Mennen plate fixation for fracture of the femoral shaft with ipsilateral total hip and knee arthroplasties

Interprosthetic and interimplant femoral fractures: is bone strut allograft augmentation with ORIF a validity alternative solution in elderly?

BACKGROUND

Nowadays orthopedic surgeons have a new challenge to treat the interimplants fractures. Although fixation strategies exist for periprosthetic hip and knee fractures, there is no standard of care regarding the more complex interprosthetic and interimplants fractures.

OBJECTIVE

The aim of our study is targeting the focus on the bone strut grafting to avoid the metal hardware failure and to achieve the bone healing in these injuries.

METHODS

A prospective case note review of all interprosthetic or interimplants femoral fractures admitted to our trauma center. There were 11 patients (2 males and 9 females) with a mean age over 85 years old. We treated all the patients by ORIF and medial graft strut allograft to reduce the main complication leading to re-operations and morbidity or mortality is the nonunion or delayed union. The criteria to evaluate the patients during the follow-up were: the survival and complication after the surgery; the objective quality of life measured by Activities of Daily Living Score (ADL). The bone healing was measured by X-rays control as the alignment was measured by radiographic UNION SCORE, and postoperative complications.

RESULTS

All the patients reduced their ADL. In the most of cases we had a good x-rays reduction. We had not: No nonunion or Not delayed union. All patients died within 2 years from the surgery but not due by surgical complications.

CONCLUSIONS

According us, the purpose of this surgery is to limit comorbidities and early mortality not to improve optimal restoration of lower limb function.

A systematic review of the surgical outcomes of interprosthetic femur fractures

Background

Interprosthetic femur fractures (IFFs) are rare, but the treatment is challenging. Currently, there are many treatment methods used in practice, but an updated systematic review of comparison of common different surgical outcomes has not been thoroughly inspected.

Methods

A systematic review of retrospective studies was conducted. The resource databases of PubMed, Cochrane, and Embase were searched using a combination of the keywords involving IFFs and surgical outcomes from inception through June 2021. Data collected included patient demographics, intraoperative data, and postoperative outcomes. Outcomes were measured based on healing time, revision rate, complication rate, and functional scores.

Results

Forty studies were included for review with a total of 508 patients. Average reported age of patients was 78.7 years old and 403 (79.3%) were females. Overall union rate was 74.0% with 376 of 508 patients achieving fracture union after primary treatment of IFF. Only 271 patients had reported healing times of fractures with a mean of 5.15 months. The plate, prosthetic revision, nail/rod, and external fixator groups had mean healing times of 4.69, 8.73, 6.5, and 5.1 months, respectively. Revision rates were highest in the femur replacement treatment group with 9 (32.1%) patients needing at least one reoperation surgery for any reason. Overall, hardware failure and non-unions were the most reported complications in treatment of IFFs. Postoperative functional outcome scores were available for 242 patients. Harris Hip Scores for the plate, revision, replacement, nail/rod, and plate + revision groups were 76.84, 77.14, 69.9, 77, and 78.4, respectively.

Conclusion

Each treatment method should be carefully considered by the surgeon depending on the patient. Locking plate was the most common method for the treatment of the patients with IFFs. Half of them combined with cerclage wires/cables. Around two thirds' patients could achieve union with the fastest mean healing time around 4.69 months. Other less common methods included prosthetic revision, femur replacement, nail/rod, external fixator, etc. A small number of patients treated with Ilizarov external fixator, and it has proven to be a viable option with few complications and high union rates.

Interprosthetic Femoral Fractures Surgical Treatment in Geriatric Patients

Background

Total hip (THA) and total knee arthroplasty (TKA) are becoming an increasingly standard procedure in the whole world. In conjunction with an aging population and increased prevalence of osteoporosis, proper management of periprosthetic, and interprosthetic fractures is of great interest to orthopedic surgeons. This study aims to report the clinical and radiographic outcomes, complications and reoperations of IFFs in geriatric patients.

Methods

A retrospective single-institution case series study was conducted. Between 2011 and 2019, 83 patients underwent surgical treatment for periprosthetic femoral fractures. Thirteen fractures were identified as IFFs. Patient demographics and comorbidities were collected preoperatively, and fractures were classified with the Vancouver and AO unified classification system (AO-UCS).

