J Am Acad Orthop Surg, Vol 12, No 1, January/February 2004, 12-20.
© 2004 the American Academy of Orthopaedic Surgeons
Periprosthetic Femoral Fractures Above Total Knee Replacements
Edward T. Su, MD,
Hargovind DeWal, MD and
Paul E. Di Cesare, MD
Dr. Su is Resident, Department of Orthopaedic Surgery, Musculoskeletal Research Center, NYU–Hospital for Joint Diseases, New York, NY. Dr. DeWal is Resident, Department of Orthopaedic Surgery, Musculoskeletal Research Center, NYU–Hospital for Joint Diseases. Dr. Di Cesare is Associate Professor, Department of Orthopaedic Surgery, Musculoskeletal Research Center, NYU–Hospital for Joint Diseases.
Reprint requests: Dr. Di Cesare, NYU–Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003.
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Abstract
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Periprosthetic femoral fractures above total knee replacements can be managed by a variety of methods, including casting, open reduction and internal fixation, external fixation, or revision arthroplasty. Because no single method has emerged as the optimal choice for all such fractures, it is important to understand which options are appropriate for each fracture pattern. Early classification systems focused on displacement as a major indication for either surgical or nonsurgical management. However, recent techniques and current implants have made surgical management preferable for most periprosthetic fractures. Classification based on fracture location can help guide such treatment. Generally, intramedullary nails are best for proximal fractures, fixed-angle devices for fractures originating at the component, and revision arthroplasty for very distal fractures or those with implant loosening.
Supracondylar periprosthetic femoral fractures—fractures above total knee replacements—are an uncommon complication (incidence, 0.3% to 2.5%),1–4 occurring more frequently in patients older than 60 years with osteoporotic bone. The most frequent mechanism is a low-velocity fall onto the knee; a smaller proportion results from high-energy trauma (eg, motor vehicle accident). The rate of these fractures is expected to increase because of the growing number of total knee replacements and greater levels of activity among elderly patients.
Neer et al5 defined the supracondylar region as the lower 3 inches (7.62 cm) of the femur. Culp et al6 specified 9 cm proximal to the knee joint line as the cutoff. Sisto et al4 included all fractures within 15 cm proximal to the knee joint line. Generally, supracondylar periprosthetic fractures are those within 15 cm of the joint line or, in the case of a stemmed component, within 5 cm of the proximal end of the implant.
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Risk Factors
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Risk factors for supracondylar periprosthetic femoral fractures include rheumatoid arthritis, neurologic disorders, chronic steroid therapy, anterior cortical notching of the femur, and revision knee arthroplasty.3,6–9 Merkel and Johnson3 reported that patients with a revision total knee replacement had a 1.6% incidence (10/637) of fracture above the prosthesis compared with 0.6% (26/4,596) for patients with primary knee replacements. Rheumatoid arthritis and chronic steroid use have been associated with an increased risk of periprosthetic fracture because both increase the likelihood of osteoporosis. It is unclear whether steroid use is a separate risk factor or an indicator of the severity of rheumatoid arthritis. In a series of 16 patients with supracondylar femoral fractures, 12 had rheumatoid arthritis; of these, 10 were chronic steroid users.10 In another study, 12 of 22 patients had rheumatoid arthritis; 9 were chronic steroid users.2
A theoretic analysis of the effects of anterior cortical notching suggested a reduction intorsional strength of 29.2% with a 3-mm anterior cortical notch.6 In contrast, in a series of 670 total knee arthroplasties (670 patients), of which 180 (27%) had notching (
3 mm), only 2 patients sustained supracondylar femoral fractures (1 with notching, 1 without).1 The authors argued that remodeling and stress redistribution around the implant accounted for the low incidence of fractures despite a high incidence of intraoperative notching. In a recent biomechanical study using cadaveric femurs, a full-thickness cortical defect was created just proximal to the anterior flange of the femoral component. The authors reported statistically significant decreases in both bending strength (18%) and torsional strength (39.2%) (P = 0.0034 and P = 0.01, respectively) with notching.11 Different fracture patterns occurred with notched and nonnotched femurs. Notched femurs tended to have short oblique fractures originating from the notched cortex, whereas nonnotched femurs tended to have diaphyseal fractures. As a general rule, anterior cortical notching should be avoided to minimize the increased risk of peri-prosthetic fracture at a weakened biomechanical interface between the distal femur and the femoral component.
