Elsevier

Injury

Volume 36, Issue 1, January 2005, Pages 163-168
Injury

Stanmore total knee replacement versus internal fixation for supracondylar fractures of the distal femur in elderly patients

https://doi.org/10.1016/j.injury.2004.04.007Get rights and content

Abstract

Background: Supracondylar fractures of the femur in the elderly are difficult to treat. Total knee replacement is often not considered. The aim of this study was to compare the short to medium term outcome of fixation and total knee replacement in medically fit active elderly patients with no pre-existing arthritis in order to determine whether total knee replacement can be an alternative to internal fixation. Patients and methods: In this retrospective study, we included patients who were aged 75 or over with an ASA grade of two or less, walked independently before their injury, and sustained a type A or C supracondylar fracture. Four were treated with internal fixation and six with a cemented Stanmore knee replacement. Patients were reviewed clinically and radiographically a minimum of 6 months after surgery. Results: The advantages of total knee replacement were a greater proportion of patients returned to independent walking, rehabilitation was more rapid, and knee flexion was better. The advantages of internal fixation were a decreased need of blood transfusion, a smaller proportion of patients reported knee pain at follow up, and a better mean Oxford knee score at follow up. Anaesthetic time and level of patient satisfaction at follow up were similar. There were no peri-operative deaths. Conclusion: In this preliminary study, total knee replacement was a reasonable alternative to internal fixation for the treatment of supracondylar fractures of the distal femur in elderly.

Introduction

Internal fixation of supracondylar fractures of the femur is challenging, particularly in the elderly. It is often impossible to achieve anatomical reduction due to comminution. A stable construct is rarely achieved due to poor bone quality and this restricts early mobilisation. In spite of this, internal fixation is perceived to be the treatment of choice.

Total knee replacement is rarely considered. There are only three reports of its use (in a total of 17 patients) in the English literature.1., 15., 16. There are no published reports on its use in fit and active elderly patients with no pre-existing arthritis. Furthermore, there are no reports which compare total knee replacement with internal fixation, and since published outcome measures vary, comparison between different papers is impossible. As a result, it is not possible to conclude from the literature whether total knee replacement is comparable to internal fixation.

Section snippets

Objective

The aim of this study was to compare the short and medium term outcome of fixation and total knee replacement for supracondylar fractures of the femur in medically fit active elderly patients with no pre-existing arthritis in order to determine whether total knee replacement can be used as an alternative to internal fixation.

Patients and methods

All patients who underwent operations for supracondylar fractures of the distal femur between March 1998 and July 2002 were identified from databases at both institutions. Information was also obtained retrospectively from hospital medical, nursing, physiotherapy and occupational therapy notes, community hospital nursing and physiotherapy notes and radiographs.

Rigorous inclusion criteria were required in order to make valid comparisons between patients who underwent internal fixation and those

Results

We identified nine patients who had undergone total knee replacement for supracondylar fractures of the distal femur. We excluded three patients for the following reasons. One of them did not walk before she sustained her fracture and had an ASA grade of four. She died on the same day as her operation. The other two patients (aged 94 and 96) did not walk before they sustained their fracture and had ASA grades of three. Their post-operative recovery was complicated by multiple medical problems.

Discussion

In 1970, the AO group14 showed that, contrary to prevailing opinion,8., 13. good outcomes could be achieved with internal fixation of supracondylar fractures of the distal femur. Their results were obtained using the principles of accurate anatomical reduction, stable internal fixation, and early motion. By adhering to these same principles, Schatzker et al.10 showed that the results obtained by the AO group were reproducible.

Up to 100% good or excellent results have been reported with various

Conclusion

In this preliminary study, total knee replacement for the treatment of supracondylar fractures of the distal femur in the elderly had advantages over internal fixation for the patient and economic advantages for health care providers. It was a reasonable alternative to internal fixation. In order to reach statistically valid conclusions regarding the best management of these difficult fractures, a prospective randomised trial is required. Given that these fractures are relatively uncommon, this

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