Locking compression plate fixation of Vancouver type-B1 periprosthetic femoral fractures

Permissive Weight Bearing in Patients With Surgically Treated Periprosthetic Femoral Fractures Around Total Hip Arthroplasty: A Scoping Review

Periprosthetic femoral fractures (PPFF) around total hip arthroplasty (THA) are one of the leading causes of hip revision. High mortality rates are observed after revision in case of PPFF around THA. To modify risk factors, early postoperative mobilization is necessary. Permissive weight bearing (PWB) is designed to optimize clinical recovery in aftercare. This study aimed to perform a scoping review to summarize the current available evidence on postoperative weight bearing in late PPFF around THA and the implementation of PWB in aftercare. A systematic search was performed on the Cochrane Library, Web of Science, Ovid MEDLINE, EMBASE, and CINAHL databases on January 26th, 2023. Articles were screened in two stages by two independent reviewers. Studies describing adult patients with a history of primary THA who were surgically treated for late PPFF and mentioning prescribed postoperative weight-bearing protocols with relevant outcome measures were included. Seven studies were included, reporting data on 22 patients (age range 47-97 years, BMI range 19-32 kg/m2, ASA classification range 2-3). No studies used PWB in aftercare. The non-weight-bearing group showed no complications. The restricted weight-bearing group had one death and one implant failure. The full weight-bearing group experienced one deep infection and one plate removal because of impingement. The main finding was that, after an extensive systematic search, no articles could be included focusing on PWB in patients with a late PPFF after THA. Addressing this gap in the literature is essential to advancing the understanding of postoperative weight-bearing protocols and PWB for late PPFF around THA.

Open Reduction and Internal Fixation for Vancouver B1 and B2 Periprosthetic Femoral Fractures: A Proportional Meta-Analysis

Purpose

Periprosthetic femoral fracture (PFF) is a common complication after total hip arthroplasty, and open reduction and internal fixation (ORIF) is a common surgical treatment. We conducted a meta-analysis to compare the outcomes of ORIF in patients with different fracture patterns (Vancouver B1 and B2).

Materials and Methods

We conducted a systematic search of PubMed, Embase, Cochrane Library and KoreaMed from inception to August 2022. We conducted a pair-wise meta-analysis (with a fixed-effects model) on the 10 comparative studies and a proportional meta-analysis on the data from the 39 articles to determine a consensus. The outcomes were the incidence of reoperations that included osteosynthesis, irrigation/debridement and revision arthroplasty.

Results

The pair-wise meta-analysis showed similar outcomes between two groups; the risk of reoperation (odds ratio [OR]=0.82, confidence interval [CI] 0.43-1.55, P=0.542), nonunion (OR=0.49; CI 0.22-1.10, P=0.085) and deep infection (OR=1.89, CI 0.48-7.46, P=0.361). In proportion meta-analysis, pooled prevalence of reoperation was 9% (95% CI, 6-12) in B1 and 8% (95% CI, 2-15) in B2 (heterogeneity between two groups (Q), P=0.772). The pooled prevalence of nonunion was same as of 4% in B1 and B2 (Q, P=0.678), and deep infection was 2% (95% CI, 1-3) in B1 and 4% (95% CI, 2-7) in B2 (Q, P=0.130).

Conclusion

ORIF is a feasible treatment for B1 and B2 periprosthetic femoral fractures, with acceptable outcomes in terms of, nonunion and infection. The results of this study would help clinicians and provide baseline data for further studies validating PFF.

Osteosíntesis en fracturas femorales periprotésicas de cadera Vancouver tipos B1 y C. Análisis multicéntrico

Introducción: Nuestro objetivo fue analizar los resultados del tratamiento con osteosíntesis en pacientes con fracturas Vancouver tipos B1 y C, evaluar las complicaciones, las reintervenciones y la tasa de mortalidad en este grupo. Materiales y Métodos: Estudio multicéntrico, retrospectivo. Se estableció una base de datos que incluía a 53 pacientes con fracturas periprotésicas de fémur Vancouver tipos B1 y C tratadas con osteosíntesis, desde 2008 hasta 2021, en dos centros hospitalarios de alta complejidad. Resultados: La fijación proximal más utilizada fue con tornillos bicorticales más lazadas de alambre. El tipo de fractura según la clasificación de Vancouver se correlacionó con un valor significativo en el uso de tornillos de compresión interfragmentaria (p 0,001), con un total de 13 pacientes (24,52%), 9 en fracturas Vancouver tipo C. El tiempo de consolidación promedio fue de 4 meses, con un puntaje promedio del Harris Hip Score de 68. Doce pacientes (22,64%) tuvieron complicaciones: retraso de la consolidación (7 casos; 13,2%), falla de la osteosíntesis con trazo de fractura a nivel distal del tallo (un caso; 1,88%), una nueva osteosíntesis por falla a nivel del material de osteosíntesis (un caso; 1,88%) y tres fallecieron (5,66%). Conclusiones: El manejo de las fracturas femorales periprotésicas es un tema complejo y desafiante. El tratamiento con osteosíntesis constituye un método exitoso que requiere de la aplicación de principios actuales de técnicas mínimamente invasivas que, junto con una fijación proximal estable, mejoran las posibilidades de éxito.

Periprosthetic Fracture around a Cemented Stem in Total Hip Arthroplasty

The increase in the number of primary total hip arthroplasties that will be performed over the next several decades will lead to an increase in the incidence of periprosthetic fractures around the femoral stem. A search of targeted articles was conducted using on-line databases of PubMed (National Library of Medicine) and articles were obtained from January 2008 to November 2021. Reliable prediction of treatment can be achieved using the Vancouver classification; internal fixation is indicated in fractures involving a stable implant and revision arthroplasty is indicated in those with unstable prostheses. To the best of our knowledge, relatively fewer studies regarding periprosthetic proximal femur fractures of cemented stems have been reported. The focus of this review is on the risk factors and strategies for treatment of these fractures for periprosthetic femoral fractures around a cemented hip arthroplasty.

Combined Surgical and Medical Treatment for Vancouver B1 and C Periprosthetic Femoral Fractures: A Proposal of a Therapeutic Algorithm While Retaining the Original Stable Stem

INTRODUCTION

There is lack of consensus regarding best operative fixation strategy for periprosthetic femoral fractures (PFFs) around a stable stem. Evidence exists that some patterns of fracture around a stable stem are better treated with revision surgery than with standard fixation. Anyway, a more aggressive surgical procedure together with medical treatment could allow for stem retention, and reduced risk of nonunion/hardware failure, even in these cases.

SIGNIFICANCE

This paper is placed in a broader context of lack of studies on the matter, and its aim is to shed some light on the management of PFFs around a stable stem, when peculiar mechanical and biological aspects are present.

RESULTS

Based on our casuistry in the treatment of nonunions after PFF successfully treated with original stem retention, and on review of Literature about risk factors for fixation failure, an algorithm is proposed that can guide in choosing the ideal surgical technique even for first-time PFFs with a stable stem, without resorting to revision. Mechanical (major and minor) and biological (local and systemic) factors that may influence fracture healing, leading to nonunion and hardware failure, and subsequent need for re-operation, are considered. The proposed surgical technique consists of rigid fixation with absolute stability (using a plate and structural allograft) plus local biological support (structural allograft and autologous bone marrow concentrate over a platelet-rich plasma-based scaffold) at fracture site. Systemic anabolic treatment (Teriparatide) is also administered in the post-operative period.

