Distal femoral fractures treated by hinged

total knee replacement in elderly patients

P. Appleton, Although the use of constrained cemented arthroplasty to treat distal femoral fractures in
M. Moran, elderly patients has some practical advantages over the use of techniques of fixation,
S. Houshian, concerns as to a high rate of loosening after implantation of these prostheses has raised
C. M. Robinson doubts about their use. We evaluated the results of hinged total knee replacement in the
treatment of 54 fractures in 52 patients with a mean age of 82 years (55 to 98), who were
From The New Royal socially dependent and poorly mobile.
Infirmary of Within the first year after implantation 22 of the 54 patients had died, six had undergone
Edinburgh, a further operation and two required a revision of the prosthesis. The subsequent rate of
Edinburgh, Scotland further surgery and revision was low.
A constrained knee prosthesis offers a useful alternative treatment to internal fixation in
selected elderly patients with these fractures, and has a high probability of surviving as
long as the patient into whom it has been implanted.

P. Appleton, MD, Consultant
Orthopaedic Surgeon

M. Moran, MRCS Ed,
Orthopaedic Specialist
Registrar

S. Houshian, FRCS Ed(Orth),
Orthopaedic Specialist
Registrar

C. M. Robinson, FRCS
Ed(Orth), Consultant
Orthopaedic Surgeon
The Edinburgh Orthopaedic
Trauma Unit
The New Royal Infirmary of
Edinburgh, Old Dalkeith Road,
Edinburgh EH16 4SU, UK.
Correspondence should be sent
to Mr C. M. Robinson; e-mail:
c.mike.robinson@ed.ac.uk
©2006 British Editorial Society
of Bone and Joint Surgery
doi:10.1302/0301-620X.88B8.
17878 $2.00
J Bone Joint Surg [Br]
2006;88-B:1065-70.
Received 13 March 2006;
Accepted after revision 17 May
2006
In patients with distal femoral metaphyseal
fractures, open reduction and internal fixation,
using either screw-plate or blade-plate devices,
has traditionally been considered to be the
most appropriate treatment,1-7 although the
recent development of femoral locking plates8-12
and retrograde intramedullary nails13-17 has
allowed this surgery to be performed in a less
invasive manner. However, such fractures are
usually comminuted and occur more often in
elderly patients with osteoporosis who may
have pre-existing osteoarthritis of the knee or
hip implants.14,18-21 In these circumstances,
stable reduction and osteosynthesis may not be
achievable and if fixation fails, further surgery
may be required.22 Even with a successful re-
construction, the internal fixation may not be
stable enough to allow early weight-bearing
and splintage of the limb may be needed.23
The elderly patients who sustain these inju-
ries usually have limited functional expecta-
tions, and there is a high mortality within the
first year after injury.19,22 In order to reduce the
risk of complications the use of a hinged joint
replacement as a primary definitive treatment
in this group of frail individuals is an alterna-
tive to internal fixation. The benefits of this
approach have been demonstrated previously
in the treatment of fractures around the hip,24
shoulder25 and distal humerus.26 We have pre-
viously reported a low risk of early complica-
tions using this technique, as have others.27-34
However, the high rate of loosening and
mechanical failure of this type of prosthesis,
when used to treat degenerative arthritis of the
knee,35-38 raises concerns about whether simi-
lar complications may occur when managing
fractures around the knee.
To our knowledge a comprehensive review
of the long-term outcome of this method of
treatment in a large series has not been under-
taken. Our aim was to evaluate the mortality,
the incidence of peri-operative complications
and the subsequent level of social dependency
in a large series of patients treated by this tech-
nique. In addition, we have assessed the longer
term prosthetic survival to revision for
implant-related complications.
Patients and Methods
Between 1987 and 2004, we treated 54 dis-
placed distal femoral metaphyseal fractures in
52 patients with a primary cemented hinged
total knee replacement. In the two patients
with bilateral fractures the injuries were three
and five years apart. Use of the technique was
restricted to those aged 55 years or older who
were socially dependent, either living in the
community with support from social services
or from relatives, or living in residential or
institutional care, and not able to walk outside,
but medically fit for anaesthesia. There were
three men and 49 women with a mean age of
82 years (55 to 98). Only four were aged under

