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中华关节外科杂志(电子版) ›› 2024, Vol. 18 ›› Issue (05) : 630 -637. doi: 10.3877/ cma.j.issn.1674-134X.2024.05.011

综述

全膝关节置换术后股骨远端假体周围骨折治疗现状
李焕玺1,2, 何淳诺1, 田志敏1, 周胜虎2, 吴昊越2, 张浩强2,()   
  1. 1.730000 兰州,甘肃中医药大学第一临床医学院
    2.730050 兰州,解放军联勤保障部队第94〇医院关节外科
  • 收稿日期:2023-11-16 出版日期:2024-10-01
  • 通信作者: 张浩强
  • 基金资助:
    兰州市青年科技人才创新项目(2023-2-28)全军训练伤防治专项课题(21XLS24)第九四〇医院院内科研计划项目(2023YXKY014)甘肃省科技计划创新项目(22JR5RA009)福建省自然科学基金项目(2020J05077)

Current status of treatment for periprosthetic fractures of distal femur after total knee arthroplasty

Huanxi Li1,2, Chunnuo He1, Zhiming Tian1, Shenghu Zhou2, Haoyue Wu2, Haoqiang Zhang2,()   

  1. 1.Gansu University of Traditional Chinese Medicine, Lanzhou 730000, China
    2.The 940th Hospital of PLA Joint Logistics Support Force,Lanzhou 730050, China
  • Received:2023-11-16 Published:2024-10-01
  • Corresponding author: Haoqiang Zhang
引用本文:

李焕玺, 何淳诺, 田志敏, 周胜虎, 吴昊越, 张浩强. 全膝关节置换术后股骨远端假体周围骨折治疗现状[J]. 中华关节外科杂志(电子版), 2024, 18(05): 630-637.

Huanxi Li, Chunnuo He, Zhiming Tian, Shenghu Zhou, Haoyue Wu, Haoqiang Zhang. Current status of treatment for periprosthetic fractures of distal femur after total knee arthroplasty[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2024, 18(05): 630-637.

全膝关节置换术(TKA)在目前临床工作中被广泛开展,可显著提高终末期膝关节疾病患者的生活质量。随着社会老龄人口基数的增加和现代人工膝关节技术的普及,因膝关节严重退化行全膝关节置换的患者数量逐年上升,作为TKA术后并发症之一的股骨远端假体周围骨折(PDFF)发病率也逐渐增加。PDFF患者常为老年人,且合并有骨质疏松和多种基础疾病,与常规骨折相比患者病情更加复杂、处理更加棘手,要求骨科医生不仅要根据骨折类型制定治疗方案,还要综合评估全身状况,并且兼顾关节功能的重建。本文就近年来对TKA术后PDFF的发病率、骨折分型和治疗方式的研究现状做一综述。

Total knee arthroplasty (TKA) is widely carried out in clinical practice and can significantly improve the quality of life of patients with end-stage knee joint diseases. With the continuous improvement of the design of artificial knee joint prosthesis and the increase of the elderly population, the number of patients receiving total knee arthroplasty has increased year by year. As one of the postoperative complications of TKA, the incidence of periprosthetic distal femoral fracture (PDFF) has also gradually increased. Most of the PDFF patients are elderly, often accompanied by osteoporosis and various underlying diseases. Compared with conventional fractures, the patient's condition is more complex and difficult to manage. Orthopedic doctors are required to not only develop treatment plans based on the type of fracture, but also comprehensively evaluate the overall condition and consider the reconstruction of joint function. This article reviewed the research status of incidence rate, fracture classification and treatment of PDFF after TKA in recent years.

