Supracondylar femur fracture after knee manipulation: a report of 3 cases.

Supracondylar femur fracture is a rare but devastating complication of knee manipulation following total knee arthroplasty (TKA). Avoidance of this complication can be achieved by careful attention to the indications and contraindications, timing, and technique of closed manipulation. We performed a retrospective chart and radiographic review to identify all patients who underwent closed manipulation under anesthesia for a diagnosis of aseptic arthrofibrosis after TKA. This article presents 3 cases of supracondylar femur fracture following closed knee manipulation of stiff TKAs that occurred at our institution over a 4-year period (1999-2002). Patient age ranged from 44 to 73 years. All patients underwent cruciate retaining TKA. Time from TKA to manipulation ranged from 3 months to 3 years. Two patients sustained an extension type supracondylar fracture. Two of the 3 patients were treated with closed reduction and casting/bracing. At a minimum 8-month follow-up after fracture, range of motion was poor with average flexion to 77 degrees and average flexion contracture of 13 degrees . In our patients, risk factors for fracture included prolonged time from arthroplasty to manipulation, arthrofibrosis, radiographic osteopenia, and rheumatoid arthritis. To our knowledge, this represents the largest case series of iatrogenic supracondylar femur fractures reported in the literature. Two manipulation techniques are described in detail. The alternative manipulation technique is highlighted with no fractures or complications over the same period. We believe that the alternative manipulation technique is a safe and effective technique to manipulate stiff TKA's and has been used for over >10 years by the senior surgeon (J.V.B.).