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Classification
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Several classification systems have been used to describe supracondylar periprosthetic fractures (Table 1
). The Neer classification,5 based on displacement and stability, was created for supracondylar fractures in knees without prostheses and fails to account for the relationship of the fracture to the implant. DiGioia and Rubash12 modified the Neer classification, again focusing on displacement of the fracture. Chen et al7 simplified the classification into two types, nondisplaced and displaced. Lewis and Rorabeck included compromised prosthesis integrity (loosening) in their classification and emphasized the need to consider revision arthroplasty as a possible course of treatment.13,14 Although these classification systems indicate which fractures are amenable to nonsurgical management, they are not widely used because they do not aid in choosing among available modes of surgical intervention.
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Management
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Several factors must be considered in choosing the most appropriate management method for these fractures, including the patient’s general health, prefracture ambulatory status, fracture pattern, location, displacement, and type of implant. Stress shielding about the femoral component may lead to distal femoral osteoporosis, which can make distal femoral fixation more tenuous. The goals of treatment, whether surgical or nonsurgical, are fracture healing, restoration and maintenance of knee range of motion, and pain-free function. A good result is a minimum of 90° of knee motion, fracture shortening 2 cm, varus/valgus malalignment 5°, and flexion/extension malalignment 10°.15 These criteria, however, do not completely assess function, which is the result most important to the patient. Additionally, malunion can potentially result in malalignment and abnormal stresses across the knee, leading to implant loosening, just as malalignment of the components during a primary total knee replacement could lead to premature loosening and failure.
Historically, nonsurgical management using skeletal traction, casting, or cast-bracing has been preferred for primary fractures.2–4,9 Nonsurgical management does eliminate surgical risks such as bleeding, infection (not including pin site infection), loss of fixation, and anesthetic complications. However, prolonged skeletal traction in elderly patients is neither practical nor well tolerated and carries the significant risks of prolonged recumbency, such as decubitus ulcers, atelectasis, pneumonia, pulmonary emboli, deep venous thrombosis, and diffuse muscle atrophy. Long-term immobilization in a cast or cast-brace also eliminates surgical risks but may result in marked loss of knee motion as well as malunion or nonunion. Surgical management is preferable for many patients with supracondylar periprosthetic femoral fractures unless they are too ill to undergo the procedure. When surgery is not an option, the extremity should be immobilized in extension for 4 to 6 weeks and the patient kept non–weight-bearing.
If the femoral component was loose before the fracture occurred or was loosened with fracture, revision arthroplasty with a stemmed component should be considered16 (Fig. 1). Figgie et al2 treated two patients with custom revision; both had satisfactory outcomes, resuming ambulation within 1 week. Kraay et al17 performed revision surgery with large distal allografts as a salvage procedure in seven patients, and despite two perioperative complications, all patients were reported to have a satisfactory result. Cordeiro et al18 treated four patients with revision arthroplasty, three with plates and screws, and two nonsurgically; the patients who underwent revision had a better outcome than did those who underwent the other treatments. Rorabeck and Taylor15 recommended that the stem extend proximally past the fracture site by least two cortical diameters. They also recommended caution in using stems >190 mm long because they may impinge on the anterior bow of the femur.
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Figure 1 Anteroposterior (A) and lateral (B) radiographs of a periprosthetic fracture extending distal to the anterior flange of the femoral component. This fracture was treated by revision of the femoral component with a stemmed component and a distal femur allograft. Postoperative anteroposterior (C) and lateral (D) radiographs.
