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Periprosthetic fracture (knee)

76 citationsUpdated Sep 2026

Overview

Periprosthetic fractures around the knee represent a significant surgical challenge, predominantly affecting elderly patients with reduced bone quality and revealing a high complication rate [8]. These injuries pose a substantial management problem [2], with intraoperative periprosthetic tibial fractures occurring fourteenfold more frequently in revision total knee arthroplasties (TKA) compared with primary procedures [5]. While intraoperative fractures are uncommon, they are notable complications that require immediate recognition and attentiveness to preoperative patient and surgical risk factors [25]. Appropriate management of periprosthetic tibial fractures depends on careful scrutiny of radiographs and a thorough clinical history to exclude infection [1].

The majority of periprosthetic knee fractures are treated with open reduction and internal fixation (ORIF) rather than revision TKA [9]. Revision arthroplasty is reserved for cases associated with loose or malaligned implants, with or without severe bone loss [10]. Although periprosthetic distal femoral fractures after TKA worsen functional outcomes at the medium term, arthroplasty complication and survival rates remain similar to non-fractured cohorts [6]. Operative fixation of these distal femoral fractures continues to be challenging due to loss of reduction and high failure rates [11], yet outcomes of surgical treatment for periprosthetic and non-periprosthetic distal femur fractures are similar [14].

Treatment strategies vary based on implant stability and fracture pattern. Locking plates offer a viable option for periprosthetic femoral fractures around well-fixed hip and knee implants [17], while both plate and nail fixation present unique benefits and pitfalls for treating fractures about a well-fixed prosthesis [16]. Long retrograde intramedullary nailing for supracondylar femoral fractures following TKA results in high union rates and encouraging functional outcomes [13], with the proper application of any chosen implant being essential for management [12]. Surgeons may cautiously recommend a supracondylar intramedullary nail for selected patients, noting advantages such as decreased operative time and the ability to start early range-of-motion exercises [136]. Periprosthetic fracture fixation can be performed as part of a standardised less invasive strategy, though the minimally invasive technique should be the preferred treatment [21]. For distal femoral fractures, megaprosthesis represent a viable treatment option, allowing immediate weight-bearing, shorter hospital stay, and fast recovery of knee function and activities of daily living [19]. Intramedullary fibular allograft and plate fixation should be considered in patients with low periprosthetic femur fractures associated with metaphyseal comminution and loss of bone stock due to their biologic and mechanical advantages [23]. Satisfactory outcomes were achieved following individualised treatment of interprosthetic femoral fractures following ipsilateral hip and knee joint replacement [7].

Anatomy & Pathophysiology

Osseous Anatomy

The knee joint comprises the distal femur, proximal tibia, and patella [41]. The medial femoral condyle is larger and projects farther posteriorly and distally than the lateral condyle [58]. Conversely, the lateral femoral condyle projects farther anteriorly and is wider in the medial-lateral direction [58]. The tibial articular surface slopes 7° to 10° in the sagittal plane [58], with the medial plateau averaging 10.7° and the lateral plateau averaging 7.2° [63]. The medial tibial plateau is larger than the lateral plateau and is concave in both frontal and sagittal planes [58]. The lateral tibial plateau is smaller, more circular, concave in the frontal plane, and convex in the sagittal plane [58]. The patella is the largest sesamoid bone in the body, with a mean thickness of 2.5 cm [58, 63]. Its articular surface features a vertical central ridge separating the broader lateral facet from the medial facet, along with a smaller odd facet [58].

Ligamentous Anatomy

The anterior cruciate ligament (ACL) prevents anterior translation and rotation of the tibia on the femur [41]. The posterior cruciate ligament (PCL) prevents posterior subluxation of the tibia on the femur [41]. The medial collateral ligament stabilizes the knee against valgus stresses [41]. The lateral collateral ligament serves as the main stabilizer against varus stress and resists external rotation as part of the posterolateral complex [41]. The ACL consists of 90% type I collagen and 10% type III collagen [58, 63]. It has a mean length of 33 mm and a mean midsubstance width of 11 mm [58, 63]. The PCL is the largest intra-articular ligament, with a cross-sectional area approximately 120% to 150% greater than that of the ACL [71]. It has a mean length of 38 mm and a mean width of 13 mm [63, 71]. The PCL comprises an anterolateral (AL) bundle and a posteromedial (PM) bundle, with the AL bundle comprising 85% of the PCL's cross-sectional area [71]. The ACL contains two bundles: the anteromedial bundle is tight in knee flexion, while the posterolateral bundle is tight in knee extension [63]. Similarly, the PCL’s anterolateral bundle is tight in knee flexion and its posteromedial bundle is tight in knee extension [63]. The popliteofibular ligament is present in 90% of knees and runs from the popliteus tendon to the posterior fibular head [41].

