Surgical Treatment of Osteoporotic Fractures About the Knee
Daniel S. Horwitz, MD and Erik N. Kubiak, MD
The Journal of Bone and Joint Surgery (American). 2009;91:2970-2982
Abstract: Treatment of osteoporotic fractures of the distal part of the femur and the tibial plateau continues to evolve. New developments with regard to implants and operative technique now provide improved means of dealing with the numerous biological and mechanical issues that directly affect osteoporotic patients. These biological and mechanical issues commonly include degenerative joint disease, multiple medical comorbidities, limited prefracture activity levels, multiple fracture planes with lower-energy injuries, and difficulty with postoperative mobilization.
This patient population has, in general, lower demands and activity levels. While there are some exceptions, the majority of patients with osteoporosis are not running, skiing, or participating in heavy-impact aerobic exercise. Further complicating treatment are the multiple medical comorbidities affecting not only the patient's final function but also the soft-tissue and osseous healing capabilities as well as the ability to recover from prolonged inactivity. Baseline weakness and dementia can dramatically affect an elderly patient's ability to protect the operatively treated extremity. This may lead to the use of additional internal fixation or protective spanning external fixation.
It is important to have a comprehensive understanding of a patient's functional level and comorbidities. Patients with osteoporotic bone are often elderly and may have functional, mental, and metabolic issues that impact the degree of correction necessary as well as their ability to withstand a surgical procedure. When a patient has internal fixation, there are additional issues related to the osteoporotic bone. The most common issue is subsidence of the articular surface during the postoperative period. This is the result of decreased bone quality, the inability of current implants to resist axial loads, and the elderly patient's diminished ability to protect the injured lower extremity during mobilization. These problems make postoperative mobilization a challenge.
The complications inherent in the typical osteoporotic patient population are more challenging when there is preexisting degenerative arthritis of the knee. Degenerative arthritis makes precise anatomic restoration (<2 mm of articular step-off) difficult, if not impossible. Additionally, a knee with degenerative arthritis is less tolerant of mechanical axis deviations; therefore, restoration of normal anatomic and mechanical alignment is critical1,2. Below, we suggest special instruments and make recommendations to assist practitioners in the treatment of fractures in osteoporotic patients with or without degenerative arthritis and to reduce the aforementioned risks associated with this patient group.
- Patellar Resurfacing Compared with Nonresurfacing in Total Knee Arthroplasty
- Conservative Treatment for the Intraoperative Detachment of Medial Collateral Ligament from the Tibial Attachment Site during Primary Total Knee Arthroplasty
- Arthroscopic Treatment of Patellar Clunk and Synovial Hyperplasia After Total Knee Arthroplasty
- The Risk of Direct Peroneal Nerve Injury Using the Ranawat “Inside-Out” Lateral Release Technique in Valgus Total Knee Arthroplasty
- Achieving Deep Flexion After Primary Total Knee Arthroplasty
- Surgical Treatment of Osteoporotic Fractures About the Knee