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Plate and Screws
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Buttress Plate
Advantages of using the buttress plate include the ability to place multiple screws distally in many directions and excellent visualization of the fracture to obtain an anatomic reduction. Disadvantages include extensive soft-tissue stripping and less rigid fixation than with a nail or fixed-angle device (eg, intramedullary rods, blade plates, dynamic condylar screw plates).19 Healy et al8 and Zehntner and Ganz20 reported good results in a total of 12 patients in their two series using the condylar buttress plate, with or without bone graft. All patients healed and returned to prefracture ambulatory status, although with some decrease in range of motion. Merkel and Johnson3 described four patients with plate-and-screw fixation with two complications. Given the limited numbers of patients in these studies and the theoretic concerns of less rigidity, determining when these plates should be used remains unclear. In addition, with the advent of recent, more rigid fixation devices, the use of condylar buttress plates in treating periprosthetic femoral fractures may become less popular.
Fixed-Angle Devices
The two basic types of fixed-angle devices are the condylar screw plate (Fig. 2) and the blade plate. Cusick et al19 found the condylar screw plate to be significantly (P < 0.05) more rigid than a condylar buttress plate and technically easier to implant than a blade plate. The blade plate is thinner than a condylar screw plate and may be placed more distally, allowing it to be used in either more distally located fractures or fractures above a posterior cruciate-substituting femoral component (eg, with an intercondylar box). The blade plate may be placed anterior to the anchoring bolts of the femoral component if the fracture is very distal.8 The blade plate also resists flexion and extension of the distal fragment more effectively than does the dynamic condylar screw. Ochsner and Pfister21 reported results of using a fork plate, which has the same profile as a blade plate but uses two 6-mm prongs separated by a 12-mm space instead of a solid blade. In a series of six patients, they placed the device in a very distal position because the prongs could pass around the anchoring bolts of the femoral knee component. Devices such as locking plates also may be useful for fixation of these fractures; they combine some of the rigidity of fracture fixation provided by fixed-angle devices with the ability to place multiple distal screws that is provided by condylar buttress plates.22
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Figure 2 Anteroposterior (A) and lateral (B) radiographs of a periprosthetic fracture starting proximal to the anterior flange of the femoral component. This fracture was treated by open reduction and fixation with a dynamic condylar screw and sideplate. Postoperative antero-posterior (C) and lateral (D) radiographs.
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Intramedullary Nails
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Supracondylar Nail
Supracondylar intramedullary nails also can be used to treat periprosthetic femoral fractures16,23 (Fig. 3). In a series of seven patients treated with supracondylar nails, all fractures healed, and all patients returned to prefracture function in 3 months.23 In some cases, the end of the nail was cut so that the locking screws could be placed more distally. Intramedullary nails are inserted retrograde through a median parapatellar approach. Before beginning surgery with this method of fixation, it is critically important to know the exact type of femoral component that will be used (Table 2). Knowing this helps to ascertain whether the intercondylar notch is open or closed and whether the opening is large enough to accommodate an intramedullary nail.
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Figure 3 Anteroposterior (A) and lateral (B) radiographs of a periprosthetic fracture starting at the anterior flange of the femoral component. This fracture was treated by fixation with a retrograde intramedullary nail. Postoperative anteroposterior (C) and lateral (D) radiographs.
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There is marked variation in the intercondylar space dimensions among the different femoral components (Table 2
). Most cruciate-retaining components have notch diameters ranging from 11 to 20 mm. Cruciate-substituting components tend to have narrower intercondylar spaces. It is recommended that the hole in the femoral component be at least 1 mm larger than the nail to be inserted. One case has been described in which the hole was widened in the femoral component with a metal-cutting tool to accommodate a 12-mm nail.24 A concern with this technique is the large amount of metal debris generated from the hole cut in the femoral component, which may contribute to third-body wear, accelerated polyethylene wear, osteolysis, and premature implant loosening. Preferably, when the notch is too narrow to accommodate a nail, an alternative technique, such as a fixed-angle device, should be considered.
