Claw plate fixation of the greater trochanter in revision total hip arthroplasty

Management of Isolated Greater Trochanter Fractures Associated With Total Hip Arthroplasty

Periprosthetic hip fractures are recognized complications associated with total hip arthroplasty. Over the past decade, there has been a 2.5-fold increase in the incidence of periprosthetic fractures which is expected to grow exponentially in the future. Most of these fractures require surgical fixation or revision arthroplasty. Fractures of the greater trochanter represent a subset of periprosthetic fractures for which there is currently no consensus in the literature regarding the optimal management. The purpose of this review was to outline the management strategies available to address these fractures, with formulation of recommendations for fractures sustained intraoperatively, postoperatively, and in the setting of primary and revision total hip arthroplasty.

Treatment of Intraoperative Trochanteric Fractures During Primary and Revision Total Hip Arthroplasty

Intraoperative trochanteric fractures during primary and revision total hip arthroplasty typically occur during femoral canal preparation and component placement. Several fixation strategies, including wires, cables, cable grips, and plating, are available for fracture fixation. Surgeons should consider patient activity level preoperatively, bone mineral density, and fracture morphology when deciding on fixation strategies. Patient activity must be modified postoperatively to prevent fracture displacement and additional complications. Patients must be counseled postoperatively about the possibility of decreased clinical outcomes.

Trochanteric Bolt Failure in a Modular Femoral Revision System

With the incidence of primary total hip arthroplasty continuing to rise in the United States, the innovation behind improving current total hip arthroplasty systems inevitably grows with it-each new design potentially ushering in new flaws. We report a case of screw failure with the Arcos Modular Femoral Revision System-Trochanteric Bolt and Claw Technique in a 74-year-old male patient. The patient presented to the investigator's clinic for their 20-month follow-up evaluation of their complex right hip revision. Radiographs revealed failure of the screw attaching the claw plate to the stem resulting in dislodgement and relocation of the screw within the intra-articular cavity. The patient elected for nonsurgical management and will continue to be monitored. Consent by the patient involved in this case report was obtained.

Outcomes of osteosynthesis of periprosthetic fractures of the greater trochanter with an anatomic claw plate

Background

The treatment of periprosthetic trochanteric fractures, especially older fractures, is often a challenge. The aim of this study was to investigate the clinical and radiological outcomes of periprosthetic fracture treatment with the anatomic Peri-Plate claw plate.

Material and methods

Thirteen new fractures (≤6 weeks after occurrence) and 8 older Vancouver AG fractures (35.4 ± 26.1 weeks after occurrence) were followed radiologically and clinically with a follow-up of 44.6 ± 18.8 (24-81) months.

Results

At 6 months, osseous consolidation had occurred in 12 cases and fibrous union in 9 cases. At 12 months one additional osseous consolidation was shown. The Harris hip score (HHS) increased from 37.2 ± 10.3 preoperatively to 87.6 ± 10.3 12 months after surgery. Thirteen patients reported no, 7 mild and one patient significant local trochanteric pain.

Conclusions

The Peri-Plate claw plate can achieve reproducibly good outcomes in terms of fracture stabilization and bony consolidation, as well as with regard to clinical outcomes in the treatment of new and older periprosthetic trochanteric fractures.

Contemporary Use of Trochanteric Plates in Periprosthetic Femur Fractures: A Displaced Trochanter Will Not Be Tamed

BACKGROUND

The objective of this study was to evaluate the reoperation and complication rate following trochanteric plate fixation of greater trochanter (GT) periprosthetic femur fractures associated with total hip arthroplasty and to identify risk factors for subsequent reoperation, nonunion, and hardware failure (plate/cable breakage or migration).

METHODS

Between 2010 and 2020, 44 patients who had 44 periprosthetic greater trochanter fractures at mean follow up of 2 years were retrospectively reviewed. Initial injury radiographs as well as immediate and final follow-up radiographs were evaluated. Subsequent reoperations, nonunion, and cases of hardware failure were identified. There were 22 (50%) Vancouver B2 fractures and 22 (50%) Vancouver A fractures.

