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.
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).
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.
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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