Meniscal Anatomy

The menisci are C-shaped fibrocartilaginous disks that provide shock absorption, increase joint congruency, enhance stability, and aid in synovial fluid distribution [41]. The medial meniscus is firmly attached to the joint capsule along its entire peripheral edge [41]. The lateral meniscus is attached to the anterior and posterior capsule but has a region posterolaterally where it is not firmly attached [41]. Consequently, the medial meniscus has less mobility than the lateral meniscus and is more susceptible to tearing when trapped between the femoral condyle and tibial plateau [41]. The lateral meniscus is larger than the medial meniscus and carries a greater share of the lateral compartment pressure [41]. The menisci consist of type I collagen fibers arranged obliquely, radially, and vertically [63]. Vascular supply derives from geniculate arteries, penetrating 20% to 30% of the peripheral medial meniscus and 10% to 25% of the peripheral lateral meniscus [63].

Vascular and Neural Anatomy

The blood supply to the knee forms an anastomosis around the joint derived from the descending geniculate artery, superior and inferior geniculate arteries, middle geniculate artery, and anterior tibial recurrent arteries [58]. The middle geniculate artery supplies both the anterior and posterior cruciate ligaments [58]. The knee is innervated by branches of the femoral nerve (L2, L3, L4), obturator nerve (L2, L3, L4), and sciatic nerve (L4, L5, S1, S2) [58]. The posterior articular branch of the tibial nerve is the largest nerve providing innervation to the intra-articular knee [58].

Kinematics

The knee is a hinge joint that incorporates gliding and rolling motion [59, 60]. The "screw-home" mechanism involves the tibia externally rotating 5 degrees in the final 15 degrees of extension [59, 60]. The greatest range of motion occurs in the sagittal plane at approximately 160° [75]. Knee rotation ranges from 45° in external rotation to 30° in internal rotation [75]. In the frontal plane, the range of motion in both abduction and adduction reaches a maximum of 10° [75]. During normal range of motion, the tibia internally rotates with flexion relative to the geometric femoral condylar axis [76]. Both femoral condyles move posteriorly on the tibia above 120° of flexion, representing bicondylar roll-back motion [76]. The popliteus muscle initiates flexion by pulling the lateral femoral condyle backward while the medial femoral condyle slides forward, resulting in tibial internal rotation [76].

Pathophysiology of Periprosthetic Fracture

Higher risks of periprosthetic knee fractures were observed in non-osteoarthritis patients and/or patients who had a higher level of TKA constraint [32]. A distal locking plate for the treatment of supracondylar fractures leads to a higher required fracture force [38]. Implantation of a constrained knee prosthesis that is not loosened does not increase the risk for a fracture [38]. The incidence of periprosthetic fracture of the distal femur in total knee arthroplasty is 0.3% to 2.5% [86]. The incidence of periprosthetic tibial fracture in primary TKA is 0.7% or less [86]. The incidence of periprosthetic tibial fracture in revision TKA is 0.9% or less [86]. Anterior femoral notching during femoral preparation weakens the anterior femur at the bone-component interface [86]. Notching decreases the fracture resistance of the distal femur but does not necessarily equate to a higher risk of supracondylar femur fracture [86].

Risk factors for periprosthetic distal femur fracture: * Rheumatoid arthritis * Neurologic disorders * Chronic steroid therapy * Osteopenia or osteoporosis * Anterior femoral notching * Osteolysis with bone loss [86]

Risk factors for periprosthetic tibial fracture: * Insertion of a long-stem component * A loose tibial component * Periprosthetic osteolysis * Malalignment of components * Component removal during revision * Tibial tubercle osteotomy [86]

The fracture line in periprosthetic fractures may be obscured by a metallic component on plain radiographs [86]. A bone scan may help identify a fracture when plain radiographs are not diagnostic [86]. Associated injuries are frequent with floating knee and can cause delays in surgical management and rehabilitation [45].