VOL. 88-B, No. 8, AUGUST 2006 1065

1066 P. APPLETON, M. MORAN, S. HOUSHIAN, C. M. ROBINSON
70 years. Of the 52 patients, nine (17%) were unable to
walk, 25 (48%) walked with the assistance of a Zimmer
frame or two helpers, 11 (21%) used one walking aid or
one helper, and seven (14%) could walk without assistance.
None regularly walked outside their residence and all of the
injuries were sustained in simple domestic falls from or
below standing height. Evidence of chronic cognitive
impairment was present in 23 patients (44%). Before their
injury, ten (19%) were living in the community, with sup-
port from social services or relatives, while the remaining
42 (81%) were in residential accommodation or long-term
care in either an institution or nursing home.
Demographic information on all patients was prospec-
tively coded onto a trauma database. The early and late
post-operative complications, including prosthetic revision,
were also recorded in the patient’s trauma records. Since
our hospital provides the only source of care of orthopaedic
trauma for the local community, no patient who was locally
resident was treated elsewhere.
A single observer (SH) retrospectively classified the ori-
ginal anteroposterior and lateral radiographs. Using the
AO system for distal femoral metaphyseal fractures,39 nine
(17%) were ‘low’ type 33-A3 (extra-articular but commi-
nuted) and 45 (83%) were type 33-C (bicondylar articular)
fractures. Minor age-related wear changes were apparent
radiologically in most knees on the pre-operative radio-
graphs, but 12 (22%) had severe degenerative changes of
the knee at the time of surgery. Of the 54 fractured limbs,
22 (41%) had previously undergone surgery to the hip.
Fracture implants were present in 19 (86%) of these
patients with 14 dynamic hip screws and five hemiarthro-
plasties, while the remaining three patients (14%) had pre-
viously undergone cemented total hip replacement for
osteoarthritis.
Operative technique. Six orthopaedic traumatologists who
were experienced in the use of the technique performed all
the operations. We used standard pre-operative antithrom-
botic (low molecular weight heparin) and antibiotic (broad-
spectrum cephalosporian) prophylaxis. The surgery was
performed under general or spinal anaesthesia within five
days of injury, under tourniquet control using a midline lon-
gitudinal incision and a medial parapatellar approach. The
femur distal to the fracture was excised with its attached
collateral ligaments and the tibial articular surface was
excised. Two fractures were treated using a Kotz prosthesis
(Stryker-Howmedica, Newbury, United Kingdom) early in
the series. We subsequently used the Guepar prosthesis
(Stryker-Howmedica) for 38 fractures treated between
1987 and 1999 and the Stanmore hinged prosthesis
(Biomet, Bridgend, United Kingdom) to treat the remaining
14 fractures between 1999 and 2004. All of these pros-
theses were non-customised implants with long-stemmed
femoral and tibial components linked intra-operatively
using a transverse metal rod and polyethylene bushings.
Trial components were initially assembled uncemented
to ensure adequate anatomical restoration of the joint line
and soft-tissue tensioning. After medullary lavage and dry-
ing of the medullary canals, both femoral and tibial
components were cemented into place and re-coupled. The
canals were unplugged and the cement was injected retro-
grade and pressurised. We also used bone cement to fill up
significant metaphyseal bone defects in the distal femur.
Post-operatively, no splints or orthoses were used and all
patients who were able to walk before their injury were
mobilised with the re-introduction of weight-bearing as tol-
erated from the second post-operative day. No specific
mobilisation programme was instituted, other than physio-
therapy and occupational therapy to supervise and regain
confidence with the use of walking aids to improve mobility.
Assessment of outcome and evaluation of results. Since the
purpose of our review was a pragmatic assessment of the
consequence of our treatment policy in a selected elderly
group of patients, we used mortality, length of hospital stay,
restoration of mobility, the incidence of post-operative
complications relating to the implant and prosthetic sur-
vival as the main outcome measures. Since the procedure
was used only in patients who were relatively immobile and
often frail or mentally impaired, we found that it was
impractical to obtain functional assessment using standard
knee functional scoring systems. We linked our patients’
clinical information to the computerised local registry of
deaths to gather information on post-injury mortality and
to analyse prosthetic survival.
Results
The mean length of in-patient stay in our acute trauma ser-
vice ward was 15 days (12 to 23). Two patients died from
pneumonia and one from cardiac failure in the first ten days
after surgery. Of the 39 patients (75%) who had been living
in residential accommodation or long-term institutional or
nursing home care before injury and who survived the
period in the acute ward, 12 (31%) were transferred
directly back to their previous residence from the acute
ward and 27 (69%) for rehabilitation in an orthogeriatric
assessment unit. Of these patients, 18 (67%) eventually
returned to their previous accommodation and nine (33%)
died on the rehabilitation ward. Of the ten surviving
patients (19%) who were admitted from their own homes
or sheltered housing before their injury, only two (20%)
were able to be discharged directly home, while the remain-
ing eight (80%) required a period of rehabilitation. Of
these patients, three ultimately required private nursing-
home care, two were able to be discharged back to their
previous residence after rehabilitation and three died in the
rehabilitation ward. At one year after injury, 22 patients
(42%) had died, but among the survivors the level of
dependency in their place of residence was not altered, and
all had regained their previous level of mobility.
Survival analysis showed that the mortality within the
first year after fracture was 41.1% (95% confidence inter-
val (CI) 27.9 to 54.3) rising to 82.0% (95% CI 71.1 to
92.9) after five years and 97.3% (95% CI 92.2 to 100) after
THE JOURNAL OF BONE AND JOINT SURGERY
 DISTAL FEMORAL FRACTURES TREATED BY HINGED TOTAL KNEE REPLACEMENT IN ELDERLY PATIENTS 1067