Supracondylar periprosthetic femoral fractures around stemmed components present a distinct problem because the stems preclude the use of retrograde nails or screws for fixation. These fractures may require alternative fixation techniques, such as attaching a hollow antegrade nail over the stem or using plates in combination with cerclage techniques.25–27
Antegrade Nails and Other Methods of Fixation
When the fracture is sufficiently proximal, an antegrade nail may be used (eg, the distal fragment is long enough to accommodate distal locking screws). There are no published reports of standard antegrade femoral nailing of these fractures. It is likely that most surgeons inclined to use an intramedullary device prefer the retrograde nail for better distal fixation. Hanks et al28 reported the early use of Brooker-Wills distal locking intramedullary nails to treat supracondylar fractures after total knee arthroplasty while cautioning that the fractures must be at least 8 cm above the joint line. Ritter et al29 used Rush rods to fix 22 displaced supracondylar femoral fractures with acceptable results; there were no nonunions and no loss of range of motion. Tani et al30 reported a single case of using a fibular graft for intramedullary fixation.
External fixation has been sparsely reported for managing supracondylar periprosthetic femoral fractures. Caution should be exercised when using an external fixator in close proximity to a total joint prosthesis because of a theoretically substantial risk of infection to the implant from the pin site. Merkel and Johnson3 reported three cases initially treated with an external fixator, with good or excellent results. In their series, Figgie et al2 treated one patient with external fixation who developed a pin tract infection, which later developed into a deep infection. Given the paucity of studies reporting external fixation of these fractures, this method may have only a very limited role, such as in the rare patient in whom use of an internal fixation device is contraindicated.
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Supplemental Bone Grafting
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Bone grafting of the fracture may be advantageous; however, studies to date are inconclusive as to the type and amount of grafting and the situations in which it is needed. Healy et al8 used primary bone grafting (either allograft or autograft) in 15 of 20 fractures, with good results. Although not statistically significant, their results suggest that patients with autogenous bone graft heal more quickly than do those with allograft. Two patients did not heal after the primary procedure, one with and one without grafting. The authors recommend directing particular attention to the bone quality of the distal fragment and, if necessary, reinforcing the fixation of the implant with methyl-methacrylate and augmenting it with bone graft.8 Grafting may be especially helpful in managing nonunions, both with and without revision of fixation. Wang and Wang31 described the use of cortical allograft struts as adjuncts for plate fixation. They reported 10 cases, 9 of which had good or excellent results. Although the placement of cortical allograft struts requires more extensive soft-tissue stripping, it may provide additional support in cases of severe comminution or for management of non-unions.
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Complications
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The lack of reports of large series of supracondylar periprosthetic femoral fractures makes estimation of complication rates difficult. High rates have been reported with both surgical and nonsurgical management. Complications include decreased range of motion, malalignment, infection, non-union, and intraoperative death. Nielsen et al32 reported complications in three of four patients treated surgically, and Merkel and Johnson3 in three of five. The authors of both studies recommended nonsurgical management as the initial form of treatment for these fractures. However, Culp et al6 recommended surgical fixation because there were only six complications in the 31 patients treated operatively (19%) but 13 complications in the 30 patients treated non-surgically (43%). Most authors of smaller series and case reports have reported few or no complications and recommend surgical management.
A search of the literature2–4,6,8–10,16–18,20,21,23–30,33–42 yielded 361 reported periprosthetic femoral fractures above total knee replacements; 140 (39%) were managed nonsurgically and 221 (61%), surgically. Of the 140 nonsurgical cases, there were 44 complications (31%), of which 19 were delayed unions or nonunions (14%) and 25, malunions (18%). Of the 221 surgical cases, there were 43 complications (19%), consisting of 6 infections (3%), 15 delayed unions or nonunions (7%), 10 malunions (4%), and 6 hardware failures (3%), as well as other complications such as intraoperative death, pulmonary embolus, and impingement of hardware (3%). No differentiation was made among types of nonsurgical management (casting, splinting, bracing, traction) or surgical management (open reduction and internal fixation, intramedullary nailing, external fixation, revision total knee arthroplasty). Thus, although the numbers alone suggest that surgically managed fractures fare better than do nonsurgically managed ones, the wide variety of treatments involved makes an across-the-board conclusion problematic.