CONCLUSION

Mechanical factors are not the only issues to be considered when choosing the surgical approach to PFFs over a stable stem. Systemic and local biological conditions should be taken into account, as well. A therapeutic algorithm is proposed, given the prosthetic stem to be stable, considering mechanical and biological criteria.

Mortality, Risk Factors and Risk Assessment after Periprosthetic Femoral Fractures-A Retrospective Cohort Study

Periprosthetic femoral fracture (PFF) is a devastating complication. Here, the authors aimed to determine the influence of the timing of surgery as a risk factor for mortality and poor postoperative outcome in patients suffering from PFF. A retrospective descriptive analysis of patients treated for PFF between January 2010 and March 2018 was performed. In addition to patient and treatment characteristics, we assessed mortality rates and postoperative functional outcome by using the Harris Hip and WOMAC score. One-year mortality after PFF was 10.7%. Delayed surgery after 48 h did not negatively influence mortality after PFF. The postoperative hospital stay did not influence the mortality rate, nor did it correlate with medical scores of comorbidities, general health or functionalities. Cementation of stem correlated negatively with the WOMAC score. Deceased patients had a higher Charlson Comorbidity Index (CCI) score, while American society of Anaesthesiologists (ASA) scores did not show a significant difference. There were no differences between ORIF and revision arthroplasty. In conclusion, delayed surgery after 48 h does not negatively influence mortality after PFF. The CCI seems to be a suitable tool to assess patients’ risk for increased mortality after PFF, while the usually used ASA score is not able to achieve a relevant risk assessment.

Finite element analysis of double-plate fixation using reversed locking compression-distal femoral plates for Vancouver B1 periprosthetic femoral fractures

Background

Internal fixation is recommended for treating Vancouver B1 periprosthetic femoral fractures. Although several fixation procedures have been developed with high fixation stability and union rates, long-term weight-bearing constructs are still lacking. Therefore, the aim of the present study was to evaluate the stability of a double-plate procedure using reversed contralateral locking compression-distal femoral plates for fixation of Vancouver B1 periprosthetic femoral fractures under full weight-bearing.

Methods

Single- and double-plate fixation procedures for locking compression-distal femoral plates were analysed under an axial load of 1,500 N by finite element analysis and biomechanical loading tests. A vertical loading test was performed to the prosthetic head, and the displacements and strains were calculated based on load-displacement and load-strain curves generated by the static compression tests.

Results

The finite element analysis revealed that double-plate fixation significantly reduced stress concentration at the lateral plate place on the fracture site. Under full weight-bearing, the maximum von Mises stress in the lateral plate was 268 MPa. On the other hand, the maximum stress in the single-plating method occurred at the defect level of the femur with a maximum stress value of 1,303 MPa. The principal strains of single- and double-plate fixation were 0.63 % and 0.058 %, respectively. Consistently, in the axial loading test, the strain values at a 1,500 N loading of the single- and double-plate fixation methods were 1,274.60 ± 11.53 and 317.33 ± 8.03 (× 10^− 6), respectively.

Conclusions

The present study suggests that dual-plate fixation with reversed locking compression-distal femoral plates may be an excellent treatment procedure for patients with Vancouver B1 fractures, allowing for full weight-bearing in the early postoperative period.

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

High Failure Rates of Locking Compression Plate Osteosynthesis with Transverse Fracture around a Well-Fixed Stem Tip for Periprosthetic Femoral Fracture

This study investigated the incidence of failure after locking compression plate (LCP) osteosynthesis around a well-fixed stem of periprosthetic femoral fractures (PFFs). We retrospectively evaluated outcomes of 63 Vancouver type B1 and C PFFs treated with LCP between May 2001 and February 2018. The mean follow-up duration was 47 months. Only patients with fracture fixation with a locking plate without supplemental allograft struts were included. We identified six periprosthetic fractures of proximal Vancouver B1 fractures with spiral pattern (Group A). Vancouver B1 fractures around the stem tip were grouped into seven transverse fracture patterns (Group B) and 38 other fracture patterns such as comminuted, oblique, or spiral (Group C). Vancouver C fractures comprised 12 periprosthetic fractures with spiral, comminuted, or oblique patterns (Group D). Fracture healing without complications was achieved in all six cases in Group A, 4/7 (57%) in Group B, 35/38 (92%) in Group C, and 11/12 (92%) in Group D, respectively. The failure rates of transverse Vancouver type B1 PFFs around the stem tip were significantly different from those of Vancouver type B1/C PFFs with other patterns. For fracture with transverse pattern around the stem tip, additional fixation is necessary because LCP osteosynthesis has high failure rates.

Periprosthetic fracture fixation in Vancouver B1 femoral shaft fractures: A biomechanical study comparing two plate systems

Introduction

Periprosthetic fractures of the femur are an increasing problem in today's trauma and orthopaedic surgery. Owing to the hip stem, implant anchorage is very difficult in the proximal femur. This study compares two plate systems regarding their biomechanical properties and the handling in periprosthetic fracture fixation of the proximal femur.

Materials and methods

Using eight pairs of fresh, frozen human proximal femora the Locking Compression Plate/Locking Attachment Plate construct (LCP/LAP) (group I, DePuy Synthes) was compared to the new LOQTEQ® periprosthetic distal lateral femur plate (group II, AAP Implantate AG). After implantation of press fit femoral hip stems a Vancouver B1 fracture model was used. Biomechanical testing was performed by cyclic axial loading with a constant increment of 0.1 N/cycle starting from 750 N axial loading. Every 250 cycles an a.p. x-ray was done to evaluate failure.

Results

The Group II showed significant higher axial stiffness (+42%) compared with Group I. In addition, Group II withstood significantly more load-cycles until failure (20%). The mode of catastrophic failure was plate breakage in Group II, whereas, in Group I, all plates showed an early bending followed by plate breakage.

Discussion and conclusion

Both plate systems enable screw placement around hip stems. The hinge plate showed superior biomechanical results compared with the locking compression plate/locking attachment plate construct. Furthermore, the hinge plate offers variable hinges and variable angel locking making bicortical screw placement around hip stems more comfortable and safe.

The translational potential of this article

The results of this study can be directly transferred to patient care. With the innovative hinge plate, the surgeon has a biomechanically superior implant, which also offers improved options for screw placement compared to a standard locking plate.

Cable plate fixation for Vancouver Type-B1 periprosthetic femoral fractures-Our experience and identification of a subset at risk of non-union

INTRODUCTION

Management of periprosthetic femoral fractures is challenging. Vancouver classification is universally accepted for fracture description and management algorithm. Guidelines for the treatment of type B1 fracture is open reduction and internal fixation. The difficulty involved in managing this group is evidenced by the array of treatment options described in the literature.

METHODS

Thirty two patients with Vancouver type B1 fracture treated with osteosynthesis using cable plate (between 2007 and 2015) were reviewed retrospectively. There were 21 females and 11 males with an average age of 81yrs (56-96 years). The average follow-up was 21 months. All patients were reviewed clinically and radiologically until fracture united or patient re-operated. Postoperative protocol followed was six weeks toe touch weight bearing, 6 weeks partial weight bearing and then full weight bearing if there was no displacement. Post-operative radiographs were evaluated for fracture union. Statistical analysis was done using contingency tables with Fishers exact test and a p-value < 0.05 for significance.

