Le Baron Marie, Cipolla Alessandra, Battut Thibaut, Bégué Thierry, Flecher Xavier, Ehlinger Matthieu
Service de Chirurgie orthopÉdique, Hôpital Nord, Pôle Locomoteur, Institut du Mouvement et de l'appareil Locomoteur, Assistance Publique-Hôpitaux de Marseille, Marseille, France.
Centre Hospitalier de Briançon, 24 Av. Adrien Daurelle, 05100 Briançon, France.
Orthop Traumatol Surg Res. 2025 Jul 1:104326. doi: 10.1016/j.otsr.2025.104326.
Periprosthetic fractures around the knee (TKAPF) often occur in old patients with concomitant diseases. Like any other fragility fracture, the aim of TKAPF management should be a patient-specific strategy considering clinical factors and associated comorbidities. The aim of the present study was to analyse if, in selected groups of unfit patients, osteosynthesis alone without revision even in cases of implant loosening (SOFCOT type 2 and 3) could be a good compromise to avoid invasive surgery and to reduce the mortality rate with reasonable results. The hypothesis was that for TKAPF SOFCOT type 2 and 3 there was no difference in survival rate between a group of patients treated by open reduction and internal fixation only compared to a group treated by revision of existing implant.
A total of 62 patients with a TKAPF and a loose implant classified as SOFCOT type 2 or 3 who have been surgical treated were included. The mean age of the population was 81.1 ± 10.3 years. Female rate was 92% (n = 57). The majority of patients had an ASA 2 or 3 score (n = 52, 83.9%). The pre-operative Parker score was 6.1 ± 2.5. Two groups were created to be compared in terms of results and complications: a group of 18 patients operated by open reduction and internal fixation (ORIF group) with a plate and a group of 44 patients operated by total knee arthroplasty revision (revision group) with or without plate osteosynthesis associated. Mortality and re-operations for mechanical complications were examined as the primary endpoint. Time to full weight-bearing (in weeks), time to bone union (in weeks) other complications such as infection and haematoma rate were collected as secondary endpoint.
The median duration of follow-up was 2 years. The re-revision rates were respectively 15,9% in revision group, 22,2% in ORIF group. No statistically significant differences were found between the groups for mechanical complications or re-revision. The survival endpoint at 2 years follow up was 88.9% (95% CI: 78.1-94.5) without differences between the groups (p = 0.64). Time to bone union was significantly longer (15.9 weeks) in the ORIF group compared to 8.6 weeks for the revision group but with a higher bone union rate in the ORIF group (p = 0.003) as well as the time to full weight-bearing (ORIF group 8.9 weeks compared to 1.7 weeks for the revision group P < 0.001). More infections were reported in the ORIF group and a higher risk of haematoma and bleeding in the revision group.
Despite longer time to bone union and time to full weight-bearing, open reduction and internal fixation with plate for TKAPF with a loose component in selected older and unfit patients does not increase the risk of re-operation or mortality compared to a more invasive revision arthroplasty strategy.
III, comparative retrospective study.
膝关节周围假体周围骨折（TKAPF）常发生于患有合并症的老年患者。与其他脆性骨折一样，TKAPF的治疗目标应是根据临床因素和相关合并症制定个体化策略。本研究的目的是分析在选定的不适合手术的患者组中，即使在植入物松动的情况下（SOFCOT 2型和3型），单纯骨固定而不进行翻修是否是避免侵入性手术并降低死亡率且能取得合理结果的良好折衷方案。假设是对于TKAPF的SOFCOT 2型和3型，单纯切开复位内固定治疗组与现有植入物翻修治疗组的生存率无差异。
共纳入62例接受手术治疗的TKAPF且植入物松动分类为SOFCOT 2型或3型的患者。患者的平均年龄为81.1±10.3岁。女性比例为92%（n = 57）。大多数患者的ASA评分为2或3分（n = 52，83.9%）。术前Parker评分为6.1±2.5。创建两组以比较结果和并发症：一组18例患者接受钢板切开复位内固定手术（ORIF组），另一组44例患者接受全膝关节置换翻修手术（翻修组）（有或无钢板骨固定）。将机械并发症的死亡率和再次手术作为主要终点。收集完全负重时间（以周为单位）、骨愈合时间（以周为单位）以及其他并发症如感染和血肿发生率作为次要终点。
随访的中位时间为2年。翻修组的再次翻修率为15.9%，ORIF组为22.2%。两组在机械并发症或再次翻修方面未发现统计学显著差异。2年随访时的生存终点为88.9%（95%CI：78.1 - 94.5），两组之间无差异（p = 0.64）。与翻修组的8.6周相比，ORIF组的骨愈合时间明显更长（15.9周），但ORIF组的骨愈合率更高（p = 0.003），完全负重时间也是如此（ORIF组为8.9周，翻修组为1.7周，P < 0.001）。ORIF组报告的感染更多，翻修组血肿和出血风险更高。
尽管骨愈合时间和完全负重时间更长，但对于选定的老年和不适合手术的TKAPF且植入物松动的患者，与更具侵入性的翻修关节成形术策略相比，钢板切开复位内固定不会增加再次手术或死亡风险。
III级，比较性回顾性研究。