表1 骨折分型及优缺点
Table 1 Fracture classificationand features
分型 骨折类型描述 优点 缺点
Rorabeck分型 Ⅰ型:假体稳定,骨量良好,无移位
Ⅱ型:假体稳定,骨折块移位,无论伴不伴骨量良好
Ⅲ型:假体松动,无论骨折块是否移位
1.考虑了骨折移位及假体稳定情况
2.推荐包括ORIF和关节翻修手术方案选择
1.没有关于ORIF手术的详细信息
2.没有阐述骨折类型与具体治疗的关系
Su分型 Ⅰ型:股骨膝关节组件近端骨折
Ⅱ型:起始于股骨膝部分近端并向近端延伸的骨折
Ⅲ型:骨折线的任何部分都位于股骨膝部件的前凸缘的上边缘的远侧
1.解释了骨折部位/走形与股骨假体的关系
2.按骨折类型进行治疗分级,考虑RIMN可行性
1.分型不全面,未考虑到骨折端骨质、骨量
2.未对锁定钢板的选择进行分类和推荐
3.未包括假体松动的分型
Kim分型 Ⅰ型:骨量良好、假体稳定无松动;ⅠA型轻度移位;ⅠB型骨折移位程度大,复位难度高
Ⅱ型:骨量良好,假体松动或移位
Ⅲ型:骨折骨量缺失、假体松动或移位
1.描述了远端残余骨量、假体位置及稳定情况、骨折可复性
2.分类介绍残余骨量问题
1.未特殊阐明内固定方式的选择
2.未考虑到骨折部位及走形对治疗效果的影响
UCS分型 A型:股骨髁无移位的骨折;A1型(外侧髁骨折),A2型(内侧髁骨折)
B型:假体骨床或者假体柄周围的骨折;B1型:假体
柄近端骨折,假体无松动,骨量无丢失;B2型:假体
柄近端骨折,假体不稳定,骨量无丢失;B3型:假体
柄近端骨折,假体松动,骨量丢失
C型:骨折未累及假体
D型:骨折位于髋关节及膝关节假体之间,靠近膝关节
E型:支撑同一部位假体的两端骨分别发生骨折或多处假体周围骨折
F型:半关节置换,假体未置换关节面骨折。
1.考虑到多假体骨折情况
2.分型全面
3.解释了假体与骨折间的关系
4.根据分型提供治疗方案选择
Kim-2分型 Ⅰ型:骨折线位于股骨假体前缘近端
Ⅱ型:骨折线位于股骨假体前缘远端;ⅡL型,存在外侧喙,ⅡM型,存在内侧喙
Ⅲ型:无论骨折线如何,存在假体松动或不稳
1.为选择锁定钢板治疗提供参考
2.描述了双锁定钢板固定的适应证
1.只针对于锁定钢板固定,未考虑到其他方式的选择
2.对不稳定假体的进一步处理提供的信息有限
表2 手术方案比较分析
Table 2 Comparative analysis of surgical regimens
手术方式 适应证 优势 不足
外固定架 1.难以获得坚强内固定:严重骨质疏松;粉碎性骨折;残余骨量少
2.合并严重基础疾病,手术、麻醉风险大,难以耐受大手术创伤
3.Rorabeck分型Ⅰ、Ⅱ型(假体未松动)
1.适合于高龄患者
2.微创手术
3.骨折愈合率高
4.可术后早期负重
5.保留关节活动性
1.针道感染风险高
2.损失少量的膝关节活动度
3.操作难度大、学习曲线长
逆行髓内钉 1.Rorabeck分型Ⅰ、Ⅱ型(假体未松动)
2.Su分型Ⅰ、Ⅱ型,部分Ⅲ型(骨折远端残余骨量足够(>20 mm))
3.股骨髁假体髁间窝类型、设计参数允许安全的逆行髓内钉手术操作
1.软组织剥离少
2.断端血供影响小
3.闭合复位、快速愈合
4.机械稳定性好
1.进入关节腔关节感染风险
2.解剖复位困难
3.畸形愈合风险高
4.抗扭转负荷低
钢板内固定 1.Rorabeck分型Ⅰ、Ⅱ型(假体未松动)
2.Su分型Ⅰ、Ⅱ型,部分Ⅲ型(骨折远端残余骨量足够完成螺钉内固定)
1.手术方法简单
2.内固定稳定可靠
3.良好的骨折复位
4.早期功能锻炼
5.多角度螺钉固定
1.骨折不愈合
2.内固定失效
3.再手术风险
4.远端螺钉植入要求高、难度大
翻修术及股骨远端置换 1.Rorabeck分型Ⅲ型(假体松动)
2.Su分型部分Ⅲ型(骨折远端残余骨量不足以保证内固定可靠以及假体稳定)
3.Kim分型Ⅱ、Ⅲ型及Kim-2分型Ⅲ型
4.内固定治疗失败的各类型PDFF
1.即刻负重锻炼
2.关节功能满意
3.手术疗效确切
4.住院时间短
5.避免骨不连
1.手术创伤大
2.技术要求高
3.治疗费用多
4.术后并发症多
[1]
胡银华,薛龙. 中国中老年人症状性膝骨关节炎的发病率及危险因素[J/OL]. 中华关节外科杂志( 电子版 ),2023,17( 4 ):470-478.
[2]
黄强,曾羿,胡钦胜,等. 单髁关节置换术与全膝关节置换术治疗膝关节内侧间室重度骨关节炎的比较研究[J]. 中国修复重建外科杂志,2021,35( 09 ): 1125-1132.
[3]
Al Thaher Y,Alfuqaha OA,Dweidari A. Health-related quality of life and outcome after total knee replacement: results from a cross-sectional survey in Jordan[J/OL]. Adv Orthop,2021,2021:5506809. DOI: 10.1155/2021/5506809.
[4]
Johnson RL,Abdel MP,Frank RD,et al. Frailty index is associated with periprosthetic fracture and mortality after total knee arthroplasty[J]. Orthopedics,2019,42( 6 ): 335-343.
[5]
Torre M,Romanini E,Zanoli G,et al. Monitoring outcome of joint arthroplasty in Italy: implementation of the national registry[J].Joints,2017,5( 2 ): 70-78.
[6]
Schwartz AM,Farley KX,Guild GN,et al. Projections and epidemiology of revision hip and knee arthroplasty in the United States to 2030[J/OL]. 2020,35( 6S ): S79-S85. DOI: 10.1016/j.arth.2020.02.030.
[7]
Kuzyk PRT,Watts E,Backstein D. Revision total knee arthroplasty for the management of periprosthetic fractures[J]. J Am Acad Orthop Surg,2017,25( 9 ): 624-633.
[8]
