{"paper_id":"07fe576d-8a49-468b-be06-c5027fd3d68a","body_text":"Risk Factors Influencing Management Outcomes of Periprosthetic Fractures Following Total Knee Arthroplasty: A Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Risk Factors Influencing Management Outcomes of Periprosthetic Fractures Following Total Knee Arthroplasty: A Retrospective Study Bashir Alenazi, Meshari Alkhalifah, Abdullah Alharbi, Hani Alhudhaif, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8058295/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Total knee replacement (TKR) is a widely performed surgery for advanced knee joint issues. The rising demand for TKR has led to an increase in periprosthetic fractures (PPFs), influenced by patient factors, surgical variables, and injury mechanisms. Understanding these factors is crucial for prevention and improvement of surgical methods and patient outcomes. Materials and methods : This retrospective cohort study evaluated knee periprosthetic fractures in patients from January 2019 to July 2025 at a tertiary center. Data was sourced from the arthroplasty unit database, encompassing various radiographs. Exclusion criteria included infections, mid shaft femur fractures, tibia periprosthetic fractures, road traffic accidents, and incomplete records. Data analysis utilized Microsoft Excel and SPSS for statistical assessments, verifying data quality with frequency tables and box plots. Comparisons included gender, obesity status, and independent risk factors, with statistical significance defined as a P value < 0.05. Results : A study of 2113 total knee replacement patients (mostly women, mean age 64) found a 0.47% incidence of periprosthetic fractures (PPFs), associated with bone fragility, obesity, and diabetes, particularly in older females and osteoporotic males. Among 10 patients with chronic conditions, treatment depended on fracture type, prosthesis stability, and bone quality: 4 underwent distal femur replacement, 5 received locking plate fixation, and 1 was managed conservatively. Late fractures (>5 years) were linked to osteoporosis and minor trauma, while early fractures (<3 months) stemmed from falls during rehabilitation, highlighting the importance of fall prevention strategies. Conclusion: An analysis of ten periprosthetic fracture cases after total knee replacement found a higher incidence in elderly, osteoporotic, and obese female patients, with osteoporosis and obesity as key risk factors. Management was challenging, and 70% required distal femoral replacement. The study emphasizes preventive measures such as weight control, patient education, and prophylactic femoral stems to reduce fracture risk and improve postoperative outcomes Periprosthetic fracture femur Osteoporosis Obesity Total knee replacement Fixation Introduction Total knee replacement (TKR) is a widely performed and effective surgical procedure aimed at relieving pain, improving mobility, and restoring function in patients with advanced knee joint diseases such as osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis [ 1 ]. With the rising global demand for TKR, particularly among aging and comorbid populations, complications associated with the procedure are becoming increasingly common [ 1 , 2 ]. Among these, periprosthetic fractures (PPFs) represent a serious and growing concern due to their association with high morbidity, functional impairment, and complex surgical management [ 3 , 4 ]. Periprosthetic fractures are defined as fractures occurring around or adjacent to the prosthesis following joint replacement surgery [ 3 ]. Although relatively uncommon, their incidence is rising in parallel with the increasing number of primary and revision knee arthroplasties being performed [ 2 , 4 ]. These fractures are influenced by a range of factors. Patient-related risk factors include advanced age, female sex, osteoporosis, diabetes, obesity, high body mass index (BMI), and smoking [ 4 , 5 , 6 ]. Surgery-related factors—such as implant type, fixation method, surgical technique, and history of revision procedures—also contribute to fracture risk [ 5 , 7 , 8 ]. Additionally, the mechanism of injury, often a low-energy fall, and the timing of the fracture from the index surgery, play a key role in supracondylar PPF occurrence [ 4 , 6 ]. Understanding the epidemiological patterns and risk factors associated with PPFs is essential for developing targeted prevention strategies, improving surgical techniques, and optimizing patient outcomes [ 3 , 6 ]. Classification systems such as the Unified Classification System (UCS) and the Vancouver classification (adapted for knee arthroplasty) offer standardized frameworks for categorizing these fractures, aiding in clinical decision-making and prognostication [ 9 , 10 ]. Materials & Methods Study design, population, and sampling: This is a retrospective cohort study included all patients diagnosed with knee periprosthetic fracture from January 2019 to July 2025 at a single tertiary centre in Riyadh, Saudi Arabia. The study was approved by the hospital ethics Committee and all participant provided informed consent. Patient's data were collected from the arthroplasty unit database. Plain, Anteroposterior and lateral radiographs, were used for diagnosis. Patients' files were reviewed to collect the mechanism of injury, comorbidities, osteoporosis, Vitamin D level, Calcium and Body mass index (BMI). We included patients who underwent TKR with well-fixed and aligned implants and clinically diagnosed with supracondylar periprosthetic fracture that visited our medical centre during the specified time We have excluded patients who were referred from other clinics, seen outside the defined time, with infection, with mid shaft femur fracture, with tibia periprosthetic fracture, Road traffic accident, or have incomplete medical records. A non-probability sampling method (convenience sampling) was used to select patients based on data availability. Data collection and validation Baseline demographic and clinical data were extracted from patient medical records and analysed. The data collected included demographics (age and sex), laterality (affected side), osteoporosis, BMI, Vitamin D, Calcium and the comorbidities. Data entry was carried out using the Microsoft Excel version 16.0 (Microsoft Corp., Redmond, WA, USA), and the data entry templates were then exported to the SPSS software version 28.0.1 for further analysis. Various assessments were performed during data analysis to verify data quality. First, a frequency table was created to identify any missing data. No missing data points were observed, indicating that the data acquired for the variables of interest were comprehensive. Additionally, a box plot analysis was performed to detect probable outliers in the dataset. No outliers were found, indicating that the data points were within respectable ranges and did not deviate considerably from the overall trends. Statistical analyses Data analyses were performed using SPSS® version 28.0.1 (IBM Corp., Armonk, NY, USA). Descriptive measures including mean, standard deviation, median, interquartile range (IQR), frequency, percentage, and proportion, were calculated, along with their corresponding 95% confidence intervals (CI) where applicable. Comparative analysis between males and females, and obese vs. non-obese groups performed using the chi-square test and linear model ANOVA, depending on the data type and distribution normality. Furthermore, a binary logistic regression model was used to assess the independent risk factors for periprosthetic fractures like osteoporosis, BMI, and comorbidities. Statistical significance was determined using a P value < 0.05. Results Between January 2019 and July 2025, a total of 2113 patients underwent total knee replacement (TKR) at tertiary care center. The average age of patients underwent total knee replacement was 64 years old. a marked predominance of females undergoing TKR during the study period. Among the total TKR cohort: 737 patients (34.9%) were male 1376 patients (65.1%) were female The prevalence of periprosthetic fractures after TKR in the dataset is 0.47%, which aligns with reported global rates, which range between 0.3%–2.5% in large arthroplasty studies (Table No.1) . A total of 10 patients (0.47%) developed a periprosthetic fracture (PPF) following