Results

We included 12 patients (13 hips) with IFFs (AO-UCS type IV.3 B (2/13) type IV.3 C (3/13), type IV.3 D (8/13)). The average patient age was 86.54 (range, 79-89) years. There were 10 females and 2 males. Perioperative morbidity has been identified in 10 of the 12 patients, and the 3-month and 1-year mortality were reported in 2 and 3 patients, respectively. Cerclage cables were used in 9 of 12 patients. One of 12 patients showed a local complication, with no documented implant failure or revision. Patients achieved complete union and returned to their preoperative ambulatory status, and full weight-bearing at an average of 5 (range, 2 to 7) months later.

Conclusion

Management of IFF can be challenging because these fractures require extensive surgical expertise. Locking plate seems to be a valuable treatment option for geriatric patients with IFFs. Despite the complexity of this type of fracture, the overall complication and revision rate, as well as the radiographic outcome are good to excellent.

Level of Evidence

Level III, Therapeutic study.

Periprosthetic hip fractures: an update into their management and clinical outcomes

The Vancouver classification is still a useful tool of communication and stratification of periprosthetic fractures, but besides the three parameters it considers, clinicians should also assess additional factors.

Combined advanced trauma and arthroplasty skills must be available in departments managing these complex injuries.

Preoperative confirmation of the THA (total hip arthroplasty) stability is sometimes challenging. The most reliable method remains intraoperative assessment during surgical exploration of the hip joint.

Certain B1 fractures will benefit from revision surgery, whilst some B2 fractures can be effectively managed with osteosynthesis, especially in frail patients.

Less invasive osteosynthesis, balanced plate–bone constructs, composite implant solutions, together with an appropriate reduction of the limb axis, rotation and length are critical for a successful fixation and uneventful fracture healing.

Cite this article: EFORT Open Rev 2021;6:75-92. DOI: 10.1302/2058-5241.6.200050

Interprosthetic femoral fractures: management challenges

Interprosthetic femur fractures are a rare but serious complication following total hip and knee arthroplasty. Classification systems have focused not only on diagnosis but also on treatment algorithm. Critical to the evaluation of patients with these fractures are an assessment of fracture location, bone quality, and the presence of stemmed implants. The gold standard for fracture fixation is locked plating with bicortical and unicortical screws, supplemented with wires or cables as needed. For patients with compromised bone stock or insufficient bony area for fixation, allograft augmentation with struts or interprosthetic sleeves may be used. For fractures with severe bone loss, conversion to a megaprosthesis or total femur replacement may be warranted.

Interprosthetic femoral fractures: Morbidity and mortality in a retrospective, multicenter study

INTRODUCTION

Interprosthetic femoral fractures (IFF) are becoming more frequent; however they have not been the subject of many publications and the largest study on this topic includes only 30 cases. The complication rate and clinical outcomes have only been evaluated in small case series. This led us to conduct a retrospective, multicenter, observational study in IFF patients with at least 12 months' follow-up to (1) determine the mortality and morbidity (2) determine the clinical and radiological outcomes and (3) identify elements of the treatment indications.

HYPOTHESIS

The morbidity and mortality rates will be comparable to those in recent studies on this topic.

MATERIALS AND METHODS

The study included 51 patients (49 women, 2 men) with a mean age of 82.8±9.2 years [55-97], a mean Parker score of 4.9±2.4 and a mean Katz score of 4.4±1.4 who had suffered an IFF between 2009 and 2015. According to the SoFCOT modifications of the Vancouver classification, 30 fractures were interprosthetic in the shaft segment where there were no implants (19 double C and 11 type D (corresponding to a type C with less than two diaphysis widths between the extension stems of the hip and knee implants)) while 21 were periprosthetic, with 12 around the THA (11 B1 and 1 B3) and 9 around the TKA (8 B1 and 1 B3). One patient was treated conservatively with an external fixator but died the next day, 2 patients received a new total hip arthroplasty and 47 underwent plate fixation of their fracture (one patient was treated non-operatively because of poor medical condition).