Classification

Vancouver: Developed by Duncan and Masri in 1995, this system categorizes fractures into Type A (trochanteric regions), Type B (around the stem), and Type C (distal to the stem) [33]. Type A fractures involve the trochanteric regions, specifically Ag (greater trochanter) and Al (lesser trochanter), and are generally stable [33]. Type B fractures are localized around the stem or immediately below it and are sub-classified based on stem stability and bone stock adequacy [33]. Vancouver Type B1 fractures are characterized by a stable stem and adequate bone stock [33]. Vancouver Type B2 fractures are characterized by an unstable stem and adequate bone stock [33]. Vancouver Type B3 fractures are characterized by an unstable stem and inadequate bone stock [33]. Vancouver Type C fractures occur distally to the stem, potentially so distal as to be considered separate from the prosthesis [33].

Su et al.: This classification system divides periprosthetic fractures of the distal femur into three sub-types based on conventional radiographs and CT-scan [97].

Other Considerations: A study proposes adding a Type D category to the Vancouver and SoFCOT classifications specifically for interprosthetic fractures on TKR with femoral shaft extension stems [92]. A simple classification system connecting fracture patterns to treatment algorithms can assist surgeons in obtaining optimal clinical results [49]. Fracture classification should guide surgical decision-making, with intraoperative Type-I fractures showing 100% 2-year survivorship free of tibial component revision compared with 10% in postoperative Type-I fractures [143]. The Non-Union Scoring System (NUSS) can be used to classify and stratify non-unions to enable the surgeon to choose the correct treatment [130].

Clinical Presentation

Periprosthetic tibial fractures predominantly affect elderly patients with reduced bone quality [8]. In the distal femur, periprosthetic fracture after total knee arthroplasty worsens functional outcomes at the medium term [6]. Despite this functional decline, arthroplasty complication and survival rates were similar in patients with periprosthetic distal femoral fracture compared to those without [6]. While the acute fracture and complications may have resolved clinically, the detrimental effect on a patient's quality of life persists up to 12 months after the injury [36].

Patellar fracture after total knee arthroplasty with retained patella is infrequent [114]. Clinical and radiological results for patellar fracture after total knee arthroplasty with retained patella are relatively improved compared with those of patellar fracture after total knee arthroplasty with resurfaced patella [114].

Investigations

Plain radiography: Plain radiographs are appropriate initial imaging studies for most knee conditions, allowing assessment of traumatic injury, arthritis, patellofemoral alignment, osteochondral injury, bone neoplasm, and surgical implants [43]. Standard evaluation includes weight-bearing AP and lateral views [77], as well as a view of the weight-bearing knee flexed at 45-degree angle, imaged posterior to anterior [77]. Standing full-length AP radiographs from hip joint to ankle joint are used to evaluate limb alignment and knee deformity [77]. Supine AP knee radiographs do not adequately estimate the joint space width [81]. To address this limitation, a 45° standing flexion view was introduced to better evaluate the joint space [81]. The fixed flexion view (FFV) has been introduced with improved reproducibility and good evaluation of the joint space [81]. Goniometer readings of long limb alignment or measured on a fixed flexion view correlated well with the angle measured on long limb radiographs, providing an alternative imaging source if long limb radiographs are not available [81].

MRI: MRI is used when osteonecrosis is suspected in the arthritic patient population [77]. It is the most useful study for differentiating osteonecrosis from other conditions such as osteochondritis dissecans, transient osteoporosis, bone bruises, or occult fractures [83]. A serpentine lesion within a well-demarcated border is a specific finding on MRI for osteonecrosis [83]. Bone edema on MRI is a common feature of osteoarthritis, osteonecrosis, cartilage injury, and transient regional osteoporosis [83].

