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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00825-3
10.1016/j.ijscr.2024.110044
110044
Case Report
A case of recurrent proximal femoral fracture after open reduction and internal fixation with bilateral locking plates for a Rorabeck type II periprosthetic fracture
Li Xiaobing
Xu Wenhe xuwenhe2023@163.com
⁎
Yin Yongqiang
Zhang Xu
Xiong Zhizheng
Yang Yuanqing
Department of Joint Surgery, Yueyang People 's Hospital, Hunan Normal University, No.263 Baling East Road, Yueyang 414000, Hunan, China
⁎ Corresponding author at: Orthopaedics, Yueyang People 's Hospital Affiliated to University of South China, China. xuwenhe2023@163.com
22 7 2024
10 2024
22 7 2024
123 11004423 5 2024
10 7 2024
12 7 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Periprosthetic distal femur fractures (PDFFs) are rare complications that may occur during or after total knee arthroplasty (TKA). The incidence of PDFFs is increasing. Plate internal fixation has demonstrated positive results. However, there is limited research available on the recurrence of periimplant fractures following open reduction and internal fixation with bilateral locking plates.

Case presentation

A 70-year-old female patient was diagnosed with a Rorabeck type II fracture. Based on the patient's physical condition and available surgical options, minimally invasive open reduction, bilateral plate fixation, and allograft artificial bone grafting were chosen. The postoperative recovery was successful. However, the patient experienced a fall 2 months after the surgery, resulting in a proximal femoral fracture. After considering the patient's condition and family preferences, conservative treatment was ultimately decided upon.

Clinical discussion

Minimally invasive bilateral Locking Compression Plate (LCP) as a surgical approach can effectively reduce surgical risks prior to the procedure. Careful selection of screws and the use of C-arm fluoroscopy during plate contouring and fixation are essential to prevent screw penetration through the contralateral cortex. Treatment outcomes were not impacted in patients with normal bone mass; however, in this particular case, the patient had severe osteoporosis, significantly increasing the risk of refracture. It is crucial to improve postoperative monitoring and raise awareness about safety among patients and their families.

Conclusion

The management of periprosthetic distal femur fractures (PDFFs) is influenced by the type of fracture and bone quality. Mechanical stability and stress dispersion of internal fixation are key factors to consider. In the perioperative setting, involving experienced clinicians is essential to reduce the risk of secondary injuries that may impact treatment outcomes, especially when choosing screws for fixation in patients with low bone density.

Highlights

• Periprosthetic distal femoral fractures (PDFFs) after total knee arthroplasty (TKA) have recurred within 2 months after minimally invasive open reduction and bilateral locking plate internal fixation.

Keywords

Rorbeck type II
Total knee replacement
Periprosthetic distal femur fracture
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pmc1 Introduction

Periprosthetic fractures (PPF) are a known complication during and after total knee arthroplasty (TKA), with an overall incidence ranging from 0.3 % to 2.5 % [1]. Rorabeck type II fractures in PPFs account for 87 % of cases, with risk factors including age, BMI, low bone mass, and trauma [2]. As the population ages and the number of TKAs increases, the incidence of PPF is expected to rise annually, making its treatment a pressing issue for the future. Current treatment options include conservative and surgical approaches. Surgical intervention is recommended for patients with displaced fractures who can tolerate anesthesia and do not have loosening of the prosthesis to avoid complications associated with conservative management [4]. Common surgical techniques involve open reduction and internal fixation using steel plates, femoral intramedullary nails, distal femoral prosthesis replacement, and revision surgery. Steel plate internal fixation and intramedullary nails are widely accepted as the gold standard in clinical practice [5]. However, there is limited literature on the management of recurrent periimplant fractures following open reduction and bilateral locking plate internal fixation, highlighting the need for reflection on surgical procedures and potential issues. This paper aims to evaluate the effectiveness of open reduction and bilateral locking plate internal fixation in treating Rorabeck type II periprosthetic knee fractures, shedding light on the causes of postoperative recurrent fractures. By presenting specific cases of recurrent PPF managed with this approach, the study aims to provide valuable insights to the medical community for improved clinical practice.

2 Method

The work has been reported in line with the SCARE criteria. [6].