Table I. Survival analysis for death after implantation of a primary hinged total knee replacement

Number Cumulative percentage of

Start time Number entering withdrawn due to Number Number of deaths patients who had died at the
(yrs) per year loss to follow-up at risk during the year end of the time period (95% CI)*
0 54 1 53.5 22 41.1 (27.9 to 54.3)
1 31 0 31 8 56.3 (43.0 to 69.6)
2 23 2 22 2 60.3 (47.1 to 73.5)
3 19 0 19 4 68.6 (55.9 to 81.3)
4 15 1 14.5 2 73.0 (60.7 to 85.3)
5 12 0 12 4 82.0 (71.1 to 92.9)
6 8 0 8 0 82.0 (71.1 to 92.9)
7 8 0 8 1 84.2 (73.8 to 94.6)
8 7 1 6.5 1 86.7 (76.9 to 96.5)
9 5 0 5 2 92.0 (83.8 to 100)
10 3 0 3 2 97.3 (92.2 to 100)
* 95% CI, 95% confidence interval

Table II. Survival analysis for re-operation after implantation of a primary hinged total knee replacement

Number withdrawn Cumulative percentage of patients

Start time Number entering due to death or loss Number Number of who had undergone re-operation at
(yrs) per year to follow-up at risk re-operations the end of the time period (95% CI)*
0 54 20 44 6 13.6 (3.4 to 23.8)
1 28 7 24.5 0 13.6 (3.4 to 23.8)
2 21 3 19.5 1 18.1 (5.4 to 30.8)
3 17 4 15 0 18.1 (5.4 to 30.8)
4 13 3 11.5 0 18.1 (5.4 to 30.8)
5 10 3 8.5 0 18.1 (5.4 to 30.8)
6 7 0 7 0 18.1 (5.4 to 30.8)
7 7 1 6.5 0 18.1 (5.4 to 30.8)
8 6 2 5 0 18.1 (5.4 to 30.8)
9 4 1 3.5 0 18.1 (5.4 to 30.8)
10 3 2 2 0 18.1 (5.4 to 30.8)
* 95% CI, 95% confidence interval