CT: Computed tomography imaging in the axial, sagittal, and coronal planes may help visualize fracture lines and displacement, osteolytic lesions around joint arthroplasty, and cortical disruption in cases of infection or neoplasia [43]. Three-dimensional CT reconstructions may help with preoperative planning for complex intra-articular fractures and reconstitution of bone loss in joint arthroplasty [43]. Three-dimensional CT with remodeling is used for preoperative planning for reconstruction associated with dysplasia, post-trauma planning, and complex total knee arthroplasty (TKA) planning [77]. Axial plane imaging of the knee can help assess the rotational alignment of components of a total knee arthroplasty in cases of patellar maltracking [43].

Bone scan: Technetium-99 (Tc-99) is a radionuclide that may help identify infection, neoplasia, occult fracture, bone healing, active phases of heterotopic ossification, implant loosening, or failure of osseointegration [43]. Gallium-67 (Ga-67) is a radionuclide that may help differentiate between aseptic and septic prosthetic loosening [43]. Increased radionuclide activity in bone may be a normal postoperative finding for up to 6 to 12 months after a fracture repair or arthroplasty [43].

Other Considerations: Age was the independent risk factor for early periprosthetic femoral fracture after total knee arthroplasty [39].

Treatment

Non-Operative

Conservative management is rarely indicated for periprosthetic distal femur fractures, as surgical treatment is required to stabilize the injury [121]. In the specific event of a patellar fracture occurring after total knee arthroplasty, conservative treatment remains a favorable choice [144].

Operative

Indications: Periprosthetic fractures around total knee arthroplasties are predominantly managed with osteosynthesis and salvage of the replacement rather than revision total knee arthroplasty [3, 9]. Appropriate management requires careful scrutiny of radiographs and a thorough clinical history to exclude infection prior to intervention [1].

Surgical Approach / Technique: For periprosthetic tibial fractures, minimally invasive plate osteosynthesis involves closed reduction via manual traction, Schanz pin joystick, reduction screw, or temporary external fixator without exposing the fracture site [95]. This technique utilizes a linear incision of approximately 5 cm over the proximal tibia and a 2-3 cm incision over the distal end of the plate [95]. In cases of severe osteoporosis, Ilizarov external fixation has been used for periprosthetic tibial fractures [29], while circular external fixation is considered a safe and reliable method for periprosthetic fractures around the knee in elderly patients [117]. For distal femur fractures, arthroscopically assisted retrograde intramedullary fixation is an operative option [94].

Implant Selection: Fixation of periprosthetic supracondylar femoral fractures with a locking plate provides satisfactory results with a low risk of complications and additional surgeries compared with non-locking plates [48]. Clinical outcomes, including nonunion and revision rates, are similar between locking compression plate and retrograde intramedullary nail fixation for periprosthetic supracondylar femoral fractures following TKA [108]. The use of either intramedullary nail or locking plate fixation for supracondylar periprosthetic fractures provides comparable clinical outcomes [120]. For patients with low periprosthetic femur fractures associated with metaphyseal comminution and loss of bone stock, intramedullary fibular allograft and plate fixation should be considered [23]. A long-locking plate combined with a locking attachment plate shows favorable radiographic and clinical outcomes in patients with periprosthetic femoral fracture around an ipsilateral stem after TKA [20]. For distal femoral fractures, megaprosthesis represent a viable treatment option because they allow immediate weight-bearing, shorter hospital stay, and fast recovery of knee function and activities of daily living [19]. Distal femoral replacement provides a functionally acceptable knee with few complications requiring re-operation, though complication rates are high and functional outcomes are relatively poor due to patient demographics [31]. A novel tibial implant has been developed to repair peri-prosthetic proximal tibia fractures, overcoming significant constraints from the tibial component of existing knee implants [22].

Other Considerations: The treatment of periprosthetic fractures of the femur in patients with total knee arthroplasties can result in a significant complication rate [4]. Operative fixation of periprosthetic distal femoral fractures after TKA is associated with loss of reduction and high failure rates [11]. The use of the LISS in combination with autogenous bone grafting adequately addresses nonunion fixation of the distal femur in elderly patients, achieving bone healing and preservation of knee function even in severe osteoporosis with substantial bone defects [111].