RESULTS

In twenty four patients fracture union was achieved. Non-union was recorded in four patients. Comparing the different fracture patterns all non-unions occurred in the fractures which were short oblique or transverse at the cemented stem tip (p = 0.001). Fractures were more common in female patients and associated more with the uncemented femoral stems, but it was not associated with increased rate of non-union (p = 0.68). All failed osteosynthesis were revised successfully using long stem prosthesis. Two patients died within 2 months, one patient died within 4 months, one patient was lost to follow-up.

CONCLUSION

Transverse or short oblique periprosthetic fractures around tip of cemented femoral stems can have high failure rates with just internal fixation. Revision arthroplasty may be the preferred option if possible otherwise may need to supplement fixation with cortical onlay graft. We should consider subcategorising Vancouver type B1 periprosthetic fractures into groups based on the pattern and fracture level in relation to the femoral stem.

Osteosynthesis of bilateral Vancouver B2 periprosthetic femoral fracture after a bilateral RM® total hip arthroplasty at 24 and 21-years follow-up: A case report

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The management of periprosthetic femoral fractures following hip arthroplasty is challenging.

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Vancouver type-B2 periprosthetic femoral fractures require revision arthroplasty by replacement of the femoral component.

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In older patients with multiple comorbidities the osteosynthesis of Vancouver type-B2 periprosthetic femoral fracture is a valid treatment.

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Anatomically fracture reduction, the use of locking compression plates, and the preservation of the hip joint, are the key-points to a successful outcome.

Introduction

The management of periprosthetic femoral fractures following hip arthroplasty is challenging, and the choice between osteosynthesis of the fracture and the revision of the prosthesis is still matter of discussion.

Case report

In a 81-year-old male patient, a bilateral Vancouver type-B2 periprosthetic femoral fracture with stem loosening occurred after an accidental fall. The patient had severe medical comorbidities. The radiographic study showed a bilateral Robert Mathys cementless total hip arthroplasty at 24 and 21-years follow-up. The fractures were treated with open reduction and fixation with locking compression plates. Bicortical fixation of the loose stem was obtained by the screws of the locking plate, due to the polymeric composition of the isoelastic femoral stem. Both fractures sites were augmented with bone allografts. At follow-up period of 12 months, the X-rays showed bone union of both fractures and bilateral stable stem fixation. The patient expressed high degree of satisfaction with surgery result.

Discussion

The standard treatment for Vancouver type-B2 periprosthetic femoral fractures is the removal of the loose implant, fixation of the fracture, and implantation of a new revision femoral stem. However, the implantation of two long revision hip prostheses is a major operation for an older patient with precarious health condition, which can contribute to higher risk of medical and prosthetic complications.

Conclusion

In older patients with multiple comorbidities, the use of locking plates can be a valid treatment of bilateral Vancouver B2-periprosthetic femoral fractures following RM^® cementless isoelastic stem, as an alternative surgical option to femoral stem revision.

Use of a long distally fixed intramedullary stem to treat a periprosthetic femoral fracture following total hip arthroplasty using a thrust plate hip prosthesis: A case report

INTRODUCTION

The thrust plate hip prosthesis (TPP; Zimmer, Winterthur, Switzerland) is a hip prosthesis that is no longer in production. Few reports have focused on periprosthetic fractures following total hip arthroplasty (THA) with the use of a TPP.

PRESENTATION OF CASE

We report a 57-year-old woman with a periprosthetic femoral fracture 13 years after THA with the use of a TPP. A plain radiograph showed a displaced subtrochanteric fracture of the right femur just below the distal tip of the lateral plate without implant loosening. She underwent revision surgery with a long distally fixed intramedullary stem in conjunction with a plate and cable system. Three months after surgery, bone union was confirmed using radiography and the patient was clinically asymptomatic.

DISCUSSION

We encountered three major problems while planning surgical treatment, these being, discontinuation of the TPP system, loss of proximal femoral cancellous bone, and difficulties with the type of subtrochanteric fracture. After considering these problems, we planned revision surgery using a long distally fixed intramedullary stem in conjunction with a plate and cable system.

CONCLUSION

This case shows that sufficient implant preparation based on precise preoperative planning is necessary to obtain good clinical results for the surgical treatment of periprosthetic femoral fractures following THA with the use of a TPP.

High union rates of locking compression plating with cortical strut allograft for type B1 periprosthetic femoral fractures

PURPOSE

Unified classification system (UCS) type B1 periprosthetic femoral fractures are associated with many complications, and management decisions continue to be controversial. The purpose of this study was to evaluate outcomes of UCS type B1 periprosthetic femoral fractures treated by locking compression plating with strut allograft augmentation.

MATERIALS AND METHODS

We retrospectively reviewed 17 consecutive UCS type B1 periprosthetic femoral fractures treated by open reduction and internal fixation using a lateral locking compression plate supplemented with an anterior cortical strut allograft. There was one man and 16 women with an average age of 74 years (range, 57-92 years). All had a cementless hip arthroplasty, and eight of the arthroplasties were revisions.

RESULTS

The mean duration of follow-up was 28 months (range, 12-74 months). All 17 fractures healed successfully at a mean of 20 weeks (range, 12-30 weeks). The mean post-operative Harris hip score was 86 points (range, 77-95 points). No mechanical complications such as failure of plate or screws and malalignment were noted. According to the graft-remodeling classification of Emerson et al., a partial bridging was observed in nine and a complete bridging in eight. Two patients required a removal of the plate due to irritation of the iliotibial band. No femoral stem loosening or deep infection was observed.

CONCLUSION

Our findings indicate that open reduction and internal fixation of UCS type B1 periprosthetic femoral fractures using a lateral locking compression plate supplemented with anterior cortical strut allograft provides adequate mechanical stability of fracture fixation and enhances the fracture healing.

Application of Far Cortical Locking Technology in Periprosthetic Femoral Fracture Fixation: A Biomechanical Study

BACKGROUND

Lack of fracture movement could be a potential cause of periprosthetic femoral fracture (PFF) fixation failures. This study aimed to test whether the use of distal far cortical locking screws reduces the overall stiffness of PFF fixations and allows an increase in fracture movement compared to standard locking screws while retaining the overall strength of the PFF fixations.

METHODS

Twelve laboratory models of Vancouver type B1 PFFs were developed. In all specimens, the proximal screw fixations were similar, whereas in 6 specimens, distal locking screws were used, and in the other six specimens, far cortical locking screws. The overall stiffness, fracture movement, and pattern of strain distribution on the plate were measured in stable and unstable fractures under anatomic 1-legged stance. Specimens with unstable fracture were loaded to failure.

RESULTS

No statistical difference was found between the stiffness and fracture movement of the two groups in stable fractures. In the unstable fractures, the overall stiffness and fracture movement of the locking group was significantly higher and lower than the far cortical group, respectively. Maximum principal strain on the plate was consistently lower in the far cortical group, and there was no significant difference between the failure loads of the 2 groups.

CONCLUSION

The results indicate that far cortical locking screws can reduce the overall effective stiffness of the locking plates and increase the fracture movement while maintaining the overall strength of the PFF fixation construct. However, in unstable fractures, alternative fixation methods, for example, long stem revision might be a better option.