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Classification
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Management of supracondylar periprosthetic fractures must take into account such factors as a patient’s comorbidities and the specific goals of treatment. Existing classification schemes focus on determining whether surgical or nonsurgical management is necessary.7,12,13 Although nonsurgical management may be acceptable for nondisplaced fractures in debilitated patients, most of these fractures should be treated surgically to minimize the risk of later displacement, facilitate patient mobility, and improve knee range of motion.42 Despite reports of high complication rates (25% to 75%), satisfactory results still can be obtained by appropriate surgical intervention.2,6,8,16,21,27,28 The following classification system (Fig. 4) may be of help in choosing among surgical options.
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Figure 4 Anteroposterior and lateral views of supracondylar periprosthetic femoral fracture classification. Type I: Fracture proximal to femoral knee component. Type II: Fracture originating at the proximal aspect of the femoral knee component and extending proximally. Type III: Any part of the fracture line is distal to the upper edge of the anterior flange of the femoral knee component.
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Type I fractures are proximal to the femoral component. These fractures usually are amenable to management with an antegrade or retrograde intramedullary nail (if the femoral component has an open box to facilitate nail placement), although sometimes a fixed-angle device may be necessary. Type II fractures originate at the proximal end of the component and extend proximally. They likely require management with either a fixed-angle device or retrograde supracondylar nail (only if the femoral box is open). In type III fractures, any part of the fracture line is distal to the upper edge of the component’s anterior flange. These fractures may be managed with either a fixed-angle device (if the segment of bone remaining can accommodate fixation) or revision arthroplasty with a stemmed femoral component, possibly in combination with a distal femoral allograft. If there is loosening of the femoral component, then revision arthroplasty with a stemmed component may be required, regardless of the fracture location. Doing so may be controversial, however, as some surgeons might favor management of the fracture first, with revision of the components later to decrease the amount of bone loss and avoid the necessity of using a large distal femoral allograft. Of course, the plan devised preoperatively may change during surgery. Even when a component does not appear to be loose on preoperative radiographs, the surgeon still should be prepared to revise the component if loosening is discovered during surgery.
Devices such as the locking condylar plate can be inserted through a relatively small incision with the screws placed percutaneously. Doing so provides rigidity and minimizes soft-tissue stripping. Disadvantages include an increased risk of neurovascular injury with a blind approach and lack of visualization of the fracture for reduction.
With significant comminution requiring open reduction, the addition of bone graft may promote faster fracture healing. It is unclear whether bone grafting is of benefit with the use of a supracondylar nail or other fixation device that does not require exposure of the fracture.
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Summary
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Although displacement has been considered the major factor in determining nonsurgical or surgical management for supracondylar femoral fractures proximal to a total knee arthroplasty, sufficient evidence now supports surgical management in most cases. Nonsurgical management should be avoided unless the patient is medically unfit to tolerate surgery. With careful preoperative planning, the surgeon can choose among a variety of appropriate treatments, depending on the intraoperative findings.
Preoperative planning is important to establish the types and dimensions of existing total knee components and whether they are stable or loose. The choice of implant may be guided by the amount of bone available for distal fixation. Intramedullary nails are usually the best treatment for more proximal fractures. A fixed-angle device may be used for fractures originating at the femoral knee component. Very distal fractures or fractures with implant loosening may require revision arthroplasty with a stemmed component and possibly a bulk allograft. The surgeon should be prepared for revision surgery if intraoperative findings are more severe than indicated by preoperative radiography.
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Footnotes
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None of the following authors or the departments with which they are affiliated has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Su, Dr. DeWal, and Dr. Di Cesare.
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References
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- Ritter MA, Faris PM, Keating EM: Anterior femoral notching and ipsilateral supracondylar femur fracture in total knee arthroplasty. J Arthroplasty 1988;3: 185–187.[Medline]
- Figgie MP, Goldberg VM, Figgie HE III, Sobel M: The results of treatment of supracondylar fracture above total knee arthroplasty. J Arthroplasty 1990;5:267–276.[Medline]
- Merkel KD, Johnson EW Jr: Supracondylar fracture of the femur after total knee arthroplasty. J Bone Joint Surg Am 1986;68:29–43.[Abstract/Free Full Text]
- Sisto DJ, Lachiewicz PF, Insall JN: Treatment of supracondylar fractures following prosthetic arthroplasty of the knee. Clin Orthop 1985;196:265–272.
