This article presents a case of femoral corrective osteotomy for malunited supracondylar femoral fracture after total knee arthroplasty (TKA) in a patient with rheumatoid arthritis. The patient underwent 1-stage bilateral TKA and 2-stage bilateral total hip arthroplasty 17 years prior at our institution. Her fall 10 years before led to a supracondylar femoral fracture that was treated nonoperatively for 3 months and led to malunion. Complaints of mild right knee pain and remarkable varus deformity were observed. On examination, the right knee was not swollen and tender. Range of motion (ROM) of the right knee was 0° to 130°. The patient needed crutches to ambulate. Knee score and function scores, according to the Knee Society clinical rating system, were 65 and 25 points, respectively. Radiographs after malunion showed remarkable varus knee and the femorotibial angle was 197·. At the time of surgery, the components were stable and bone union was completed. Valgus corrective osteotomy of the femur was performed using a retrograde intramedullary nail, with satisfactory results at 10-year follow-up. The patient is able to walk without a cane and has 0° to 130° ROM. Knee and function scores were 88 and 80 points, respectively. Radiographs showed complete bone union and the femorotibial angle was 179· with no loosening of the prostheses. Femoral corrective osteotomy is recommended for malunited supracondylar femoral fracture after TKA.
Periprosthetic fractures of the supracondylar femur and proximal tibia after total knee arthroplasty (TKA) can be the most difficult complication to effectively manage. The treatment method depends on factors such as the stability of implant fixation, location of the fracture, quality of the bone, and presence or absence of an open-box femoral component. This article presents a case of femoral corrective osteotomy for malunited supracondylar femoral fracture after TKA in a patient with rheumatoid arthritis.
A 73-year-old woman was diagnosed with rheumatoid arthritis 27 years ago and took methotrexate 6 mg/week. Gradually, increasing pain in both knees and both hips made walking difficult (Figure 1). The patient underwent 1-stage bilateral TKA and 2-stage bilateral total hip arthroplasty (THA) 17 years before. Total knee arthroplasty was performed using the AXIOM system (Wright Medical Technology Inc, Arlington, Tennessee), which is a cruciate retaining prosthesis with an open femoral intercondylar box. Weight-bearing anteroposterior (AP) and lateral radiographs and the femorotibial angle were examined. Radiographs of the right knee showed correct alignment (femorotibial angle, 175·) and no loosening (Figure 2).
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|Figure 1: Preoperative lateral (A) and AP (B) radiographs of the right knee. Marked bony destruction was observed. |
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|Figure 2: Lateral (A) and AP (B) radiographs of the right knee 7 years after TKA. The component fixation was stable, and the femorotibial angle was 175°. |
The patient’s fall 10 years before led to a supracondylar femoral fracture that was treated nonoperatively for 3 months and led to malunion. She presented with right knee deformity with walking disturbance.
On examination, the right knee was not swollen and tender. Range of motion (ROM) of the right knee was 0° to 130°. Mild right knee pain and remarkable varus deformity were observed. The patient needed crutches to ambulate. The knee score and function scores according to the Knee Society clinical rating system1 were 65 and 25 points, respectively. Radiographs after malunion showed remarkable varus knee and the femorotibial angle was 197° (Figure 3).
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|Figure 3: Lateral (A) and AP (B) radiographs of the right knee. Supracondylar femoral fracture was completely malunited. Remarkable varus knee was observed and femorotibial angle was 197°. |
The patient underwent surgery for femoral corrective osteotomy. Intraoperatively, the previous skin incision was extended and a medial parapatellar approach was performed to check for component stability, bone union, and to expose the osteotomy site. Both tibial and femoral components were stable and supracondylar femoral fractures were completely malunited. One-third of the distal femur was landmarked in a wedge shape to obtain 22°, and osteotomized with a bone saw. The osteotomized part was fixed with a Huckstep retrograde nail (Smith & Nephew, Memphis, Tennessee). A short femoral nail was used because the patient previously underwent THA. The osteotomized part was grafted with autologous bone grafts from the iliac bone. Postoperative raediographs showed correct alignment and the femorotibial angle was 179°.
At closure, the osteotomized part attained a good stability, with a ROM of 0° to 130·. Range of motion exercises were initiated on the next postoperative day. The patient was advised to remain nonweight bearing for the first 3 weeks, and then partial weight bearing for the next 3 weeks. At 4-month follow-up, the patient was fully mobile using a cane, with a ROM of 0° to 130°.
Ten years postoperatively, the patient is able to walk without a cane and has a ROM of 0° to 130°. The knee and function scores were 88 and 80 points, respectively. Radiographs showed complete bone union and correct alignment (femorotibial angle, 179°) with no loosening of the prostheses (Figure 4).
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|Figure 4: Lateral (A) and AP (B) radiographs of the right knee 10 years postoperatively. The component fixation was stable, and the femorotibial angle was 179°. |
Many cases have been reported in the literature about supracondylar femoral fractures after TKA. The incidence of these fractures was reported at approximately 0.54% to 1.7%.2-4 Recently, some reports have been published about these fractures after computer-assisted TKA.5 The fracture line extended from previous anchoring pinholes into the supracondylar area. Possible complications of pinhole-oriented fracture with a navigation system should be kept in mind.