The influence of the operation technique and implant used in the treatment of periprosthetic hip and interprosthetic femur fractures: a systematic literature review of 1571 cases

INTRODUCTION

A systematic literature review on periprosthetic/interprosthetic fracture fixation after hip arthroplasties was performed to summarize available clinical data. Operation techniques and implants used were evaluated as possible risk factors for outcomes.

MATERIALS AND METHODS

MEDLINE and Cochrane databases were searched. Articles describing patients with postoperative periprosthetic femur fractures sustained around a hip arthroplasty and with interprosthetic fractures treated with plates, nails, screws and/or cerclage were included. Considered articles were from 2000 or newer. Eligible abstracts were screened by two independent persons and discrepancies were resolved by consensus. Absolute numbers of complications and/or reoperation events along with their corresponding rates were calculated according to operation technique and type of implant. Relative risks of having a complication and/or a reoperation according to the operation technique and the type of implant used were estimated.

RESULTS

Available data from 49 prospective and retrospective studies were analyzed. Of 1574 fractures, 81.7 % were treated with plating. For 83.0 % of all fractures, an open approach was applied. The overall complication rate was 14.3 %. Fixation failure and nonunion were most often reported (fixation failure: 4.4 %; nonunion: 3.9 %). Nonunion and refracture occurred more often after open approaches than after minimal invasive osteosynthesis (nonunion: 4.5 vs. 0.0 %, p = 0.001; refracture: 3.8 vs. 0.6 %. p = 0.024). The relative risk for nonunion was 11.9 (95 % CI 4.5-31.5) times higher (p < 0.0001) for non-locking plates (13.0 %) than for locking plates (1.1 %).

CONCLUSIONS

The clinical evidence of published studies dealing with periprosthetic/interprosthetic fractures after hip arthroplasty is generally low. This literature search suggested higher rates of nonunion and refracture after an open approach and a higher risk of nonunion for non-locking plates compared to locking plates. Based on the available clinical evidence, no treatment recommendations can be given.

Enhancing fixation strength in periprosthetic femur fractures by orthogonal plating-A biomechanical study

Orthogonal plate osteosynthesis enhances fixation stability in periprosthetic femur fractures. Another option are locking attachment plates (LAP) allowing bicortical locking screw placement lateral to the prosthesis stem. Stability of lateral plate osteosynthesis with two LAP (2LAP) was compared to anterolateral orthogonal plate osteosynthesis (OP) with one LAP in a periprosthetic femur fracture model. In six pairs of fresh frozen human femora with cemented Charnley hip prosthesis, a transverse osteotomy was set distal to the tip of the prosthesis simulating a Vancouver type B1 fracture. Each pair was instrumented using a plate tensioner with either one lateral plate and two LAP, or two orthogonal anterolateral plates and one LAP. Stiffness was determined in a four-point-bending test prior to cyclic testing (2Hz) with physiologic profile and progressively increasing load up to catastrophic construct failure. Paired t-test and Wilcoxon-signed-rank test were used for statistical evaluation at a level of significance p = 0.05. The OP construct exhibited a significantly higher number of cycles and load to failure (39,627 cycles ± 4,056; 4,463 N ± 906) compared to the 2LAP construct (32,927 cycles ± 3,487; 3,793 N ± 849), p < 0.01. Mediolateral bending and torsional stiffness of the OP (1610 N/mm ± 249; 16.9 Nm/mm ± 6.3) were significantly higher compared to 2 LAP (1077 N/mm ± 189; 12.1 Nm/mm ± 3.9), p = 0.03 for both comparisons. Orthogonal plate osteosynthesis is a valuable option in periprosthetic fracture surgery, offering increased stability compared to a single lateral plate fixed with two LAP.

Combination of low-contact cerclage wiring and osteosynthesis in the treatment of femoral fractures

BACKGROUND AND PURPOSE

Objectives were (1) to evaluate results after cerclage wiring technique for femoral primary and periprosthetic fracture (PPF); (2) to report the incidence of complications and their treatment; (3) to analyze possible prognostic factors.

PATIENTS AND METHODS

We analyzed 54 patients treated with different techniques associated with low-contact cerclage wires for femoral fracture. Fractures were stratified according to AO, Vancouver or Rorabeck classification. Cerclage was used as an exclusive implant in four PPFs or combined with internal devices in 50 cases. Comorbidities were assessed using Charlson Comorbidity Index. The Glasgow Outcome Scale was used to compare activities of daily living pre/postoperatively.

RESULTS

Cerclage wires with three or four spacers were used in 22 and 32 cases, respectively. Nine patients died within 6 months. Mean follow-up of the remaining 42 patients was 10.5 months. Fracture healing was achieved in 38/42 patients (71 %), with a mean time to callus formation of 57 days and to radiographic union of 3 months (1.5-9 months). Four patients had nonunion. Survival to major complications was 92 and 70 % at 1 and 2 years, respectively, significantly better in cerclage wires with three spacers than those with four spacers (p = 0.0188). No other statistical correlations were found.

CONCLUSION

Cerclage wiring in difficult femoral fractures offers minimally invasive reduction and fixation technique, low cost and early holding. We reinforce the concept of "reduce with cerclage cables first, then nail" for displaced long subtrochanteric fractures and support the use of cerclage wiring for challenge PPF using low-contact wires.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.

Biomechanical Concepts for Fracture Fixation

Application of the correct fixation construct is critical for fracture healing and long-term stability; however, it is a complex issue with numerous significant factors. This review describes a number of common fracture types and evaluates their currently available fracture fixation constructs. In the setting of complex elbow instability, stable fixation or radial head replacement with an appropriately sized implant in conjunction with ligamentous repair is required to restore stability. For unstable sacral fractures with vertical or multiplanar instabilities, "standard" iliosacral screw fixation is not sufficient. Periprosthetic femur fractures, in particular Vancouver B1 fractures, have increased stability when using 90/90 fixation versus a single locking plate. Far cortical locking combines the concept of dynamization with locked plating to achieve superior healing of a distal femur fracture. Finally, there is no ideal construct for syndesmotic fracture stabilization; however, these fractures should be fixed using a device that allows for sufficient motion in the syndesmosis. In general, orthopaedic surgeons should select a fracture fixation construct that restores stability and promotes healing at the fracture site, while reducing the potential for fixation failure.

Periprosthetic fractures around the femoral stem: overcoming challenges and avoiding pitfalls

Management of periprosthetic fractures around the femoral stem after total hip arthroplasty (THA) represents a significant challenge and optimal treatment remains controversial. The most common treatment paradigm involves treating fractures around a well-fixed stem with osteosynthesis, whereas fractures around a loose stem require revision arthroplasty and those with poor bone require augmentation with bone graft. Paradoxically, the literature reports a higher rate of failure for osteosynthesis around prostheses considered to be well-fixed. Such a high rate of poor outcomes may result not only from difficult fracture fixation and compromised biologic healing, but also from unrecognized peri-implant pathology. Therefore, proper preoperative and intraoperative evaluation is key, and a subset of patients may benefit from alternative management. We review the appropriate methods for evaluation and treatment of Vancouver type B fractures with particular emphasis on avoiding missteps that can lead to failure.

Plate failure following plate osteosynthesis in periprosthetic femoral fractures

BACKGROUND

Increasing numbers of total knee and hip arthroplasties result in a growing number of periprosthetic femoral fractures (PPFF). PPFF with a stable stem component are treated commonly with plate osteosynthesis. Therefore plate failure is seen as a major complication. The aim of this retrospective study was to investigate the patients' outcome after plate failure.

