{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T01:29:09Z","timestamp":1790213349380,"version":"4.1.0"},"reference-count":24,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2023,2,14]],"date-time":"2023-02-14T00:00:00Z","timestamp":1676332800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives Perioperative distal femoral fracture is rare in patients undergoing total knee arthroplasty (TKA). In such rare cases, additional fixation might be required, and recovery can be delayed. Several studies have focused on perioperative distal femoral fractures in TKA, but there remains a lack of information on risk factors. The purpose of this study was to investigate risk factors for perioperative distal femoral fractures in patients undergoing TKA and suggest preventive strategies. Materials and Methods: This retrospective study included a total of 5364 TKA cases in a single institution from 2011 to 2022. Twenty-four distal femoral fractures occurred during TKA or within one month postoperatively (0.45%). Patient demographics, intraoperative findings, and postoperative progress were obtained from patient medical records and radiographs. Risk factors for fractures were analyzed using multivariate Firth logistic regression analysis. Results: Although all 24 distal femoral fractures occurred in female patients (24 of 4819 patients, 0.50%), the incidence rate of fracture between male and female patients was not significantly different (p = 0.165). The presence of osteoporosis and insertion of a polyethylene (PE) insert with knee dislocation were statistically significant risk factors (p = 0.009 and p = 0.046, respectively). However, multivariate logistic regression analysis showed that only osteoporosis with bone mineral density (BMD) &lt; \u22122.8 (odds ratio (2.30), 95% CI (1.03\u20135.54), p = 0.043) was an independent risk factor for perioperative distal femoral fracture in TKA patients. Conclusions: Our results suggest that osteoporosis with BMD &lt; \u22122.8 is a risk factor for distal femoral fractures in patients undergoing TKA. In these patients, careful bone cutting, adequate gap balancing, and especially the use of the sliding method for insertion of a PE insert are recommended as preventive strategies.<\/jats:p>","DOI":"10.3390\/medicina59020369","type":"journal-article","created":{"date-parts":[[2023,2,15]],"date-time":"2023-02-15T02:31:23Z","timestamp":1676428283000},"page":"369","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Risk Factors and Preventive Strategies for Perioperative Distal Femoral Fracture in Patients Undergoing Total Knee Arthroplasty"],"prefix":"10.3390","volume":"59","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4815-7985","authenticated-orcid":false,"given":"Ki","family":"Kang","sequence":"first","affiliation":[{"name":"Department of Orthopaedic Surgery, Seoul St. Mary\u2019s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1374-9964","authenticated-orcid":false,"given":"Man","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Seoul St. Mary\u2019s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jae","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Seoul St. Mary\u2019s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5932-3934","authenticated-orcid":false,"given":"Yong","family":"In","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Seoul St. Mary\u2019s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,2,14]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"90","DOI":"10.1007\/s11999-009-0876-9","article-title":"Intraoperative fracture during primary total knee arthroplasty","volume":"468","author":"Alden","year":"2010","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"183","DOI":"10.1016\/j.otsr.2008.04.002","article-title":"Intraoperative fractures and ligament tears during total knee arthroplasty. A 1795 posterostabilized TKA continuous series","volume":"95","author":"Pinaroli","year":"2009","journal-title":"Orthop. Traumatol. Surg. Res."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"100704","DOI":"10.1016\/j.tcr.2022.100704","article-title":"Nonsurgical management of atraumatic early distal femoral periprosthetic insufficiency fracture after primary total knee arthroplasty, a report of two cases","volume":"42","author":"Abdelaal","year":"2022","journal-title":"Trauma Case Rep."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"40","DOI":"10.1186\/s43019-020-00054-3","article-title":"Intra-operative fractures in primary total knee arthroplasty\u2014A systematic review","volume":"32","author":"Purudappa","year":"2020","journal-title":"Knee Surg. Relat. Res."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"571","DOI":"10.1016\/j.jcot.2018.10.009","article-title":"Intra-operative fractures in primary Total Knee Arthroplasty","volume":"10","author":"Agarwala","year":"2019","journal-title":"J. Clin. Orthop. Trauma"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1186\/s43019-020-00043-6","article-title":"Intraoperative femoral condyle fracture in primary total knee arthroplasty\u2014A case-control study in Asian population","volume":"32","author":"Mak","year":"2020","journal-title":"Knee Surg. Relat. Res."