3 Case presentation

A 70-year-old retired female presented with a right periprosthetic femoral fracture and was diagnosed with Rorabeck type II following a high-energy injury from a car accident, according to Lewis and Rorabeck et al.'s classification of single after trauma [7] (Fig. 2). The patient, who had severe osteoporosis and multiple underlying diseases(Fig. 1), underwent minimally invasive open reduction, bilateral plate internal fixation, and allogeneic artificial bone graft based on her physical condition and current evidence. The femoral prosthesis remained stable without any signs of loosening during the operation. A bone defect was observed at the fracture site, leading to the performance of minimally invasive incision bilateral plate internal fixation after removal of the hematoma and excess bone block (Fig. 3, Fig. 4). Antibiotics and wound drainage were discontinued 3 days post-surgery, followed by routine wound disinfection and guidance on active and passive knee rehabilitation exercises. Postoperative reexamination of X-ray and CT results are shown in Fig. 5, Fig. 6. By the 7th day after surgery, active knee flexion reached 45° and passive flexion reached 55°; by the 17th day (discharge), active flexion was at 60° and passive at 75°(Fig. 7). The patient refrained from bearing weight on the affected leg post-surgery until a recurrent fracture occurred. Following a fall 2 months after surgery resulting in a recurrent proximal femoral fracture(Fig. 8), conservative treatment was chosen based on the patient's condition and family preferences.Fig. 1 Patient bone density.

Fig. 1

Fig. 2 bone density and preoperative X-rays and CT.

Fig. 2

Fig. 3 (A) Fracture showed fracture displacement but prosthesis did not loosen (lateral); (B) Intraoperative reduction and fixation.

Fig. 3

Fig. 4 (A)Intraoperative distal medial. (B) Intraoperative distal lateral.

Fig. 4

Fig. 5 (A) intraoperative proximal fluoroscopy. (B) intraoperative distal fluoroscopy. (C) postoperative appearance.

Fig. 5

Fig. 6 Cortical destruction proximal to instrumentation on postoperative CT.

Fig. 6

Fig. 7 Postoperative knee range of motion.

Fig. 7

Fig. 8 Recurrent periprosthetic fracture X-ray.

Fig. 8

4 Discussion

Femoral supracondylar periprosthetic fractures typically affect the elderly population and are commonly seen following osteoporosis and minor traumatic events. Risk factors for these fractures include gender, rheumatoid arthritis, long-term steroid use, neurological conditions, recurrent falls, intraoperative anterior femoral notch, and revision arthroplasty [8]. However, bone loss is considered a more significant contributing factor [9]. There are different types of these fractures, with stable undisplaced fractures often managed conservatively through plaster external fixation and prolonged immobilization to minimize perioperative risks and complications [10]. Nevertheless, studies have shown that nonunion can occur in 12 % to 40 % of patients undergoing conservative treatment, with reoperation needed in 15 % to 30 % of cases. Additionally, some stable fractures may progress to unstable fractures during conservative management [11]. Complications such as venous thromboembolism, hypostatic pneumonia, and pressure ulcers due to prolonged immobilization can be severe. Therefore, surgical intervention is frequently favored as the primary treatment option in clinical practice.

Currently, the more established and clinically applied surgical methods for treating periprosthetic distal femoral fractures include open reduction and internal fixation (ORIF), external fixation, antegrade or retrograde intramedullary nail fixation, locking plate internal fixation, and distal femoral replacement. Shin YS et al. found that the clinical outcomes, such as nonunion and revision rates, were comparable between locking compression plate and retrograde intramedullary nail fixation [12]. Ebraheim NA et al. reported a 35 % complication rate with locking plates and a 53 % complication rate with intramedullary nails in a systematic review, with similar union rates [13]. Park YG et al. concluded that minimally invasive plate osteosynthesis (MIPO) with double locking compression plates is a dependable method for stabilizing periprosthetic distal femoral fractures after total knee arthroplasty, yielding satisfactory results and low complication rates [14]. Rita Moukarzel et al. suggested using intramedullary allograft support along with bilateral locking plates as a practical alternative for treating these complex fractures, enhancing stability through intramedullary fibular strut allografts supplemented by bilateral plate insertion [15]. While the effectiveness of these treatment approaches has been preliminarily validated and is increasingly widespread, their efficacy and complication rates remain subject to debate regardless of the chosen surgical technique [16]. Nevertheless, the guiding principle for all surgical modalities should prioritize restoring lower limb alignment, rotation, and fracture stability, enabling early mobilization and functional recovery, and promoting straightforward fracture healing. Key considerations include reconstructing appropriate bone stock, ensuring mechanical stability of the prosthesis, and minimizing stress to ensure successful treatment [17].