Postoperative Care and Rehabilitation: Following minimally invasive plate osteosynthesis for periprosthetic tibial fracture, quadriceps strengthening and continuous passive motion of the knee are performed on the second postoperative day [95]. Full weight-bearing is permitted after healing of the fracture site [95]. Rehabilitation for retrograde intramedullary nailing of distal femur fractures starts on the second postoperative day with quadriceps setting and continuous passive motion of the hip and knee joints [96]. Partial weight bearing with crutches is started as soon as pain becomes tolerable [96]. Fracture union is defined by callus formation on 3/4 cortices and radiographic evidence of fracture line fading [96]. Malunion is defined as more than 5 degrees of angulation at any level [94]. Following arthroscopically assisted retrograde intramedullary fixation for distal femur fractures, partial weight bearing is allowed after early signs of callus formation, usually after 6 weeks [94]. Full weight bearing is possible when the union is complete [94].

Complications and Outcomes: The risk of non-union, delayed union, infection and additional procedures is high in segmental tibial fractures [55]. Delayed unions and non-unions of fractures are associated with significant patient morbidity [54]. Treatment of non-union should consider preservation of the blood supply at the fracture site [146].

Complications

General Complication Burden: Periprosthetic fractures around total knee arthroplasties pose a significant surgical challenge [3]. The annual incidence of proximal and distal periprosthetic fractures has increased significantly, with high rates of mortality and return to the operating room within 1 year [150].

Fixation-Specific Complications: In a multicenter series of 55 patients treated with precontoured lateral locking plates, the overall rate of nonunion was 18% and the total complication rate was 24% [34]. Nonunion rates of up to 22% have been reported for periprosthetic fractures of the distal femur [34]. After additional surgery, 49 of 55 patients (89%) with periprosthetic distal femur fractures treated with precontoured lateral locking plates went on to heal [34]. No patient or surgical variables were identified as independent risk factors for nonunion in a regression analysis of 55 patients treated with precontoured lateral locking plates [34]. Peri-implant fracture could occur in patients with rheumatoid arthritis or periprosthetic fracture after TKA following locking plate fixation for osteoporotic distal femur fractures [27].

Functional and Quality of Life Outcomes: At a mean of 4 years after injury, fracture-related infection and nonunion became chronic conditions in nearly a quarter of the participants who experienced these complications, regardless of reintervention [40].

Recovery

Light activity (weeks): The evidence base does not provide specific week-based timelines for desk work, driving, or light activities of daily living. While megaprosthesis facilitates a fast recovery of knee function and activities of daily living [19], no precise week range is defined in the provided data.

Full activity (months): Specific month ranges for manual work, sport, or full range-of-motion and strength return are not established in the evidence. Radiographic union for femoral shaft non-unions treated with autologous concentrated bone-marrow grafting occurs at an average of 4.75±1.75 months (range 3 to 8 months) [57]. Complete clinical and radiological union for failed femoral nailing treated with augmentation plating is achieved in a mean duration of 5.2 months [154].

Complete recovery / outcome plateau (months): Patient-reported outcomes of lower limb long bone shaft fractures do not return to normal at one year despite modern treatment [124]. The detrimental effect on a patient's quality of life persists up to 12 months after tibial fracture and complications, even if the acute fracture and complications have resolved clinically [36].

Rehabilitation protocol: Closed fracture and regular follow-up were determining factors for better functional outcomes in distal femur fractures treated with open reduction and internal fixation [126]. Megaprosthesis allow immediate weight-bearing, shorter hospital stay, and a fast recovery of knee function and activities of daily living in patients with distal femoral fractures [19]. For tibial shaft fractures, time to radiographic union and full weight-bearing did not differ significantly between external fixation and locked intramedullary nailing groups, but unprotected weight-bearing was achieved earlier in the intramedullary nail group [152].

Functional milestones: Periprosthetic distal femoral fracture after total knee arthroplasty (TKA) worsens functional outcomes at the medium term [6]. Arthroplasty complication and survival rates were similar in patients with periprosthetic distal femoral fracture after TKA compared to those without [6]. All fractures progressed to clinical and radiological union at final follow-up when treated with the Polyax Locked Plating System for distal femoral non-implant related and periprosthetic fractures [56]. Satisfactory outcomes were observed following individualised treatment of interprosthetic femoral fractures following ipsilateral hip and knee joint replacement [7].