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1016\/S0035-1040(06)75699-9","article-title":"Intra-and postoperative fractures of the femur in total knee arthroplasty: Risk factors in 32 cases","volume":"92","author":"Hernigou","year":"2006","journal-title":"Rev. Chir. Orthop. Reparatrice Appar. Mot."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"202","DOI":"10.1177\/230949901502300218","article-title":"Distal femoral fracture during primary total knee arthroplasty","volume":"23","author":"Delasotta","year":"2015","journal-title":"J. Orthop. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"643","DOI":"10.1016\/S0883-5403(05)80209-8","article-title":"Intercondylar distal femoral fracture. An unreported complication of posterior-stabilized total knee arthroplasty","volume":"10","author":"Lombardi","year":"1995","journal-title":"J. Arthroplast."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1177\/230949901502300219","article-title":"Intra-operative fracture in posterior-stabilised total knee arthroplasty","volume":"23","author":"Pun","year":"2015","journal-title":"J. Orthop. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"180","DOI":"10.1111\/os.12177","article-title":"Intraoperative Femoral Condylar Fracture during Primary Total Knee Arthroplasty: Report of Two Cases","volume":"7","author":"Huang","year":"2015","journal-title":"Orthop. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"2478","DOI":"10.1016\/j.arth.2013.11.004","article-title":"How effective is multiple needle puncturing for medial soft tissue balancing during total knee arthroplasty? A cadaveric study","volume":"29","author":"Koh","year":"2014","journal-title":"J. Arthroplast."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1093\/biomet\/80.1.27","article-title":"Bias Reduction of Maximum-Likelihood-Estimates","volume":"80","author":"Firth","year":"1993","journal-title":"Biometrika"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"605","DOI":"10.1002\/jbmr.3671","article-title":"Treated Osteoporosis Is Still Osteoporosis","volume":"34","author":"Lewiecki","year":"2019","journal-title":"J. Bone. Miner. Res."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1007\/s11914-005-0005-y","article-title":"The relationship between bone mineral density and fracture risk","volume":"3","author":"McClung","year":"2005","journal-title":"Curr. Osteoporos. Rep."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"2049","DOI":"10.1007\/s00198-021-05900-y","article-title":"The clinician\u2019s guide to prevention and treatment of osteoporosis","volume":"33","author":"LeBoff","year":"2022","journal-title":"Osteoporos. Int."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1111\/j.1756-185X.2011.01608.x","article-title":"The epidemiology of osteoarthritis in Asia","volume":"14","author":"Fransen","year":"2011","journal-title":"Int. J. Rheum. Dis."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"167","DOI":"10.1097\/01.blo.0000214417.29335.19","article-title":"Periprosthetic fractures after total knee arthroplasties","volume":"446","author":"Kim","year":"2006","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1097\/BLO.0b013e3181591c48","article-title":"Total knee arthroplasty using a pie-crusting technique for valgus deformity","volume":"464","author":"Aglietti","year":"2007","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1151","DOI":"10.1016\/j.arth.2010.03.007","article-title":"A new surgical technique for medial collateral ligament balancing: Multiple needle puncturing","volume":"25","author":"Bellemans","year":"2010","journal-title":"J. Arthroplast."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1007\/s00167-014-3362-1","article-title":"The pie-crusting technique using a blade knife for medial collateral ligament release is unreliable in varus total knee arthroplasty","volume":"24","author":"Kwak","year":"2016","journal-title":"Knee Surg. Sports Traumatol. Arthrosc."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"109","DOI":"10.5435\/00124635-199603000-00006","article-title":"Periarticular Fractures after Total Knee Arthroplasty: Principles of Management","volume":"4","author":"Chmell","year":"1996","journal-title":"J. Am. Acad. Orthop. Surg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1054","DOI":"10.1016\/j.arth.2015.01.006","article-title":"A Unique Pattern of Peri-Prosthetic Fracture Following Total Knee Arthroplasty: The Insufficiency Fracture","volume":"30","author":"Shahi","year":"2015","journal-title":"J. Arthroplast."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Moldovan, F., Gligor, A., and Bataga, T. (2021). Structured Integration and Alignment Algorithm: A Tool for Personalized Surgical Treatment of Tibial Plateau Fractures. J. Pers. Med., 11.","DOI":"10.3390\/jpm11030190"}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/59\/2\/369\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T18:35:36Z","timestamp":1760121336000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/59\/2\/369"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,2,14]]},"references-count":24,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2023,2]]}},"alternative-id":["medicina59020369"],"URL":"https:\/\/doi.org\/10.3390\/medicina59020369","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,2,14]]}}}