Periprosthetic fractures are fractures that occur in association with an orthopaedic implant, most often used for joint arthroplasty or fracture fixation. They are associated with significant morbidity and increased mortality in some cases. The incidence of periprosthetic fractures appears to be increasing as a result of increasing patient longevity, more demanding activity levels that persist into advanced age for some patients, and as a result of the increasing rate of revision arthroplasty which accompanies increasing patient longevity. Implant, surgeon, and patient factors all contribute to the risk of periprosthetic fracture. In this review, we intend to discuss current trends in periprosthetic fractures and risk factors associated with their development in the joint arthroplasty and fracture patient.

Periprosthetic Fractures: Epidemiology and Future Projections

Background Arthrofibrosis is a debilitating postoperative complication of total knee arthroplasty (TKA). It is one of the leading causes of hospital readmission and a predominant reason for TKA failure. The prevalence of arthrofibrosis will increase as the annual incidence of TKA in the United States rises into the millions. Methods In a narrative review of the literature, the etiology, economic burden, treatment strategies, and future research directions of arthrofibrosis after TKA are examined. Results Characterized by excessive proliferation of scar tissue during an impaired wound healing response, arthrofibrotic stiffness causes functional deficits in activities of daily living. Postoperative, supervised physiotherapy remains the first line of defense against the development of arthrofibrosis. Also, adjuncts to traditional physiotherapy such as splinting and augmented soft tissue mobilization can be beneficial. The effectiveness of rehabilitation on functional outcomes depends on the appropriate timing, intensity, and progression of the program, accounting for the patient's ability and level of pain. Invasive treatments such as manipulation under anesthesia, debridement, and revision arthroplasty improve range of motion, but can be traumatic and costly. Future studies investigating novel treatments, early diagnosis, and potential preoperative screening for risk of arthrofibrosis will help target those patients who will need additional attention and tailored rehabilitation to improve TKA outcomes. Conclusion Arthrofibrosis is a multi-faceted complication of TKA, and is difficult to treat without an early, tailored, comprehensive rehabilitation program. Understanding the risk factors for its development and the benefits and shortcomings of various interventions are essential to best restore mobility and function.

Arthrofibrosis Associated With Total Knee Arthroplasty

The purpose of this study was to quantify the effect of sex on the clinical outcome and survivorship of a total knee arthroplasty (TKA) with clinical and radiographic follow-up. Seven thousand three hundred twenty-six primary AGC (Biomet, Warsaw, Ind) cruciate-retaining TKAs were performed from 1987 to 2004. Of these, 59.5% were performed on women. We examined preoperative and postoperative Knee Society knee score, function scores, pain scores, walking ability, stair-climbing ability, flexion, and implant survivorship based on sex. Female sex was associated with lower overall preoperative clinical scores for all parameters (P < .01). Improvement in Knee Society knee score and flexion was greater for women (P = .006), and there were equal pain relief and walking improvements for both sexes (P < .32). Stair and function score improvements were greater for men (P = .002). Implant survival was 98% for women and men at 15 years (P = .4684). We conclude that improvement after TKA is similar for men and women, with few clinically significant differences. Sex-specific implants would appear to offer no clinical advantage.

The clinical effect of gender on outcome of total knee arthroplasty.

The diversity of surgical options for the management of distal femoral fractures reflects the challenges inherent in these injuries. These fractures are frequently comminuted and intra-articular, and they often involve osteoporotic bone, which makes it difficult to reduce and hold them while maintaining joint function and overall limb alignment. Surgery has become the standard of care for displaced fractures and for patients who must obtain rapid return of knee function. The goal of surgical management is to promote early knee motion while restoring the articular surface, maintaining limb length and alignment, and preserving the soft-tissue envelope with a durable fixation that allows functional recovery during bone healing. A variety of surgical exposures, techniques, and implants has been developed to meet these objectives, including intramedullary nailing, screw fixation, and periarticular locked plating, possibly augmented with bone fillers. Recognition of the indications and applications of the principles of modern implants and techniques is fundamental in achieving optimal outcomes.

Distal femoral fractures: current concepts.

Background
Multiple modalities have been used to treat the stiff TKA, including manipulation under anesthesia (MUA), arthroscopy, and open arthrolysis

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How to Treat the Stiff Total Knee Arthroplasty?: A Systematic Review

Background: The treatment of a supracondylar femoral fracture following total knee arthroplasty is complicated by the presence of the prosthetic components. Anterior femoral notching during arthroplasty has been implicated as a contributing risk factor for femoral fracture. We retrospectively reviewed the effect of anterior femoral notching on the subsequent occurrence of a periprosthetic supracondylar fracture of the distal aspect of the femur and the outcomes of primary total knee arthroplasty in such patients.