Aebischer AS,Hau R,deSteiger RN,et al. Distal femoral replacement for periprosthetic fractures after TKA: Australian orthopaedicassociation national joint replacement registry review[J].J Arthroplasty,2022,37( 7 ): 1354-1358.
[9]
Canton G,Ratti C,Fattori R,et al. Periprosthetic knee fractures.A review of epidemiology,risk factors,diagnosis,management and outcome[J]. Acta Biomed,2017,88( 2S ): 118-128.
[10]
李二亮,王文己,韩兴文,等. 全膝关节置换术后股骨假体周围骨折的研究进展[J]. 骨科,2019,10( 1 ): 78-84.
[11]
Rubinger L,Khalik HA,Gazendam A,et al. Very distal femoral periprosthetic fractures: replacement versus fixation: a systematic review[J]. J Orthop Trauma,2021,35( 11 ): 573-583.
[12]
Su ET,DeWal H,di Cesare PE. Periprosthetic femoral fractures above total knee replacements[J]. J Am Acad Orthop Surg,2004,12( 1 ): 12-20.
[13]
Rorabeck CH,Taylor JW. Classification of periprosthetic fractures complicating total knee arthroplasty[J]. Orthop Clin North Am,1999,30( 2 ): 209-214.
[14]
Kim KI,Egol KA,Hozack WJ,et al. Periprosthetic fractures after total knee arthroplasties[J]. Clin Orthop Relat Res,2006,446:167-175.
[15]
Kim JH,Kim KI,Park KC,et al. New classification for periprosthetic distal femoral fractures based on locked-plate fixation following total knee arthroplasty: a multicenter study[J]. J Arthroplasty,2022,37( 5 ): 966-973.
[16]
Duncan CP,Haddad FS. The unified classification system( UCS ):improving our understanding of periprosthetic fractures[J]. Bone Joint J,2014,96-B( 6 ): 713-716.
[17]
Beris AE,Lykissas MG,Sioros V,et al. Femoral periprosthetic fracture in osteoporotic bone after a total knee replacement:treatment with Ilizarov external fixation[J]. J Arthroplasty,2010,25( 7 ): 1168.e9-1168.12.
[18]
NozakaK,MiyakoshiN,HongoM,et al. Effectiveness of circular external fixator in periprosthetic fractures around the knee[J/OL].BMC Musculoskelet Disord,2020,21( 1 ): 317. DOI: 10.1186/s12891-020-03352-9.
[19]
Gausden EB,Lim PK,Rabonivich A,et al. Outcomes of periprosthetic distal femur fractures following total knee arthroplasty:Intramedullary nailing versus plating[J]. Injury,2021,52( 7 ):1875-1879.
[20]
Wall R,Syed F,Arastu M,et al. Treatment of supracondylar periprosthetic femoral fractures with retrograde intramedullary nailing versus distal femoral plating: a systematic review and metaanalysis of current evidence[J/OL]. Orthop Traumatol Surg Res,2023,109( 5 ): 103489. DOI: 10.1016/j.otsr.2022.103489.
[21]
Virkus W,Lieder C,Jang Y,et al. Results of low distal femur periprosthetic fractures[J/OL]. J Orthop Trauma,2022,36( 8 ):e300-e305. DOI: 10.1097/BOT.0000000000002352.
[22]
Kerr MS,Young EG,Shaath MK,et al. Periprosthetic distal femur fractures treated by retrograde intramedullary nails with a 10-degree distal bend achieve significantly better post-operative radiographic alignment when compared to conventional retrograde nails[J].Injury,2023,54( 2 ): 694-697.
[23]