RESULTS

One patient was lost to follow-up, and nine died during the first 6 months. Six early surgical site complications occurred and 13 general ones. Within 1 year of the IFF, there were six mechanical complications, two surgical site infections and two cases of loosening. The mean follow-up was 27.6±17.2 months. The mean time to union was 19.25±8.8 weeks. The mean final Parker score was 3.37±2.6 and the mean Katz score was 2.98±1.8; both were significantly lower than the initial scores. Six patients died between months 12 and 50. The overall mortality at the final review was 31% (16/51) with a median survival of 3.45 years.

DISCUSSION

Our hypothesis was not confirmed because the mortality and morbidity in our study were higher than in other published studies. In the six relevant studies identified, the surgical site infection rate was 12.3%, the major revision rate was 11.6% and the mortality rate was 6.5%. In our study, these values were 24%, 24% and 31%, respectively. These worse results may be explained by the very fragile nature of the studied population and the surgeons not following appropriate technical rules for fracture fixation.

LEVEL OF EVIDENCE

IV, Retrospective study.

Orthogonal plating of Vancouver B1 and C-type periprosthetic femur fracture nonunions

BACKGROUND

Periprosthetic femoral shaft fractures are a significant complication after total hip arthroplasty (THA). Plate osteosynthesis has been the mainstay of treatment around well-fixed stems. Nonunions are a rare and challenging complication of this fixation method. We report the outcomes of a novel orthogonal plating surgical technique for Vancouver B1 and C-type periprosthetic fractures that previously failed open reduction internal fixation (ORIF).

METHODS

A retrospective review identified all patients with Vancouver B1/C THA periprosthetic femoral nonunions from 2010 to 2015. Exclusion criteria included open fractures and periprosthetic infections. The technique utilised a mechanobiologic strategy of atraumatic exposure, resection of necrotic tissue, bone grafting with adjuvant bone morphogenetic protein (BMP) and revision open reduction internal fixation with orthogonal plate osteosynthesis.

RESULTS

6 Vancouver B1/C periprosthetic femoral nonunions were treated. 5 patients were female with an average age of 80.3 years (range 72-91 years). The fractures occurred at a mean of 5.8 years (range 1-10 years) from their initial arthroplasty procedure. No patients underwent further revision surgery; there were no perioperative complications. All patients had a minimum of 11 months follow-up (mean 18.6, range 11-36 months). All fractures achieved osseous union, defined as solid bridging callus over at least 2 cortices and pain free, independent ambulation, at an average of 24.4 weeks (range 6.1-39.7 weeks).

CONCLUSIONS

This is the 1st series describing orthogonal locked compression plating using modern implants for periprosthetic femoral nonunions. This technique should be considered in periprosthetic femur fracture nonunions around a well-fixed stem.

Management of Interprosthetic Femur Fractures

Femoral fractures between a total hip arthroplasty prosthesis and total knee arthroplasty prosthesis, also called interprosthetic fractures, are challenging clinical problems. The number of patients who have undergone ipsilateral primary or revision joint arthroplasty procedures in both the hip and the knee continues to rise, and the number of interprosthetic fractures is increasing, as well. The growing body of biomechanical and clinical literature on interprosthetic fractures reflects the increased frequency of and interest in these injuries. Similar to the management of periprosthetic fractures, the management of interprosthetic fractures depends on the location of the fracture, the stability of the implant, and the ability to achieve stable fracture fixation. These factors are the basis of recently described classification systems and treatment strategies. In patients with stable implants, fracture fixation alone is performed. When the implant is loose, both revision arthroplasty and fracture fixation may be required to provide stability of the limb.

Use of Locking Plate and Strut Onlay Allografts for Periprosthetic Fracture Around Well-Fixed Femoral Components

BACKGROUND

The purpose of this study was to determine: validated clinical and radiographic outcomes of periprosthetic femoral fractures around stable hip implants treated with plate fixation and additional cortical strut onlay allografts without revision of the stem; radiographic signs of fracture healing; allograft-to-host bone union; resorption of cortical strut allograft; and frequency of complications.

METHODS

At our institute, 24 patients (25 hips) were identified with Vancouver type B1 fracture at the tip of the femoral stem and one patient (one hip) was identified with a Vancouver type C fracture of the femur. All these fractures were treated with combined use of locking plate fixation and cortical strut onlay allografts. There were 18 women and 7 men, with an average age of 63 years. Harris hip score and University of California, Los Angeles activity score were used to assess postoperative function. The average duration of follow-up was 3.7 years (range, 1-7 years).