TKR. 9 cases (90%) occurred in female patients 1 case (10%) occurred in a male patient The mean age of female patients was 72.8 years (range: 56–86) while male patient was aged 82 years. This reflects the well-documented predisposition for PPF among elderly female patients, likely due to postmenopausal bone loss and increased frailty. Table No.1 Patient demographics and baseline characteristics Category Count Percentage Total TKR Patients 2113 100% Total PPF Cases 10 0.47% Male PPF Cases 1 0.14% of males (1/737) Female PPF Cases 9 0.65% of females (9/1376) Among the ten patients who developed periprosthetic fractures following total knee arthroplasty (TKA), the anatomical distribution and laterality were as follows (Table No.2) : The nearly symmetric distribution of fracture laterality (5 right vs. 4 left) and a single bilateral case suggest no dominant laterality pattern. However: The bilateral case occurred in a morbidly obese female (BMI 51) with osteoporosis and hypothyroidism. This patient underwent simultaneous bilateral distal femoral replacements, underscoring the severity of bone compromise and biomechanical stress in such high-risk individuals. Table No.2 Anatomical distribution and laterality for patients who sustained periprosthetic fractures Side Cases Percentage (of 10) Left 4 40% Right 5 50% Bilateral 1 10% Total Reported 10 100% Biomechanically, the supracondylar femoral region is a zone of stress concentration post-TKA. Out of 2113 patients who underwent total knee replacement (TKR), the estimated prevalence of osteoporosis in the general TKR population ranges from 28% to 40% overall, 34% to 45% in females, and 15% to 23% in males (Table No.3). In contrast, among the 10 patients who developed periprosthetic fractures (PPF), 8 patients (80%) were confirmed to have osteoporosis. Specifically: 7 of 9 female patients (77.8%) were osteoporotic The only male patient (100%) was also osteoporotic Table No.3 The prevalence of osteoporosis among PPF and total TKR patient groups. Group PPF Patients with Osteoporosis Estimated Prevalence in Total TKR Patients All Patients 8 of 10 (80%) 28% to 40% Females 7 of 9 (77.8%) 34% to 45% Males 1 of 1 (100%) 15% to 23% These rates indicate a substantially higher prevalence of osteoporosis in the PPF group compared to the general TKR population — with a 2–3× increase overall. This highlights the strong association between bone fragility and PPF risk following TKR, especially in older females and osteoporotic males. Among the 10 patients who sustained a periprosthetic fracture, 6 patients (60%) were classified as obese (BMI ≥ 30). When stratified by sex, 6 of 9 female patients (66.7%) were obese, while the only male patient had a BMI of 26.6, thus not obese (Table No.4). In contrast, the expected prevalence of obesity in the general total knee replacement (TKR) patients in this study ranges between: 33% to 38% overall 38% to 44% in females 29% to 36% in males Table No.4 The prevalence of obesity among PPF and total TKR patient groups. Group PPF Patients with Obesity Estimated Prevalence in Total TKR Patients All Patients 6 of 10 (60%) 33% to 38% Females 6 of 9 (66.7%) 38% to 44% Males 0 of 1 (0%) 29% to 36% These findings indicate that obesity, particularly among females, was substantially more prevalent in the PPF subgroup In the total TKR population, the estimated prevalence of diabetes mellitus is approximately 30% overall, with 34.1% in males and 27.6% in females (Table No.5). In contrast, among the 10 PPF patients: 8 of 10 (80%) were diagnosed with diabetes This included 7 of 9 female patients (77.8%) The only male PPF patient (100%) was also diabetic These findings show that diabetes was highly prevalent among PPF patients, far exceeding the expected rates in the general TKR population, suggesting a strong link between metabolic disease and post-TKR fracture risk. Table No.5 The prevalence of diabetes among PPF and total TKR patient groups. Group PPF Patients with Diabetes Estimated Diabetes Prevalence in Total TKR Patients All Patients 8 of 10 (80%) ~ 30% Females 7 of 9 (77.8%) 27.6% Males 1 of 1 (100%) 34.1% Patients presented with other multiple chronic health conditions: Hypertension was present in 6 patients Dyslipidaemia (3 patients) Hypothyroidism (2 patients) Rheumatoid arthritis (1 patient) One patient had a history of long-term corticosteroid use, which is known to contribute to decreased bone mass. The combination of these comorbid conditions may have a synergistic effect, further increasing the risk for low-energy fracture events, especially when coupled with reduced mobility and poor bone quality. The management of periprosthetic fractures (PPFs) in this cohort of 10 patients was dictated by fracture classification, prosthetic stability, bone stock, and patient-specific factors such as age, comorbidities, and mobility status (Table No.6) . Distal femur replacement was chosen in 4 patients, including one case with bilateral fractures, where traditional osteosynthesis was not feasible due to: Severely compromised bone quality Prosthetic loosening Extensive metaphyseal comminution Failure risk with fixation methods. Table No.6 Management Approaches for PPF Patients. Procedure Number of Patients Percentage (%) ORIF (Open Reduction and Internal Fixation) 5 50.0 Distal Femoral Replacement (DFR) 2 20.0 Revised ORIF with DFR 2 20.0 Conservative (Bed Bound) 1 10.0 A bilateral DFR (simultaneous) was performed in a morbidly obese, osteoporotic female — a rare and technically demanding scenario. A total of 5 patients were treated with internal fixation: Patients had adequate remaining bone stock. Femoral components were radiographically stable. Fixation was performed using locking compression plates (LCP) and biomechanically optimised constructs to address shear and rotational forces, especially in patients with high BMI. And one patient was treated with conservative treatment (bed bound) and regular follow ups in the clinic. Fractures occurred at widely varying intervals from the index TKA procedure ( Table No.7) . Late-onset fractures (> 5 years) were the most frequent (40%), were all associated with osteoporosis, poor mobility, and often minor trauma. Table No.7 The time span between a primary total knee replacement (TKR) and the occurrence of a periprosthetic fracture (PPF) Interval from TKR to PPF No. of Patients Percentage 0–3 months 1 10% 3 months – 1 year 2 20% 1–5 years 3 30% > 5 years 4 40% Early fractures (within 3 months) were linked to falls during rehabilitation, underscoring the importance of fall-prevention protocols post-op. Discussion In this retrospective analysis of ten cases of periprosthetic fracture (PPF) following total knee replacement (TKR), several key risk factors were identified, with implications for both prevention and management. The overwhelming majority of cases (90%) occurred in female patients, consistent with the well-established higher prevalence of osteoporosis and fragility fractures in postmenopausal women. The mean age of the female patients was 72.8 years, compared to 82 years for the single male case, further reinforcing the role of advanced age and sex-specific bone loss as predisposing factors. Nearly all fractures (9 out of 10) occurred in patients with confirmed osteoporosis, highlighting low bone mineral density as the single most important determinant of periprosthetic fracture risk in our cohort. Additionally, the mechanism of injury was typically low-energy trauma such as falls, emphasizing the vulnerability of this patient population to fractures even with minimal insult. The anatomical distribution of fractures in this series is noteworthy: all ten patients sustained supracondylar femoral fractures, a location well recognized as the most common site of PPF following TKR worldwide, accounting for approximately 70% of cases in the literature. The supracondylar region represents a biomechanical zone of stress concentration, particularly in the presence of compromised bone quality. This uniform finding in our cohort underscores both the inherent vulnerability of this region and the need for heightened awareness during both primary TKR implantation and postoperative follow-up. Obesity was another prominent factor in our analysis. The mean BMI among females was 31.7, with three patients classified as morbidly obese (BMI > 35). Obesity