ten years (Table I). The median survival after fracture was
1.7 years (95% CI 0.9 to 2.5). In all cases the cause of death
on certification was attributed to medical co-morbidities,
most commonly cardiopulmonary disease and dissemi-
nated malignancy.
Since a considerable number of the patients did not sur-
vive long enough to develop implant-related complications,
we used survival analysis to assess the rate of re-operation
and that of prosthetic revision. With censorship of patients
at the time of death or loss to follow-up, the cumulative
rate of re-operation for a fracture-related complication at
one year after injury was 13.6% (95% CI 3.4 to 23.8)
which rose to 18.1% (95% CI 5.4 to 30.8) by three years
(Table II), but with no further re-operation.
Of the seven patients who required a further procedure,
one developed an acutely ischaemic foot 25 months after
the initial operation and required an above-knee amputa-
tion. One developed a post-operative haematoma of the
wound, which was successfully treated by surgical evacua-
tion, lavage and immediate wound closure. This patient
later ruptured a patellar tendon 15 months after surgery
and had a successful repair without further complications.
One patient developed a deep wound infection, which was
uncontrolled by repeated debridement and eventually
required an above-knee amputation.
Four patients sustained a peri-prosthetic fracture at the
tip of the femoral component in simple falls within the first
three months after implantation (Fig. 1). Three of these
fractures occurred between the hinged knee and a previ-
ously inserted hip implant (two cemented total hip replace-
ments and one dynamic hip screw). All were treated by
open reduction and plate fixation, supplemented by cer-
clage wiring (Fig. 1). In three of these patients the original
hinged knee was retained and in one revision of the femoral
component was required for loosening of the cement
mantle. All four peri-prosthetic fractures healed satisfacto-
rily.
Three patients required revision or removal of the origi-
nal total knee replacement (two above-knee amputations
and one peri-prosthetic fracture with a loose prosthesis)
producing a cumulative rate of revision of the original knee
replacement on survival analysis of 4.6% (95% CI 0 to
10.9) at one year after injury, rising to 9.1% (95% CI 0 to
19.7) at three years, but with no further revisions thereafter
(Table III).
Discussion
We have described the results of treatment in a small well-
defined group of elderly, dependent and medically frail
patients with difficult fractures of the distal femur in whom

VOL. 88-B, No. 8, AUGUST 2006

1068 P. APPLETON, M. MORAN, S. HOUSHIAN, C. M. ROBINSON

Fig. 1a Fig. 1b

Figure 1a – Anteroposterior and lateral radiographs of

an 83-year-old woman who fell sustaining an AO type
33-C distal femoral metaphyseal fracture with dis-
placement. Figure 1b – Since she was relatively immo-
bile, the fracture was initially treated by a Stanmore
hinged knee replacement. She fell again six weeks
later sustaining a peri-prosthetic fracture at the tip of
the stemmed femoral component. Figure 1c – The frac-
ture was treated by open reduction and plate fixation
with cerclage wiring. Although her peri-prosthetic frac-
ture subsequently healed, she died 14 months later.

Fig. 1c

Table III. Survival analysis for revision of the prosthesis after implantation of a primary hinged total knee replacement

Number withdrawn Cumulative percentage of patients

Start time Number entering due to death or loss Number Number of who had undergone revision at the
(yrs) per year to follow-up at risk revisions end of the time period (95% CI)*
0 54 21 43.5 2 4.6 (0 to 10.9)
1 31 8 27 0 4.6 (0 to 10.9)
2 23 4 21 1 9.1 (0 to 19.7)
3 18 4 16 0 9.1 (0 to 19.7)
4 14 3 12.5 0 9.1 (0 to 19.7)
5 11 3 9.5 0 9.1 (0 to 19.7)
6 8 0 8 0 9.1 (0 to 19.7)
7 8 1 7.5 0 9.1 (0 to 19.7)
8 7 2 6 0 9.1 (0 to 19.7)
9 5 2 4 0 9.1 (0 to 19.7)
10 3 2 2 0 9.1 (0 to 19.7)
* 95% CI, 95% confidence interval

the anticipated results from either non-operative treatment bidities in this group is greater than that for patients with
or operative reduction and internal fixation would have proximal femoral fractures.40,41 The goals of treatment dif-
been poor. Our results show that the mortality rate during fer from those in younger patients, with the main aim being
the first post-operative year of 4.1% from medical co-mor- the early restoration of a stable limb which will allow the