Other Considerations: The distal femoral nail may be used successfully in selected cases with a periprosthetic fracture, provided careful preoperative planning is performed [15]. The overall rate of nonunion was 18% and the total complication rate was 24% in a series of 55 patients with periprosthetic distal femur fractures treated with precontoured lateral locking plates [34]. No patient demographic or injury variables were identified as independent risk factors for nonunion in the regression analysis of 55 patients with periprosthetic distal femur fractures [34]. Delayed union or nonunion occurred in 60 of 485 patients (12.4%) with tibial or femoral shaft fractures [151]. At a mean of 4 years after injury, fracture-related infection and nonunion became chronic conditions in nearly a quarter of participants who experienced these complications, regardless of reintervention [40].

Key Evidence

  • [L5] Appropriate management of periprosthetic tibial fractures depends on careful scrutiny of radiographs and a thorough clinical history to exclude infection. [1] (10.5435/jaaos-d-16-00387)
  • [L5] The management of periprosthetic fractures around the knee remains a challenging problem. [2] (10.1097/01.blo.0000214417.29335.19)
  • [L4] Periprosthetic fractures around total knee arthroplasties pose a significant surgical challenge that can mostly be managed with osteosynthesis and salvage of the replacement. [3] (10.1302/0301-620x.98b11.bjj-2016-0029.r1)
  • [L4] The treatment of periprosthetic fractures of the femur in patients with total knee arthroplasties can result in a significant complication rate due to the challenges present. [4] (10.1016/j.arth.2011.08.007)
  • [L3] Intraoperative periprosthetic fracture of the tibia was fourteenfold more likely in revision TKRs compared with primary TKRs. [5] (10.2106/jbjs.24.01407)
  • [L3] Periprosthetic distal femoral fracture after TKA worsens functional outcomes at the medium term, but arthroplasty complication and survival rates were similar in both groups. [6] (10.1016/j.arth.2013.03.007)
  • [L4] We had a satisfactory outcome following individualised treatment of interprosthetic femoral fractures following ipsilateral hip and knee joint replacement. [7] (10.1016/j.injury.2010.08.020)
  • [L4] Periprosthetic tibial fractures predominantly affect elderly patients with reduced bone quality and reveal a high complication rate. [8] (10.1186/s12891-018-2250-0)
  • [L3] Periprosthetic knee fractures are predominantly treated with ORIF rather than revision total knee arthroplasty (TKA), whereas periprosthetic hip fractures are predominantly treated with revision total hip arthroplasty (THA) rather than ORIF. [9] (10.2106/jbjs.23.00868)
  • [L5] Revision TKA is considered for periprosthetic fractures associated with loose or malaligned implants, with or without severe bone loss. [10] (10.5435/jaaos-d-15-00680)
  • [L3] Operative fixation of periprosthetic distal femoral fractures after TKA continues to be challenging with loss of reduction and high failure rates. [11] (10.1016/j.injury.2012.01.025)
  • [L3] Regardless of which implant is used, the proper application is essential in management of periprosthetic supracondylar femur fractures above TKA. [12] (10.1007/s00402-015-2374-8)
  • [L4] Surgical treatment of periprosthetic supracondylar femoral fractures following TKA with long retrograde intramedullary nailing resulted in high union rates and encouraging functional outcomes. [13] (10.1007/s00402-013-1890-7)
  • [L3] Outcomes of surgical treatment for periprosthetic and non-periprosthetic distal femur fractures are similar. [14] (10.1186/s13018-019-1204-z)
  • [L4] The DFN may be used successfully in selected cases with a periprosthetic fracture, provided careful preoperative planning is performed. [15] (10.1016/s0020-1383(03)00191-8)
  • [L4] Both plate and nail fixation present unique benefits and pitfalls for treating periprosthetic fractures about a well-fixed prosthesis. [16] (10.1016/j.otsr.2016.11.018)
  • [L4] Locking plates offer a viable treatment option for periprosthetic femoral fractures around well-fixed hip and knee implants. [17] (10.1016/j.arth.2010.07.002)