was overrepresented among PPF cases, with two-thirds of female patients affected compared to 38–44% expected in the general TKR cohort. Excess body weight likely contributes to increased mechanical loading at the bone–prosthesis interface, further predisposing to fractures in osteoporotic bone. The combination of osteoporosis and obesity thus creates a synergistic risk profile, which was particularly evident in the bilateral fracture case involving a morbidly obese, osteoporotic female. Comorbid medical conditions further complicated the risk landscape. Diabetes mellitus (70%), hypertension (60%), dyslipidemia, hypothyroidism, rheumatoid arthritis, and long-term corticosteroid use were prevalent among our PPF patients. These comorbidities are known to impair bone metabolism, delay healing, and increase fall risk, thereby acting as both direct and indirect contributors to fracture susceptibility. Importantly, the clustering of multiple chronic conditions in these patients suggests that medical optimization and multidisciplinary management are critical preventive strategies. Treatment decisions were dictated by fracture characteristics, prosthetic stability, and patient factors. Distal femoral replacement (DFR) was required in 70% of patients, including one rare case of simultaneous bilateral replacement. DFR was chosen primarily in the context of poor bone stock, prosthetic loosening, and extensive comminution, where fixation methods would be prone to failure. In contrast, four patients with adequate bone stock and stable femoral components were successfully managed with internal fixation using locking compression plates, highlighting the importance of individualized surgical planning. One patient was managed conservatively, underscoring that select cases may avoid surgery when comorbidities, fracture pattern, and mobility status permit. The findings of this study have several important clinical implications. First, patient counseling before TKR should explicitly address the elevated risks of PPF in elderly, osteoporotic, and obese females [ 11 ]. Patients should be encouraged to participate in preoperative physical therapy, weight management programs, and bone health optimization prior to surgery. Second, prophylactic measures should be considered in very high-risk individuals, including the use of femoral stems that bypass the supracondylar region, thereby reducing stress risers in osteoporotic bone [ 12 , 13 , 14 , 15 ]. Such strategies may mirror tibial stem extensions already used in primary TKR and could reduce the incidence of catastrophic fractures. Third, referral to endocrinology for osteoporosis management, coupled with optimization of diabetes, thyroid function, and cardiovascular risk factors, represents an essential component of holistic care [ 16 , 17 ]. Finally, fall-prevention protocols should be emphasized in the early postoperative period, given the association of early PPFs with rehabilitation-related falls in this series [ 18 , 19 ]. Overall, this study reinforces that PPFs are multifactorial in origin, arising from the interplay of biological risk factors (osteoporosis, female sex, comorbidities), mechanical stressors (obesity, supracondylar location), and surgical factors (prosthetic design, fixation strategies). Effective prevention and management therefore demand a multidisciplinary, patient-tailored approach. Conclusion In conclusion, our analysis of ten periprosthetic fracture cases following TKR revealed that elderly, osteoporotic, and obese female patients are disproportionately affected. All fractures in our cohort involved the supracondylar femoral region, consistent with the global literature, where this location accounts for approximately 70% of PPFs. Osteoporosis was present in 90% of cases, and obesity was significantly overrepresented compared to the general TKR population, confirming these as key modifiable risk factors. Management was challenging, with 70% of patients requiring distal femur replacement due to poor bone quality and prosthetic instability. These findings emphasize the necessity of preventive strategies, including preoperative optimization of bone health, weight reduction, patient education, and consideration of prophylactic femoral stems in high-risk individuals. By addressing these factors and adopting a multidisciplinary approach, it is possible to reduce the burden of PPFs and improve both functional outcomes and patient satisfaction after TKR. Abbreviations -TKR Total knee replacement -PPF Periprosthetic fracture -BMI Body mass index -DFR Distal femoral replacement - LCP Locking compression plate References Mayr MF, Südkamp NP, Konstantinidis L (2021) Periprosthetic fracture management around total knee arthroplasty. J Orthop 23:239e45. https://doi.org/10.1016/j.jor.2020.12.024 Meek RMD, Norwood T, Smith R, Brenkel IJ, Howie CR (2011) The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement. J Bone Joint Surg Br 93(1):96–101 Lindahl H (2007) Epidemiology of periprosthetic femur fracture around a total hip arthroplasty. Injury 38(6):651–654 Platzer P, Schuster R, Aldrian S, Prosquill S, Krumboeck A, Zehetgruber I, Kovar F, Schwameis K, Vecsei V (2010) Management and outcome of periprosthetic fractures after total knee arthroplasty. J Trauma 68:1464–1470 McGraw P, Kumar A (2010) Periprosthetic fractures of the femur after total knee arthroplasty. J Orthopaed Traumatol 11:135–141. https://doi.org/10.1007/s10195-010-0099-6 Gujarathi N, Putti AB, Abboud RJ, MacLean JGB, Espley AJ, Kellett CF (2009) Risk of periprosthetic fracture after anterior femoral notching. Acta Orthop 80:553–556. https://doi.org/10.3109/17453670903350099 Bhattacharyya T, Chang D, Meigs JB, Estok DM 2nd, Malchau H (2007) Mortality after periprosthetic fracture of the femur. J Bone Joint Surg Am 89:2658–2662 El Khassawna T, Knapp G, Scheibler N et al (2021) Mortality, risk factors and risk assessment after periprosthetic femoral fractures-a retrospective cohort study. J Clin Med 10(19):4324 Duncan C, Haddad F (2014) The unified classification system (UCS): improving our understanding of periprosthetic fractures. Bone Joint J 96(B):713–716 Müller K, Zeynalova S, Fakler JK et al (2025) Risk factors for mortality in periprosthetic femur fractures about the hip-a retrospective analysis. Int Orthop (SICOT) 49:211–217. https://doi.org/10.1007/s00264-024-06346-7 Gausden EB, Bedard NA, Gililland JM, Haidukewych GJ (2024) What’s New in peri-prosthetic femur fractures? J Arthroplasty 39:S18e25. https://doi.org/10.1016/j.arth.2024.04.037 Inui H, Yamagami R, Kono K, Kawaguchi K What are the causes of failure after total knee arthroplasty? J Joint Surg Res 1, Issue 1,2023, Pages 32–40, ISSN 2949–7051. https://doi.org/10.1016/j.jjoisr.2022.12.002 Hegde V, Bracey DN, Brady AC, Kleeman-Forsthuber LT, Dennis DA, Jennings JM et al (2021) A prophylactic tibial stem reduces rates of early aseptic loosening in patients with severe preoperative varus deformity in primary total knee arthroplasty. J Arthroplasty 36:2319–2324. https://doi.org/10.1016/j.arth.2021.01.049 Abdel MP, Cottino U, Mabry TM (2015) Management of periprosthetic femoral fractures following total hip arthroplasty: a review. Int Orthop (SICOT) 39:2005–2010. https://doi.org/10.1007/s00264-015-2979-0 Kanakaris NK, Obakponovwe O, Krkovic M, Costa ML, Shaw D, Mohanty KR et al (2019) Fixation of periprosthetic or osteoporotic distal femoral fractures with locking plates: a pilot randomised controlled trial. Int Orthop 43(5):1193–1204 Kanis JA, Oden A, Johnell O et al (2007) The use of clinical risk factors enhances the performance of BMD in the prediction of hip and osteoporotic fractures in men and women. Osteoporos Int 18:1033–1046 Springer B, Parvizi J, Austin M et al (2013) Obesity and total joint arthroplasty. A literature based review. J Arthroplast 28(5):714–721 Wu KA, Kutzer KM, Kugelman DN, Seyler TM (2024) Fall prevention after hip and knee arthroplasty. Orthop Clin North Am 56:121–134. https://doi.org/10.1016/j.ocl.2024.05.003 Johnson RL, Duncan CM, Ahn KS, Schroeder DR, Horlocker TT, Kopp SL (2014) Fall-prevention strategies and patient characteristics that impact fall rates after total knee arthroplasty. Anesth Analg 119(5):1113–1118. https://doi.org/10.1213/ANE.0000000000000438 Additional Declarations The authors declare no competing interests. 