Definition
- Fracture of the distal femur, proximal tibia or patella around a knee replacement
- Supracondylar femoral fractures are the most common, tibial fractures are rare
Epidemiology
- About 1.3% after total knee replacement, mostly in older women
- Risk factors. Osteoporosis, rheumatoid arthritis, steroids, neurological disease and revision surgery
- Anterior femoral notching is a proposed but disputed risk factor
Classification
Lewis and Rorabeck classification of supracondylar fractures (Rorabeck and Taylor, 1999)
| Type | Description |
|---|---|
| I | Undisplaced, prosthesis intact |
| II | Displaced, prosthesis intact |
| III | Prosthesis loose or failing, with any displacement |
- Su classification grades the level of the fracture against the femoral component. See Distal Femoral Fractures
- Felix classification for tibial fractures. Type I plateau, II beside the stem, III below the stem, IV tibial tubercle. Subtype A well fixed, B loose, C intraoperative
- Ortiguera and Berry for patellar fractures. See Painful Total Knee Replacement
Investigations
- AP and lateral radiographs of the knee and whole femur, compared with earlier films
- CT for comminution, distal bone stock and component fixation
- Identify the implant. A closed box femoral component blocks a retrograde nail
Management
- Type I. Non-operative in frail patients, or fixation to allow early mobilisation
- Type II. Locking plate or retrograde nail
- Nailing needs an open box and enough distal bone for locking screws
- Very distal or comminuted fractures in older patients. Distal femoral replacement
- Type III. Revision with stemmed components or distal femoral replacement
Prognosis
- Union with locking plates 87% and with nails 84% in a systematic review of 448 fractures
- Meta-analyses found no clear difference between plate and nail in union, infection or revision
- Complications. Nonunion, malunion, fixation failure, stiffness and infection
References
- Rorabeck CH, Taylor JW. Classification of periprosthetic fractures complicating total knee arthroplasty. Orthop Clin North Am. 1999, 30(2), 209-14. PubMed
- Konan S, Sandiford N, Unno F, Masri BS, Garbuz DS, Duncan CP. Periprosthetic fractures associated with total knee arthroplasty. An update. Bone Joint J. 2016, 98-B(11), 1489-1496. PubMed
- Krbec M, Motycka J, Lunácek L, Dousa P. Osteosynthesis for periprosthetic supracondylar fracture above a total knee arthroplasty using a locking compression plate. Acta Chir Orthop Traumatol Cech. 2009, 76(6), 473-8. PubMed
- Ebraheim NA, Kelley LH, Liu X, Thomas IS, Steiner RB, Liu J. Periprosthetic distal femur fracture after total knee arthroplasty. A systematic review. Orthop Surg. 2015, 7(4), 297-305. PubMed
- Magill H, Ponugoti N, Selim A, Platt J. Locked compression plating versus retrograde intramedullary nailing in the treatment of periprosthetic supracondylar knee fractures. A systematic review and meta-analysis. J Orthop Surg Res. 2021, 16(1), 78. PubMed
- Wall R, Syed F, Arastu M, Riemer B, Boutefnouchet T. Treatment of supracondylar periprosthetic femoral fractures with retrograde intramedullary nailing versus distal femoral plating. A systematic review and meta-analysis of current evidence. Orthop Traumatol Surg Res. 2023, 109(5), 103489. PubMed
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 15 October 2026.