METHODS

The database of a Level 1 trauma center was searched for all patients treated for a PPFF with plate osteosynthesis. Patients with plate failure were investigated specifically. Standard demographic data, details on initial arthroplasty, trauma, and treatment were recorded for all patients. All fractures were classified and their outcome reviewed.

RESULTS

Seven (8.8%) out of 80 patients treated with plate osteosynthesis following PPFF met our inclusion criterion being plate failure. All these patients were female, with an average age at primary surgery of 74 ± 13 years and a mean follow-up of 885 days (range, 264-2549). Four patients suffered a PPFF after total hip arthroplasty (THA) (2 Vancouver Type B1 and 2 Type C) and three after total knee arthroplasty (TKA) (Lewis-Rorabeck Type II). Following plate failure, four patients healed uneventfully and three patients experienced complications such as pseudarthrosis, screw loosening, and further plate failure.

CONCLUSION

In patients with poor bone quality, bone graft, bone cement, and bone biologics have to be considered in revision surgery. Furthermore, long-stem revision and tumor prosthesis are an additional solution.

Treatment of periprosthetic femoral fractures after femoral revision using a long stem

BACKGROUND

Periprosthetic femoral fractures are becoming increasingly common and are a major complication of total hip arthroplasty and hemiarthroplasty. The treatment of periprosthetic femoral fracture after femoral revision using a long stem is more complex and challenging. The purpose of this study was to identify the clinical and radiographical features of periprosthetic femoral fractures after revision using a long stem.

METHODS

We report a retrospective review of the outcomes of treatment of 11 periprosthetic fractures after femoral revision using a long stem. Eleven female patients with a mean age of 79.2 years (70 to 91) were treated for a Vancouver type B1 fracture between 1998 and 2013. The mean numbers of previous surgeries were 3.1 (2 to 5).

RESULTS

The average follow-up was 58.9 months (8 to 180). We found several important features that might influence the outcome of treatment for periprosthetic femoral fractures after femoral revision using a long stem: 1) all cases were classified as Vancouver type B1. 2) 6 patients (55%) had a transverse fracture around the tip of the long stem. 3) 7 patients (64%) had a history of previous fracture of the ipsilateral femur. The type B1 fractures were treated with open reduction and internal fixation in 9 hips, 6 of which were reinforced with bone grafts. Two other periprosthetic fractures were treated with femoral revision. One was revised because of stem breakage, and the other was a transverse fracture associated with poor bone quality, which received a femoral revision with a long stem and a plate. All fractures except one achieved primary union. This failed case had a bone defect at the fracture site, and revision surgery using a cementless long stem and allografts was successful.

CONCLUSIONS

These findings suggest that most cases of type B1 fracture after revision using a long stem have been treated successfully with open reduction and internal fixation. However, a transverse fracture with very poor bone quality might be considered as a type B3 fracture, and femoral revision might be a treatment of choice.

Mid-Term Results of 121 Periprosthetic Femoral Fractures: Increased Failure and Mortality Within but not After One Postoperative Year

Periprosthetic femoral fractures are associated with high failure rates and mortality, particularly within one postoperative year. However, mid-term results related to this issue are lacking. Thus, we performed a retrospective follow-up evaluation. Between 2007 and 2012, we treated a total of 121 consecutive patients for periprosthetic femoral fractures. After a mean of 57.2 postoperative months, we documented a total surgical revision rate of 16.5% within the first year, and the one-year mortality rate was 13.2%. Between one year and up to 7.3 postoperative years, only one surgical revision was necessary, and the mortality rate also decreased. No significant factors related to surgical revisions were detected. However, the initial hip fracture, older age, higher ASA score and dementia were associated with a higher mortality rate.

Orthogonal femoral plating: a biomechanical study with implications for interprosthetic fractures

Objectives

This study tests the biomechanical properties of adjacent locked plate constructs in a femur model using Sawbones. Previous studies have described biomechanical behaviour related to inter-device distances. We hypothesise that a smaller lateral inter-plate distance will result in a biomechanically stronger construct, and that addition of an anterior plate will increase the overall strength of the construct.

Methods

Sawbones were plated laterally with two large-fragment locking compression plates with inter-plate distances of 10 mm or 1 mm. Small-fragment locking compression plates of 7-hole, 9-hole, and 11-hole sizes were placed anteriorly to span the inter-plate distance. Four-point bend loading was applied, and the moment required to displace the constructs by 10 mm was recorded.

Results

We found that a 1 mm inter-plate distance supported greater moments than a 10 mm distance in constructs with only lateral plates. Moments supported after the addition of a 9- or 11-hole anterior plate were greater for both 10 mm and 1 mm inter-plate distance, with the 11-hole anterior plate supporting a greater moment than a 9-hole plate. Femurs with a 7-hole anterior plate fractured regardless of lateral inter-plate distance size.

Conclusion

This suggests that the optimal plate configuration is to minimise lateral inter-plate distance and protect it with an anterior plate longer than seven holes.

Cite this article: Bone Joint Res 2015;4:23–8.

Periprosthetic femoral fractures after hemiarthroplasty. An analysis of 17 cases

PURPOSE

To describe the characteristics of patients with periprosthetic femoral fractures after hemiarthroplasty and analyze their treatment.

MATERIAL AND METHOD

An observational, longitudinal, retrospective study was conducted on a series of 17 patients with periprosthetic femoral fractures after hip hemiarthroplasty. Fourteen fractures were treated surgically. The characteristics of patients, fractures and treatment outcomes in terms of complications, mortality and functionality were analyzed.

RESULTS

The large majority (82%) of patients were women, the mean age was 86 years and with an ASA index of 3 or 4 in 15 patients. Ten fractures were type B. There were 8 general complications, one deep infection, one mobilization of a non-exchanged hemiarthroplasty, and 2 non-unions. There were 85% consolidated fractures, and only 5 patients recovered the same function prior to the injury. At the time of the study 9 patients had died (53%).

DISCUSSION

Periprosthetic femoral fractures after hemiarthroplasty will increase in the coming years and their treatment is difficult.

CONCLUSION

Periprosthetic femoral fractures after hemiarthroplasty are more common in women around 90 years-old, and usually occur in patients with significant morbidity. Although the Vancouver classification is reliable, simple and reproducible, it is only a guide to decide on the best treatment in a patient often fragile. The preoperative planning is essential when deciding a surgical treatment.

The management of type B1 periprosthetic femoral fractures: when to fix and when to revise

The incidence of periprosthetic fractures around total hip arthroplasty is increasing as patient longevity rises and the number of patients with hip implants continues to grow. Type B1 periprosthetic femoral fractures are associated with a well-fixed stem and have traditionally been treated with internal fixation. However, there are a subset of these fractures which fare badly when internal fixation is undertaken, and revision of the femoral component to a long-stemmed implant may be more appropriate. We look at the traditional methods of fixation, and the evidence and indications for revision of these fractures.