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06:54:03\",\"extension\":\"xml\",\"order_by\":2,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":65988,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"rs80582951enriched.xml\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8058295/v1/83ab1cccfdcc911297e8999f.xml\"},{\"id\":95508702,\"identity\":\"3ab04af5-c31e-468d-998a-57b454e04ed9\",\"added_by\":\"auto\",\"created_at\":\"2025-11-10 06:54:02\",\"extension\":\"xml\",\"order_by\":3,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":64482,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"rs80582951structuring.xml\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8058295/v1/a0f647eb4f649e86d143be75.xml\"},{\"id\":95508703,\"identity\":\"e00b9755-0721-4472-a127-39d604f5ea03\",\"added_by\":\"auto\",\"created_at\":\"2025-11-10 06:54:02\",\"extension\":\"html\",\"order_by\":4,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":69975,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"earlyproof.html\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8058295/v1/f6877f8d506bce3a3c55609f.html\"},{\"id\":95528566,\"identity\":\"b51efe07-71dd-498a-8d11-a2c5f62d5143\",\"added_by\":\"auto\",\"created_at\":\"2025-11-10 10:16:16\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":640680,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8058295/v1/79bb0664-05f5-4e73-8218-268df4869c92.pdf\"}],\"financialInterests\":\"The authors declare no competing interests.\",\"formattedTitle\":\"\\u003cp\\u003e\\u003cstrong\\u003eRisk Factors Influencing Management Outcomes of Periprosthetic Fractures Following Total Knee Arthroplasty: A Retrospective Study\\u003c/strong\\u003e\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eTotal knee replacement (TKR) is a widely performed and effective surgical procedure aimed at relieving pain, improving mobility, and restoring function in patients with advanced knee joint diseases such as osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. With the rising global demand for TKR, particularly among aging and comorbid populations, complications associated with the procedure are becoming increasingly common [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. Among these, periprosthetic fractures (PPFs) represent a serious and growing concern due to their association with high morbidity, functional impairment, and complex surgical management [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003ePeriprosthetic fractures are defined as fractures occurring around or adjacent to the prosthesis following joint replacement surgery [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. Although relatively uncommon, their incidence is rising in parallel with the increasing number of primary and revision knee arthroplasties being performed [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]. These fractures are influenced by a range of factors. Patient-related risk factors include advanced age, female sex, osteoporosis, diabetes, obesity, high body mass index (BMI), and smoking [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. Surgery-related factors\\u0026mdash;such as implant type, fixation method, surgical technique, and history of revision procedures\\u0026mdash;also contribute to fracture risk [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. Additionally, the mechanism of injury, often a low-energy fall, and the timing of the fracture from the index surgery, play a key role in supracondylar PPF occurrence [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eUnderstanding the epidemiological patterns and risk factors associated with PPFs is essential for developing targeted prevention strategies, improving surgical techniques, and optimizing patient outcomes [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. Classification systems such as the Unified Classification System (UCS) and the Vancouver classification (adapted for knee arthroplasty) offer standardized frameworks for categorizing these fractures, aiding in clinical decision-making and prognostication [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e].\\u003c/p\\u003e\"},{\"header\":\"Materials \\u0026 Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eStudy design, population, and sampling:\\u003c/h2\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003eThis is a retrospective cohort study included all patients diagnosed with knee periprosthetic fracture from January 2019 to July 2025 at a single tertiary centre in Riyadh, Saudi Arabia. The study was approved by the hospital ethics Committee and all participant provided informed consent. Patient's data were collected from the arthroplasty unit database. Plain, Anteroposterior and lateral radiographs, were used for diagnosis. Patients' files were reviewed to collect the mechanism of injury, comorbidities, osteoporosis, Vitamin D level, Calcium and Body mass index (BMI). We included patients who underwent TKR with well-fixed and aligned implants and clinically diagnosed with supracondylar periprosthetic fracture that visited our medical centre during the specified time We have excluded patients who were referred from other clinics, seen outside the defined time, with infection, with mid shaft femur fracture, with tibia periprosthetic fracture, Road traffic accident, or have incomplete medical records. A non-probability sampling method (convenience sampling) was used to select patients based on data availability.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\n\\u003ch3\\u003eData collection and validation\\u003c/h3\\u003e\\n\\u003cp\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003eBaseline demographic and clinical data were extracted from patient medical records and analysed. The data collected included demographics (age and sex), laterality (affected side), osteoporosis, BMI, Vitamin D, Calcium and the comorbidities. Data entry was carried out using the Microsoft Excel version 16.0 (Microsoft Corp., Redmond, WA, USA), and the data entry templates were then exported to the SPSS software version 28.0.1 for further analysis.\\u003c/p\\u003e\\u003cp\\u003eVarious assessments were performed during data analysis to verify data quality. First, a frequency table was created to identify any missing data. No missing data points were observed, indicating that the data acquired for the variables of interest were comprehensive. Additionally, a box plot analysis was performed to detect probable outliers in the dataset. No outliers were found, indicating that the data points were within respectable ranges and did not deviate considerably from the overall trends.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\n\\u003ch3\\u003eStatistical analyses\\u003c/h3\\u003e\\n\\u003cp\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003eData analyses were performed using SPSS\\u0026reg; version 28.0.1 (IBM Corp., Armonk, NY, USA). Descriptive measures including mean, standard deviation, median, interquartile range (IQR), frequency, percentage, and proportion, were calculated, along with their corresponding 95% confidence intervals (CI) where applicable. Comparative analysis between males and females, and obese vs. non-obese groups performed using the chi-square test and linear model ANOVA, depending on the data type and distribution normality. Furthermore, a binary logistic regression model was used to assess the independent risk factors for periprosthetic fractures like osteoporosis, BMI, and comorbidities. Statistical significance was determined using a P value\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eBetween January 2019 and July 2025, a total of 2113 patients underwent total knee replacement (TKR) at tertiary care center. The average age of patients underwent total knee replacement was 64 years old. a marked predominance of females undergoing TKR during the study period.\\u003c/p\\u003e\\u003cp\\u003eAmong the total TKR cohort:\\u003c/p\\u003e\\u003cp\\u003e\\u003cul\\u003e\\u003cli\\u003e\\u003cp\\u003e737 patients (34.9%) were male\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003e1376 patients (65.1%) were female\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/ul\\u003e\\u003c/p\\u003e\\u003cp\\u003eThe prevalence of periprosthetic fractures after TKR in the dataset is 0.47%, which aligns with reported global rates, which range between 0.3%\\u0026ndash;2.5% in large arthroplasty studies \\u003cb\\u003e(Table No.1)\\u003c/b\\u003e.