RESULTS

Harris hip score at final review was 86 points (range, 65-95 points). University of California, Los Angele activity score averaged 5.8 ± 1.3 point (range, 3.5-10 points) at final follow-up. All but 2 patients returned to their preoperative functional level within 1 year. Twenty-three of 26 hips had fracture union following the first operation. Three hips were failed to obtain fixation because of insufficient length of plate and allograft. Cortical strut onlay allografts were incorporated in the host femur in all hips by one year. Minor resorption of allograft was noticed, but there was no failure of any of the cortical strut allografts.

CONCLUSION

The cortical strut onlay allografts facilitated the mechanical stability and the biological fracture healing in addition to plate fixation.

Clinical outcome of interprosthetic femoral fractures treated with polyaxial locking plates

INTRODUCTION

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common procedures in the increasing older population. According to the AAOS, approximately 19,200 Americans are actually living with ipsilateral prosthetic hip and knee leading to 240 interprosthetic fractures annually. Few reviews and case reports give an idea of the obvious problem to achieve consolidation in interprosthetic fractures. Preconfigured plates have been shown to be superior compared with other treatments in patients with stable components. Utilization of internal fixators for interprosthetic fractures might be advantageous. The purpose of this study was to evaluate interprosthetic femoral fractures with polyaxial locking plate treatment in regard to surgical procedure, complications, and clinical outcome.

METHODS

Between 2005 and 2012, 143 patients underwent surgical treatment for periprosthetic femur fractures. Thirty-two fractures were identified as interprosthetic fractures. Five patients were excluded. Fractures were classified according to OTA/AO system, Vancouver, Rorabeck, Soenen and Pires. Trauma fellowship trained orthopaedic surgeons performed the surgeries using a NCB-construct (Zimmer Inc., Warshaw, IN). Plate choice was determined according to radiographic classification. Submuscular plate insertion was performed if possible. Complications were recorded concerning infection, union, fixation failure, and revision surgery.

RESULTS

Twenty-seven patients were identified. There were 92.6% females. Follow-up by regular outpatient clinic visits was 24 months. Surface replacements were found in 18 TKA. Nine patients had a stemmed femur component of their TKA. 89% healed after the index procedure. Three patients developed a nonunion with 1 construct leading to hardware failure. Previous revision THA or Pires/modified Vancouver classification did not influence nonunion formation, but all patients with nonunion formation were classified as AO/OTA type B (p=0.001). These fractures were treated with longer plates (p=0.015), but with similar working length (p=0.400). Plate design, additional cerclages, or submuscular insertion did not influence nonunion formation.

CONCLUSION

Interprosthetic fracture treatment remains challenging. NCB-locked plating can achieve satisfactory results. Additional soft tissue damage can be prevented by submuscular plate insertion. Treatment of type B fractures resulted in significantly greater nonunion rate. Therefore, consideration of the individual fracture type is essential to determine plate length, plate type, and additional bone grafting or BMP supplementation.

What is new in distal femur periprosthetic fracture fixation?

Distal femoral periprosthetic fractures are on the rise. Increased mortality of these injuries is also evident from recent data. Their incidence and risk factors have been extensively reported in the past but new data are being available that merit attention. The increased incidence and the even higher projected incidence should direct the focus of future strategies to the education of surgeons, relevant capacity of hospital and reconfiguration of health care resources. New and potentially modifiable risk factors should be taken into consideration to the informed consent process and new studies should be developed to clarify the causative relationship of the new risk factors such as the peptic ulcer disease and the COPD. The main internal fixation techniques remain the lateral locking plating and the retrograde intramedullary nailing. New techniques in plating are the supplementary medial plate in selected cases and the far cortical locking. Nailing is considered a valid option especially in fractures located well above the anterior flange of the femoral component of the arthroplasty. Results and outcomes from good quality studies are still sparse regarding the comparison between plating and nailing. Interprosthetic fractures constitute an entity that is lately gaining considerable attention. The best method of management of these injuries is still evolving with considerable amount of work being done in the clinical and biomechanical level.