RESULTS

The 2-year cumulative probability of any subsequent reoperation was 20%. There were 9 total subsequent reoperations. The trochanteric fracture went on to nonunion in 14 patients (39%), and hardware failure occurred in 10 (28%) patients. A trochanteric bolt was used in addition to the trochanteric plate in 6 patients (14%), of which 4 (67%) patients had trochanteric plate displacement and 3 (50%) patients had trochanteric nonunion. Displacement of the greater trochanter prior to fixation was a predictor of subsequent nonunion (77% versus 23%, P = .02).

CONCLUSION

In this large contemporary series, there was a high incidence of reoperation (20%) with in the first 2-years following plating of periprosthetic GT fractures, as well as a high rate of nonunion (39%), and hardware failure (28%). Displacement of the GT prior to plating predicted nonunion.

LEVEL OF EVIDENCE

Level IV, retrospective observational study.

Greater trochanter fixed with a claw plate and cable system in complex primary and revision total hip arthroplasty: long-term follow-up

BACKGROUND

Maintaining continuity of the greater trochanter and restoring abductor function are of paramount importance in primary and revision total hip arthroplasty. Failure to rigidly fix the greater trochanter can lead to failure. Because of the lack of reports on the clinical results of greater trochanter fixation with a claw plate and cable system, we aimed to analyze the indications for the use of such a system that produces the best clinical results.

METHODS

We retrospectively studied 41 consecutive patients who had undergone primary or revision total hip arthroplasty at our institution between January 2004 and December 2014 using a claw plate and cable system to achieve stable fixation of the greater trochanter.

RESULTS

The mean follow-up duration was ten years. The median Harris hip score improved from 47 points before surgery to 87 points after surgery (p < 0.01). Significant improvements were observed in the range of motion, hip function, and routine activity. Osseous and fibrous union occurred in all patients, and one patient had severe complications (sciatica). Based on the Beals and Tower classification, 67%, 21%, and 13% of outcomes were considered excellent, good, and poor, respectively.

CONCLUSIONS

Our data support the use of a claw plate and cable system for greater trochanter fixation in complex primary and revision hip arthroplasty. The system showed promising results in patients with floating greater trochanters, intertrochanteric fractures requiring extra devices to maintain rotational stability, and extended trochanteric osteotomy fragments with a weakened proximodistal junction. The use of this system should be further investigated and compared to other methods.

Fixation options for reconstruction of the greater trochanter in unstable intertrochanteric fracture with arthroplasty

INTRODUCTION

With the aggravation of population aging, the incidence of intertrochanteric fracture also increases dramatically. Patients are often elderly accompany with severe osteoporosis and various complications. Therefore, we should select an individualized treatment based on the each patient's state. Arthroplasty is recommended for unstable fractures with obvious osteoporosis, ipsilateral femoral head necrosis or arthritis. Rigid fixation of the greater trochanter with arthroplasty is challenging because of the powerful pulling forces created by multiple muscles being transmitted to the greater trochanter. Currently, there are few contemporary literatures on the evaluation of unstable intertrochanteric fracture with efficient fixation of the greater trochanter. Moreover, there is no consensus to choose which implant to immobilize the greater trochanter. The purpose of this study was to review previous literatures and provide a valuable guidance.

CONCLUSIONS

The locking plate, which not only provides rigid fixation but also results in lower rate of postoperative complications. However, further prospective randomized and cohort studies are needed.

Fixation Options Following Greater Trochanteric Osteotomies and Fractures in Total Hip Arthroplasty: A Systematic Review

BACKGROUND

The optimal system for greater trochanteric fixation following osteotomy or fracture remains unknown. This systematic review aims to synthesize the available English-language literature on 5 commonly reported trochanteric fixation methods to quantify and compare rates of complications and reoperation.

METHODS

A comprehensive search of MEDLINE and Embase databases from January 1946 to June 2017 was performed for articles in English describing fixation of trochanteric osteotomies and fractures using wires, cables, cable-plate devices, claw or locking plates, and trochanteric bolts. Pooled mean rates of complications and reoperation with 95% confidence intervals (CIs) were analyzed using a random-effects model.

