JBJS | The Consequences of Anterior Femoral Notching in Total Knee Arthroplasty : A Biomechanical Study*

The Journal of Bone & Joint Surgery, Volume 82, Issue 8

Articles | August 01, 2000

The Consequences of Anterior Femoral Notching in Total Knee Arthroplasty : A Biomechanical Study*

Mark L. Lesh, M.D.; David J. Schneider, M.D.; Gurvinder Deol, M.D.; Barclay Davis, M.S.; Christopher R. Jacobs, Ph.D.; Vincent D. PelligriniJr., M.D.

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Investigation performed at the Department of Orthopaedics and Rehabilitation, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
Department of Orthopaedics and Rehabilitation, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, P.O. Box 850, 500 University Drive, Hershey, Pennsylvania 17033. E-mail address for V. D. Pellegrini, Jr.: vpellegrini@psu.edu.

The Journal of Bone & Joint Surgery. 2000; 82:1096-1096

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Abstract

Background: Notching of the anterior femoral cortex during total knee arthroplasty has been implicated as a cause of subsequent periprosthetic supracondylar femoral fracture. However, other than observational clinical data, no reliable association between these events has been established, to our knowledge. The purpose of the present study was to investigate the biomechanical effects of notching of the anterior femoral cortex.

Methods: The femoral component of a total knee replacement was implanted in twelve matched pairs of human cadaveric femora; one specimen in each pair had preservation of the anterior femoral cortex, and the other had a full-thickness cortical defect created just proximal to the anterior flange of the femoral component. The pairs were then subjected to either bending or torsional loading to failure. Both the fracture pattern and the quantitative load to failure were analyzed. Two matched pairs were excluded from the analysis because of inadvertent fracture during placement of the component.

Results: Following the application of a bending load, femora with notching of the anterior femoral cortex sustained a short oblique fracture that originated at the cortical defect proximal to the femoral component and femora without notching had a midshaft fracture. In contrast, notching of the anterior femoral cortex had no effect on the fracture pattern that was observed after the application of a torsional load. The mean load to failure was significantly reduced by notching in both testing modes. Notching decreased bending strength from 11,813 to 9690 newtons (18 percent; p = 0.0034), and it decreased torsional strength from 134.7 to 81.8 newton-meters (39.2 percent; p = 0.01).

Conclusions: Biomechanical testing demonstrated that notching of the anterior femoral cortex significantly lessens the load to failure following total knee arthroplasty and influences the subsequent fracture pattern. These effects are manifested in different ways under the two loading conditions: the fracture pattern is altered under bending load, and there is a greater quantitative decrease in load to failure with torsional loading.

Clinical Relevance: Weakening of the femur by notching of the anterior cortex after total knee arthroplasty may warrant alteration in the customary postoperative regimen for these patients. Manipulation of a total knee replacement with a notched anterior femoral cortex should probably be avoided.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Total joint arthroplasty has greatly improved the treatment of disabling arthritis of the knee, but it is not without complications, including supracondylar fracture of the femur. Notching of the anterior femoral cortex during total knee arthroplasty has been implicated as one factor contributing to these periprosthetic femoral fractures. The prevalence of inadvertent cortical notching of the femur during total knee arthroplasty has been reported to be as high as 27 percent (180 of 670 knees)⁸, but we found no studies in the literature quantifying the effects of notching on the strength of the total knee construct. Therefore, the need for modification of postoperative care of patients with a notched femur after total knee replacement is uncertain. Accordingly, the purpose of the present study was to quantify the reduction in bending and torsional strength resulting from femoral notching in an attempt to provide the clinician with useful information related to the postoperative management of these patients.

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Fig. 1:: Lateral radiograph of a matched pair of femora, with a full-thickness cortical defect in the specimen on the left.

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Fig. 2:: Illustration of the experimental setup for the bending test.

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Fig. 3:: Drawing, from a lateral view, of a specimen with a full-thickness cortical notch and a fracture that extends from the cortical defect.