  • [L4] Megaprosthesis represent a viable treatment option in patients affected by distal femoral fractures because they allow immediate weight-bearing, shorter hospital stay, a fast recovery of knee function and activities of daily living. [19] (10.1016/j.injury.2019.08.011)
  • [L4] Long-locking plate combined with LAP showed favorable radiographic and clinical outcomes in patients with periprosthetic femoral fracture around ipsilateral stem after TKA. [20] (10.1186/s12891-023-06726-x)
  • [L4] Periprosthetic fracture fixation can be performed as part of a standardised less invasive strategy, but the minimally invasive technique should be the preferred treatment. [21] (10.1016/j.injury.2012.10.035)
  • [L4] A novel tibial implant has been developed to repair peri-prosthetic proximal tibia fractures which overcomes significant constraints from the tibial component of existing knee implant. [22] (10.1016/j.injury.2018.01.032)
  • [L4] This technique should be considered in patients with low periprosthetic femur fractures associated with metaphyseal comminution and loss of bone stock due to its biologic and mechanical advantages. [23] (10.1016/j.arth.2007.05.054)
  • [L1] Comparable low incidences of periprosthetic tibial fractures in cementless and cemented UKA can be achieved. [24] (10.1007/s00167-021-06449-3)
  • [L5] Intraoperative periprosthetic fractures are uncommon but notable complications requiring intraoperative recognition and attentiveness to preoperative patient and surgical risk factors. [25] (10.5435/jaaos-d-23-00153)
  • [L4] However, peri-implant fracture could occur in patients with RA or periprosthetic fracture after TKA. [27] (10.1016/j.otsr.2017.08.008)
  • [Case_report] To the best of our knowledge, this is the first report in which Ilizarov external fixation has been used for a periprosthetic tibial fracture after TKA. [29] (10.1186/s12891-020-3176-x)
  • [L4] It provides a functionally acceptable knee with few complications requiring re-operation, though complication rates are high and functional outcomes are relatively poor due to patient demographics. [31] (10.1016/j.injury.2013.10.032)
  • [L3] Higher risks were observed in non-osteoarthritis patients and/or patients who had a higher level of TKA constraint. [32] (10.1016/j.arth.2024.05.033)
  • [L4] [33] (10.1016/j.injury.2013.09.028)
  • [L4] [34] (10.1016/j.injury.2020.05.009)
  • [L2] While the acute fracture and complications may have resolved clinically, the detrimental effect on a patient's quality of life persists up to 12 months after the injury. [36] (10.1302/0301-620x.100b9.bjj-2017-1488.r1)
  • [L5] A distal locking plate for the treatment of supracondylar fractures leads to a higher required fracture force, and implantation of a constrained knee prosthesis that is not loosened does not increase the risk for a fracture. [38] (10.1007/s00264-012-1697-0)
  • [L3] This study determined that age was the independent risk factor for early periprosthetic femoral fracture. [39] (10.1186/s12891-021-04875-5)
  • [L4] At a mean of 4 years after injury, fracture-related infection and nonunion became chronic conditions in nearly a quarter of the participants who experienced these complications, regardless of reintervention. [40] (10.2106/jbjs.22.00016)
  • [L4] Associated injuries are frequent with floating knee and can cause delays in surgical management and rehabilitation. [45] (10.1186/1471-2474-10-7)
  • [L3] Fixation of periprosthetic supracondylar femoral fractures with a locking plate provided satisfactory results with a low risk of complications and additional surgeries compared with fixation with a non-locking plate. [48] (10.1007/s00167-013-2572-2)
  • [L4] A simple classification system connecting fracture patterns to treatment algorithms can assist surgeons in obtaining optimal clinical results. [49] (10.1016/j.arth.2006.12.054)
  • [L5] Delayed unions and non-unions of fractures continue to be of great interest and are associated with significant patient morbidity. [54] (10.1016/j.injury.2017.04.019)
  • [L4] The risk of non-union, delayed union, infection and additional procedures is high as seen in this series of patients. [55] (10.1016/s0020-1383(02)00393-5)
  • [L4] All fractures progressed to clinical and radiological union at final follow-up. [56] (10.1016/j.injury.2015.08.008)
