Merkel K D, Johnson E W
J Bone Joint Surg Am. 1986 Jan;68(1):29-43.
We reviewed the data on thirty-six supracondylar fractures of the femur (in thirty-four patients) that occurred after total knee arthroplasties that were done between April 1974 and December 1981. Patients who had osteoporosis, rheumatoid arthritis, one or more previous arthroplasties of the knee, or inadvertent breeching of the anterior aspect of the femoral cortex at operation appeared to be particularly at risk for a supracondylar femoral fracture. Malalignment of the component could not be implicated as a cause. Twenty-six fractures (in twenty-five patients) were treated by non-operative methods. Seventeen of them (65.4 per cent) healed and required no surgical treatment. Fourteen of the seventeen were followed for more than two years; they had no significant difference in the knee score and lost less than 10 degrees of motion. The nine remaining knees required revision of the arthroplasty because of non-union in four knees, malunion in two, loosening of the component in two, and extension lag in one. At an average of forty months after revision, the nine knees were rated as having one excellent, four good, three satisfactory, and one failed result. In contrast, only three of the five fractures that were treated by early open reduction and internal fixation had a satisfactory result, and one of them required a second bone-grafting procedure. One patient died perioperatively and another required an above-the-knee amputation because of sepsis. Of the three fractures that were initially treated by external fixation, one had an excellent and two had a good result at an average of forty-five months after fracture. We have found that supracondylar fractures that occur after total knee arthroplasty can be managed by either traction or application of a cast, or both, which usually results in healing of the fracture and a satisfactory outcome of the arthroplasty. Patients who have a poor arthroplasty result after non-operative treatment of the fracture usually can undergo a revision arthroplasty with the expectation of a satisfactory outcome. Operative treatment of the fracture should be reserved for patients who do not have osteopenia and in whom stable fixation can be achieved, for those who demand a highly functional arthroplasty, and for those in whom adequate closed reduction cannot be maintained.
我们回顾了1974年4月至1981年12月期间全膝关节置换术后发生的36例股骨髁上骨折（34例患者）的数据。患有骨质疏松症、类风湿性关节炎、既往有一次或多次膝关节置换术，或手术中意外穿破股骨皮质前方的患者，似乎特别容易发生股骨髁上骨折。假体排列不齐不能被认为是病因。26例骨折（25例患者）采用非手术方法治疗。其中17例（65.4%）愈合，无需手术治疗。17例中有14例随访超过两年；他们的膝关节评分无显著差异，活动度丧失小于10度。其余9例膝关节因4例不愈合、2例畸形愈合、2例假体松动和1例伸直延迟而需要翻修关节置换术。翻修术后平均40个月，9例膝关节的评定结果为1例优秀、4例良好、3例满意和1例失败。相比之下，早期切开复位内固定治疗的5例骨折中只有3例结果满意，其中1例需要再次植骨手术。1例患者围手术期死亡，另1例因败血症需要行膝上截肢术。最初采用外固定治疗的3例骨折中，1例结果优秀，2例在骨折后平均45个月时结果良好。我们发现，全膝关节置换术后发生的股骨髁上骨折可以通过牵引或石膏固定，或两者结合来处理，这通常会使骨折愈合，并使关节置换术取得满意的结果。骨折非手术治疗后关节置换术结果不佳的患者通常可以接受翻修关节置换术，预期会有满意的结果。骨折的手术治疗应保留给没有骨质减少且能够实现稳定固定的患者、那些要求关节置换术具有高度功能的患者，以及那些无法维持充分闭合复位的患者。
