A new classification of TKA periprosthetic femur fractures considering the implant type

Johannes K. M. Fakler, Cathleen Pönick, Melanie Edel, Robert Möbius, Alexander Giselher Brand, Andreas Roth, Christoph Josten, Dirk Zajonz

The treatment aims of periprosthetic fractures (PPF) of the distal femur are a gentle stabilization, an early load-bearing capacity and a rapid postoperative mobilization of the affected patients. For the therapy planning of PPF a standardized classification is necessary which leads to a clear and safe therapy recommendation. Despite different established classifications, there is none that includes the types of prosthesis used in the assessment. For this purpose, the objective of this work is to create a new more extensive fracture and implant-related classification of periprosthetic fractures of the distal femur based on available classifications which allows distinct therapeutic recommendations. In a retrospective analysis all patients who were treated in the University Hospital Leipzig from 2010 to 2016 due to a distal femur fracture with total knee arthroplasty (TKA) were established. To create an implant-associated classification the cases were discussed in a panel of experienced orthopaedists and well-practiced traumatologists with a great knowledge in the field of endoprosthetics and fracture care. In this context, two experienced surgeons classified 55 consecutive fractures according to Su et al., Lewis and Rorabeck and by the new created classification. In this regard, the interobserver reliability was determined for two independent raters in terms of Cohen Kappa. On the basis of the most widely recognized classifications of Su et al. as well as Lewis and Rorabeck, we established an implant-dependent classification for PPF of the distal femur. In accordance with the two stated classifications four fracture types were created and defined. Moreover, the four most frequent prosthesis types were integrated. Finally, a new classification with 16 subtypes was generated based on four types of fracture and four types of prosthesis. Considering all cases the presented implant-associated classification (κ = 0.74) showed a considerably higher interobserver reliability compared to the other classifications of Su et al. (κ = 0.39) as well as Lewis and Rorabeck (κ = 0.31). Excluding the cases which were only assessable by the new classification, it still shows a higher interobserver reliability (κ = 0.70) than the other ones (κ = 0.63 or κ = 0.45). The new classification system for PPF of the distal femur following TKA considers fracture location and implant type. It is easy to use, shows agood interobserver reliability and allows conclusions to be drawn on treatment recommendations. Moreover, further studies on the evaluation of the classification are necessary and planned.