A retrospective review of the Dall-Miles plate for periprosthetic femoral fractures: twenty-seven cases and a review of the literature

A retrospective review of the use of the Dall-Miles plate for periprothetic femoral fractures was performed at our institution. Twenty-seven fractures around a hip replacement were fixed using a Dall-Miles plate within 34 months. The mean age at operation was 74 (33-90) years. Twenty fractures were Vancouver B1, two B2, and five type C. Mean follow-up was 11 (2-41) months. Two fractured plates required revision and two fixations loosened, developing varus malunion. One malunion was related to deep infection. All four events occurred within six months of fixation. Two individuals were deceased within 3 months of surgery. Similar complications were evident in nine series published between 1990 and 2012. Increased incidence of periprosthetic femoral fractures is anticipated in a population with significant co-morbidities. Cortical strut allograft, iliac autograft and orthobiological supplementation remain options where non-union is anticipated.

Mono- versus polyaxial locking plates in distal femur fractures - a biomechanical comparison of the Non-Contact-Bridging- (NCB) and the PERILOC-plate

Background

The aim of this cadaveric study was to compare a polyaxial (NCB®, Zimmer) to a fixed-angle monoaxial locking plate (PERILOC®, Smith & Nephew) in comminuted fractures of the distal femur regarding stability of the construct. Up to date there is no published biomechanical data concerning polyaxial plating in cadaveric distal femurs.

Methods

Fourteen formalin fixed femora were scanned by dual-energy x-ray absorptiometry. As fracture model an unstable supracondylar comminuted fracture was simulated. Fractures were pairwise randomly fixed either with a mono- (group A) or a polyaxial (group B) distal femur plate. The samples were tested in a servohydraulic mechanical testing system starting with an axial loading of 200 N following an increase of 200 N in every step with 500 cycles in every sequence up to a maximum of 2 000 N. The end points were implant failure or relevant loss of reduction. Data records included for each specimen time, number of cycles, axial load and axial displacement. Statistical analysis was performed using the exact Wilcoxon signed rank test.

Results

The mean donor age at the time of death was 75 years. The bone mass density (BMD) of the femurs in both groups was comparable and showed no statistically significant differences. Five bones failed before reaching the maximum applied force of 2000 N. Distribution curves of all samples in both groups, showing the plastic deformation in relation to the axial force, showed no statistically significant differences.

Conclusions

Operative stabilization of distal femur fractures can be successfully and equally well achieved using either a monoaxial or a polyaxial locking plate. Polyaxial screw fixation may have advantages if intramedullary implants are present.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-369) contains supplementary material, which is available to authorized users.

Clinical and radiological results of locking plate fixation for periprosthetic femoral fractures around hip arthroplasties: a retrospective multi-center study

BACKGROUND

Osteosynthesis of periprosthetic femoral fractures around hip arthroplasties is challenging, and locking plate fixation has been found to be a reasonable treatment. However, there is a paucity of evidence of the extent to which patients recover their activities of daily living (ADL). The purpose of this study was to study the clinical results, particularly recovery of ADL, radiological results, and potential complications arising from the use of locking plate fixation for periprosthetic femoral fractures around hip arthroplasties.

METHODS

We conducted a retrospective, multi-center study. Patients with periprosthetic femoral fractures around hip arthroplasties who were treated by osteosynthesis with use of locking plates and who underwent follow-up for at least 6 months postoperatively were enrolled in the study. For each patient, recovery of ADL, in terms of social and ambulatory recovery and Parker mobility score, were compared before fracture and at last follow-up. Postoperative complications were investigated. Bony union, loss of reduction, and malunion were assessed radiologically.

RESULTS

Thirty-two patients were enrolled in this study. Mean follow-up was 25.1 months. For 84.4, 68.8, and 53.1% of patients, respectively, social status, ambulation, and Parker mobility score at last follow-up were determined to be equal to that before the fracture. Bony union was observed for 30 patients within the follow-up period. Four patients had not achieved bony union 6 months postoperatively. There was no loss of reduction, malunion, or implant breakage, and no infection. For one patient each, partial pullout of the locking screws and a supracondylar fracture at the plate end were observed, and additional surgery was required.

CONCLUSIONS

Our results reveal that locking plate fixation provided sufficient stability for satisfactory recovery of ADL for most elderly patients with periprosthetic femoral fractures around hip arthroplasties.

Postoperative periprosthetic fractures in patients with an Exeter stem due to a femoral neck fracture: cumulative incidence and surgical outcome

PURPOSE

The purpose of this study is to report on the cumulative incidence and the outcome of surgically-treated postoperative PPFs in patients with femoral neck fractures treated with a THA or HA using an Exeter stem.

METHODS

A consecutive series of patients operated during 1998-2010 due to a non-pathological femoral neck fracture using an Exeter stem were included in this cohort study. Patients were followed until 2012, or death, in order to obtain information about reoperations due to postoperative PPFs, and subsequent re-operations after surgery due to PPFs. In addition to local audit data the Swedish National Board of Health and Welfare's registry was used to identify patients who had been re-operated upon elsewhere in Sweden.

RESULTS

A total of 2,757 patients (median age 82 years, 2,019 females) were identified and included in the study. Of these patients, 63 (2.3%) sustained a postoperative PPF that was treated surgically. The majority of the Vancouver B1 (n = 21/23) and C (n = 14/14) fractures were treated using open reduction and internal fixation (ORIF), whereas most of the B2 (n = 16/25) fractures and the only B3 fracture were treated with stem revision. Three (4.8%) patients were subsequently re-operated upon due to fracture-related complications, all B2 fractures, and were treated with ORIF (n = 2) or stem revision (n = 1).

CONCLUSION

The cumulative incidence of surgically treated PPFs was considerable among patients with Exeter stems operated due to a femoral neck fracture. The re-operation rate due to fracture-related complications was highest among patients with B2 fractures.

Outcomes of post-operative periprosthetic femur fracture around total hip arthroplasty: a review

As the number of primary total hip arthroplasties increase over the next several decades so will the incidence of periprosthetic fractures around the femoral stem. Treatment can reliably be predicted using the Vancouver classification with internal fixation being indicated in fractures involving a stable implant and revision arthroplasty indicated in those with unstable prostheses. Non-displaced fractures involving the greater and lesser trochanter can generally be treated non-operatively. Extensively porous-coated stems and the use of modular uncemented revision stems to treat Vancouver B fractures have shown encouraging results. The treatment of Vancouver C periprosthetic fractures continues to follow basic AO fixation principles with an emphasis on eliminating stress risers with adequate implant overlap and length. This review will focus on the risk factors and classification of these fractures, as well as highlight the treatment options for post-operative periprosthetic femoral fractures around a total hip arthroplasty.

Outcomes following surgical treatment of periprosthetic femur fractures: a single centre series

BACKGROUND

Periprosthetic femoral fracture after total hip arthroplasty (THA) is an increasing clinical problem and a challenging complication to treat surgically. The aim of this retrospective study was to review the treatment of periprosthetic fractures and the complication rate associated with treatment at our institution.

METHODS

We reviewed the cases of patients with periprosthetic femoral fractures treated between January 2004 and June 2009. We used the Vancouver classification to assess fracture types, and we identified the surgical interventions used for these fracture types and the associated complications.

RESULTS

We treated 45 patients with periprosthetic femoral fractures during the study period (15 men, 30 women, mean age 78 yr). Based on Vancouver classification, 2 patients had AL fractures, 9 had AG, 15 had B1, 24 had B2, 2 had B3 and 4 had C fractures. Overall, 82% of fractures united with a mean time to union of 15 (range 2-64) months. Fourteen patients (31%) had complications; 11 of them had a reoperation: 6 to treat an infection, 6 for nonunion and 2 for aseptic femoral component loosening.

