Technical Note The Use of a Revision Femoral Stem to Manage a Distal Femoral Periprosthetic Fracture in a Well-Fixed Total Knee Arthroplasty Richard P. Jeavons, MRCSed, Daniel Dowen, MRCSed, and Shaun O'Brien, FRCSorth Abstract: Managing very distal femoral periprosthetic fracture above a total knee arthroplasty (TKA) is a difficult problem. When a cruciate sacrificing TKA is used, bone stock around the implant is compromised and, therefore, can limit fixation options. We present technique using the revision system femoral stem for the PFC Sigma TKA (Depuy; Leeds, England) to stabilize this particular type of fracture. Keywords: total knee arthroplasty, periprosthetic fracture, intramedullary canal, revision arthroplasty. © 2012 Elsevier Inc. All rights reserved. The management of periprosthetic fractures around a total knee arthroplasty (TKA) is a complex problem. Depending on the level of fracture, multiple methods of fixation have been described including open reduction and internal fixation with plate and screw constructs, fixed angle devices, and intramedullary (IM) nailing as well as conservative measures. When fractures occur adjacent to a cruciate sacrificing (CS) replacement, fixation options become limited as the intercondylar box preparation requires resection of bone stock and the box itself can prevent distal screw placement for many constructs. Intramedullary techniques cannot be used, as passage through the box is not always possible. Here, we present a method of IM fixation not previously described but worth considering when faced with a distal fracture of the femur close to a well-fixed femoral component of a CS TKA. Case Report An 84-year-old woman was admitted to the trauma and orthopedic department after a simple trip and fall. She complained of significant pain in her left total knee replacement and an inability to weight bare. It was 3 months after a left primary PFC sigma posterior cruciate substituting total knee replacement (Depuy; Leeds, England). Radiographs revealed a transverse type fracture, with a split extending proximally, close to the femoral component of the distal femur (Fig. 1). The femoral component was well fixed to the fracture fragment. Intramedullary stabilization was the fixation method of choice, as there was insufficient bone stock for a periarticular locking plate. However, because of the intercondylar box of the CS implant, a standard retrograde nailing technique would have proven impossible. The idea to use the femoral stem from the TC3 revision system (Depuy) became apparent. The femoral stem screws into the intercondylar box attached to the CS femoral component. Fixation using this method was undertaken. The patient made an uneventful postoperative recovery and was discharged a few days later. At 3 months, she had a well-healed scar and a range of movement from 0° to 110° flexion. Check x-rays showed her fracture was in good alignment and healing. She progressed well over the next 18 months, and on most recent follow up at 2 years, the fracture was healed; the TKA, well fixed (Fig. 2); and the patient had no discomfort. She was pleased with her outcome, walking with no aids again. Description of Technique Under general anesthesia and using a high thigh tourniquet at 300 mm Hg, the old midline incision was From the Department of Trauma and Orthopaedics, Sunderland Royal Hospital, Sunderland, UK. Submitted August 11, 2010; accepted June 15, 2011. The Conflict of Interest statement associated with this article can be found at doi:10.1016/j.arth.2011.06.036. Reprint requests: Richard P. Jeavons, MRCSed, 38 The Wynd, Wynyard, Cleveland, United Kingdom, TS22 5QE. © 2012 Elsevier Inc. All rights reserved. 0883-5403/2701-0026$36.00/0 doi:10.1016/j.arth.2011.06.036 156 The Journal of Arthroplasty Vol. 27 No. 1 2012