Jeavons RP,Dowen D,O'Brien S. The use of a revision femoral stem to manage a distal femoral periprosthetic fracture in a wellfixed total knee arthroplasty[J]. J Arthroplasty,2012,27( 1 ):156-159.
[24]
Wallace SS,Bechtold D,Sassoon A. Periprosthetic fractures of the distal femur after total knee arthroplasty: Plate versus nail fixation[J]. Orthop Traumatol Surg Res,2017,103( 2 ): 257-262.
[25]
Bae DK,Song SJ,Yoon KH,et al. Periprosthetic supracondylar femoral fractures above total knee arthroplasty: comparison of the locking and non-locking plating methods[J]. Knee Surg Sports Traumatol Arthrosc,2014,22( 11 ): 2690-2697.
[26]
周胜虎,周莹佳,李金锁,等. 单锁定钢板内固定联合自体髂骨植骨治疗全膝关节置换术后Rorabeck Ⅱ型股骨远端假体周围骨折的疗效[J]. 中华创伤杂志,2022,38( 10 ): 909-915.
[27]
Caterini A,Luciano C,Rovere G,et al. Periprosthetic distal femoral fractures after total knee replacement treated by ORIF. Mid to longterm follow-up study in 12 patients[J/OL]. Orthop Rev,2023,15:87871. DOI: 10.52965/001c.87871.
[28]
Ross LA,Keenan OJF,Magill M,et al. Management of low periprosthetic distal femoral fractures[J]. Bone Joint J,2021,103-B( 4 ): 635-643.
[29]
Shon OJ,Kim GB,On JW. Bone hook reduction technique combined with lateral parapatellar arthrotomy for periprosthetic distal femoral fractures following total knee arthroplasty: atechnicalnote[J].Orthop Surg,2022,14( 8 ): 1902-1906.
[30]
Ehlinger M,Adam P,diMarco A,et al. Periprosthetic femoral fractures treated by locked plating: feasibility assessment of the mini-invasive surgical option. A prospective series of 36 fractures[J]. Orthop Traumatol Surg Res,2011,97( 6 ): 622-628.
[31]
Park YG,Kang H,Song JK,et al. Minimally invasive plate osteosynthesis with dual plating for periprosthetic distal femoral fractures following total knee arthroplasty[J/OL]. J Orthop Surg Res,2021,16( 1 ): 433. DOI: 10.1186/s13018-021-02586-0.
[32]
Corap Y,Brix M,Emmeluth C,et al. Patient safety in distal femoral resection knee arthroplasty for non-tumor indications: a single-center consecutive cohort study of 45 patients[J/OL]. BMC Musculoskelet Disord,2022,23( 1 ): 199. DOI: 10.1186/s12891-022-05100-7.
[33]
Saidi K,Ben-Lulu O,Tsuji M,et al. Supracondylar periprosthetic fractures of the knee in the elderly patients: a comparison of treatment using allograft-implant composites,standard revision components,distal femoral replacement prosthesis[J]. J Arthroplasty,2014,29( 1 ): 110-114.
[34]
Cannon SR. The use of megaprosthesis in the treatment of periprosthetic knee fractures[J]. Int Orthop,2015,39( 10 ):1945-1950.
[35]
Darrith B,Bohl DD,Karadsheh MS,et al. Periprosthetic fractures of the distal femur: is open reduction and internal fixation or distal femoral replacement superior?[J]. J Arthroplasty,2020,35( 5 ):1402-1406.
[36]
Stancil R,Romm J,Lack W,et al. Distal femoral replacement for fractures allows for early mobilization with low complication rates: a multicenter review[J]. J Knee Surg,2023,36( 2 ): 146-152.