RESULTS

Fifty-seven studies involving 10,956 hips were eligible for inclusion. Five studies had Level-III evidence and 52 had Level-IV evidence. The pooled mean rate of nonunion was 4.17% (95% CI, 3.21% to 5.13%; I = 79%) for wires, 5.07% (95% CI, 0.37% to 9.77%; I = 74%) for cables, 16.11% (95% CI, 10.85% to 21.37%; I = 89%) for cable-plate systems, 9.60% (95% CI, 2.23% to 16.97%; I = 59%) for claw or locking plates, and 12.42% (95% CI, 3.41% to 21.43%; I = 75%) for trochanteric bolts. Substantial heterogeneity in the data precluded formal statistical comparison of outcomes and complications between implants.

CONCLUSIONS

Available literature on the various trochanteric fixation implants is heterogeneous and consists primarily of retrospective case series. Based on the current literature, it is difficult to support the use of one implant over another. Despite superior mechanical properties, rates of complication and reoperation following cable-plate fixation remains suboptimal, especially in complex revision scenarios. Additional rigorous prospective randomized and cohort studies are needed to make definitive recommendations regarding the most reliable method of trochanteric fixation.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Radiographic outcomes of cable-plate versus cable-grip fixation in periprosthetic fractures of the proximal femur

BACKGROUND

Newer generation cable-plate designs are commonly used for periprosthetic proximal femur fractures; however, comparisons relative to cable-grips remain limited. The aim of this study was to compare radiographic healing rates of cable-plate versus cable-grip fixation for periprosthetic proximal femur fractures.

PATIENTS AND METHODS

Consecutive patients with an acute or chronic Vancouver A, B1, or B2 periprosthetic proximal femur fracture undergoing trochanteric fixation with a cable-plate (n = 46 cases) or cable-grip (n = 24 cases) system were identified retrospectively from a single-centre hospital database (mean follow-up 28 months [range 6-89 months]). Demographics, radiographic fracture healing, and complications were compared between the 2 groups. Radiographic union rates were not different between the cable-grip versus cable-plate group (67% vs. 76% respectively; p = 0.4). Healing rates of greater trochanteric fractures alone were not different between the cable-plate versus cable-grip groups (75% vs. 71% respectively; p = 0.38). The cable-plates were used for a more diverse range of fracture patterns relative to the cable-grips.

RESULTS

An increased number of cables was associated with radiographic healing (odds ratio 14 [95% confidence interval 2-64]; p = 0.01), and body mass index had a negative correlation with radiographic healing (odds ratio -0.4 [95% confidence interval 0.5-0.9].

CONCLUSIONS

Similar rates of periprosthetic fracture healing were seen using a cable-grip versus cable-plate system; however, the cable-plate system could be used for a more diverse range of fracture patterns.

Trochanteric Fixation With a Third-Generation Cable-Plate System: An Independent Experience

BACKGROUND

Greater trochanteric fracture/nonunion can be a devastating complication with significant functional impact after total hip arthroplasty, and their fixation remains a challenge because of the significant forces being transmitted as well as the poor bone quality often associated with these fractures. The objective of this study is to investigate the rates of reoperation and trochanteric nonunion using a third-generation cable-plate system at one center.

METHODS

Thirty-five patients, mean age 72.9 years (range 46-98 years) with 24 women and 11 men, underwent fixation of their fractured greater trochanter using a third-generation cable-plate system. The indications were: periprosthetic fracture (n = 17), complex primary arthroplasty (n = 5), and complex revision arthroplasty (n = 13). Primary outcomes included rates of reoperation and radiographic union.

RESULTS

At a mean follow-up of 2.5 years, trochanteric union rate was 62.9% with nonunion rate of 31.4%, and fibrous union in 5.7%. In regard to quality of initial apposition, only 40% achieved a perfect bone on bone reduction. Ten patients (28.6%) had evidence of wire breakage. Five patients (14.3%) required reoperation and removal of the internal fixation because of lateral hip pain.