Recently, fixation of supracondylar femoral fracture after TKA with a locking plate, buttress plate or condylar blade plate has provided satisfactory results.6-8 Kumar et al7 recommended the use of intramedullary fibular allograft and buttress plate fixation. Kolb et al8 suggested the good long-term results of the condylar blade plate in the indirect reduction technique.
However, some reports suggest the good outcome with retrograde intramedullary supracondylar nailing.9,10 Chettiar et al10 reviewed a large series of 14 cases and reported a good functional outcome, low complication rates, and 100% fracture union.
Some studies exist that evaluate the outcome of open reduction internal fixation (ORIF) compared to retrograde intramedullary nailing.11,12 Large et al11 reported a lower incidence of complications, revisions, malunion, and nonunion with locked plating. However, Thomson et al12 suggested that the bone grafting rates and malunion were significantly higher with ORIF compared to retrograde intramedullary nailing.
Pap and Neumann13 reported that the presence of rheumatoid arthritis is associated with a high risk of periprosthetic fracture due to poor bone quality induced by steroid, multiple joint involvement with the replacement of different joints, and considerable comorbidity. Their management can be difficult and often requires an interdisciplinary approach. Delport et al2 showed the satisfactory results of conservative treatment of supracondylar femoral fracture after TKA.
In our patient, osteoporosis presented itself when induced by steroids, thus periprosthetic femoral fracture occurred with minor trauma. Consequently, the patient was treated conservatively for 3 months, leading to malunion.
Occasionally, supracondylar femoral fracture after TKA can lead to malunion, possibly resulting in abnormal force transmission and accelerated wear of the prosthesis. Kendoff et al14 recommended femoral corrective osteotomy with computer-assisted navigation. However, some reports exist about the complications of pinhole-oriented fracture after computer-assisted navigation. Therefore, we chose femoral corrective osteotomy without computer navigation.
In our patient, both tibial and femoral components were stable and the femoral component was of an open-box type. We selected retrograde intramedullary nailing at the time of surgery. Our patient obtained satisfactory alignment and fracture union.
- Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989; (248):13-14.
- Delport PH, Van Audekercke R, Martens M, Mulier JC. Conservative treatment of ipsilateral supracondylar femoral fracture after total knee arthroplasty. J Trauma. 1984; 24(9):846-849.
- Webster DA, Murray DG. Complications of variable axis total knee arthroplasty. Clin Orthop Relat Res. 1985; (193):160-167.
- Merkel KD, Johnson EW Jr. Supracondylar fracture of the femur after total knee arthroplasty. J Bone Joint Surg Am. 1986; 68(1):29-43.
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- Ricci WM, Loftus T, Cox C, Borrelli J. Locked plates combined with minimally invasive insertion technique for the treatment of periprosthetic supracondylar femur fractures above a total knee arthroplasty. J Orthop Trauma. 2006; 20(3):190-196.
- Kumar A, Chambers I, Maistrelli G, Wong P. Management of periprosthetic fracture above total knee arthroplasty using intramedullary fibular allograft and plate fixation. J Arthroplasty. 2008; 23(4):554-558.
- Kolb K, Koller H, Lorenz I et al. Operative treatment of distal femoral fractures above total knee arthroplasty with the indirect reduction technique: a long-term follow-up study. Injury. 2009; 40(4):433-439.
- Pao JL, Jiang CC. Retrograde intramedullary nailing for nonunions of supracondylar femur fracture of osteoporotic bones. J Formos Med Assoc. 2005; 104(1):54-59.
- Chettiar K, Jackson MP, Brewin J, Dass D, Butler-Manuel PA. Supracondylar periprosthetic femoral fractures following total knee arthroplasty: treatment with a retrograde intramedullary nail. Int Orthop. 2009; 33(4):981-985.
- Large TM, Kellam JF, Bosse MJ, Sims SH, Althausen P, Masonis JL. Locked plating of supracondylar periprosthetic femur fractures. J Arthroplasty. 2008; 23(6):115-120.
- Thomson AB, Driver R, Kregor PJ, Obremskey WT. Long-term functional outcomes after intra-articular distal femure fracture: ORIF versus retrograde intramedullary nailing. Orthopedics. 2008; 31(8):748-750.
- Pap G, Neumann HW. Periprosthetic fractures in patients with rheumatoid arthritis. Z Rheumatol. 2007; 66(1):22-27.
- Kendoff DO, Fragomen AT, Pearle AD, Citak M, Rozbruch SR. Computer navigation and fixator-assisted femoral osteotomy for correction of malunion after periprosthetic femur fracture. J Arthroplasty. 2010; 25(2):13-19.
Drs Saito, Tokuhashi, Ishii, Mori, Hosaka, and Ishigami are from the Department of Orthopedic Surgery, Nihon University School of Medicine, Tokyo, Japan.
Drs Saito, Tokuhashi, Ishii, Mori, Hosaka, and Ishigami have no relevant financial relationships to disclose.
Correspondence should be addressed to: Shu Saito, MD, Department of Orthopedic Surgery, Nihon University School of Medicine, 30-1 Oyaguchi, Kami-machi, Itabashi-Ku, Tokyo 173-8610 Japan (firstname.lastname@example.org,jp).