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Surgical Technique to Manage Periprosthetic Fractures of the Knee in Patients with Infected Leg Ulcers

A Report of Two Cases*

Smitham, Peter J. PhD, FRCS (Tr&Orth), FRACS1; Vohora, Ashray MBBS2; Howie, Donald W. PhD, FRACS1; Atkins, Gerald J. PhD3; Solomon, Lucian B. PhD, FRACS1

doi: 10.2106/JBJS.CC.18.00347
Case Reports
Free
Disclosures

Cases: We describe 2 cases of nonagenarians with periprosthetic knee fractures that were not amenable to either standard internal fixation nor prosthesis revision because of infected leg ulcers in the same limb. The fractures were internally fixed by percutaneous insertion of medial and lateral plates that spanned the knee. Both patients returned to their baseline level of activity without developing surgical site infections.

Conclusions: Percutaneous bridging plates that span the knee are a useful option for treating these difficult cases.

1Department of Orthopaedics and Trauma, Royal Adelaide Hospital and Discipline of Orthopaedics and Trauma, The University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, Australia

2Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia

3Centre for Orthopaedic and Trauma Research and Discipline of Orthopaedics and Trauma, The University of Adelaide, Adelaide, South Australia, Australia

E-mail address for L.B. Solomon: bogdan.solomon@sa.gov.au

Investigation performed at the Royal Adelaide Hospital and The University of Adelaide, Adelaide, South Australia, Australia

*This topic was presented in Melbourne at the Asia Pacific Orthopaedic Association Congress March 29-April 1, 2016.

Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/A830).

Each author certifies that his institution has approved the human protocol for this investigation, all investigations were conducted in conformity with ethical principles of research, and informed consent for participation in the study was obtained. All authors have read and approved this manuscript and each author believes that the manuscript represents honest work.

Periprosthetic fractures around the knee are becoming more frequent as the number of patients with total knee replacement (TKR) increases in an aging population1-7. Furthermore, the management of these cases is becoming more challenging as patients typically present with osteoporotic bone and multiple co-morbidities. One such challenging co-morbidity is infected venous leg ulcers. Although the number of patients with both periprosthetic fractures and ulcers is unknown, epidemiological data suggest that the prevalence of chronic leg ulcers increases with age and is higher among women8-10. It is therefore possible that surgeons will encounter patients with chronically infected leg ulcers and an ipsilateral periprosthetic fracture.

Decision-making regarding the best management of periprosthetic fractures remains controversial for frail, elderly patients because of osteopenia, delayed healing, reduced mobility, and other comorbidities2,4,7. Operative treatment options include the following: open reduction and internal fixation (ORIF); revision arthroplasty; or in extreme situations, amputation.

The main advantage of operative intervention is early mobility; however, these interventions are associated with an increased risk of periprosthetic joint infection11-13. Leg ulcers and in particularly infected leg ulcers compound this risk. Reconstructive surgery is seen as a contraindication until the infection is cured due to the perceived high risk of periprosthetic joint infection14. While nonoperative management might therefore seem an attractive option in these situations, prolonged periods of bracing or splinting can further decrease mobility in an already vulnerable population, increasing the risk of inactivity-related morbidity6. In addition, bracing may prevent healing of the leg ulcers or cause further skin breakdown.

A joint bridging technique has been previously reported in patients with unreconstructable wrist injuries15 and is regularly used for temporary external fixation of fractures around the knee. This paper describes a new technique for treating complex periprosthetic fracture cases using an internal bridging plate construct. The cases presented in this paper report on the treatment of periprosthetic knee fractures in 2 nonagenarians with bilateral infected leg ulcers with percutaneous double plating spanning the knee.

Both patients were informed that data concerning their case might be submitted for publication, and they provided consent.

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Case Reports

Case 1. The first case was a 91-year-old nursing home resident with poor mobility who presented with left knee pain following a fall. Radiographs revealed periprosthetic fractures of both the distal femur and proximal tibia that were not amenable to ORIF (Fig. 1). Her preinjury mobility was also limited by severe ipsilateral hip osteoarthritis. She had bilateral leg ulcers diagnosed as infected based on the breakdown of their base and the discharge of large amounts of exudate and pus emitting a foul odor16,17 (Fig. 2). Group C streptococcus was cultured from the ulcers and antibiotic treatment was initiated as per recommended guidelines17,18.

Fig. 1

Fig. 1

Fig. 2

Fig. 2

Computed tomography suggested the TKR components were stable with no loosening apparent around the implant bone interface; however, there was inadequate distal femoral and proximal tibial bone stock for internal fixation. As the ulcers prevented effective splinting of the fracture, and revision surgery and amputation were thought to have unacceptably high risks of complications and death, the patient was treated with closed reduction and internal fixation with percutaneously inserted, dual knee-spanning plates (Fig. 3). The procedure and postoperative recovery were uneventful. The patient was instructed to bear weight as tolerated immediately without any additional bracing. The ulcers were treated with antibiotics for 2 weeks and with daily dressings until healing, which occurred at 4 weeks (Fig. 4). Her plates were removed after 4 months (Fig. 5), at which time she immediately regained 30° of knee flexion. Her knee remained infection-free and she maintained her prefracture level of mobility until she died of an unrelated cause 1 year later.

