Minimally invasive surgery with locking plate for periprosthetic femoral fractures: technical note

Anthropometric Factors on Safe Distances between Popliteal Vessels to the Femur for Cerclage Wiring of the Distal Femoral Fracture: A Magnetic Resonance Imaging Study

Background and Objectives: The proximity of the popliteal vessels in the distal femur may increase the risk of iatrogenic vascular injury during cerclage wiring. In this study, the closest location and distance of the popliteal vessels to the femur was examined using magnetic resonance imaging (MRI). The associations between anthropometric factors and the distance that would guide the placement of wires safely during surgery were also identified. Materials and Methods: We reviewed adult knee magnetic resonance images and recorded: (1) the relation and the shortest horizontal distance (d-H) from the femoral cortex to the popliteal vessels in axial images and (2) the vertical distance (d-V) from the adductor tubercle to the axial level of the d-H values in coronal images. The effects of anthropometric factors (sex, age, body height, body weight, body mass index, thigh circumference, femoral length and femoral width) on these distances were analysed. Results: Analysis of 206 knee magnetic resonance images revealed that the closet locations of popliteal vessels were at the posteromedial aspect of the femur. The d-H and d-V were 7.38 ± 3.22 mm and 57.01 ± 11.14 mm, respectively, and were both shorter in women than in men (p < 0.001). Multivariate analysis identified thigh circumference and femoral length as the most influential factors for the d-H and d-V, respectively (p < 0.001). Linear regression demonstrated a strong positive linear correlation between the thigh circumference and the d-H and between the femoral length and the d-V (Pearson’s r = 0.891 and 0.806, respectively (p < 0.001)). Conclusions: The closet location and distance of the popliteal vessels to the femur provide useful information for wire placement during distal femoral fracture surgery while minimising the risk of vascular injury. Given that patients with a smaller thigh circumference and a shorter femoral length are more likely to have a smaller d-H and a shorter d-V, respectively, cautious measures should be taken in such cases.

Minimally invasive plate osteosynthesis with locking compression plate in patients with Vancouver type B1 periprosthetic femoral fractures

BACKGROUND

Periprosthetic femoral fractures (PFF) following total hip arthroplasty (THA) remain one of the most challenging complications to address. Although the principal treatment modalities for Vancouver type B1 fractures are open reduction and internal fixation (ORIF), surgeons have not yet reached a consensus on the optimal method for reduction and fixation. We therefore investigated whether minimally invasive plate osteosynthesis (MIPO) using locking compression plate (LCP) would lead to favorable outcomes for patients with Vancouver type B1 PFFs. In addition, we also compared the outcomes of patients treated with MIPO to those treated with ORIF.

METHOD

We retrospectively evaluated the clinical and radiographic outcomes of a series of 21 Vancouver type B1 PFFs treated with MIPO and LCP between February 2011 and February 2017. The mean duration of follow-up was 33.8 months. We also compared outcomes of these patients to those of patients with 19 Vancouver type B1 fractures treated with ORIF between April 2006 and December 2011.

RESULTS

Fracture healing without complications was achieved in 20 (95.2%) out of 21 cases in the MIPO group and in 14 (87.5%) out of 16 cases in the ORIF group. There was one case of fixation failure with stem subsidence in the MIPO group. In the ORIF group, there were 2 nonunion with metal failure. Operation time was significantly shorter and intraoperative blood loss was significantly less in the MIPO group compared to the ORIF group. However, there were no significant differences in frequency of transfusion, time-to-union, walking abilities, modified Harris hip score, or complications.

CONCLUSION

The radiological and clinical outcomes of MIPO using LCP in patients with Vancouver type B1 PFFs were shown not to be inferior to ORIF and resulted in fewer intraoperative complications than ORIF. If care is taken regarding the stability of femoral implant and optimal surgical techniques, MIPO may be a recommended option in the treatment of Vancouver type B1 periprosthetic fracture.

Vascular complication after percutaneous femoral cerclage wire

Cerclage wire is an effective fracture fixation method. However, its mechanical benefits are countered by local ischemia. Its efficacy for treating femoral periprosthetic fractures has been demonstrated since femoral fixation is possible even there is a stem in the diaphysis. It securely holds the proximal femur typically with an additional plate. The development of minimally-invasive surgery with plate fixation has led to the cerclage wire being inserted percutaneously. Here, we report on a case of secondary femoral ischemia following percutaneous cerclage wire of a periprosthetic femoral fracture. This was a Vancouver type B1 fracture. On the 3rd day after admission, minimally-invasive fixation with a femoral locking plate was performed with five cerclage wires added percutaneously. During the immediate postoperative course, the patient developed ischemia of the operated leg that required vascular surgery after confirmation by CT angiography. An arterial stop was visible with deviation of the superior femoral artery, which was not properly surrounded by the cerclage wire. The latter pulled perivascular tissues towards the femur. When combined with reduced arterial elasticity due to severe atherosclerosis, it resulted in arterial plication. The postoperative course was marked by multiple organ failure and death of the patient. Percutaneous surgery is an attractive option but has risks. The presence of severe atherosclerosis is a warning sign for loss of tissue elasticity. This complication can be prevented by preparing the bone surfaces and carefully positioning the patient on the traction table to avoid forced adduction. The surgeon must also be familiar with alternative techniques to cerclage wire such as polyaxial screws and additional plates.

[Periprosthetic knee fractures]

BACKGROUND

The cumulative incidence of periprosthetic fractures around the knee is increasing further because of an extended indication for knee replacement, previous revision arthroplasty, rising life expectancy and comorbidities.

AIM OF THE WORK

The relevance of local parameters such as malalignment, osseous defects, neighbouring implants, aseptic loosening and low-grade infections may sometimes be hidden behind the manifestation of a traumatic fracture. A differentiated diagnostic approach before the treatment of a periprosthetic fracture is of paramount importance, while the physician in-charge should also have particular expertise in fracture treatment and in advanced techniques of revision endoprosthetics. The following work gives an overview of this topic.

RESULTS

Valid classifications are available for categorising periprosthetic fractures of the femur, the tibia and the patella respectively, which are helpful for the selection of treatment.

CONCLUSIONS

With the wide-ranging modern treatment portfolio bearing in mind the substantial rate of complications and the heterogeneous functional outcome, the adequate analysis of fracture aetiology and the corresponding transformation into an individualised treatment concept offer the chance of an acceptable functional restoration of the patient at early full weight-bearing and prolonged implant survival. The management of complications is crucial to the final outcome.