Periprosthetic Femoral Fracture With Broken Implant Insitu: - A Treatment Prospect

Introduction:

Fractures involving bones containing a component of a prosthetic joint are becoming more common. The causation is multifactorial but most of these injuries are associated with trivial trauma. The options available for operative management of these fractures include internal fixation of the fracture alone, fixation of the fracture with revision of the prosthesis, and reconstruction of proximal femur with either modified impaction bone grafting or proximal femoral replacement.

Case Report:

We present here a case of periprosthetic fracture Vancouver type B1 with a broken cemented bipolar prosthesis insitu, in which the broken implant was firmly fixed in the proximal fragment and could not be removed following which the whole of the proximal fragment along with the broken implant was removed and replaced by a customized steel long stem cemented mega prosthesis.

Conclusion:

This case is being presented on account of its unusual presentation and fracture pattern. A broken prosthesis along with a periprosthetic fracture is not a common incident. Thus the treatment had to be individualized. Since the prosthesis was well fixed, its broken stem could not be removed from the proximal fragment and so the whole of the proximal fragment along with stem was removed and replaced with a long stem custom made bipolar prosthesis.

Interprosthetic femoral fractures-A challenge of treatment. A systematic review of the literature

The success of prosthetic surgery has led to an increase in the percentage of the population having more than one prosthetic implant. This, combined with an increase in the average life expectancy and functional requirements for the elderly, has led to a higher incidence of periprosthetic and interprosthetic fractures. More precisely, the femoral shaft is compressed between two ipsilateral implants with most of these fractures being located on the supracondylar femoral shaft. Their treatment is not only technically demanding and challenging, but can also be associated with serious complications. Treatment must be determined and assessed according to the type of fracture, the stability of the prosthesis, the bone quality and the general condition of the patient. There is little information in the literature about this type of injury: there are several published case reports detailing unconventional solutions and the case studies presented are limited and not significant. This review aims to provide an updated and comprehensive list of diagnostic and therapeutic protocols accepted today, while recognising that these protocols are being continuously updated according to experience gained.

Management and outcome of interprosthetic femoral fractures

INTRODUCTION

Interprosthetic femoral fractures following ipsilateral hip and knee arthroplasty are a rare but serious complication in clinical practice. In most cases, adequate management of these injuries might constitute a challenging problem. However, the literature provides only few data regarding the treatment and outcome of interprosthetic femoral fractures, and there are only few classifications available, which might assist in finding an appropriate treatment concept. The purpose of this study was to analyse our experience in the management of interprosthetic femoral fractures following ipsilateral hip and knee joint replacement.

MATERIALS AND METHODS

We reviewed the clinical and radiographic records of 23 patients (15 female and eight male, average age: 79.2 years) with an interprosthetic fracture after ipsilateral hip and knee joint replacement between 1992 and 2008. For the classification of interprosthetic femoral fractures, the fractures were divided into three types, depending on the fracture site and the adjacency to the prostheses. All patients underwent operative stabilisation, either by lateral plate fixation (n=19), by revision arthroplasty using a long stem (n=2) or by plate fixation and revision arthroplasty (n=2).

RESULTS

Referring to the clinical outcome, 16 patients returned to their pre-injury activity level and were satisfied with their clinical outcome. In six patients, we saw a relevant decrease of hip or knee function and severe limitations in gait and activities of daily living. We had a mean Harris Hip Score (HHS) of 78.4 points, and a mean Knee injury and Osteoarthritis Outcome Score (KOOS) of 71.8 points. Relating to the radiographic outcome, successful fracture healing was achieved in 19 of 22 patients (86%) within 6 months. Failures of reduction and fixation were noted in four (18%) of 22 patients.

CONCLUSION

We had a satisfactory outcome following individualised treatment of interprosthetic femoral fractures following ipsilateral hip and knee joint replacement. Compared to the rare data in current literature, we had promising functional result and high rate of bony fusion. Regarding the complexity and challenges in many of these cases, interprosthetic fractures require an adequate analysis of the fracture aetiology and a suitable transfer into the best possible treatment concept.

Interprosthetic fractures of the femur: treatment with a single-locked plate

Interprosthetic fractures of the femur, those between an ipsilateral hip and knee arthroplasty, are challenging to treat secondary to limited bone available for fixation, osteopenic bone, a compromised intramedullary blood supply, and an often elderly patient population. From 2002 to 2006, 22 consecutive patients with an interprosthetic femur fracture were treated with a single-locking plate. Follow-up averaged 17.7 months, with fracture union achieved an average of 13.8 weeks postoperatively. All patients regained their preoperative ambulatory status and subjectively reported unchanged function of their hip and knee arthroplasties. Single-locked plating is an effective method of treatment of interprosthetic fractures of the femur. Emphasis on preservation of the soft tissue envelope and sufficient cortical purchase both above and below the fracture is of paramount importance.