\\u003c/p\\u003e\\u003cp\\u003eA total of 10 patients (0.47%) developed a periprosthetic fracture (PPF) following TKR.\\u003c/p\\u003e\\u003cp\\u003e\\u003cul\\u003e\\u003cli\\u003e\\u003cp\\u003e9 cases (90%) occurred in female patients\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003e1 case (10%) occurred in a male patient\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/ul\\u003e\\u003c/p\\u003e\\u003cp\\u003eThe mean age of female patients was 72.8 years (range: 56\\u0026ndash;86) while male patient was aged 82 years.\\u003c/p\\u003e\\u003cp\\u003eThis reflects the well-documented predisposition for PPF among elderly female patients, likely due to postmenopausal bone loss and increased frailty.\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eTable No.1\\u003c/strong\\u003e\\u003cp\\u003ePatient demographics and baseline characteristics\\u003c/p\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"No\\\" id=\\\"Taba\\\" border=\\\"1\\\"\\u003e\\u003ccolgroup cols=\\\"3\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eCategory\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eCount\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003ePercentage\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eTotal TKR Patients\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e2113\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e100%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eTotal PPF Cases\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e10\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.47%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eMale PPF Cases\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.14% of males (1/737)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFemale PPF Cases\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e9\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.65% of females (9/1376)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eAmong the ten patients who developed periprosthetic fractures following total knee arthroplasty (TKA), the anatomical distribution and laterality were as follows \\u003cb\\u003e(Table No.2)\\u003c/b\\u003e:\\u003c/p\\u003e\\u003cp\\u003eThe nearly symmetric distribution of fracture laterality (5 right vs. 4 left) and a single bilateral case suggest no dominant laterality pattern. However:\\u003c/p\\u003e\\u003cp\\u003e\\u003cul\\u003e\\u003cli\\u003e\\u003cp\\u003eThe bilateral case occurred in a morbidly obese female (BMI 51) with osteoporosis and hypothyroidism.\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003eThis patient underwent simultaneous bilateral distal femoral replacements, underscoring the severity of bone compromise and biomechanical stress in such high-risk individuals.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/ul\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eTable No.2\\u003c/strong\\u003e\\u003cp\\u003eAnatomical distribution and laterality for patients who sustained periprosthetic fractures\\u003c/p\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"No\\\" id=\\\"Tabb\\\" border=\\\"1\\\"\\u003e\\u003ccolgroup cols=\\\"3\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSide\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eCases\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003ePercentage (of 10)\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eLeft\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e4\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e40%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eRight\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e5\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e50%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eBilateral\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e10%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eTotal Reported\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e10\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e100%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eBiomechanically, the supracondylar femoral region is a zone of stress concentration post-TKA.\\u003c/p\\u003e\\u003cp\\u003eOut of 2113 patients who underwent total knee replacement (TKR), the estimated prevalence of osteoporosis in the general TKR population ranges from 28% to 40% overall, 34% to 45% in females, and 15% to 23% in males \\u003cb\\u003e(Table No.3).\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eIn contrast, among the 10 patients who developed periprosthetic fractures (PPF), 8 patients (80%) were confirmed to have osteoporosis. Specifically:\\u003c/p\\u003e\\u003cp\\u003e\\u003cul\\u003e\\u003cli\\u003e\\u003cp\\u003e7 of 9 female patients (77.8%) were osteoporotic\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003eThe only male patient (100%) was also osteoporotic\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/ul\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eTable No.3\\u003c/strong\\u003e\\u003cp\\u003eThe prevalence of osteoporosis among PPF and total TKR patient groups.\\u003c/p\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"No\\\" id=\\\"Tabc\\\" border=\\\"1\\\"\\u003e\\u003ccolgroup cols=\\\"3\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eGroup\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePPF Patients with Osteoporosis\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eEstimated Prevalence in Total TKR Patients\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eAll Patients\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e8 of 10 (80%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e28% to 40%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFemales\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e7 of 9 (77.8%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e34% to 45%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eMales\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1 of 1 (100%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e15% to 23%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eThese rates indicate a substantially higher prevalence of osteoporosis in the PPF group compared to the general TKR population \\u0026mdash; with a 2\\u0026ndash;3\\u0026times; increase overall.\\u003c/p\\u003e\\u003cp\\u003eThis highlights the strong association between bone fragility and PPF risk following TKR, especially in older females and osteoporotic males.\\u003c/p\\u003e\\u003cp\\u003eAmong the 10 patients who sustained a periprosthetic fracture, 6 patients (60%) were classified as obese (BMI\\u0026thinsp;\\u0026ge;\\u0026thinsp;30).\\u003c/p\\u003e\\u003cp\\u003eWhen stratified by sex, 6 of 9 female patients (66.7%) were obese, while the only male patient had a BMI of 26.6, thus not obese \\u003cb\\u003e(Table No.4).\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eIn contrast, the expected prevalence of obesity in the general total knee replacement (TKR) patients in this study ranges between:\\u003c/p\\u003e\\u003cp\\u003e\\u003cul\\u003e\\u003cli\\u003e\\u003cp\\u003e33% to 38% overall\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003e38% to 44% in females\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003e29% to 36% in males\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/ul\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eTable No.4\\u003c/strong\\u003e\\u003cp\\u003eThe prevalence of obesity among PPF and total TKR patient groups.\\u003c/p\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"No\\\" id=\\\"Tabd\\\" border=\\\"1\\\"\\u003e\\u003ccolgroup cols=\\\"3\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eGroup\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePPF Patients with Obesity\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eEstimated Prevalence in Total TKR Patients\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eAll Patients\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e6 of 10 (60%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e33% to 38%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFemales\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e6 of 9 (66.7%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e38% to 44%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eMales\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0 of 1 (0%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e29% to 36%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eThese findings indicate that obesity, particularly among females, was substantially more prevalent in the PPF subgroup\\u003c/p\\u003e\\u003cp\\u003eIn the total TKR population, the estimated prevalence of diabetes mellitus is approximately 30% overall, with 34.1% in males and 27.6% in females \\u003cb\\u003e(Table No.5).