Peri-implant femoral fractures in hip fracture patients treated with osteosynthesis: a retrospective cohort study of 1965 patients

Is nail-plate docking worth the effort? A biomechanical analysis of docking a plate and a nail in peri-implant femur fractures

Purpose

The ideal treatment of peri-implant femur fractures (PIFFs) remains unclear due to the thin clinical and biomechanical evidence concerning the most suitable form of osteosynthesis. The purpose of the present study was thus to determine the biomechanical stability that results from combining a cephalomedullary nail and a plate for proximal PIFFs, especially when the nail-plate docking technique is applied.

Methods

Twenty four PIFFs were simulated in both 12 foam and 12 composite specimens and were stabilized via a combination of a cephalomedullary nail and a plate. The control group (n = 6) had a nail and a plate without a connection, while the intervention group (n = 6) had a screw that connected the plate with the interlocking screw hole of the nail, thereby creating a nail-plate docking system. The specimens were evaluated under axial and torsional loading using a material-testing machine and a 3D metrology system.

Results

The data regarding stiffness, failure load, and failure displacement showed significantly higher stability for specimens without nail-plate docking. For docked specimens, a non-significant trend toward a higher resistance to torque was observed. Both techniques displayed no significant difference in fracture gap displacement or total displacement.

Conclusion

The present study suggests that nail-plate docking of a cephalomedullary nail, and a plate significantly decreases the stiffness and stability of osteosynthesis under axial loading. However, there seems to be a tendency toward higher resistance to torque. Therefore, surgeons should consider this technique if higher torsional stability is necessary, and they should decide against it, if axial stability is preferred.

Therapy aspects of peri-implant femoral fractures-a retrospective analysis of 64 patients

PURPOSE

The incidence of peri-implant femoral fractures (PIFF) is increasing. Information regarding outcomes, timing of surgery, risk factors, and a clinically applicable treatment algorithm are lacking. The aim of this study was to identify outcome-related risk factors and to derive a treatment algorithm.

METHODS

Sixty-four PIFFs treated between 01.01.2006 and 31.12.2020 in a level I trauma centre were evaluated retrospectively for fracture pattern, surgical technique, risk factors, complications, and 1-year mortality. The study was approved by the ethics committee (No. 21-2714-104).

RESULTS

One-year mortality was 24.1%. Surgical complications occurred in 4.7%, and general complications in 15.6% of the patients. General complications, low haemoglobin level at admission, elevated CHA2DS2-VASc, and Charlson score resulted in increased 1-year mortality. Time to surgery > 24 h did not increase complication or mortality rates. The three predominant fracture patterns were fractures close or distal to cephalomedullary nails, close or proximal to distal lateral plates, and close or distal to sliding hip screws. Recommendations for surgical treatment were derived: Osteosynthesis should enable as much weight-bearing as possible; the initial implant should only be removed, if this is essential for the new osteosynthesis; lateral locking plates should span the whole femur; antegrade nails should have a cephalomedullary component to avoid consecutive femoral neck fractures; implants should overlap to reduce the risk of consecutive inter-implant fractures.

CONCLUSION

Risk factors for 1-year mortality in patients with PIFFs were identified. A treatment algorithm and general principles for surgery of PIFFs were developed.

Peri-implant distal radius fracture due to car collision

Peri-implant fractures have gained increasing importance in orthopedics as the number of surgical procedures involving orthopedic implants rises globally. These fractures pose a significant challenge in terms of diagnosis, treatment, and postoperative management. They manifest as stress fractures distal to the implant site. Developing an effective treatment strategy involves evaluating multiple influencing factors. This article presents a rare case of a peri-implant distal radius fracture in a 63-year-old man, with no comorbidities, resulting from a car accident, classified as C1U in the Michele D'Arienzo system. The surgical intervention included plate fixation for the radius and wire fixation for the ulna. The wire was used for ulna instead of a plate, due to skin injuries, with good results. As life expectancy rises and individuals remain active in their elder years, the incidence of peri-implant fractures is expected to increase. Factors such as the implant type, surgeon's approach, and patient-specific elements may influence peri-implant fracture occurrence. The widespread use of plate fixation for distal radius fractures may also contribute to a parallel increase in such fractures. Providing detailed context and specific case presentation allows better understanding and implications for clinical practice.

Peri-implant femoral fractures: Challenges, outcomes and proposal of a treatment algorithm

PURPOSE

Non-prosthetic peri-implant fractures are challenging injuries. Multiple factors must be carefully evaluated for an adequate therapeutic strategy, such as the state of bone healing, the type of implant, the time and performed personnel of previous surgery, and the stability of fixation. The aim of this study is to propose a rationale for the treatment.