Controlled plastic deformation for the fastening mechanism of an internal fixation device. The new Mennen 3 PeriPro plate

The Mennen femur plate is a fixation device used for the treatment of femoral periprosthetic fractures. It features a novel fastening method where curved prongs are plastically deformed securing the implant to the bone. Although this "clamp-on" method has been successfully used to treat fractures of long bones, there are no literature data assessing the nature of the required plastic deformation. In the present study, the parameters influencing the performance of the prongs were identified and further explored using numerical modeling. The new Mennen 3 PeriPro plate is briefly discussed focusing on the new sculpted formation of the prongs. Their design was optimized to effectively control the magnitude and position of the required plastic deformation achieving enhanced anchorage on the fractured bone with minimum effort. The work presented contains all the necessary steps in analysing a clinical problem using finite elements and illustrates how effective use of simulation techniques can accurately predict and effectively control the required plastic deformation of a structure.

Classification of femoral periprosthetic fractures

Classification systems for fractures of the femur with a prosthetic hip in situ are diverse and complex. Most of them are based on the site of the fracture, which is not the most important differentiating factor in treatment planning. The Coventry classification system groups the periprosthetic fractures into 'happy hips' and 'unhappy hips' based on whether or not the stem is loose. In 'happy' hips, treatment only needs to address the fracture itself, unless the fixation has been compromised by the fracture. In the 'unhappy hips', revision of the prosthesis is recommended.

Development of the Mennen 3 PeriPro fixation plate for the treatment of periprosthetic fractures of the femur

The Mennen femur plate is an internal fixation device used for the management of femoral perisprosthetic fractures, usually after total hip replacement surgery. The implant uses a number of curved prongs that embrace the fractured bone around its circumference without interfering with the stem of the prosthesis. Although the device has been used with considerable clinical success since its first introduction, a number of negative clinical results have been reported in the literature. The failure modes of the device are described and an evaluation of its performance is briefly presented. Based on this assessment as well as comments in the open literature, modifications in the design of the device have been implemented. The new Mennen 3 PeriPro plate is presented, with all the necessary data for a coherent explanation of its improved characteristics as defined using numerical simulations and experimental tests. The new device has all the beneficial features of the previous plate with improved structural performance and fatigue life and new sculpted formation of the prongs, providing a simple implantation technique with maximum gripping and minimum effort from the surgeon. The unique mode of fixation has been further improved, providing ample anchorage on the fracture bone without compromising its biomechanical integrity. By combining the device with a cable system, the spectrum of applications will be further expanded, enabling the surgeon to treat a broader range of fracture patterns.

"Sandwich technique" in the surgical treatment of primary complex fractures of the femur and humerus

In this prospective study, our aim was to determine the clinical and radiographic outcomes of the surgical treatment of primary complex problem femoral and humeral shaft fractures treated by a new technique called "sandwich technique." A total of 45 patients with comminuted, complex and/or osteopoenic fractures of the femur or humerus (30 femoral and 15 humeral fractures) were treated using this technique. The patients were followed up for a mean of 25 months. In 24 (85.7%) of 28 patients with femoral fractures and in 14 (93.3%) of 15 patients with humeral fractures, union was achieved within 3-6 months of the operation (mean: 4.5 months). The total union rate was 88.4%. The pseudoarthrosis rate was 12%. There was no infection or implant failure seen during the follow-up period. The cortical allograft struts can be used to provide collateral support to weakened osteopoenic/osteoporotic bone. This technique provides a union rate of about 88% in osteoporotic and/or complex primary humerus or femur fractures.