\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eIn contrast, among the 10 PPF patients:\\u003c/p\\u003e\\u003cp\\u003e\\u003cul\\u003e\\u003cli\\u003e\\u003cp\\u003e8 of 10 (80%) were diagnosed with diabetes\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003eThis included 7 of 9 female patients (77.8%)\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003eThe only male PPF patient (100%) was also diabetic\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/ul\\u003e\\u003c/p\\u003e\\u003cp\\u003eThese findings show that diabetes was highly prevalent among PPF patients, far exceeding the expected rates in the general TKR population, suggesting a strong link between metabolic disease and post-TKR fracture risk.\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eTable No.5\\u003c/strong\\u003e\\u003cp\\u003eThe prevalence of diabetes among PPF and total TKR patient groups.\\u003c/p\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"No\\\" id=\\\"Tabe\\\" border=\\\"1\\\"\\u003e\\u003ccolgroup cols=\\\"3\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eGroup\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePPF Patients with Diabetes\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eEstimated Diabetes Prevalence in Total TKR Patients\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eAll Patients\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e8 of 10 (80%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e~\\u0026thinsp;30%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFemales\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e7 of 9 (77.8%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e27.6%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eMales\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1 of 1 (100%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e34.1%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003ePatients presented with other multiple chronic health conditions:\\u003c/p\\u003e\\u003cp\\u003e\\u003cul\\u003e\\u003cli\\u003e\\u003cp\\u003eHypertension was present in 6 patients\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003eDyslipidaemia (3 patients)\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003eHypothyroidism (2 patients)\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003eRheumatoid arthritis (1 patient)\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/ul\\u003e\\u003c/p\\u003e\\u003cp\\u003eOne patient had a history of long-term corticosteroid use, which is known to contribute to decreased bone mass. The combination of these comorbid conditions may have a synergistic effect, further increasing the risk for low-energy fracture events, especially when coupled with reduced mobility and poor bone quality.\\u003c/p\\u003e\\u003cp\\u003eThe management of periprosthetic fractures (PPFs) in this cohort of 10 patients was dictated by fracture classification, prosthetic stability, bone stock, and patient-specific factors such as age, comorbidities, and mobility status \\u003cb\\u003e(Table No.6)\\u003c/b\\u003e.\\u003c/p\\u003e\\u003cp\\u003eDistal femur replacement was chosen in 4 patients, including one case with bilateral fractures, where traditional osteosynthesis was not feasible due to:\\u003c/p\\u003e\\u003cp\\u003e\\u003cul\\u003e\\u003cli\\u003e\\u003cp\\u003eSeverely compromised bone quality\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003eProsthetic loosening\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003eExtensive metaphyseal comminution\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003eFailure risk with fixation methods.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/ul\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eTable No.6\\u003c/strong\\u003e\\u003cp\\u003eManagement Approaches for PPF Patients.\\u003c/p\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"No\\\" id=\\\"Tabf\\\" border=\\\"1\\\"\\u003e\\u003ccolgroup cols=\\\"3\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eProcedure\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eNumber of Patients\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003ePercentage (%)\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eORIF (Open Reduction and Internal Fixation)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e5\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e50.0\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eDistal Femoral Replacement (DFR)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e2\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e20.0\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eRevised ORIF with DFR\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e2\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e20.0\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eConservative (Bed Bound)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e10.0\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eA bilateral DFR (simultaneous) was performed in a morbidly obese, osteoporotic female \\u0026mdash; a rare and technically demanding scenario. A total of 5 patients were treated with internal fixation:\\u003c/p\\u003e\\u003cp\\u003e\\u003cul\\u003e\\u003cli\\u003e\\u003cp\\u003ePatients had adequate remaining bone stock.\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003eFemoral components were radiographically stable.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/ul\\u003e\\u003c/p\\u003e\\u003cp\\u003eFixation was performed using locking compression plates (LCP) and biomechanically optimised constructs to address shear and rotational forces, especially in patients with high BMI.\\u003c/p\\u003e\\u003cp\\u003eAnd one patient was treated with conservative treatment (bed bound) and regular follow ups in the clinic.\\u003c/p\\u003e\\u003cp\\u003eFractures occurred at widely varying intervals from the index TKA procedure (\\u003cb\\u003eTable No.7)\\u003c/b\\u003e. Late-onset fractures (\\u0026gt;\\u0026thinsp;5 years) were the most frequent (40%), were all associated with osteoporosis, poor mobility, and often minor trauma.\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eTable No.7\\u003c/strong\\u003e\\u003cp\\u003eThe time span between a primary total knee replacement (TKR) and the occurrence of a periprosthetic fracture (PPF)\\u003c/p\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"No\\\" id=\\\"Tabg\\\" border=\\\"1\\\"\\u003e\\u003ccolgroup cols=\\\"3\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eInterval from TKR to PPF\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eNo. of Patients\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003ePercentage\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e0\\u0026ndash;3 months\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e10%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e3 months \\u0026ndash; 1 year\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e2\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e20%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e1\\u0026ndash;5 years\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e3\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e30%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u0026gt;\\u0026thinsp;5 years\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e4\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e40%\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eEarly fractures (within 3 months) were linked to falls during rehabilitation, underscoring the importance of fall-prevention protocols post-op.