Intraoperative Proximal Tibia Periprosthetic Fractures in Primary Total Knee Arthroplasty

Abstract

Intraoperative fracture of the proximal tibia is a rare complication of total knee arthroplasty (TKA) with few studies available reporting risk factors or prognosis. A review of our prospective joint registry was performed to determine the incidence and associated risk factors of intraoperative tibia fractures during primary TKA; 14,966 TKAs of all manufacturers were performed with 9 intraoperative tibia fractures. All fractures occurred in a single TKA design. There were 8,155 TKAs of this design performed with a fracture incidence of 0.110%. All but one fracture occurred on the medial tibial plateau, and all but one occurred during preparation of the tibia with keel punching. A control group of 75 patients (80 knees) with the same TKA design were randomly selected. Baseplates size 3 or smaller were less likely to experience an intraoperative fracture (odds ratio [OR]: 0.864, 95% confidence interval [CI]: 0.785–0.951), as were knees with a polyethylene insert thickness of 13 mm or larger (OR: 0.882, 95% CI: 0.812–0.957). Fractures were treated with a variety of different methods, but every patient had at least one screw placed and most (67%) had postoperative weight-bearing restrictions. At final follow-up, there were no cases of nonunion, component subsidence, or need for reoperation. Intraoperative tibia fractures are a rare complication of this TKA design at 0.11%. Knees with baseplates of size ≤3 and polyethylene thickness ≥13 mm were less likely to experience intraoperative fracture. These findings may be related to the depth of tibial resection, requiring the use of a thicker polyethylene insert, and a change in the keel width in implants size 4 or larger. No fracture patients required reoperation.

Intraoperative Fractures of the Tibia and Femur in Knee Revision Surgery

“…Most post-operative traumatic peri-prosthetic fractures involve the femur 22 . Intra-operative fractures in primary arthroplasty are mostly of metaphyseal origin and most frequently affect the metaphyseal femur 4 , 7 , 23 . In contrast, fractures during revision arthroplasty occur more frequently on the tibial side and most frequently on the diaphyseal side 11 , 21 .…”

“…Die meisten postoperativen traumatischen periprothetischen Frakturen betreffen das Femur 22 . Die intraoperativen Frakturen in der Primärendoprothetik sind meist metaphysär lokalisiert und betreffen ebenfalls am häufigsten das metaphysäre Femur 4 , 7 , 23 . Demgegenüber treten Frakturen in der Revisionsendoprothetik häufiger tibialseitig auf und dabei am häufigsten diaphysär 11 , 21 .…”

Diagnosis and Management of Intraoperative Periprosthetic Fractures in Primary Total Knee Arthroplasty

“…13 Tibia Tibial baseplates with greater keel size relative to their medial-lateral size increases risk for plateau fracture. 5,14 This may be attributed to the increased proximity of the keel cut to the cortex. 14 Damsgaard et al 14 reported that utilization of larger thickness polyethylene ($13 mm) from deeper tibial resection was associated with a decreased fracture risk.…”

“…5,14 This may be attributed to the increased proximity of the keel cut to the cortex. 14 Damsgaard et al 14 reported that utilization of larger thickness polyethylene ($13 mm) from deeper tibial resection was associated with a decreased fracture risk. The authors suggested that thicker tibial resection removed weaker, sclerotic subchondral bone and allowed the tibial baseplate to rest on a stronger metaphyseal undersurface.…”

Current Reconstruction Options in Periprosthetic Fractures Around the Knee

“…If the fracture is recognized and treated correctly intra-operatively, there is no difference in post-operative rehabilitation compared to a normal primary or revision knee replacement. 6 , 33 , 40 , 41 In case of unstable type IC fractures, a secure option may be screw fixation and implant of a long-stemmed tibial component that bridges the fracture engaging the distal diaphysis and enhances fixation. In case of type IIC, a long-stemmed tibial component can be used while bone grafting the fracture site.…”