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Fig. 4:: Drawing, from a lateral view, of a control specimen with a fracture proximal to the instrumentation.

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Fig. 5:: Graph showing the mean bending load to failure (and standard error of the mean) for the notched and the control specimens.

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Fig. 6:: Graph showing the results of bending load to failure for the individual pairs.

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Fig. 7:: Graph showing the mean torsional load to failure (and standard error of the mean) for the notched and the control specimens.

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Fig. 8:: Graph showing the results of torsional load to failure for the individual pairs.

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TABLE I: Prevalence of Supracondylar Fracture After Total Knee Arthroplasty

Study	Total No. of Knees	No. (Percent) of Knees with Fracture
Merkel and Johnson⁷	5233	36 (0.69)
Ritter et al.⁸	670	2 (0.30)
Figgie et al.⁴	567	24 (4.20)
Aaron and Scott¹	250	5 (2.00)
Overall	6720	67 (1.00)

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TABLE I: Prevalence of Supracondylar Fracture After Total Knee Arthroplasty

Study	Total No. of Knees	No. (Percent) of Knees with Fracture
Merkel and Johnson⁷	5233	36 (0.69)
Ritter et al.⁸	670	2 (0.30)
Figgie et al.⁴	567	24 (4.20)
Aaron and Scott¹	250	5 (2.00)
Overall	6720	67 (1.00)

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TABLE II: Prevalence of Notching in Knees with Periprosthetic Fracture

Study	No. of Knees with Fracture	No. (Percent) of Fractured Knees with Notching
Hirsh et al.⁶	4	1
Healy et al.⁵	23	2 (8.7)
Merkel and Johnson⁷	36	8 (22.2)
Ritter et al.⁸	2	1
Culp et al.³	61	27 (44.3)
Figgie et al.⁴	24	8 (33.3)
Cain et al.²	14	3
Overall	164	50 (30.5)

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TABLE II: Prevalence of Notching in Knees with Periprosthetic Fracture

Study	No. of Knees with Fracture	No. (Percent) of Fractured Knees with Notching
Hirsh et al.⁶	4	1
Healy et al.⁵	23	2 (8.7)
Merkel and Johnson⁷	36	8 (22.2)
Ritter et al.⁸	2	1
Culp et al.³	61	27 (44.3)
Figgie et al.⁴	24	8 (33.3)
Cain et al.²	14	3
Overall	164	50 (30.5)

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TABLE III: Prevalence of Fractures in Knees with and without Notching After Total Knee Arthroplasty

Study	Total No. of Knees	No. (Percent) of Knees with Fracture
Knees with Notching	Knees without Notching
Merkel and Johnson⁷	5233	8 (0.15)	26 (0.49)
Ritter et al.⁸	670	1 (0.15)	1 (0.15)
Figgie et al.⁴	567	8 (1.4)	16 (2.8)
Overall	6470	17 (0.26)	43 (0.66)

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TABLE III: Prevalence of Fractures in Knees with and without Notching After Total Knee Arthroplasty

Study	Total No. of Knees	No. (Percent) of Knees with Fracture
Knees with Notching	Knees without Notching
Merkel and Johnson⁷	5233	8 (0.15)	26 (0.49)
Ritter et al.⁸	670	1 (0.15)	1 (0.15)
Figgie et al.⁴	567	8 (1.4)	16 (2.8)
Overall	6470	17 (0.26)	43 (0.66)

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Twelve matched pairs of femora were harvested from cadavera, with an age at the time of death that ranged from sixty-seven to eighty-four years. A radiograph was made of each specimen to verify a lack of preexisting osseous abnormality. All specimens were frozen at -20 degrees Celsius and stored until testing, and they were thawed overnight prior to experimentation. The right and left specimens of each pair were then randomized to the two testing groups.