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eIn this retrospective analysis of ten cases of periprosthetic fracture (PPF) following total knee replacement (TKR), several key risk factors were identified, with implications for both prevention and management. The overwhelming majority of cases (90%) occurred in female patients, consistent with the well-established higher prevalence of osteoporosis and fragility fractures in postmenopausal women. The mean age of the female patients was 72.8 years, compared to 82 years for the single male case, further reinforcing the role of advanced age and sex-specific bone loss as predisposing factors. Nearly all fractures (9 out of 10) occurred in patients with confirmed osteoporosis, highlighting low bone mineral density as the single most important determinant of periprosthetic fracture risk in our cohort. Additionally, the mechanism of injury was typically low-energy trauma such as falls, emphasizing the vulnerability of this patient population to fractures even with minimal insult.\\u003c/p\\u003e\\u003cp\\u003eThe anatomical distribution of fractures in this series is noteworthy: all ten patients sustained supracondylar femoral fractures, a location well recognized as the most common site of PPF following TKR worldwide, accounting for approximately 70% of cases in the literature. The supracondylar region represents a biomechanical zone of stress concentration, particularly in the presence of compromised bone quality. This uniform finding in our cohort underscores both the inherent vulnerability of this region and the need for heightened awareness during both primary TKR implantation and postoperative follow-up.\\u003c/p\\u003e\\u003cp\\u003eObesity was another prominent factor in our analysis. The mean BMI among females was 31.7, with three patients classified as morbidly obese (BMI\\u0026thinsp;\\u0026gt;\\u0026thinsp;35). Obesity was overrepresented among PPF cases, with two-thirds of female patients affected compared to 38\\u0026ndash;44% expected in the general TKR cohort. Excess body weight likely contributes to increased mechanical loading at the bone\\u0026ndash;prosthesis interface, further predisposing to fractures in osteoporotic bone. The combination of osteoporosis and obesity thus creates a synergistic risk profile, which was particularly evident in the bilateral fracture case involving a morbidly obese, osteoporotic female.\\u003c/p\\u003e\\u003cp\\u003eComorbid medical conditions further complicated the risk landscape. Diabetes mellitus (70%), hypertension (60%), dyslipidemia, hypothyroidism, rheumatoid arthritis, and long-term corticosteroid use were prevalent among our PPF patients. These comorbidities are known to impair bone metabolism, delay healing, and increase fall risk, thereby acting as both direct and indirect contributors to fracture susceptibility. Importantly, the clustering of multiple chronic conditions in these patients suggests that medical optimization and multidisciplinary management are critical preventive strategies.\\u003c/p\\u003e\\u003cp\\u003eTreatment decisions were dictated by fracture characteristics, prosthetic stability, and patient factors. Distal femoral replacement (DFR) was required in 70% of patients, including one rare case of simultaneous bilateral replacement. DFR was chosen primarily in the context of poor bone stock, prosthetic loosening, and extensive comminution, where fixation methods would be prone to failure. In contrast, four patients with adequate bone stock and stable femoral components were successfully managed with internal fixation using locking compression plates, highlighting the importance of individualized surgical planning. One patient was managed conservatively, underscoring that select cases may avoid surgery when comorbidities, fracture pattern, and mobility status permit.\\u003c/p\\u003e\\u003cp\\u003eThe findings of this study have several important clinical implications. First, patient counseling before TKR should explicitly address the elevated risks of PPF in elderly, osteoporotic, and obese females [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. Patients should be encouraged to participate in preoperative physical therapy, weight management programs, and bone health optimization prior to surgery. Second, prophylactic measures should be considered in very high-risk individuals, including the use of femoral stems that bypass the supracondylar region, thereby reducing stress risers in osteoporotic bone [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. Such strategies may mirror tibial stem extensions already used in primary TKR and could reduce the incidence of catastrophic fractures. Third, referral to endocrinology for osteoporosis management, coupled with optimization of diabetes, thyroid function, and cardiovascular risk factors, represents an essential component of holistic care [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e]. Finally, fall-prevention protocols should be emphasized in the early postoperative period, given the association of early PPFs with rehabilitation-related falls in this series [\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eOverall, this study reinforces that PPFs are multifactorial in origin, arising from the interplay of biological risk factors (osteoporosis, female sex, comorbidities), mechanical stressors (obesity, supracondylar location), and surgical factors (prosthetic design, fixation strategies). Effective prevention and management therefore demand a multidisciplinary, patient-tailored approach.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eIn conclusion, our analysis of ten periprosthetic fracture cases following TKR revealed that elderly, osteoporotic, and obese female patients are disproportionately affected. All fractures in our cohort involved the supracondylar femoral region, consistent with the global literature, where this location accounts for approximately 70% of PPFs. Osteoporosis was present in 90% of cases, and obesity was significantly overrepresented compared to the general TKR population, confirming these as key modifiable risk factors. Management was challenging, with 70% of patients requiring distal femur replacement due to poor bone quality and prosthetic instability. These findings emphasize the necessity of preventive strategies, including preoperative optimization of bone health, weight reduction, patient education, and consideration of prophylactic femoral stems in high-risk individuals. By addressing these factors and adopting a multidisciplinary approach, it is possible to reduce the burden of PPFs and improve both functional outcomes and patient satisfaction after TKR.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e-TKR\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eTotal knee replacement\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e-PPF\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003ePeriprosthetic fracture\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e-BMI\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eBody mass index\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e-DFR\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eDistal femoral replacement\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e- LCP\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eLocking compression plate\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eMayr MF, S\\u0026uuml;dkamp NP, Konstantinidis L (2021) Periprosthetic fracture management around total knee arthroplasty. J Orthop 23:239e45. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.jor.2020.12.024\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.jor.2020.12.024\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eMeek RMD, Norwood T, Smith R, Brenkel IJ, Howie CR (2011) The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement. J Bone Joint Surg Br 93(1):96\\u0026ndash;101\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eLindahl H (2007) Epidemiology of periprosthetic femur fracture around a total hip arthroplasty. Injury 38(6):651\\u0026ndash;654\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003ePlatzer P, Schuster R, Aldrian S, Prosquill S, Krumboeck A, Zehetgruber I, Kovar F, Schwameis K, Vecsei V (2010) Management and outcome of periprosthetic fractures after total knee arthroplasty. J Trauma 68:1464\\u0026ndash;1470\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eMcGraw P, Kumar A (2010) Periprosthetic fractures of the femur after total knee arthroplasty. J Orthopaed Traumatol 11:135\\u0026ndash;141. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1007/s10195-010-0099-6\\u003c/span\\u003e\\u003cspan address=\\\"10.1007/s10195-010-0099-6\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eGujarathi N, Putti AB, Abboud RJ, MacLean JGB, Espley AJ, Kellett CF (2009) Risk of periprosthetic fracture after anterior femoral notching. Acta Orthop 80:553\\u0026ndash;556. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.3109/17453670903350099\\u003c/span\\u003e\\u003cspan address=\\\"10.3109/17453670903350099\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eBhattacharyya T, Chang D, Meigs JB, Estok DM 2nd, Malchau H (2007) Mortality after periprosthetic fracture of the femur. J Bone Joint Surg Am 89:2658\\u0026ndash;2662\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eEl Khassawna T, Knapp G, Scheibler N et al (2021) Mortality, risk factors and risk assessment after periprosthetic femoral fractures-a retrospective cohort study. J Clin Med 10(19):4324\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eDuncan C, Haddad F (2014) The unified classification system (UCS): improving our understanding of periprosthetic fractures. Bone Joint J 96(B):713\\u0026ndash;716\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eM\\u0026uuml;ller K, Zeynalova S, Fakler JK et al (2025) Risk factors for mortality in periprosthetic femur fractures about the hip-a retrospective analysis. Int Orthop (SICOT) 49:211\\u0026ndash;217. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1007/s00264-024-06346-7\\u003c/span\\u003e\\u003cspan address=\\\"10.1007/s00264-024-06346-7\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eGausden EB, Bedard NA, Gililland JM, Haidukewych GJ (2024) What\\u0026rsquo;s New in peri-prosthetic femur fractures? J Arthroplasty 39:S18e25. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.arth.2024.04.037\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.arth.2024.04.037\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eInui H, Yamagami R, Kono K, Kawaguchi K What are the causes of failure after total knee arthroplasty? J Joint Surg Res 1, Issue 1,2023, Pages 32\\u0026ndash;40, ISSN 2949\\u0026ndash;7051. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.jjoisr.2022.12.002\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.jjoisr.2022.12.002\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eHegde V, Bracey DN, Brady AC, Kleeman-Forsthuber LT, Dennis DA, Jennings JM et al (2021) A prophylactic tibial stem reduces rates of early aseptic loosening in patients with severe preoperative varus deformity in primary total knee arthroplasty. J Arthroplasty 36:2319\\u0026ndash;2324. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.arth.2021.01.049\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.arth.2021.01.049\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eAbdel MP, Cottino U, Mabry TM (2015) Management of periprosthetic femoral fractures following total hip arthroplasty: a review. Int Orthop (SICOT) 39:2005\\u0026ndash;2010. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1007/s00264-015-2979-0\\u003c/span\\u003e\\u003cspan address=\\\"10.1007/s00264-015-2979-0\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eKanakaris NK, Obakponovwe O, Krkovic M, Costa ML, Shaw D, Mohanty KR et al (2019) Fixation of periprosthetic or osteoporotic distal femoral fractures with locking plates: a pilot randomised controlled trial. Int Orthop 43(5):1193\\u0026ndash;1204\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eKanis JA, Oden A, Johnell O et al (2007) The use of clinical risk factors enhances the performance of BMD in the prediction of hip and osteoporotic fractures in men and women. Osteoporos Int 18:1033\\u0026ndash;1046\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eSpringer B, Parvizi J, Austin M et al (2013) Obesity and total joint arthroplasty. A literature based review. J Arthroplast 28(5):714\\u0026ndash;721\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eWu KA, Kutzer KM, Kugelman DN, Seyler TM (2024) Fall prevention after hip and knee arthroplasty. Orthop Clin North Am 56:121\\u0026ndash;134. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.ocl.2024.05.003\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.ocl.2024.05.003\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eJohnson RL, Duncan CM, Ahn KS, Schroeder DR, Horlocker TT, Kopp SL (2014) Fall-prevention strategies and patient characteristics that impact fall rates after total knee arthroplasty. Anesth Analg 119(5):1113\\u0026ndash;1118. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1213/ANE.0000000000000438\\u003c/span\\u003e\\u003cspan address=\\\"10.1213/ANE.0000000000000438\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":true,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"Prince Sultan Military Medical City\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Periprosthetic fracture, femur, Osteoporosis, Obesity, Total knee replacement, Fixation\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8058295/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8058295/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cu\\u003eBackground\\u003c/u\\u003e: Total knee replacement (TKR) is a widely performed surgery for advanced knee joint issues. The rising demand for TKR has led to an increase in periprosthetic fractures (PPFs), influenced by patient factors, surgical variables, and injury mechanisms. Understanding these factors is crucial for prevention and improvement of surgical methods and patient outcomes.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eMaterials and methods\\u003c/u\\u003e: This retrospective cohort study evaluated knee periprosthetic fractures in patients from January 2019 to July 2025 at a tertiary center. Data was sourced from the arthroplasty unit database, encompassing various radiographs. Exclusion criteria included infections, mid shaft femur fractures, tibia periprosthetic fractures, road traffic accidents, and incomplete records. Data analysis utilized Microsoft Excel and SPSS for statistical assessments, verifying data quality with frequency tables and box plots. Comparisons included gender, obesity status, and independent risk factors, with statistical significance defined as a P value \\u0026lt; 0.05.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eResults\\u003c/u\\u003e: A study of 2113 total knee replacement patients (mostly women, mean age 64) found a 0.47% incidence of periprosthetic fractures (PPFs), associated with bone fragility, obesity, and diabetes, particularly in older females and osteoporotic males. Among 10 patients with chronic conditions, treatment depended on fracture type, prosthesis stability, and bone quality: 4 underwent distal femur replacement, 5 received locking plate fixation, and 1 was managed conservatively. Late fractures (\\u0026gt;5 years) were linked to osteoporosis and minor trauma, while early fractures (\\u0026lt;3 months) stemmed from falls during rehabilitation, highlighting the importance of fall prevention strategies.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eConclusion:\\u003c/u\\u003e An analysis of ten periprosthetic fracture cases after total knee replacement found a higher incidence in elderly, osteoporotic, and obese female patients, with osteoporosis and obesity as key risk factors. Management was challenging, and 70% required distal femoral replacement. The study emphasizes preventive measures such as weight control, patient education, and prophylactic femoral stems to reduce fracture risk and improve postoperative outcomes\\u003c/p\\u003e\",\"manuscriptTitle\":\"Risk Factors Influencing Management Outcomes of Periprosthetic Fractures Following Total Knee Arthroplasty: A Retrospective Study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-11-10 06:53:32\",\"doi\":\"10.21203/rs.3.rs-8058295/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"ba571472-79e7-458b-a570-70232be05de0\",\"owner\":[],\"postedDate\":\"November 10th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-11-10T06:53:32+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-11-10 06:53:32\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8058295\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8058295\",\"identity\":\"rs-8058295\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}