**4. Periprosthetic fracture**

Periprosthetic fracture after TKA is found increasingly in recent years due to a large number of performed TKAs and growing of geriatric population. This serious complication is impact to the quality of life and functional recovery of the patients, which is recognized to develop high morbidity and mortality [32]. The incidence


*Complications after Total Knee Arthroplasty: Stiffness, Periprosthetic Joint Infection… DOI: http://dx.doi.org/10.5772/intechopen.105745*

### **Table 4.**

*Tsukayama classification and treatment options.*

of fracture following TKA varies from 0.3 to 5.5 percent in primary knee replacement and has been reported as high as 30 percent in revision knee surgery [33, 34]. The most common site of fracture is a supracondylar area of the distal femur which occurs ranging from 0.3 to 2.5 percent [32, 35], followed by patellar periprosthetic fracture, especially in the resurfaced patella, with an incidence around 0.68 percent. However, the true incidence of this type of fracture may be obscured from undetected and asymptomatic patients [36]. The least common pattern is a proximal tibial fracture which affected approximately 0.3 to 0.5 percent [37]. Most frequently, periprosthetic fracture results from low-energy trauma, and osteoporosis is considered a significant predictor of fracture risk [38]. The other predisposing factors are any causes that affected bone quality, for example, prolonged corticosteroid

use, inflammatory joint diseases, especially rheumatoid arthritis, and patients with neurological and musculoskeletal problems, which have a high risk of falls [32, 35]. Iatrogenic causes from surgical procedure including anterior femoral notching, or alteration of anterior femoral cortex during bone preparation of distal femur is theorized to be an association of supracondylar femoral fracture after TKA [35]. A biomechanical study by Lesh et al. revealed a reduction of torsional strength and bending strength of the distal femur by 39.2 and 18 percent, respectively, after the full-thickness cortical defect was created [39]. However, the clinical outcome is still controversial [32, 40, 41]. The risk factors of periprosthetic tibial fractures in TKA are the use of long tibial stems, cementless press-fit fixation, malalignment of tibial component, and previous osteotomy of the tibia [37]. All other predisposing factors are detailed in **Table 5** [42].


#### **Table 5.**

*Predisposing factors associated with periprosthetic fractures after TKA.*