The patient's initial fracture was caused by a high-energy impact when struck directly on the right knee by an oncoming motorcycle while traveling in a wheelchair. Following relevant examinations and assessment of clinical symptoms, a diagnosis of Rorabeck type II periprosthetic knee fracture was determined. Although the femoral component remained stable despite bony defects, revision surgery was not deemed necessary. Due to the eccentric forces acting on the distal femur, compressive stresses are predominantly concentrated on the medial side, while the lateral cortex experiences both compressive and tensile stresses. Typically, internal fixation plates used for distal femoral fractures are positioned laterally in clinical practice, functioning as tension band plates [18]. However, unilateral plate fixation may not uniformly distribute stresses, particularly in patients with bone defects and low bone mineral density, leading to an increased risk of fixation failure [19]. As a result, some experts suggest dual plate fixation for distal femoral fractures lacking support from the medial cortex. Alongside the standard lateral plate placement, a smaller plate is recommended to be positioned medially on the distal femur to enhance mechanical stability [20].

The authors concluded that bilateral minimally invasive LCP and retrograde intramedullary nailing are viable options for Rorabeck II patients post TKA, with LCP showing slightly better outcomes based on available clinical comparisons. Preoperative risks were minimized, but bone defects were discovered during the procedure after removing the fracture hematoma and reducing the fracture. The plate was then contoured and positioned with a synthetic bone graft, but fixation errors led to proximal screws penetrating the contralateral cortex. While the authors noted that this oversight may not impact patients with normal bone density, the patient in this case had severe osteoporosis, increasing the risk of refracture. Postoperatively, the patient received treatment for underlying conditions, anti-infective measures, and rehabilitation. Despite reaching a knee flexion and extension range of 0–75° with a knee brace, the patient was discharged after basic daily activities. Unfortunately, the fracture recurred at the internal fixation site two months later due to a fall. With severe coronary atherosclerotic heart disease, Killip class III heart function, and renal anemia, the patient could not undergo reoperation and opted for conservative treatment.

For Rorabeck type II, minimally invasive bilateral LCP surgery should adhere to specific principles related to the plate span and screw density. The plate length should be at least 2 to 3 times greater than the fracture line. The ratio of screws placed to total screw holes in the plate should not exceed 0.5 to 0.4. The proximal plate should be positioned in the lateral midline of the femur, while the distal plate should be located in the anteromedial third of the lateral aspect of the femoral condyle. Screws should be parallel to the articular surface and unicortical screws are recommended for areas with good cortical bone quality. It appears in this case that there were issues with an excessively long lateral plate and incorrect screw usage.

5 Conclusion

Treatment of periprosthetic distal femur fractures (PDFFs) post TKA is challenging. Minimally invasive bilateral LCP should not be chosen blindly and must be tailored to individual patient factors such as knee prosthesis type, fracture classification, and overall physical condition. Adherence to strict surgical principles is crucial when performing minimally invasive bilateral LCP, and further research is needed to assess the efficacy of this approach compared to retrograde intramedullary nails for complex Rorabeck type II fractures. Retrograde intramedullary nailing may yield favorable outcomes in such cases.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Ethical approval

This case report has been exempt from ethical approval.

Reason for exemption: This report is a retrospective study and does not involve any new intervention or experiment in humans and only describes the medical events and treatment processes that have occurred and do not pose additional risks to patients.

Institution Name: Ethics Committee, Yueyang People 's Hospital, Hunan, China

Funding

No external funding was received for this study.

The study sponsor was involved in the collection, analysis and interpretation of part of the data, writing of the manuscript, and submission of the manuscript for publication.

Author contribution

Xiaobing Li (First Author): Conceptualization, Writing - original draft, Writing - review & editing.

Wenhe Xu (Corresponding Author and Guarantor): Supervision.

Yongqiang Yin: Writing - review & editing.

Xu Zhang: Writing - review & editing.

Zhizheng Xiong: Writing - review & editing.

Yuanqing Yang: Writing - review & editing.

Guarantor

Wenhe Xu (Corresponding Author and Guarantor)

Research registration number

1. Name of the registry: A case of recurrent proximal femoral fracture after open reduction and internal fixation with bilateral locking plates for a Rorabeck type II periprosthetic fracture

2. Unique identifying number or registration ID: reviewregistry1825

3. Hyperlink to your specific registration (must be publicly accessible and will be checked):

https://researchregistry.knack.com/research-registry#registryofsystematicreviewsmeta-analyses/?view_13_search=reviewregistry1825&view_13_page=1

Conflict of interest statement

No conflict of interest to declare.

Acknowledgments

None.
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