Fig. 3

Fig. 3

Fig. 4

Fig. 4

Fig. 5

Fig. 5

Case 2. The second case was a 90-year-old female nursing home resident with poor mobility (walked 15 to 20 m with a frame and assistance) who presented with a left knee (femoral) periprosthetic fracture following a fall. Her past medical history included a TKR, diabetes, peripheral vascular disease, ankle fracture, and actively infected bilateral leg ulcers, with the same characteristics of those in Case 1. Staphylococcus aureus was isolated from her ulcers and antibiotic treatment was initiated.

Computed tomography suggested the TKR components were stable but there was inadequate distal femoral stock for internal fixation. She underwent the same fracture treatment as Case 1. The surgery and postoperative progress was uneventful. The patient was allowed to immediately bear weight as tolerated, without any additional bracing, and returned to her preoperative mobility. She received systemic antibiotics for 2 weeks. Her ulcers healed 2 weeks later. No antibiotics were given postdischarge and her knee remained infection-free. She refused plate removal, as she felt that her rigid knee was not adversely affecting her overall functional ability. Radiographs at 4 years (when she was reviewed following an ankle fracture) revealed no complications related to the fracture or internal fixation (Fig. 6).

Fig. 6

Fig. 6

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Surgical Technique

At surgery, the patients were placed on a radiolucent table, and the calf and ulcers were sealed in a bag before the knee was prepared and free draped. Two large locking plates (Synthes) were selected, based on the length needed to span the fracture and remain above the infected ulcers, pre-contoured, and re-sterilized before surgery to shorten the operative time. A small 2 to 3 cm transverse incision was made over the lateral aspect of the knee joint which remained superficial to the capsule. An elevator was then inserted upward under the vastus lateralis and downward under the muscles of the lower leg's anterior compartment. The lateral plate was then slid upward under the vastus lateralis and then down the leg. The knee was aligned under image intensification and the plate was stabilized to the tibia and femur through small wounds. The procedure was repeated on the medial side. The skin-to-skin operating time was 30 minutes. The surgical wounds were covered with a vacuum-assisted dressing until they healed to minimize the risk of wound contamination during healing.

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Discussion

The management of periprosthetic fracture in cases of TKR is difficult, particularly in frail, elderly patients and even more so in the presence of ipsilateral leg ulcers. Ideally, the treatment of periprosthetic knee fractures should aim to return patients at minimum to their baseline level of functioning. From an operative perspective, it should be protective of the underlying vascular structures to minimize the risk of infection and facilitate healing, be amenable to various TKR constructs, maintain leg and prosthetic alignment, and allow an immediate return to bearing weight. The periprosthetic fractures presented in this case report, in frail elderly patients with actively infected lower leg ulcers, were managed effectively with close reduction and percutaneous insertion of medial and lateral plates that spanned the knee.

In the examples presented, nonoperative treatment was deemed to be unacceptable because the knees could not be immobilized without impeding local treatment of the ulcers: regular dressing changes and application of ointments. For these types of cases, ORIF, necessitating a more invasive operative technique, would have carried a higher risk of blood loss, impaired healing, infection,3,19 and a higher risk of mortality. It was also felt that the limited bone stock within both patients' distal femurs and proximal tibias may not have been sufficient to fix the fractures without spanning the joint. Similarly, the other established surgical technique for the treatment of periprosthetic TKR fractures, revision surgery, was seen as posing too high a risk in these 2 patients. Whilst amputation was an initial treatment option, it would have increased the general risks to the patients and would have rendered them bed-bound.

Minimally invasive dual knee-spanning plating offered a distinct advantage by stabilizing the fracture allowing immediate unrestricted mobilization. The procedure limited soft tissue disruption at the fracture site and devascularization, thereby promoting wound healing and minimizing the risk of infection. It also allowed successful management of the periprosthetic fracture of both the proximal tibia and the distal femur. The use of preoperative 3D printing, based on the mirroring of the contralateral leg, was found useful for the preoperative molding of the plates as it reduced the surgical time to as much as possible.

Percutaneous dual plating cannot be generalized to all cases, but may offer an alternative treatment option in complex circumstances. It is possible that this technique might be successfully applied in the presence of a loose or infected TKR, even if it is undertaken as part of a staged procedure to allow healing of both the fracture and infection before proceeding to revision surgery. It could then allow revision after the distal femoral periprosthetic fracture has healed, enabling a subsequent revision TKR in the presence of improved bone stock and therefore reliance on shorter stem components. In addition, this technique may be particularly useful for periprosthetic fractures of the proximal tibia where revision arthroplasty and proximal tibial replacement are extremely challenging.

The incidence of periprosthetic fractures in the presence of chronic leg ulcers is likely to increase. Surgical fixation with bridging plates can be used to treat these complex cases with periprosthetic fractures of the distal femur, proximal tibia, or a floating knee, and potentially reduces the increased morbidity and mortality risks associated with more extensive surgical options such as ORIF or revision TKR.

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References

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