Periprosthetic Fractures: Intraoperative and Postoperative

CHAPTER PREVIEW

CHAPTER SYNOPSIS:

If not recognized and treated appropriately, intraoperative periprosthetic fractures around total ankle arthroplasties can lead to disastrous consequences. The surgeon should not leave the operating room until radiographs demonstrate that any potential fractures have been indentified and treated. Common periprosthetic fractures are discussed and treatment algorithms are presented for treatment. After ankle replacements have healed, perioperative fractures should be treated using standard fixation techniques.

IMPORTANT POINTS:

1

Intraoperative iatrogenic periprosthetic fractures must be recognized.
2

The mechanical axis of limb and the stability of the fracture and the implants must be considered when treating these fractures.
3

When in doubt, be more aggressive when it comes to fixation of these fractures.
4

Always disclose these fractures to the patients and document these fractures, their treatment, and the disclosure in the patient record.

CLINICAL/SURGICAL PEARLS:

1

Use antiglide plates if a fracture line is vertically oriented, especially if the implant does not replace a portion of the malleolus.
2

Additional fixation (K-wires, tension bands, sutures, or plates) should always be used if there is any question about the stability of the fixation.
3

The overall mechanical axis of the limb will affect the way these fractures are stabilized and how they heal after surgery.
4

It is always easier to fix the problem during the initial trip to the operating room rather than after radiographs have been obtained in the recovery room or in the clinic.

CLINICAL/SURGICAL PITFALLS:

1

Avoiding these fractures is much easier than their treatment.
2

K-wires can be placed prophylactically and axially in the malleoli to prevent straying of the saw blade. The K-wire can be used as a guide pin should a screw be required to stabilize a fracture.
3

Obtaining good-quality radiographs before leaving the operating room is important in the diagnosis and treatment of these fractures.
4

If these fractures are recognized and aggressively treated intraoperatively, good outcomes can be expected.
5

If not recognized or not treated appropriately, some disasters can be expected.

VIDEO AVAILABLE:

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HISTORY/INTRODUCTION/SCOPE OF THE PROBLEM

Total ankle arthroplasties (TAAs) have been performed for four decades or longer. End-stage arthritis of the ankle is the indication for TAA. There are many causes of end-stage arthritis of the ankle; one retrospective review of patients showed that almost 70% of patients receiving a TAA developed arthritis as a result of trauma-induced injury to the joint. Most of these were the result of fractures of the tibia, ankle, or foot. Many were also the result of chronic instability of the ankle from repeated ligamentous injuries.

Early designs usually used cement for fixation and were constrained or semiconstrained. More recent designs have used predominantly press fit designs with stems, pegs, or posts for fixation, relying on bony in-growth for stability to the osseous structures of the ankle.

Most of the first-generation prostheses were eventually pulled from the market because of high failure rates with subsidence, continued pain, and deformities leading to poor function. One such complication that leads to poor outcomes was the periprosthetic fracture.

Over the years, component designs have changed but indications and contraindications have largely remained unchanged. In the past two decades, however, the incidence of TAA has increased largely as a result of improved designs and outcomes, patient and surgeon awareness, and increased posttraumatic arthritis.

Fractures have occurred around these implants from their beginning. Early reports of fracture were published in the 1970s. The rate of periprosthetic fractures has been reported to be as high as 40%. Periprosthetic fractures can be classified according to the time of the fracture (intraoperative or postoperative) or according to the location of the fracture. There are no formal or widely acceptable classification systems for these fractures. We discuss them with respect to both the time when the fracture occurs (intraoperatively or postoperatively) and the location of the fractures. Periprosthetic fractures that occur around TAAs can present a challenge for even the most skilled surgeon. Most often these are treated by a fellowship-trained foot and ankle surgeon or a fellowship-trained traumatologist.

REVIEW

In many series of total ankle replacements reported in the literature, intraoperative medial and lateral malleolar ankle fractures are a common complication. Medial malleolar fractures are more common than lateral malleolar fractures. There are multiple studies to suggest that as surgeon experience with the procedure increases, the incidence of fractures decreases. However, this trend is not reported in all series. It is interesting to note that fractures occur at fairly consistent rates with multiple implant designs. The overall rate of fracture in conjunction with total ankle replacement as reported by McGarvey et al. in 2004 ranged from 12% to 24%. A more recent review of the literature and doubling of the sample size of procedures show an overall fracture rate of 13% ( Table 17-1 ).

TABLE 17-1

Literature Review of the Number of Perioperative Fractures During Total Ankle Arthroplasty

Study (Year)	Implant		Cases	Fractures	%
Stauffer (1979)	Mayo		102	5	4.9
Bolton-Maggs et al. (1985)	ICLH Ankle		62	3	4.8
Buechal et al. (1988)	LCS		23	1	4.3
Wynn and Wilde (1992)	Beck-Steffee		36	8	22.2
Kitaoka and Patzer (1996)	Mayo		160	10	6.3
Wood et al. (2000)	TPR		7	0	0
	STAR		7	1	14.3
Buechal et al. (2003)	Buechel-Pappas		50	3	6.0
Myerson and Mroczek (2003)	Agility	*	25	5	20.0
		†	25	2	8.0
Saltzman et al. (2003)	Agility		90	12	13.3
Haskell and Mann (2003)	STAR	‡	50	9	18.0
		§	137	15	10.9
Wood and Deakin (2003)	STAR		200	19	9.5
McGarvey et al. (2004)	Agility		25	5	20.0
	STAR		20	4	20.0
Doets et al. (2006)	LCS/Buechel-Pappas		93	27	29.0
San Giovanni et al. (2006)	Buechel-Pappas		31	10	32.3
Kopp et al. (2006)	Agility		43	4	9.3
Schuberth et al. (2006)	Agility	*	25	11	44.0
		†	25	8	32.0
Morgan and Van Boerum (2008)	Agility		74	13	17.6
	Salto-Talaris		13	2	11.7
Total			1310	176	13.4