Stancil Ryan, Romm Jacob, Lack William, Bohnenkamp Frank, Sems Stephen, Cross William, Cass Joseph, Keeney James, Nam Denis, Nunley Ryan, Fernando Navin, Sassoon Adam
Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington.
Division of Orthopaedic Surgery, OrthoIllinois, Algonquin, Illinois.
J Knee Surg. 2023 Jan;36(2):146-152. doi: 10.1055/s-0041-1731353. Epub 2021 Jun 29.
Periprosthetic fractures around a total knee arthroplasty (TKA), comminuted and intra-articular femur fractures, or fracture nonunions in osteoporotic bone represent technically challenging problems. This is particularly true when the fracture involves a loose femoral component or the pattern results in suboptimal fixation potential. These clinical indications often arise in an older and comorbid patient population in whom a principal goal of treatment includes allowing for early mobilization. Limited data indicate that arthroplasty via distal femoral replacement (DFR) is a reasonable alternative to open reduction and internal fixation, allowing for early ambulation with low complication rates. We performed a retrospective review of trauma and arthroplasty surgeries at three tertiary referral institutions. Adult patients treated for the above with a DFR were included. Patients with active infection, open and/or high-energy injuries and revisions unrelated to fracture were excluded. Patient demographics, treatment details, and outcomes were assessed. Between 2002 and 2017, 90 DFR's were performed for the above indications with a mean follow-up of 24 months. Postoperatively, 80 patients (88%) were allowed to weight bear as tolerated, and at final follow-up, 9 patients (10%) remained dependent on a wheelchair. The average arc of motion at final follow-up was 95 degrees. There were seven (8%) implant-related complications requiring secondary surgeries: two infections, one with associated component loosening; one fracture of the hinge mechanism and one femoral component failure in conjunction with a patellofemoral dislocation (both requiring revision); one case of patellofemoral arthrosis in a patient with an unresurfaced patella; one periprosthetic fracture with associated wound dehiscence; and one case of arthrofibrosis. In each of these cases, only modular components of the DFR were exchanged. All nonmodular components cemented into the femur or tibia were retained. DFR provides a viable reconstruction option in the treatment of acute distal femur fractures, periprosthetic femur fractures, and fracture nonunions. We noted that in an elderly patient population with high comorbidities, the complication and secondary surgery rates remained relatively low, while allowing for immediate weight bearing.
全膝关节置换术（TKA）周围的假体周围骨折、粉碎性和关节内股骨骨折，或骨质疏松性骨骨折不愈合，是技术上具有挑战性的问题。当骨折涉及松动的股骨部件或骨折类型导致固定潜力不理想时，情况尤其如此。这些临床指征常出现在老年和合并症患者群体中，治疗的主要目标之一是允许早期活动。有限的数据表明，通过股骨远端置换（DFR）进行关节成形术是切开复位内固定的合理替代方案，可实现早期行走且并发症发生率低。我们对三家三级转诊机构的创伤和关节成形术手术进行了回顾性研究。纳入接受DFR治疗上述疾病的成年患者。排除有活动性感染、开放性和/或高能损伤以及与骨折无关的翻修患者。评估患者的人口统计学特征、治疗细节和结果。2002年至2017年间，因上述指征进行了90例DFR手术，平均随访24个月。术后，80例患者（88%）可根据耐受情况负重，在最终随访时，9例患者（10%）仍依赖轮椅。最终随访时的平均活动弧度为95度。有7例（8%）与植入物相关的并发症需要二次手术：2例感染，其中1例伴有部件松动；1例铰链机制骨折，1例股骨部件失效合并髌股关节脱位（均需翻修）；1例未行髌骨表面置换患者发生髌股关节病；1例假体周围骨折伴伤口裂开；1例关节纤维化。在每种情况下，仅更换DFR的模块化部件。所有用骨水泥固定在股骨或胫骨中的非模块化部件均予以保留。DFR为治疗急性股骨远端骨折、假体周围股骨骨折和骨折不愈合提供了可行的重建选择。我们注意到，在合并症高的老年患者群体中，并发症和二次手术率相对较低，同时允许立即负重。