CONCLUSION

Periprosthetic fractures are difficult to manage. Careful preoperative planning and appropriate intraoperative management in the hands of experienced surgeons may increase the chances of successful treatment. However, patients should be counselled on the high risk of complications when presenting with this problem.

Interprosthetic femoral fractures treated with locking plate

PURPOSE

Interprosthetic fractures are challenging to manage. Although treatment of femoral fractures around a single implant has been described, there is little literature for treatment of interprosthetic femoral fractures. This study analyses the management and outcomes of 15 patients with interprosthetic femoral fractures treated with locking plates.

METHODS

A retrospective chart review was conducted of 17 patients with interprosthetic femur fracture treated with locking plates from 2002 to 2013. Patient demographics and comorbidities were collected. Preoperatively, patients were classified with the Vancouver or Su classification system. Intraoperative use of bone graft and/or cerclage cables was also examined. Clinical and radiographic outcomes were evaluated for union, time to full weight bearing, return to preinjury level of activity, and pain assessed with visual analog scale (VAS).

RESULTS

There were 15 patients with interprosthetic fractures meeting criteria for this study. Average patient age was 80.53 (range, 61-92) years. Bone grafting was used in 23.5% (four of 17) and cerclage cables in 29.4% (five of 17). Patients achieved complete union and return to full weight bearing an average of 4.02 (range, two to six) months later. Average VAS pain score was 1.00 (range, zero to six). All patients returned to their preoperative ambulatory status.

CONCLUSION

Locking plates could achieve satisfactory results for interprosthetic fractures. Considering an individual's fracture type, bone quality and protheses to determine the appropriate plate length and optional use of cerclage and/or bone graft was essential. In this limited sample size, interprosthetic fractures occurred at similar rates at the supracondylar region and diaphysis.

The effect of strut allograft and its position on Vancouver type B1 periprosthetic femoral fractures: a biomechanical study

The aim of this study is to assess the biomechanical advantage of adding strut allograft and the effect of its position on the construct in Vancouver type B1 fractures. Fifteen forth-generation synthetic femurs were used and created a fracture model at the tip of prosthesis, and subsequently fixated with a lateral plate only, lateral plate and medial strut, lateral plate and anterior strut. Rotational and axial tests were performed. In all loading tests, the plate with medial strut group was stiffer than the other constructs and had higher failure load values and had less displacement in the fracture site. A combination of a plate with a medial strut allograft provides more mechanical stability on periprosthetic femoral fractures near the tip of a total hip arthroplasty.

A systematic review of open reduction and internal fixation of periprosthetic femur fractures with or without allograft strut, cerclage, and locked plates

Few comparative studies exist for open reduction and internal fixation of Vancouver B1 and C fractures. We therefore performed a systematic review of fractures treated with or without an allograft strut, and using various fixation techniques. Thirty-seven manuscripts including 682 fractures were identified between 1992 and 2012. Percent union was similar for Vancouver B1 fractures treated with or without an allograft strut (90.7% vs. 91.5%). Time to union (4.4 vs. 6.6 months) and deep infection (3.8% vs. 8.3%) were increased with use of allograft struts. Percent union and time to union were unaffected by plate type or use of cerclage. We conclude that due to increased infection and time to union, allograft struts should be used cautiously during operative treatment of Vancouver B1 factures.

Locking plate fixation of periprosthetic femur fractures with and without cerclage wires

OBJECTIVE

The number of patients requiring knee and hip arthroplasty has been steadily increasing, and periprosthetic fractures are on the rise. Locking plates are the most common treatment for periprosthetic fractures, but the use of cerclage wires with locking plate fixation has been controversial.

METHODS

Forty-seven patients with periprosthetic femur fractures were reviewed retrospectively. Twenty-four patients received locking plate alone and twenty-three patients were treated with locking plate and cerclage wires. Patients were evaluated for clinical and radiographic signs of union at two, six, twelve, twenty-four, and forty-eight weeks postoperatively.

RESULTS

The average follow-up time in the plate group was 9.4 ± 6.7 months, while it was 6.0 ± 4.2 months in the cerclage wire group. The time to union in the cerclage wire group (3.6 ± 1.0 months) was significantly less than the plate group (4.8 ± 2.6 months). The group with the cerclage wires had a significantly lower revision rate of 0% compared to 20.8%. There was no statistical significance of union rate and complication rate between the two groups.

CONCLUSION

Cerclage wires used with locking plate fixation successfully treats periprosthetic fractures of the femur with faster time to union, less complication, and fewer revisions.

Periprosthetic femoral fracture--a biomechanical comparison between Vancouver type B1 and B2 fixation methods

Current clinical data suggest a higher failure rate for internal fixation in Vancouver type B1 periprosthetic femoral fracture (PFF) fixations compared to long stem revision in B2 fractures. The aim of this study was to compare the biomechanical performance of several fixations in the aforementioned fractures. Finite element models of B1 and B2 fixations, previously corroborated against in vitro experimental models, were compared. The results indicated that in treatment of B1 fractures, a single locking plate can be without complications provided partial weight bearing is followed. In case of B2 fractures, long stem revision and bypassing the fracture gap by two femoral diameters are recommended. Considering the risk of single plate failure, long stem revision could be considered in all comminuted B1 and B2 fractures.

Treatment of periprosthetic femur fractures around a well-fixed hip arthroplasty implant: span the whole bone

INTRODUCTION

Periprosthetic femur fractures are a growing problem in the geriatric population. This study examines Vancouver B1 periprosthetic femur fractures treated with open reduction internal fixation using a laterally based plate. Outcomes using plates which spanned the length of the femur to the level of the femoral condyles were compared to those which did not. The hypothesis was that spanning internal fixation would result in a decreased rate of refracture and subsequent reoperation.

MATERIALS AND METHODS

Patients admitted to three affiliated academic hospitals treated with open reduction internal fixation for a periprosthetic femur fracture in the setting of a preexisting total hip arthroplasty or hemiarthroplasty stem were identified. Patient data were reviewed for age, gender, fracture classification, operative intervention, time to union, as well as complications related to treatment and need for further surgery.

RESULTS

Over a 5-year period, 58 patients were treated with open reduction internal fixation using a laterally based plate for Vancouver B1 femur fractures. Twenty-one patients were treated with plates that extended to the level of the femoral condyles. In that group there were no nonunions or subsequent periprosthetic fractures reported. Of 36 patients treated with short plates, 3 went on to nonunion resulting in plate failure and refracture and 2 sustained a subsequent fracture distal to the existing fixation.

CONCLUSIONS

In this series, fixation for periprosthetic femur fractures around a well-fixed arthroplasty stem which spans the length of the femur to the level of the femoral condyles is associated with a decreased rate of nonunion and refracture. By decreasing the rate of refracture and nonunion, spanning fixation decreases the morbidity and mortality associated with additional surgery in a fragile geriatric population.