Posterior-cruciate-retaining femoral components (Johnson and Johnson, Raynham, Massachusetts) were inserted with cement in both groups. In the control group, the femoral component was placed without notching of the anterior femoral cortex. In the experimental group, the femoral component was malpositioned posteriorly to create a full-thickness anterior cortical defect, or notch, measuring approximately three millimeters in depth. The notch was created in a reproducible manner with the aid of a stylus that allowed visualization of the degree of the cortical defect before the anterior femoral cut was performed. Radiographs were made after the procedure to confirm an intact anterior cortex in the control group and to verify a full-thickness cortical notch in the experimental group (Fig. 1). In addition, the radiographs were used to identify any inadvertent fractures as a result of the placement of the components.

Following fixation with cement, each specimen was potted for mechanical testing in an aluminum cylinder with use of polyester resin and reinforcing pins. The matched pairs were loaded to failure in either bending (Fig. 2) or torsion. For testing in bending, the femora were loaded to failure at a displacement rate of one millimeter per second in an electromechanical materials testing machine (model 30D; Sintech, Cary, North Carolina). For torsional testing, the specimens were loaded to failure at a displacement rate of 1 degree per second in a servohydraulic axial and torsional-loading machine (model 3300; Interlaken, Eden Prairie, Minnesota). Load displacement curves were generated, and load to failure was recorded for each specimen. The results of the matched-pair testing were subjected to statistical analysis with use of a paired t test; a p value of less than 0.05 was considered significant.

A power analysis was performed with use of InStat software (version 2.0; GraphPad, San Diego, California). Given our sample size, the analysis yielded a power of greater than 99 percent for an alpha of 0.05 for bending experimentation and a power of 90 percent for an alpha of 0.05 for torsional testing. In the bending experiment, if one were seeking to detect a significant difference of 1000 newtons, the power would be 90 percent for an alpha of 0.05. In the torsional experiment, if one were seeking to detect a significant difference of thirty-five newton-meters, the power would be 90 percent for an alpha of 0.05. We believe that these values probably represent clinically meaningful changes with weakening of the femur-prosthesis construct.

Results

Introduction | Materials and Methods | Results | Discussion | References

Ten tested pairs of femora were available for statistical analysis. Two matched pairs of the original twelve were excluded because of an inadvertent fracture in one specimen of each pair during placement of the component; both of these fractures occurred in the notched specimens. The first fracture was visually obvious at the time that the component was placed, and the second was noted only radiographically after placement of the component.

Qualitatively, fracture patterns were related to the mode of load application as well as to the integrity of the femur. In the five notched femora subjected to bending load, failure resulted in a short oblique fracture that originated at the site of cortical disruption and extended posteriorly and proximally (Fig. 3). In contrast, when the five specimens with intact cortices were subjected to bending load, they fractured most commonly in the midpart of the shaft at a distance from the proximal margin of the femoral component (Fig. 4). In the torsion group, failure of both the five notched specimens and the five intact specimens resulted in a spiral fracture that originated along the anterior aspect of the bone-component interface and extended proximally. Notching of the anterior part of the femur did not appear to influence the character of the fracture that resulted from torsional loading to failure.

In the bending experiment, the mean load to failure (and standard error of the mean) was 9690 2130 newtons for the notched femora compared with 11,813 1980 newtons for the intact specimens (p = 0.0034) (Fig. 5). The mean decrease in bending strength as a result of notching was 18 percent (range, 8 to 31 percent). Individual variation in bending load to failure among specimens was modest (Fig. 6).

In the torsional test, the mean load to failure (and standard error of the mean) was 81.8 ± 27.95 newton-meters for the notched femora compared with 134.7 ± 35.03 newton-meters for the intact specimens (p = 0.01) (Fig. 7). These results represent a mean decrease in torsional strength of 39.2 percent (range, 19 to 73 percent) as a result of notching. Individual differences in loss of torsional strength were more varied than were the results in the bending group (Fig. 8).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The prevalence of ipsilateral supracondylar femoral fracture in patients with total knee replacement has ranged from 0.30 to 4.2 percent^1,4,7,8 (Table I). The most commonly suggested predisposing factors for a periprosthetic femoral fracture after total knee arthroplasty are osteopenia, revision arthroplasty, rheumatoid arthritis, use of steroids, a neurological disorder, malalignment of the components, and notching of the anterior femoral cortex. Hirsh et al. were the first, as far as we know, to propose that a notch in the anterior cortex of the femur during placement of the component may predispose to fracture⁶. They reported on four knees that had a supracondylar fracture following total knee arthroplasty; one of the fractures was associated with notching of the anterior part of the femur. All of the fractures were transverse or short oblique and had resulted from minimal trauma such as a fall. Culp et al. reported on five patients who had sustained a fracture during manipulation of the knee; four of the knees demonstrated anterior notching³. The bending moment resulted in a transverse or short oblique fracture, which was propagated through the anterior cortical notch defect.