- Neer CS II, Grantham SA, Shelton ML: Supracondylar fracture of the adult femur: A study of one hundred and ten cases. J Bone Joint Surg Am 1967;49: 591–613.[Abstract/Free Full Text]
- Culp RW, Schmidt RG, Hanks G, Mak A, Esterhai JL Jr, Heppenstall RB: Supracondylar fracture of the femur following prosthetic knee arthroplasty. Clin Orthop 1987;222:212–222.
- Chen F, Mont MA, Bachner RS: Management of ipsilateral supracondylar femur fractures following total knee arthroplasty. J Arthroplasty 1994;9:521–526.[Medline]
- Healy WL, Siliski JM, Incavo SJ: Operative treatment of distal femoral fractures proximal to total knee replacements. J Bone Joint Surg Am 1993;75: 27–34.[Abstract/Free Full Text]
- Cain PR, Rubash HE, Wissinger HA, McClain EJ: Periprosthetic femoral fractures following total knee arthroplasty. Clin Orthop 1986;208:205–214.
- Bogoch E, Hastings D, Gross A, Gschwend N: Supracondylar fractures of the femur adjacent to resurfacing and MacIntosh arthroplasties of the knee in patients with rheumatoid arthritis. Clin Orthop 1988;229:213–220.
- Lesh ML, Schneider DJ, Deol G, Davis B, Jacobs CR, Pellegrini VD Jr: The consequences of anterior femoral notching in total knee arthroplasty: A biomechanical study. J Bone Joint Surg Am 2000;82:1096–1101.[Abstract/Free Full Text]
- DiGioia AM III, Rubash HE: Periprosthetic fractures of the femur after total knee arthroplasty: A literature review and treatment algorithm. Clin Orthop 1991;271:135–142.
- Rorabeck CH, Taylor JW: Classification of periprosthetic fractures complicating total knee arthroplasty. Orthop Clin North Am 1999;30:209–214.[ISI][Medline]
- Lewis PL, Rorabeck CH: Periprosthetic fractures, in Engh GA, Rorabeck CH (eds): Revision Total Knee Arthroplasty. Baltimore, MD: Williams & Wilkins, 1997, pp 275–295.
- Rorabeck CH, Taylor JW: Periprosthetic fractures of the femur complicating total knee arthroplasty. Orthop Clin North Am 1999;30:265–277.[ISI][Medline]
- Danziger MB, Caucci D, Zecher SB, Segal D, Covall DJ: Treatment of inter-condylar and supracondylar distal femur fractures using the GSH supracondylar nail. Am J Orthop 1995;24:684–690.[Medline]
- Kraay MJ, Goldberg VM, Figgie MP, Figgie HE III: Distal femoral replacement with allograft/prosthetic reconstruction for treatment of supracondylar fractures in patients with total knee arthroplasty. J Arthroplasty 1992;7:7–16.[Medline]
- Cordeiro EN, Costa RC, Carazzato JG, Silva J dos S: Periprosthetic fractures in patients with total knee arthroplasties. Clin Orthop 1990;252:182–189.
- Cusick RP, Lucas GL, McQueen DA, Graber CD: Construct stiffness of different fixation methods for supracondylar femoral fractures above total knee prostheses. Am J Orthop 2000;29:695–699.[Medline]
- Zehntner MK, Ganz R: Internal fixation of supracondylar fractures after condylar total knee arthroplasty. Clin Orthop 1993;293:219–224.
- Ochsner PE, Pfister A: Use of the fork plate for internal fixation of periprosthetic fractures and osteotomies in connection with total knee replacement. Orthopedics 1999;22:517–521.[ISI][Medline]
- Marti A, Fankhauser C, Frenk A, Cordey J, Gasser B: Biomechanical evaluation of the less invasive stabilization system for the internal fixation of distal femur fractures. J Orthop Trauma 2001;15:482–487.[ISI][Medline]
- McLaren AC, Dupont JA, Schroeber DC: Open reduction internal fixation of supracondylar fractures above total knee arthroplasties using the intramedullary supracondylar rod. Clin Orthop 1994;302:194–198.