  • [L4] Radiographic evidence of fracture union was observed at an average of 4.75±1.75 months (range 3 to 8 months). [57] (10.1016/s0020-1383(14)70013-0)
  • [L4] The study proposes adding a type D category to the Vancouver and SoFCOT classifications for interprosthetic fractures on TKR with femoral shaft extension stem. [92] (10.1016/j.otsr.2011.07.009)
  • [L4] [94] (10.1007/s00167-005-0660-7)
  • [L4] [95] (10.1016/j.otsr.2016.10.007)
  • [L3] [96] (10.1007/s00402-018-2961-6)
  • [L4] [97] (10.1007/s00402-013-1730-9)
  • [L1] Clinical outcomes, including nonunion and revision rates, were similar in patients who underwent locking compression plate and retrograde intramedullary nail fixation for periprosthetic supracondylar femoral fracture following TKA. [108] (10.1007/s00167-016-4050-0)
  • [L4] The use of the LISS in combination with autogenous bone grafting adequately addresses nonunion fixation of the distal femur in elderly patients, achieving bone healing and preservation of knee function even in severe osteoporosis with substantial bone defects. [111] (10.1007/s00402-006-0102-0)
  • [L4] Patellar fracture after TKA with retained patella is infrequent, with relatively improved clinical and radiological results compared with those of patellar fracture after TKA with resurfaced patella reported in the literature. [114] (10.1016/j.arth.2021.03.053)
  • [L4] Circular external fixation is a safe and reliable method for periprosthetic fractures around the knee in elderly patients. [117] (10.1186/s12891-020-03352-9)
  • [L3] The use of either IM nail or locking plate fixation for supracondylar periprosthetic fractures provides comparable clinical outcomes. [120] (10.1016/j.arth.2016.06.056)
  • [L4] Surgical treatment is indicated to stabilize distal femur fractures as non-surgical treatment is a rare option. [121] (10.1016/j.otsr.2012.10.014)
  • [L3] Despite modern treatment, the patient-reported outcomes of lower limb long bone shaft fractures do not return to normal at one year. [124] (10.1016/j.injury.2014.06.025)
  • [L3] Closed fracture and regular follow up were determining factors for better functional outcomes. [126] (10.1186/s13018-024-05054-7)
  • [L4] This indicates that NUSS could be an appropriate scoring system to classify and stratify non-unions and to enable the surgeon to choose the correct treatment. [130] (10.1016/j.injury.2014.10.030)
  • [L4] The authors cautiously recommend the use of a supracondylar intramedullary nail for selected patients with supracondylar fractures of the femur proximal to a total knee arthroplasty, noting advantages such as decreased operative time and the ability to start early range-of-motion exercises. [136] (10.2106/00004623-199506000-00013)
  • [L4] This commentary reinforces that fracture classification should guide surgical decision-making, noting that intraoperative Type-I fractures have 100% 2-year survivorship free of tibial component revision compared with 10% in postoperative Type-I fractures, while highlighting the need for future research on modern fixation techniques and functional outcomes. [143] (10.2106/jbjs.25.00234)
  • [L3] In the event that a fracture does occur, conservative treatment seems a favorable choice. [144] (10.1016/j.arth.2012.04.022)
  • [L5] In case of non-union, its treatment should consider preservation of the blood supply at the fracture site. [146] (10.1016/s0020-1383(15)30044-9)
  • [L4] The annual incidence of proximal and distal periprosthetic fractures has increased significantly, with high rates of mortality and return to the operating room within 1 year, emphasizing the need for better prevention strategies and thoughtful surgical management. [150] (10.1097/corr.0000000000002686)
  • [L3] Delayed union/nonunion occurred in 60/485 patients (12.4%). [151] (10.1186/s12891-026-10074-x)
  • [L1] Time to radiographic union and full weight-bearing did not differ significantly between groups, but unprotected weight-bearing was achieved earlier in the intramedullary nail group. [152] (10.1007/s00402-004-0768-0)
  • [L4] Complete clinical and radiological union was achieved in all cases in a mean duration of 5.2 months. [154] (10.1016/s0020-1383(17)30490-4)

See Also

References

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