[37]
Lewis PL,Robertsson O,Graves SE,et al. Variation and trends in reasons for knee replacement revision: a multi-registry study of revision burden[J]. Acta Orthop,2021,92( 2 ): 182-188.
[38]
Fu P,Liang W,Gao Z,et al. Optimal surgical treatment for periprosthetic distal femoral fractures after total knee arthroplasty: a Bayesian-based network analysis[J/OL]. J Orthop Surg Res,2023,18( 1 ): 122. DOI: 10.1186/s13018-023-03586-y.
[39]
Matar HE,Bloch BV,James PJ. Distal femoral replacements for acute comminuted periprosthetic knee fractures: satisfactory clinical outcomes at medium-term follow-up[J]. Arthroplast Today,2021,7:37-42.
[40]
ShinYS,Kim HJ,Lee DH. Similar outcomes of locking compression plating and retrograde intramedullary nailing for periprosthetic supracondylar femoral fractures following total knee arthroplasty:a meta-analysis[J]. Knee Surg Sports Traumatol Arthrosc,2017,25( 9 ): 2921-2928.
[41]
Shah JK,Szukics P,Gianakos AL,et al. Equivalent union rates between intramedullary nail and locked plate fixation for distal femur periprosthetic fractures-a systematic review[J]. Injury,2020,51( 4 ): 1062-1068.
[42]
Magill H,Ponugoti N,Selim A,et al. Locked compression plating versus retrograde intramedullary nailing in the treatment of periprosthetic supracondylar knee fractures: a systematic review and meta-analysis[J/OL]. J Orthop Surg Res,2021,16( 1 ): 78. DOI:10.1186/s13018-021-02222-x.
[43]
Ponugoti N,Raghu A,Kosy JD,et al. A comparison of distal femoral replacement versus fixation in treating periprosthetic supracondylar femur fractures: a systematic review and meta-analysis[J]. Arch Orthop Trauma Surg,2023,143( 6 ): 3335-3345.
[44]
Quinzi DA,Ramirez G,Kaplan NB,et al. Early complications and reoperation rates are similar amongst open reduction internal fixation,intramedullary nail,and distal femoral replacement for periprosthetic distal femur fractures: a systematic review and metaanalysis[J]. Arch Orthop Trauma Surg,2021,141( 6 ): 997-1006.
[45]
Liporace FA,Yoon RS. Nail plate combination technique for native and periprosthetic distal femur fractures[J/OL]. J Orthop Trauma,2019,33( 2 ): e64-e68. DOI: 10.1097/BOT.0000000000001332.
[46]
Stoffel K,Sommer C,Lee M,et al. Double fixation for complex distal femoral fractures[J]. EFORT Open Rev,2022,7( 4 ): 274-286.
[47]
冉伟,王咫桥,董军,等. 改良持续收肌管阻滞对全膝关节置换术后运动功能的影响[J/OL]. 中华关节外科杂志( 电子版 ),2023,17( 2 ): 216-223.
[48]
Vicenti G,Bizzoca D,Solarino G,et al. Periprosthetic femoral refractures pathogenesis,classification,and surgical implications[J/OL]. Injury,2023,54( Suppl 1 ): S24-S30. DOI: 10.1016/j.injury.2020.11.030.
[49]
Randelli F,Pace F,Priano D,et al. Re-fractures after periprosthetic femoral fracture: a difficult to treat growing evidence[J/OL]. Injury,2018,49( Suppl 3 ): S43-S47. DOI: 10.1016/j.injury.2018.09.045.
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