METHODS

The peri-implant femoral fractures (PIFFs) system, a therapeutic algorithm was developed for the management of all patients presenting a subtype A PIFF, based on the type of the original implant (extra- vs. intra-medullary), implant length and fracture location. The adequacy and reliability of the proposed algorithm and the fracture healing process were assessed at the last clinical follow-up using the Parker mobility score and radiological assessment, respectively. In addition, all complications were noticed. Continuous variables were expressed as mean and standard deviations, or median and range according to their distribution. Categorical variables were expressed as frequency and percentages.

RESULTS

This is a retrospective case series of 33 PIFFs, and the mean post-operative Parker mobility score was (5.60 ± 2.54) points. Five patients (15.1%) achieved complete mobility without aids (9 points) and 1 (3.0%) patient was not able to walk. Two other patients (6.1%) were non-ambulatory prior to PPIF. The mean follow-up was (21.51 ± 9.12) months (range 6-48 months). There were 7 (21.2%) complications equally distributed between patients managed either with nailing or plating. There were no cases of nonunion or mechanical failure of the original implant.

CONCLUSION

The proposed treatment algorithm shows adequate, reliable and straightforward to assist the orthopaedic trauma surgeon on the difficult decision-making process regarding the management of PIFF occurring in previously healed fractures. In addition, it may become a useful tool to optimize the use of the classification, thus potentially improving the outcomes and minimizing complications.

No Difference in Conversion Rate to Hip Arthroplasty After Intramedullary Nail or Sliding Hip Screw for Extracapsular Hip Fractures: An Observational Cohort Study of 19,604 Individuals

BACKGROUND

The widespread use of intramedullary nails (IMNs) compared with sliding hip screws (SHSs) in extracapsular hip fractures (AO/OTA 31-A1, 31-A2, 31-A3) has been questioned because of a higher complication rate, although the outcome might have improved through more recent implant designs and the learning curve. This study aimed to investigate if there is a difference with regard to the cumulative incidence of conversion to arthroplasty or any reoperation during the first 5 years after IMN or SHS fixation of extracapsular hip fractures.

METHODS

In this nationwide, observational cohort study, individuals who were ≥60 years of age and were registered in the Swedish Fracture Register (SFR) from 2012 to 2018 due to extracapsular fracture and were primarily treated with an IMN or SHS were followed in the SFR and the Swedish Arthroplasty Register (SAR) for a minimum of 1 year. The primary outcome was the cumulative incidence of conversion to arthroplasty (conversion rate). The secondary outcome was the cumulative incidence of all reoperations (reoperation rate). Both were calculated in a competing risk analysis during the first 5 years.

RESULTS

We included 19,604 individuals (70% women), with a median age of 85 years (range, 60 to 107 years). The 31-A2 fracture was most prevalent (52%), followed by the 31-A1 fracture (28%). No significant differences were seen in the 1-year conversion rate after IMN or SHS use (1.0% compared with 0.9% in the 31-A1 fractures, 1.7% compared with 1.3% in the 31-A2 fractures, and 1.3% compared with 1.5% in the 31-A3 fractures) or in the 1-year reoperation rate (1.9% compared with 1.9% in the type-A1 fractures, 3.4% compared with 2.5% in the type-A2 fractures, and 4.0% compared with 5.2% in the type-A3 fractures). Only in 31-A2 fractures were more reoperations seen after IMN use at 2 and 5 years (p < 0.05). The crude 1-year-mortality was 26.4% (5,178 of 19,604), without significant differences between implants.

CONCLUSIONS

Considering conversion arthroplasty, IMNs and SHSs performed equally well in general. IMN use was associated with more reoperations than SHS use in 31-A2 fractures at 2 years. However, from a clinical perspective, the differences between the implants were small, in particular when considering the competing risk of dying.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Fractures after cephalomedullary nailing of the femur : Systematization of surgical fixation based on the analysis of a single-center retrospective cohort

PURPOSES

Femoral implant related fractures (IRF) are a growing pathology in an increasingly elderly and frail population. A series of IRF after cephalomedullary nail (CMN) fixation of a femoral fracture is analyzed and an algorithm described to guide the management of such fractures.

METHODS

All eligible patients operated on for IRF fixation after CMN were reviewed regarding their demographics, comorbidities, injury pattern, and treatment. Primary outcomes were mortality and local complications. Secondary outcomes were time to consolidation, time to weight-bearing initiation, length of hospitalization, and discharge destination.

RESULTS

The incidence of IRF requiring fixation was 1.3% after 3401 CMN implantation procedures. Elderly women with comorbidities and plate fixation predominated. One-year mortality was 18.6%, being higher for patients presenting with infection and those unable to walk at the end of follow-up. Local complications occurred in 25.6%. Median time to weight-bearing was 9.1 weeks, but longer for patients with plate fixation or complications. Patients presenting with an infection and those discharged to nursing facilities had more comorbidity.

CONCLUSIONS

Following an algorithm presented here, patients were treated either with nail exchange or lateral locking plate fixation, permitting straightforward evaluations and acceptable results in a very high-risk population.