Management of types B2 and B3 femoral periprosthetic fractures by a tapered, fluted, and distally fixed stem

The management of periprosthetic femoral fractures is difficult and challenging. Nonsurgical and surgical treatment modalities have been described. We reviewed 24 patients (average age, 74 years) with types B2 and B3 fractures (Vancouver classification) managed with a cementless, tapered, fluted, and distally fixed stem using a transfemoral approach. Most fractures occurred after trivial trauma. This technique resulted in average operative periods of 3 hours 14 minutes with cup and stem revision and 2 hours 14 minutes with stem-only revision and in an average blood loss of 1700 and 940 mL, respectively. The average Harris hip score at follow-up was 69. Most fractures (91%) united uneventfully. The postoperative average radiological subsidence was 5 mm, occurring within the first 6 months before fracture union with no subsidence thereafter. Subsidence was absent in patients in whom the fracture failed to unite. There were 5 dislocations and 2 nonunions with 1 associated infection. The technique has proven to be reliable in the treatment of difficult fractures in this elderly population although concerns regarding the high dislocation rate remain.

Periprosthetic fractures evaluation and treatment

Periprosthetic fracture is a serious complication of total hip arthroplasty (THA) that can be difficult to treat, and can be potentially fraught with complications. The incidence of such fractures is increasing, especially after the use of cementless revision arthroplasty. The prevention of these fractures is achieved by understanding the risk factors involved. If the risks are not understood, the best outcome is achieved when the surgeon has a thorough understanding of the principles of treatment of these fractures and has access to various fixation and prosthetic devices, and allograft bone when necessary. Acetabular fractures are rare and relatively little has been reported on their treatment. Periprosthetic femoral fracture treatment is based on the site of fracture, implant stability, and bone stock. The Vancouver classification offers a reproducible description of these factors with the subsequently easy formation of a treatment plan.

The management of periprosthetic femoral fractures around hip replacements

Periprosthetic femoral fractures are increasing in frequency and in complexity. They occur intra-operatively, or post-operatively, when they are frequently associated with loosening, with or without osteolysis. Periprosthetic femoral fractures usually occur at low energy levels, either after falls or spontaneously during activities of daily living. At present, the Vancouver classification system probably comes closest to the ideal, as it considers the fracture configuration, the stability of the implant and the quality of the bone stock. When the stem is stable, open reduction and internal fixation is suggested. Several authors have used strut grafts for the treatment of periprosthetic femoral fractures, with good results. If the stem is loose, or revision is indicated for other reasons, it is generally advisable to by-pass the most distal fracture line with a longer stem prosthesis by at least two femoral diameters. Augmentation of this intra-medullary fixation with an external cortical strut to improve rotational stability and/or internally with impaction allografting to compensate for bone defects is also advisable. Vigilant post-operative clinical and radiological assessment following total hip replacement should identify those with recurrent dislocation, loosening, subsidence and osteolysis. These patients are at greatest risk of developing femoral periprosthetic fractures.

Mennen plate fixation for the treatment of periprosthetic femoral fractures: a multicenter study of thirty-six fractures

BACKGROUND

The management of periprosthetic femoral fractures after total hip and knee replacement remains difficult and controversial. This study was performed to determine the results of Mennen plate fixation for the treatment of periprosthetic femoral fractures.

METHODS

This retrospective multicenter study consists of a review of a consecutive series of thirty-five patients in whom a total of thirty-six periprosthetic femoral fractures were treated with Mennen plate fixation. The average duration of follow-up was twenty-seven months (range, eight to forty-six months).

RESULTS

Twenty-six fractures (72%) had united at an average of five months (range, three to ten months) after surgery. One of them had varus bending (10 degrees) of the plate. The remaining ten fractures had a nonunion and varus bending (20 degrees to 30 degrees) of the plate, with a fracture of the plate in eight. A revision procedure was successfully performed in the eight patients with nonunion.

CONCLUSIONS

The treatment of unstable periprosthetic femoral fractures with Mennen plate fixation was complicated by high rates of mechanical failure (31%) and nonunion (28%). For this reason, we do not recommend the use of the Mennen plate for the treatment of periprosthetic femoral fractures.

Dall-Miles plating for periprosthetic B1 fractures of the femur

Eight patients (9 fractures) who have been treated with Dall-Miles plating in this unit between April 1996 and October 1997 for ipsilateral periprosthetic fractures around total hip replacement (7 cases) and total knee replacement (2 cases) have been reviewed. Four were men, and 4 were women. The average age at the time of operation was 77 years (range, 65-89 years). The average follow-up period was 14.6 months (range, 6-24 months). Three fractures healed satisfactorily with no evidence of malunion (3 of 9). The final result was unsatisfactory in the other 6 fractures. The femoral component had been inserted in a varus position in all the failures but was in a neutral position in the 3 successes. Procedures other than Dall-Miles plating might be more appropriate in the management of periprosthetic fractures in which the femoral component is in a varus position.