CONCLUSION

Fixation of the trochanteric fractures remains a challenge with a relatively high reoperation rate. Poor bone quality and capacity to maintain a stable reduction continue to make this complication after total hip arthroplasty a difficult problem to solve.

Use of locking plates for fixation of the greater trochanter in patients with hip replacement

BACKGROUND

Fixation of the greater trochanter with total hip replacement is challenging and associated with short- and long-term complications. Locking plate technology has been used for fixation of other bones and may be applied successfully in trochanteric fixation. The purpose of this retrospective study was to analyze the utility of the use of trochanteric locking plates in total hip arthroplasty (THA) patients.

METHODS

From 2004 to 2014, 32 procedures were performed to fix the greater trochanter in patients with trochanteric fracture, osteotomy, or nonunion in the setting of THA. The median age at the time of surgery was 69 years. This was a primary arthroplasty in 8 of the patients, conversion from prior hip surgery in 5, and a revision in 19. The greater trochanter was fixed with locking plate alone in 15 hips and with the addition of a single cerclage cable in 17 hips. Patients were followed clinically and radiographically until healing occurred. The median duration of radiographic follow-up was 41.6 months (range: 10-112 months).

RESULTS

Osseous union occurred in 29 (90.6%) of 32 hips. The median Harris hip score was 94 (range 54-100, standard deviation = 10.4) at latest follow-up. Complications included broken hardware in 5 (15.6%) patients, of which 3 underwent subsequent hardware removal. Two additional patients elected hardware removal due to trochanteric pain.

CONCLUSIONS

Locking plate technology is a successful method of fixation of the greater trochanter in patients with THA. Postoperative trochanteric pain and reoperation for hardware-related issues remain a challenge.

Combined bilateral femoral head necrosis and pertrochanteric fracture: a case report

INTRODUCTION

Modular femoral implants have become a regular feature of revision hip surgery. However, for a primary hip arthroplasty, such as a femoral neck fracture case, the implant of choice is a standard femoral component, while compelling literature evidence have made osteosynthesis the standard procedure for the vast majority of trochanteric fractures.

CASE PRESENTATION

We present the case of a 66-year-old Caucasian woman presenting with two trochanteric fractures associated with primary and secondary hip osteoarthritis that were treated with an uncemented total hip replacement with a modular femoral component.

CONCLUSIONS

We found that a modular femoral component can address the issues of stability and, in our case, proved to be a viable solution for treating cases that are complicated by concomitant acetabular or femoral head and neck pathology.

Periprosthetic femoral fractures in total hip arthroplasty

Periprosthetic fractures in total hip arthroplasty (THA) are a significant problem facing hip surgeons, and were responsible for revision surgery in 9% of single stage revision THAs recorded in the National Joint Registry of England and Wales (NJR) in 2012; the 5th most common cause after aseptic loosening, osteolysis, pain and dislocation. The incidence has increased along with the number of THAs performed. Implants and techniques of THA continue to evolve, surgical indications are expanding and the number performed annually continues to rise. Furthermore, patients are undergoing THA earlier and living longer, leading to a rise in the average number of years at risk for periprosthetic fracture. In this review we will discuss the epidemiology of femoral periprosthetic fractures, their prevention, classification and the evidence base for their treatment.

An in-vitro biomechanical study of different fixation techniques for the extended trochanteric osteotomy in revision THA

Background

The wire fixation and the cable grip fixation have been developed for the extended trochanteric osteotomy (ETO) in the revision of total hip arthroplasty (THA). Many studies reported the postoperative performance of the patients, but with little quantitative biomechanical comparison of the two fixation systems.

Methods

An in-vitro testing approach was designed to record the loosening between the femoral bed and the greater trochanter after fixations. Ten cadaveric femurs were chosen in this study. Each femur underwent the THA, revision by ETO and fixations. The tension to the greater trochanter was from 0 to 500N in vertical and lateral direction, respectively. The translation and rotation of the greater trochanter with respect to the bony bed were captured by an optical tracking system.