- Maniar RN, Umlas ME, Rodriguez JA, Ranawat CS: Supracondylar femoral fracture above a PFC posterior cruciate-substituting total knee arthroplasty treated with supracondylar nailing: A unique technical problem. J Arthroplasty 1996;11:637–639.[ISI][Medline]
- Sekel R, Newman AS: Supracondylar fractures above a total knee arthroplasty: A novel use of the Huckstepp nail. J Arthroplasty 1994;9:445–447.[Medline]
- Roscoe MW, Goodman SB, Schatzker J: Supracondylar fracture of the femur after GUEPAR total knee arthroplasty: A new treatment method. Clin Orthop 1989;241:221–223.
- Oxborrow NJ, Stone MH: A new method of treatment for periprosthetic supracondylar fractures of the femur for prostheses with a stemmed femoral component. J Arthroplasty 1997;12:596–597.[ISI][Medline]
- Hanks GA, Mathews HH, Routson GW, Loughran TP: Supracondylar fracture of the femur following total knee arthroplasty. J Arthroplasty 1989;4:289–292.[Medline]
- Ritter MA, Keating EM, Faris PM, Meding JB: Rush rod fixation of supracondylar fractures above total knee arthroplasties. J Arthroplasty 1995;10:213–216.[ISI][Medline]
- Tani Y, Inoue K, Kaneko H, Nishioka J, Hukuda S: Intramedullary fibular graft for supracondylar fracture of the femur following total knee arthroplasty. Arch Orthop Trauma Surg 1998;117:103–104.
- Wang J-W, Wang CJ: Supracondylar fractures of the femur above total knee arthroplasties with cortical allograft struts. J Arthroplasty 2002;17:365–372.[ISI][Medline]
- Nielsen BF, Petersen VS, Varmarken JE: Fracture of the femur after knee arthroplasty. Acta Orthop Scand 1988;59:155–157.[ISI][Medline]
- Smith WJ, Martin SL, Mabrey JD: Use of a supracondylar nail for treatment of a supracondylar fracture of the femur following total knee arthroplasty. J Arthroplasty 1996;11:210–213.[ISI][Medline]
- Murrell GA, Nunley JA: Interlocked supracondylar intramedullary nails for supracondylar fractures after total knee arthroplasty: A new treatment method. J Arthroplasty 1995;10:37–42.[Medline]
- Short WH, Hootnick DR, Murray DG: Ipsilateral supracondylar femur fractures following knee arthroplasty. Clin Orthop 1981;158:111–116.
- Jabczenski FF, Crawford M: Retrograde intramedullary nailing of supracondylar femur fractures above total knee arthroplasty: A preliminary report of four cases. J Arthroplasty 1995;10:95–101.[Medline]
- Weber D, Pomeroy DL, Schaper LA, et al: Supracondylar nailing of distal periprosthetic femoral fractures. Int Orthop 2000;24:33–35.[ISI][Medline]
- Sochart DH, Hardinge K: Nonsurgical management of supracondylar fracture above total knee arthroplasty: Still the nineties option. J Arthroplasty 1997;12: 830–834.[ISI][Medline]
- Hirsh DM, Bhalla S, Roffman M: Supracondylar fracture of the femur following total knee replacement: Report of four cases. J Bone Joint Surg Am 1981;63: 162–163.[Free Full Text]
- Rolston LR, Christ DJ, Halpern A, O’Connor PL, Ryan TG, Uggen WM: Treatment of supracondylar fractures of the femur proximal to a total knee arthroplasty: A report of four cases. J Bone Joint Surg Am 1995;77:925–931.
- Al-Shawi AK, Smith SP, Anderson GH: The use of a carbon fiber plate for periprosthetic supracondylar femoral fractures. J Arthroplasty 2002;17:320–324.[ISI][Medline]
- Moran MC, Brick GW, Sledge CB, Dysart SH, Chien EP: Supracondylar femoral fracture following total knee arthroplasty. Clin Orthop 1996;324:196–209.
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Abstract
Risk Factors