The Mennen plate: unsuitable for elderly femoral peri-prosthetic fractures

The Mennen plate has been advocated for femoral shaft and femoral peri-prosthetic fractures. We utilised this fixation system in five patients with peri-prosthetic femoral shaft fractures. The operative technique was that described by the CMW laboratories. The postoperative regimen deviated from that recommended, i.e. prolonged bed-rest, since the patients were elderly and complicated by chest problems and pressure sores. Once the surgical wounds had healed, at an average of 11 days (range 10-14 days), one patient achieved non-weight-bearing mobilisation. Four patients were managed with bed-to-chair transfer only. All five plates failed at an average of 32 days (range 15-42 days). Only one patient had an identifiable accident to account for the failure. Two patients underwent revision hip arthroplasty and two had revision fixation with Dall-Miles (Howmedica), and Cable Ready (Zimmer) plate and cables. Femoral shaft peri-prosthetic fractures are not adequately stabilised with the Mennen plate system, and prolonged recumbency in such an elderly population often worsens pre-existing medical problems. We advocate the use of one of the many available plate and cable fixation systems for such fractures in the elderly and in those in whom revision arthroplasty may not be possible.

Peri-prosthetic femoral shaft fractures treated with plate and cable fixation

Management of post-operative peri-prosthetic femoral shaft fractures remains difficult and controversial, with no widely accepted form of treatment. Fractures at the tip of a femoral component are associated with poor union rates. We present a series of 15 fractures at the component tip extending proximally in association with a loose cement mantle. All 15 patients were treated with open reduction and internal fixation using a plate and cable system. They were followed to clinical and radiological union, at an average of 3.5 months (range 3-5 months). At final review examination, 13 patients had achieved pre-fracture mobility, with one patient requiring a single walking stick, and one requiring a Zimmer frame. Three patients under-went revision surgery after successful fracture union and rehabilitation, with long stemmed femoral components. The plate and cable procedure is not technically demanding and avoids hip exposure. This form of internal fixation provides immediate fracture stability, allowing early ambulation, hence avoiding the complications and difficulties of other methods of treatment. Such fractures should be acutely treated to achieve fracture union with a plate, cable, and screw internal fixation technique. The loose components can be revised electively, preferably by a revision hip surgeon.

Interprosthetic fracture of the femoral shaft

Experience in the management of a complication of ipsilateral hip and knee arthroplasty is described. The cases of four female patients who sustained a femoral shaft fracture after ipsilateral hip and knee arthroplasty are reported. All fractures were treated operatively, and in all cases internal fixation devices failed. This complication of multiple joint arthroplasty presents a difficult management problem. Rigid fixation has a high failure rate for this type of fracture. Surface knee arthroplasty provides a better opportunity for internal fixation than a knee arthroplasty with a stemmed femoral component.

Conservative treatment of femoral shaft fractures in patients with total hip arthroplasty

Over a period of 20 years, 34 patients with a total hip arthroplasty were treated conservatively for a femoral shaft fracture. Thirty-five fractures were treated by traction followed by cast-brace or by cast-brace alone. Sound healing was obtained in 33 fractures. Problems were angular malalignment jeopardizing revision surgery in cases of loosening, long hospitalization, and a considerable complication rate. As a consequence, the authors no longer recommend conservative treatment as the first choice for these difficult fractures.

Mennen plate fixation for fractures of the femoral shaft after ipsilateral hip arthroplasty

We performed osteosynthesis with the use of a Mennen plate for six patients with femoral fractures in the vicinity of the stem, which occurred after ipsilateral hip arthroplasty. The fixation was so favorable that postoperative deformity was slight. At 4 months after surgery, bone fusion was obtained in all patients, and their hip joint functions recovered to the preinjury level. For femoral fractures in the vicinity of the stem after ipsilateral arthroplasty, there are no suitable fixation methods other than treatment with the Mennen plate. Therefore, this method is recommended.