609

3%to 9%; loss ofthe reduction,from 4%to 27%; and the

incidenceofreoperationsisaround13%.8,9_Sometypeof

com-plicationmaybepresentinover50%ofcases.9

Orthopedic surgeons who treat patients with severe

osteoarthritis of the knee generally have little interest in

investigatingbonequality,probablybecausetheincidenceof

osteoporosisislowerinpatientswithosteoarthritis.Chang

etal.,10_{afterevaluatingthebonedensityof347patients}

under-goingTKA,allfemaleandover65years,foundanosteoporosis

prevalenceof31%,lowerthaninthecontrolgroup(42%).The

presentpatienthad awarningsignforosteoporosis,which

was the left proximalfemur fracture. Orthopedicsurgeons

mustbeawareofthispossibility,becausetreatingthe

underly-ingdiseasemayavoidapotentiallycatastrophiccomplication.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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1. SinghJA,JensenM,LewallenD.Predistorsofperiprosthetic fractureaftertotalkneereplacement.Ananalysisof21,723 cases.ActaOrthop.2013;84(2):170–7.

2. MeekRMD,NorwoodT,SmithR,BrenkelIJ,HowieCR.Therisk ofperi-prostheticfractureafterprimaryandrevisiontotal

hipandkneereplacement.JBoneJointSurgBr.2011;93(1): 96–101.

3.DavisN,HigginsG.Periprostheticfracturesaroundtotalknee arthroplasty.Trauma.2014;16(3):174–82.

4.ToogoodPA,VailTP.Periprostheticfractures:acommon problemwithadisproportionatelyhighimpactonhealthcare resources.JArthroplasty.2015;30(10):1688–91.

5.CarvalhoM,FonsecaR,SimõesP,BahuteA,Mendonc¸aA, FonsecaF.Bilateraldistalfemoralmailinginraresymmetrical periprosthetickneefracture.CaseRepOrthop.

2014;2014:745083.

6.RorabeckCH,TaylorJW.Classificationofperiprosthetic fracturescomplicatingtotalkneearthroplasty.OrthopClin NorthAm.1999;30(2):209–14.

7.RitterMA,ThongAE,KeatingEM,FarisPM,MedingJB,Berend ME,etal.Theeffectoffemoralnotchingduringtotalknee arthroplastyontheprevalenceofpostoperativefemoral fracturesandonclinicaloutcome.JBoneJointSurgAm. 2005;87(11):2411–4.

8.HerreraDA,GregorPJ,ColePA,LevyBA,JönssonA,Zlowodzki M.Treatmentofacutedistalfêmurfracturesaboveatotal kneearthroplasty.Systematicreviewof415cases(1981–2006). ActaOrthop.2008;79(1):22–7.

9.PlatzerP,SchusterR,AldrianS,ProsquillS,KrumboeckA, ZehetgruberI,etal.Managementandoutcomeof periprostheticfracturesaftertotalkneearthroplasty.J Trauma.2010;68(6):1464–70.

10.ChangBC,KimTK,KangYG,SeongSC,KangSB.Prevalenceof osteoporosisinfemalepatientswithadvancedknee