Evaluation of Intraoperative and Early Postoperative Periprosthetic Fractures Following Total Knee Arthroplasty and Identification of Contributing Risk Factors.

Abstract

Previous research on periprosthetic fractures (PPF) following total knee arthroplasty (TKA) has primarily addressed late postoperative complications. Evidence concerning intraoperative and early (≤ 90 day) fractures remains limited, particularly within Eastern European and Middle Eastern populations. This study aimed to evaluate the incidence and identify risk factors for such fractures in a large national cohort. A retrospective analysis was conducted on 1,243 patients and 1,440 knees who underwent primary TKA between 2014 and 2023. Fractures developed in 35 knees (2.4%) intraoperatively or within 90 days after surgery and constituted the study group. Patients in the fracture group were older, with a mean age of 71 ± 8.8 years compared with 68 ± 7.6 years in the non-fracture group (P = 0.014). Demographic data, comorbidities, preoperative coronal alignment, and characteristics of the implants were compared between the two groups. Uni- and multivariate regression analyses were performed to determine risk factors based on the location of the fracture. In multivariate regression analyses, independent risk factors for femoral PPF included the use of a constrained condylar insert without a femoral stem (odds ratio (OR): 54, 95% confidence interval (CI): 3.7 to 1016; P = 0.002), a diagnosis of osteoporosis (OR: 20.5, 95% CI: 5.4 to 77.2; P = 0.001), anterior femoral notching (OR: 11.4, 95% CI: 2.9 to 44.6; P = 0.001), and the use of a posterior-stabilized femoral component (OR: 6.9, 95% CI: 1.8 to 27; P = 0.003). For tibial fractures, preoperative valgus alignment was identified as a risk factor (OR: 11, 95% CI: 2.7 to 45.9; P = 0.001). Preoperative identification and optimization of osteoporotic patients, careful management of valgus deformities, avoidance of anterior femoral notching, and the use of femoral stems when employing high-constraint inserts may help reduce the risk of PPF.