We set out to better define the relationship between anterior cortical notching and subsequent supracondylar femoral fracture with use of quantitative biomechanical testing. In our model, notching significantly reduced the mean load to failure in both bending (p = 0.0034) and torsional (p = 0.01) testing; the reduction in strength observed after torsional loading was more than twice that seen after straight bending. The most commonly reported radiographic patterns are transverse, short oblique, and spiral fractures originating at the notch in the anterior femoral cortex^1-4,6,7. Both short oblique and spiral fracture patterns were reliably reproduced in the present study.

A review of the literature revealed that the prevalence of notching of the anterior femoral cortex has been between 3.5 and 26.9 percent in series ranging in size from 250 to 670 knees^1,4,8. Reports that have implicated notching of the anterior femoral cortex in subsequent periprosthetic fracture have been either anecdotal or retrospective in nature. On the basis of our calculations, fifty (30.5 percent) of 164 supracondylar periprosthetic femoral fractures reported in the literature were associated with intraoperative notching^2-8 (Table II). However, the majority of these patients also had other risk factors for fracture, such as rheumatoid arthritis, osteopenia, steroid use, a neurological disorder, or revision total knee arthroplasty. Clearly, notching of the anterior femoral cortex is neither the only risk factor nor the principal risk factor for supracondylar femoral fracture after knee replacement. Of a total of 6470 total knee arthroplasties included in reports on this subject, only seventeen (0.26 percent) were complicated by a supracondylar femoral fracture associated with anterior cortical notching compared with nearly three times as many fractures that occurred in the absence of notching^4,7,8(Table III) . Ritter et al. studied the prevalence of notching in a large series of patients and attempted to correlate this finding with the prevalence of supracondylar fracture⁸. Of 670 total knee replacements, 138 (20.6 percent) had anterior femoral notching that was more than three millimeters deep. Only two of the 670 knees had a periprosthetic femoral fracture, and only one of the two had a cortical notch. Ritter et al. concluded that there was no association between anterior femoral notching and periprosthetic supracondylar femoral fracture.

To our knowledge, there are no reports of the biomechanical evaluation of notching of the distal part of the femur following total knee arthroplasty. Culp et al. hypothesized that a three-millimeter-deep notch would lead to a 29.2 percent reduction in torsional strength; however, this was not supported by any mechanical testing³. The present study is the first that we are aware of to characterize quantitatively the biomechanical effects of femoral notching following total knee arthroplasty. A mean decrease in bending strength of 18 percent (range, 8 to 31 percent) and a mean reduction in torsional strength of 39.2 percent (range, 19 to 73 percent) were observed in our cadaveric specimens. It might be anticipated from Wolff's law⁹ that the distal part of the femur would strengthen as a result of remodeling; thus, we realize that these reductions in strength may apply only in the immediate postoperative period. Indeed, Merkel and Johnson reported that seven of eight patients with anterior femoral cortical notching had a fracture within three months after the operation⁷. The degree of osseous remodeling in patients with a notch in the distal femoral cortex has not been quantified. The femoral component may actually contribute to stress-shielding of the adjacent, notched part of the femur, perpetuating a region of persistent relative weakness long after the operation.