THE JOURNAL OF BONE AND JOINT SURGERY

 DISTAL FEMORAL FRACTURES TREATED BY HINGED TOTAL KNEE REPLACEMENT IN ELDERLY PATIENTS
patient to mobilise or transfer at an early stage, depending
on their previous level of mobility.
The use of a hinged knee replacement satisfies these
requirements. Most of our patients were allowed to mobil-
ise at an early stage without needing ancillary splintage,
and their period of acute in-patient stay was minimised
before discharge back to their previous level of accommo-
dation or transfer to an orthogeriatric rehabilitation unit.
The mean length of in-patient stay of our patients was 15
days, which compares favourably with a mean stay of 31
days when internal fixation techniques were used.2,5,6,14,19
There was subsequently an increase in the level of social
dependency in some of the surviving patients, which
reflected their declining physiological status, rather than
impairment of their mobility from the fracture, since the
pre-injury level of mobility was restored in the surviving
patients at one year after injury.
Previous studies have reported the use of knee replace-
ment to treat 68 distal femoral fractures, including 22
established cases of nonunion and 46 acute fractures.27-34,42
The surgical techniques and type of prosthesis have varied
considerably, ranging from excision of the fracture frag-
ments and implantation of a constrained replace-
ment,27,29,31,32 fracture fixation and simultaneous primary
unconstrained replacement33 and primary unconstrained
replacement with a long-stemmed femoral compo-
nent.28,30,42 Retention of the fracture fragments with their
attached collateral ligaments allows the use of a primary
resurfacing knee replacement, rather than a constrained
prosthesis. However, the use of a resurfacing replacement in
an elderly patient increases the risk of fracture-related com-
plications, and it is probably best reserved for younger
patients with more proximal extra-articular AO type 33-A
fractures with a large distal fragment and co-existing
osteoarthritis of the knee.
Our series represents the largest study of the use of a
hinged knee replacement to treat distal femoral fractures to
date. We have been able to quantify the risks of post-oper-
ative complications, implant survival and mortality. How-
ever, because of the poor physiological status of the
patients who were selected to undergo this procedure, and
who were unable to complete detailed functional outcome
questionnaires, we were unable to make any detailed state-
ments about how these prostheses functioned once
implanted.
Other techniques, such as the 95˚ dynamic condylar
screw4 or blade plate1 and more recently retrograde locked
intramedullary nailing14 and minimally-invasive locked
plate fixation8 have been used successfully, even in elderly
patients. However, in such patients it is rare for open reduc-
tion and internal fixation to restore sufficient stability to
allow early mobilisation and weight-bearing, and supple-
mentary support with a brace may be required.19 In addi-
tion, complications requiring further surgery for either
infection, fixation failure or nonunion are more likely to
occur when these techniques are used.
VOL. 88-B, No. 8, AUGUST 2006
1069
Peri-prosthetic fracture within the first three months
after surgery was the most common and most serious early
post-operative complication. Despite the small numbers of
patients involved, the presence of a hip implant appeared to
be associated with an increased risk of this occurrence,
since peri-prosthetic fractures occurred in three of the 22
femora (14%) with a pre-existing hip prosthesis, and in
only one of the remaining 32 (3%) with no hip implant.
The presence of two long-stemmed implants introduced
through opposite ends of the femur produces a substantial
stress riser when the two implants meet at the femoral isth-
mus. The increased risk of peri-prosthetic fracture in the
presence of a previous hip implant is therefore not confined
to the use of a long stemmed total knee replacement to treat
the distal femoral fracture, and may also occur when either
intramedullary nailing or plate fixation are used.
This technique provides a relatively simple method of
treatment for a difficult fracture. With appropriate patient
selection, the prosthesis has a high probability of surviving
as long as the patient into whom it is implanted, and if there
is co-existing symptomatic arthritis of the knee, this may be
definitively treated by the surgery. The subsequent risk of
nonunion is abolished, and the risk of implant failure,
malalignment and deep infection is low. However, the tech-
nique should be used with caution in the presence of a pre-
existing proximal hip implant, in which case the best treat-
ment has still to be identified. A prospective, randomised
trial of the use of primary knee replacement compared with
newer fixation techniques, such as minimally-invasive
locked plating, is needed to address the relative merits of
each method.
Supplementary Material
A table showing the details of a literature review, and
a full list of references is available with the electronic
version of this article on our website at www.jbjs.org.uk
We would like to thank the other Consultants working in the Edinburgh Ortho-
paedic Trauma Unit for allowing access to details of patients under their care.
No benefits in any form have been received or will be received from a com-
mercial party related directly or indirectly to the subject of this article.
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