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Tibial fracture fixation: Peri-prosthetic fracture fixed with Zimmer Biomet non-contact bridging system (NCB-PT)

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Periprosthetic fractures of the femur following total hip replacement are more common than periprosthetic fractures of the tibia following total knee replacement.  However, given the demographic of an ageing populations and increased availability of arthroplasty, the incidence of these complex tibial fractures continues to grow.

With total knee replacements, fractures around the femoral component are in fact far more common than fractures around the tibial component, which may be one of the reasons that far less has been published on the optimal strategies for managing periprosthetic fractures around the tibial component of a total knee replacement.

The two key questions to ask yourself before managing a periprosthetic tibial fracture are:

  1. Which structures have been affected by the fracture line (a partial plateau fracture, a complete plateau fracture or a fracture below the stem of the prosthesis, for example).
  2. Whether the tibial component is well-fixed or has loosened.

There are two classification systems in use and these are the AO whose classification system (UCPF) provides detailed specific anatomical information, and the Felix classification system which correlates their classifications with outcome.  Unfortunately, neither of these is overly used in the published literature.

The Felix classification has four groups which are defined by the location of the fracture line.

Type 1:    Partially crosses the tibial plateau.

Type 2:    Fully across the tibial plateau.

Type 3:    Across the tibial shaft distal to the tibial implant stem.

Type 4:    Through the tibial tubercle.

Each of these types can further be classified into two subgroups, with a Type A denoting a stable prosthesis and a Type B an unstable prosthesis.

If the prosthesis is loose then a revision of the tibial component needs to be given strong consideration.  If, however, the tibial component is well-fixed, then further consideration is given to the fracture. The specific questions to be answered are:

Firstly, is the fracture unstable ?, and if not it could be treated conservatively.  If it is, then open reduction internal fixation would be recommended.

Revision total knee replacement with various different modular and custom stems are well documented elsewhere on the OrthOracle platform.

If the fracture is stable , then it could be treated conservatively.  If however, the configuration is unstable, then open reduction internal fixation is recommended in the presence of a well-fixed prosthesis.

It is key that any implant used has multiple options for a fixation in particular in terms of being able to angle screws to avoid both prosthesis and the cement mantle.

I favour the Zimmer Biomet non-contact bridging system (NCB-PT).  This is an anterolateral plate which is anatomically contoured and also has a polyaxial locking mechanism.  The whole geometry for the screws allows poly-axial insertion of the screws with up to 15° of deviation from an axis that is perpendicular to the plate.  Both cortical and cancellous screws can be used, and once the screws are fully seated home, then a locking cap is used to fix the head of the screw into the plate.  Fragments can also be lagged to the plate with a standard technique since the screw is only locked as a final and secondary step.

Author: Professor Peter Biberthaler MD.

Institution: Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.

Clinicians should seek clarification on whether any implant demonstrated is licensed for use in their own country.

In the USA contact: fda.gov
In the UK contact: gov.uk
In the EU contact: ema.europa.eu

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