The findings in the present study lend objective support to the intuitive impression that a notch in the anterior femoral cortex contributes to an increased risk of periprosthetic fracture following total knee replacement. Patients who sustain inadvertent notching should have additional protection in the early postoperative period, and consideration should be given to use of a femoral component with a stem as a means to bypass the stress-riser of the anterior cortical notch. Perhaps most importantly, we believe that an anterior cortical notch should be considered a contraindication to manipulation of the knee replacement in the early postoperative period.

References

Introduction | Materials and Methods | Results | Discussion | References

Aaron, R. K., and Scott, R.: Supracondylar fracture of the femur after total knee arthroplasty. Clin. Orthop.,219: 136-139, 1987.219136 1987 [PubMed]

Cain, P. R.; Rubash, H. E.; Wissinger, H. A.; and McClain, E. J.: Periprosthetic femoral fractures following total knee arthroplasty. Clin. Orthop.,208: 205-214, 1986.208205 1986 [PubMed]

Culp, R. W.; Schmidt, R. G.; Hanks, G.; Mak, A.; Esterhai, J. L., Jr.; and Heppenstall, R. B.: Supracondylar fracture of the femur following prosthetic knee arthroplasty. Clin. Orthop.,222: 212-222, 1987.222212 1987 [PubMed]

Figgie, M. P.; Goldberg, V. M.; Figgie, H. E., III; and Sobel, M.: The results of treatment of supracondylar fracture above total knee arthroplasty. J. Arthroplasty,5: 267-276, 1990.5267 1990 [PubMed]

Healy, W. L.; Siliski, J. M.; and Incavo, S. J.: Operative treatment of distal femoral fractures proximal to total knee replacements. J. Bone and Joint Surg.,75-A: 27-34, Jan 1993.75-A27 1993

Hirsh, D. M.; Bhalla, S.; and Roffman, M.: Supracondylar fracture of the femur following total knee replacement. Report of four cases. J. Bone and Joint Surg.,63-A: 162-163, Jan 1981.63-A162 1981

Merkel, K. D., and Johnson, E. W., Jr.: Supracondylar fracture of the femur after total knee arthroplasty. J. Bone and Joint Surg.,68-A: 29-43, Jan 1986.68-A29 1986

Ritter, M. A.; Faris, P. M.; and Keating, E. M.: Anterior femoral notching and ipsilateral supracondylar femur fracture in total knee arthroplasty. J. Arthroplasty,3: 185-187, 1988.3185 1988 [PubMed]

Wolff, J.: The Law of Bone Remodelling, translated by P. Maquet and R. Furlong. Berlin, Springer, 1986.

Topics

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Fig. 1:: Lateral radiograph of a matched pair of femora, with a full-thickness cortical defect in the specimen on the left.

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Fig. 2:: Illustration of the experimental setup for the bending test.

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Fig. 3:: Drawing, from a lateral view, of a specimen with a full-thickness cortical notch and a fracture that extends from the cortical defect.

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Fig. 4:: Drawing, from a lateral view, of a control specimen with a fracture proximal to the instrumentation.

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Fig. 5:: Graph showing the mean bending load to failure (and standard error of the mean) for the notched and the control specimens.

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Fig. 6:: Graph showing the results of bending load to failure for the individual pairs.

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Fig. 7:: Graph showing the mean torsional load to failure (and standard error of the mean) for the notched and the control specimens.

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Fig. 8:: Graph showing the results of torsional load to failure for the individual pairs.

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TABLE I: Prevalence of Supracondylar Fracture After Total Knee Arthroplasty

Study	Total No. of Knees	No. (Percent) of Knees with Fracture
Merkel and Johnson⁷	5233	36 (0.69)
Ritter et al.⁸	670	2 (0.30)
Figgie et al.⁴	567	24 (4.20)
Aaron and Scott¹	250	5 (2.00)
Overall	6720	67 (1.00)

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TABLE I: Prevalence of Supracondylar Fracture After Total Knee Arthroplasty

Study	Total No. of Knees	No. (Percent) of Knees with Fracture
Merkel and Johnson⁷	5233	36 (0.69)
Ritter et al.⁸	670	2 (0.30)
Figgie et al.⁴	567	24 (4.20)
Aaron and Scott¹	250	5 (2.00)
Overall	6720	67 (1.00)