Results

In the vertical tension tests, the overall translation of the greater trochanter was observed 0.4 mm in the cable fixations and 7.0 mm in the wire fixations. In the lateral tension tests, the overall motion of the greater trochanter was 2.0 mm and 1.2° in the cable fixations, while it was 6.2 mm and 5.3° in the wire fixations. The result was significantly different between the two fixation systems.

Conclusions

The stability of the proximal femur after ETO using different fixations in the revision THA was investigated. The cable grip fixation was significantly more stable than the wire fixation.

Operative treatment of early peri-prosthetic femur fractures following primary total hip arthroplasty

The risk factors for and results of operatively treated peri-prosthetic femoral fractures sustained within 90 days following primary THA were evaluated. 5,313 consecutive THAs were reviewed and 32 (0.60%) fractures were identified which included 9 A(g), 2 B(1), 18 B(2), 1 B(3), and 2 A(g)/B(2) fractures. 19 (61%) patients sustained 23 complications including 9 greater trochanter non-unions, 2 femoral shaft non-unions, 3 patients with Brooker III HO, and 2 deep infections. 7 patients (23%) required a second operative procedure and one patient required a third. Peri-prosthetic fractures were associated with advancing age, female gender, developmental hip dysplasia, and cementless metaphyseal engaging components, particularly flat wedge tapers. Overall, operative treatment of acute peri-prosthetic fractures is associated with a high rate of complications (61%) and re-operation (23%).

Current concepts of hip arthroplasty for radiologists: part 2, revisions and complications

OBJECTIVE

This article reviews the imaging features of revisions and complications of hip replacement arthroplasty and relates these features to the current understanding about how and why these failures occur.

CONCLUSION

Short-term failures of hip replacements are most commonly the result of instability and dislocation. Complications ranging from osteolysis caused by granulomatous reaction to particulate wear debris lead to many long-term failures. Attempts to reduce wear debris through changes in design and materials have reduced the rate of some complications but have resulted in new ones. Infection remains a devastating complication that is difficult to resolve.

Tension and motion measurement for extended trochanteric osteotomy with different fixation methods

The revision of total hip arthroplasty (THA) is becoming an increasingly common procedure around the world. The extended trochanteric osteotomy (ETO) has proved to be an effective way in revision of THA. Four generations of trochanteric osteotomy fixation systems have been developed, all of which has its own clinical application. However, few studies on the biomechanical stability of the above fixation methods have been reported, though many clinical follow-up studies showed some postoperative functional differences among them. Research in this field is mainly subject to constraints of measurement devices and 3D motion analysis. We designed a synchronous testing approach to acquire the tension data loaded to the greater trochanter and minimal rotation or migration of osteotomy fragment which could not be solved by strain gauge method. Active markers were designed to precisely track proximal femoral bed and the osteotomy fragment in 3D space. Six cadaver femurs constructed as vitro biomechanical models were chosen for a preliminary study. Each femur underwent the steps of prosthesis implanting, ETO and a series of five fixation methods in a random order with 2 wires, 3 wires, 2 wires and a short claw plate,2 cables and a short claw plate, and a long claw plate. We also gave a preliminary result of the displacement of fragment and the stiffness of femur after ETO in this paper. Further clinical significance remains to be discussed.

The use of locking plates for greater trochanteric fixation

Stable fixation for healing of the greater trochanter after fracture or osteotomy is difficult to achieve, especially when associated with periprosthetic osteolysis. Wiring techniques are cumbersome and cable grip fixation has an unacceptable rate of non-union, cable fraying, and production/migration of third-body debris. Using 4 case examples, we present a novel and straightforward locking plate technique that we currently use to achieve such fixation. This method also allows placement of bulk allograft that may restore trochanteric bone stock in cases of marked osteolysis. The technique uses implants that are readily available, and can be employed not only in fixation of trochanteric osteotomy but also in trochanteric advancement. At a minimum of 20 months follow-up, healing of the fracture or osteotomy with full abductor function and a significant improvement in hip score was observed in each of the 4 patients. We acknowledge that biomechanical and larger clinical studies are necessary to confirm the success of this technique, but we are pleased with our preliminary findings and continue to use this approach.