Methods: The prevalence and depth of femoral notching were determined on a review of the lateral radiographs by observers blinded to the clinical results of 1089 consecutive total knee replacements performed in 1997 and 1998. Linear and logistic regression modeling was used to analyze the relationship between femoral notching and the prevalence of supracondylar femoral fracture, postoperative range of motion, the Knee Society score, and the Knee Society functional and pain scores.

Results: Femoral notching was performed in 325 (29.8%) of the 1089 knees in our series. During an average follow-up period of 5.1 years, only two supracondylar femoral fractures occurred, both in femora treated without notching. Femoral notching was not associated with an increased rate of fracture (p = 1.000) or with significant differences in the measures of outcome (range of motion [p = 0.117], knee score [p = 0.967], functional score [p = 0.861], need for a lateral release [p = 0.234], or postoperative pain [p = 0.948]).

Conclusions: This study demonstrated no difference in knees managed with or without notching of the anterior distal aspect of the femur with respect to the occurrence of a supracondylar fracture, range of motion, Knee Society score, Knee Society function, or pain.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

The effect of femoral notching during total knee arthroplasty on the prevalence of postoperative femoral fractures and on clinical outcome.

Background: Following total knee arthroplasty, some patients who fail to achieve >90° of flexion in the early perioperative period may be considered candidates for manipulation of the knee under anesthesia. The purpose of this study was to assess the outcomes of manipulation following total knee arthroplasty.

Methods: One hundred and thirteen knees in ninety patients underwent manipulation for postoperative flexion of ≤90° at a mean of ten weeks after surgery. Flexion was measured with a goniometer prior to total knee arthroplasty, at the conclusion of the operative procedure, before manipulation, immediately after manipulation, at six months, and at one, three, and five years postoperatively.

Results: Eighty-one (90%) of the ninety patients achieved improvement of ultimate knee flexion following manipulation. The average flexion was 102° prior to total knee arthroplasty, 111° following skin closure, and 70° before manipulation. The average improvement in flexion from the measurement made before manipulation to that recorded at the five-year follow-up was 35° (p < 0.0001, paired t test). There was no significant difference in the mean improvement in flexion when patients who had manipulation within twelve weeks postoperatively were compared with those who had manipulation more than twelve weeks postoperatively. Patients who eventually underwent manipulation had significantly lower preoperative Knee Society pain scores (more pain) than those who had not had manipulation (p = 0.0027).

Conclusions: Manipulation generally increases ultimate flexion following total knee arthroplasty. Patients with severe preoperative pain are more likely to require manipulation.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Manipulation after total knee arthroplasty.

Background: Range of motion is recognized as an important indicator of the success of a total knee replacement; however, an optimal range of motion has yet to be defined This study was designed to determine the optimal range of motion for knee function after total knee arthroplasty with a posterior cruciate-retaining prosthesis

Methods: We retrospectively reviewed 5556 primary total knee arthroplasties performed with posterior cruciate-retaining prostheses between 1983 and 2003 The relationship between postoperative range of motion and pain, walking ability, stair-climbing ability, and knee function scores was examined at three to five years postoperatively The relationship between a postoperative flexion contracture or hyperextension and knee function was also examined

Results: Patients with 128° to 132° of motion obtained the highest scores for pain, walking, and knee function and the highest Knee Society scores The outcomes became substantially compromised with motion of <118° Patients with 133° to 150° of motion had the highest scores for stair-climbing A postoperative flexion contracture and hyperextension were associated with lower scores for pain, walking, stair-climbing, and knee function

Conclusions: The best functional results following total knee arthroplasty are achieved with 128° to 132° of motion A postoperative flexion contracture and hyperextension of ≥10° are associated with a poorer outcome except that stair-climbing is improved with more motion

Level of Evidence: Prognostic Level II See Instructions to Authors for a complete description of levels of evidence

The Effect of Postoperative Range of Motion on Functional Activities After Posterior Cruciate-Retaining Total Knee Arthroplasty

Seasonal variation in adult hip disease secondary to osteoarthritis and developmental dysplasia of the hip

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Merrill A. Ritter

Papers

The effect of femoral notching during total knee arthroplasty on the prevalence of postoperative femoral fractures and on clinical outcome.

Manipulation after total knee arthroplasty.

The Effect of Postoperative Range of Motion on Functional Activities After Posterior Cruciate-Retaining Total Knee Arthroplasty

Seasonal variation in adult hip disease secondary to osteoarthritis and developmental dysplasia of the hip

Seasonal variation in adult hip disease secondary to osteoarthritis and developmental dysplasia of the hip