Intraoperative femoral condyle fracture in primary total knee arthroplasty - a case-control study in Asian population

Abstract

Intraoperative femoral condyle fracture is a significant but rarely reported complication during primary total knee arthroplasty (TKA). This is the first study to identify the incidence, risk factors, location and outcome of these fractures in an Asian population with modern posterior-stabilized (PS) TKA. Materials and methods: We reviewed 2682 consecutive primary TKAs performed between 2011 and 2017 in a single centre; 23 femoral condyle fractures were identified and analysed. Results: Fractures were managed conservatively with screw fixation or revision arthroplasty. Mean follow up was 3.0 years (range 3 months to 5.9 years). All patients achieved bone union and good functional outcome. The mean Knee Society Knee score was 89.4 (range 71-100) and the function score was 80.2 (range 60-95) at a mean of 3.0 years post-operation. Bilateral surgery was found to be a significant risk factor for femoral condyle fracture, while there was a higher trend of fracture in female patients and Stryker articular surface mounted (ASM) navigation. Conclusions: Intraoperative fracture is not uncommon with modern PS TKA. Postulated risk factors for fracture were discussed. Early identification of risk factors and a rigorous surgical technique may reduce risk of fracture. A good functional result was expected after proper treatment.

Intraoperative Femoral Condyle Fracture during Bone Preparation in a Cruciate-retaining Primary Total Knee Arthroplasty

“…Intraoperative fractures are commonly seen in revision TKA with a reported incidence of 1.9-3% [7]. Although, the reported incidence of intraoperative fracture in primary TKA ranges from 0.2% to 4.4%, the true incidence is underestimated with limited literature available on this topic as many of them go unnoticed or not reported [2,3,4]. The cause of intraoperative femoral condyle fracture is multifactorial [2,3] and several patients, implant, and technique-related factors known to increase the risk of intraoperative fracture in primary TKA are presented in [Table 1].…”

“…Although, the reported incidence of intraoperative fracture in primary TKA ranges from 0.2% to 4.4%, the true incidence is underestimated with limited literature available on this topic as many of them go unnoticed or not reported [2,3,4]. The cause of intraoperative femoral condyle fracture is multifactorial [2,3] and several patients, implant, and technique-related factors known to increase the risk of intraoperative fracture in primary TKA are presented in [Table 1]. In our case, osteoporosis, difficulty in surgical exposure, microfractures during intramedullary positioning and bone preparation, and deeper penetration of the medial pin while securing the femoral cutting block were the possible reasons responsible for the medial condyle fracture.…”

“…[Table 2] shows a list of things to avoid during primary TKA in patients with risk factors for the prevention of intraoperative fracture of the femoral condyle. intercondylar notch/box cut which can act as a stress riser [1,2,3,4,9]. Therefore, the surgeon should be cautious when using PS knee design in a patient with increased risk factors such as female gender, osteoporosis, rheumatoid arthritis, and smaller knees.…”

“…Common complications associated with primary TKA include aseptic loosening, infection, polyethylene wear, stiffness, and periprosthetic fracture [ 1 ]. Post-operative periprosthetic fracture after TKA is a well-documented and potentially devastating complication adversely affecting the outcome [ 2 ].…”

“…However, intraoperative fractures in primary TKA are rare and there are limited clinical data available in the literature on this topic [ 3 , 4 ]. Intraoperative femoral condyle fracture is commonly described during posterior-stabilized (PS) TKA attributing to excessive box cut or osteoporotic bone [ 2 , 3 , 4 ]. These can occur at any step during TKA including surgical exposure, bony preparation, component trial, cementation, insertion of the final components, and seating of the polyethylene insert [ 3 , 4 , 5 ].…”