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TABLE II: Prevalence of Notching in Knees with Periprosthetic Fracture

Study	No. of Knees with Fracture	No. (Percent) of Fractured Knees with Notching
Hirsh et al.⁶	4	1
Healy et al.⁵	23	2 (8.7)
Merkel and Johnson⁷	36	8 (22.2)
Ritter et al.⁸	2	1
Culp et al.³	61	27 (44.3)
Figgie et al.⁴	24	8 (33.3)
Cain et al.²	14	3
Overall	164	50 (30.5)

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TABLE II: Prevalence of Notching in Knees with Periprosthetic Fracture

Study	No. of Knees with Fracture	No. (Percent) of Fractured Knees with Notching
Hirsh et al.⁶	4	1
Healy et al.⁵	23	2 (8.7)
Merkel and Johnson⁷	36	8 (22.2)
Ritter et al.⁸	2	1
Culp et al.³	61	27 (44.3)
Figgie et al.⁴	24	8 (33.3)
Cain et al.²	14	3
Overall	164	50 (30.5)

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TABLE III: Prevalence of Fractures in Knees with and without Notching After Total Knee Arthroplasty

Study	Total No. of Knees	No. (Percent) of Knees with Fracture
Knees with Notching	Knees without Notching
Merkel and Johnson⁷	5233	8 (0.15)	26 (0.49)
Ritter et al.⁸	670	1 (0.15)	1 (0.15)
Figgie et al.⁴	567	8 (1.4)	16 (2.8)
Overall	6470	17 (0.26)	43 (0.66)

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TABLE III: Prevalence of Fractures in Knees with and without Notching After Total Knee Arthroplasty

Study	Total No. of Knees	No. (Percent) of Knees with Fracture
Knees with Notching	Knees without Notching
Merkel and Johnson⁷	5233	8 (0.15)	26 (0.49)
Ritter et al.⁸	670	1 (0.15)	1 (0.15)
Figgie et al.⁴	567	8 (1.4)	16 (2.8)
Overall	6470	17 (0.26)	43 (0.66)

Aaron, R. K., and Scott, R.: Supracondylar fracture of the femur after total knee arthroplasty. Clin. Orthop.,219: 136-139, 1987.219136 1987 [PubMed]

Cain, P. R.; Rubash, H. E.; Wissinger, H. A.; and McClain, E. J.: Periprosthetic femoral fractures following total knee arthroplasty. Clin. Orthop.,208: 205-214, 1986.208205 1986 [PubMed]

Healy, W. L.; Siliski, J. M.; and Incavo, S. J.: Operative treatment of distal femoral fractures proximal to total knee replacements. J. Bone and Joint Surg.,75-A: 27-34, Jan 1993.75-A27 1993

Hirsh, D. M.; Bhalla, S.; and Roffman, M.: Supracondylar fracture of the femur following total knee replacement. Report of four cases. J. Bone and Joint Surg.,63-A: 162-163, Jan 1981.63-A162 1981

Merkel, K. D., and Johnson, E. W., Jr.: Supracondylar fracture of the femur after total knee arthroplasty. J. Bone and Joint Surg.,68-A: 29-43, Jan 1986.68-A29 1986

Ritter, M. A.; Faris, P. M.; and Keating, E. M.: Anterior femoral notching and ipsilateral supracondylar femur fracture in total knee arthroplasty. J. Arthroplasty,3: 185-187, 1988.3185 1988 [PubMed]

Wolff, J.: The Law of Bone Remodelling, translated by P. Maquet and R. Furlong. Berlin, Springer, 1986.

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Mark L. Lesh, David J. Schneider, Gurvinder Deol, Barclay Davis, Christopher R. Jacobs, Vincent D. PelligriniJr.; The Consequences of Anterior Femoral Notching in Total Knee Arthroplasty A Biomechanical Study*. The Journal of Bone & Joint Surgery. 2000 Aug;82(8):1096-1096.

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