Evaluation of fracture topography and bone quality in periprosthetic femoral fractures: A preliminary radiographic study of consecutive clinical data

The unique configuration of periprosthetic femoral fractures (PFFs) is a major determinant of the subsequent management. The aim of this preliminary study was to investigate potential relationships between fracture angle (FA), fracture level (FL) and bone quality of Vancouver type B PFF. The FA, FL and the canal thickness ratio (CTR) were quantified for 27 patient X-rays. The CTR is an indicator of the underlying bone quality. Relationships between these factors were studied for the whole X-ray set, for a subgroup involving fracture above the tip of the stem and for subgroups with stable and unstable implants. When considering all cases, no significant correlation was found between the FA and any other measurement. Considering only cases with unstable implants, a statistically significant correlation was found between the FA and the FL (R(2)=0.489, p=0.002). No correlation was found between FA and any other measurement for stable implants suggesting that FA could be considered as an independent factor when classifying B1 fractures. Considering all cases, a weak correlation was found between CTR and FL (R(2)=0.152, p=0.044) suggesting that fractures below the tip of the stem may indicate a lower bone quality. This preliminary study suggests that the effect of FA on the optimal management of Vancouver type B1 fractures could be considered, independent of the quality of the bone or fracture position. Furthermore, fractures around or below the tip of the stem may suggest a poor bone quality. Larger number of patients is required to confirm these initial findings.

Superior outcome of strut allograft-augmented plate fixation for the treatment of periprosthetic fractures around a stable femoral stem

PURPOSE

This study was designed to compare the outcome of two surgical approaches for treating femoral periprosthetic fractures around a stable femoral stem. The hypothesis was that plate fixation alone might be associated with a higher complication rate due to insufficient mechanical stability. We also considered that the addition of a strut allograft would contribute to fracture healing by means of osteoconduction.

METHODS

We retrospectively assessed the outcome of 21 patients who sustained periprosthetic fractures around a total hip replacement system (Vancouver type B1 and type C fractures) and who were treated in our department (January 2006 and August 2011) either by plate fixation alone or by plate fixation and a strut allograft. The mean postoperative follow-up was 23 months (range 9-69 months). Eleven patients were treated by plate fixation alone (Plate Group), and 10 patients were treated by plate fixation and a deep frozen cortical strut allograft (AG Group). Functional outcome was rated by the Harris Hip scoring system. Postoperative radiographs were assessed for evidence of fracture union. Surgical failure was defined as any complication requiring surgical revision.

RESULTS

The 21 patients included 17 females and 4 males. The average age was 79 years (range, 73-88) for the Plate Group and 82 years (range, 53-94) for the AG Group, and the average time to fracture union was 12 weeks (range, 2.5-6 months) and 12.95 weeks (range, 1.5-3) respectively. The overall failure rate was significantly higher in the Plate Group: 5 of them required revision surgery compared to none in the AG Group (p=0.014).

CONCLUSION

The results of this analysis indicate that a strut allograft augmentation approach to Vancouver type B1 and type C periprosthetic fractures results in a better outcome than plate fixation alone by apparently adding mechanical stability and enhancing the biological healing process.

Biomechanical comparison of two angular stable plate constructions for periprosthetic femur fracture fixation

PURPOSE

Fractures of the femur associated with total hip arthroplasty are a significant concern in orthopaedic and trauma surgery. However, little is known about the different biomechanical properties of internal fixation systems in combination with periprosthetic fractures. In this study two new internal fixation systems for periprosthetic fractures are investigated using a cadaver fracture model simulating a Vancouver B1 periprosthetic femur fracture.

METHODS

Nine pairs of fresh-frozen cadaver femurs were scanned by dual X-ray absorptiometry. Cementless total hip prostheses were implanted and a periprosthetic femur fracture was simulated. Fractures were randomly fixed either with the fixed angle locking attachment plate (LAP®, Depuy Synthes®, Solothurn, Switzerland) or the variable angle non-contact bridging plate (NCB®, Zimmer GmbH, Winterthur, Switzerland). Each construct was cyclically loaded to failure in axial compression.

RESULTS

Axial stiffness and cycles to failure were significantly higher in the NCB group. Both systems were able to be fixed well around the femoral stem.

CONCLUSION

The two different internal fixation systems for periprosthetic fractures differed significantly in our setup. The non-contact bridging plate system revealed significantly higher failure load and may be the preferred option where high stability and load capacity is needed right after operation.

Extracortical plate fixation with new plate inserts and cerclage wires for the treatment of periprosthetic hip fractures

PURPOSE

Fixation of periprosthetic hip fractures with intracortical anchorage might not be feasible in cases with bulky implants and/or poor bone stock.

METHODS

Rotational stability of new plate inserts with extracortical anchorage for cerclage fixation was measured and compared to the stability found using a standard technique in a biomechanical setup using a torsion testing machine. In a synthetic PUR bone model, transverse fractures were fixed distally using screws and proximally by wire cerclages attached to the plates using "new" (extracortical anchorage) or "standard" (intracortical anchorage) plate inserts. Time to fracture consolidation and complications were assessed in a consecutive series of 18 patients (18 female; mean age 81 years, range 55-92) with periprosthetic hip fractures (ten type B1, eight type C-Vancouver) treated with the new device between July 2003 and July 2010.

RESULTS

The "new" device showed a higher rotational stability than the "standard" technique (p < 0.001). Fractures showed radiographic consolidation after 14 ± 5 weeks (mean ± SD) postoperatively in patients. Revision surgery was necessary in four patients, unrelated to the new technique.

CONCLUSION

In periprosthetic hip fractures in which fixation with intracortical anchorage using conventional means might be difficult due to bulky revision stems and/or poor bone stock, the new device may be an addition to the range of existing implants.

The effect of fracture stability on the performance of locking plate fixation in periprosthetic femoral fractures

Periprosthetic femoral fracture (PFF) fixation failures are still occurring. The effect of fracture stability and loading on PFF fixation has not been investigated and this is crucial for optimum management of PFF. Models of stable and unstable PPFs were developed and used to quantify the effect of fracture stability and loading in a single locking plate fixation. Stress on the plate was higher in the unstable compared to the stable fixation. In the case of unstable fractures, it is possible for a single locking plate fixation to provide the required mechanical environment for callus formation without significant risk of plate fracture, provided partial weight bearing is followed. In cases where partial weight bearing is unlikely, additional biological fixation could be considered.

Periprosthetic fractures around hip hemiarthroplasty performed for hip fracture

Hip fracture is associated with considerable morbidity and mortality and occurs in an elderly and infirm group of patients. Periprosthetic fracture after hip hemiarthroplasty is a serious complication. In this study, we have reviewed our experience of this injury. The outcome measures used were fracture union, mortality, infection and requirement for further surgery.

METHOD

We identified a cohort of 79 patients who sustained periprosthetic fractures after hip hemiarthroplasty from a prospective hip fracture database of 8354 patients (3611 were treated with hemiarthroplasty). Seventy-two percent were female and the mean age was 86 years at time of periprosthetic fracture.

RESULTS

Sixty-two fractures occurred around uncemented prostheses (Austin Moore n=61); the remainder occurred around cemented prostheses. The mean time from hip fracture surgery to periprosthetic fracture was 35 months (median time 5 months). Fractures were classified according to the Vancouver system. Fifteen percent (n=12) were type A fractures, 26% (n=21) were type B1 fractures, 41% (n=32) were type B2 fractures, 9% (n=7) were type B3 fractures and 9% (n=7) were type C fractures. Twenty-eight patients underwent open reduction internal fixation (ORIF), 36 required revision surgery, one required fixation and simultaneous revision and 14 were treated non-operatively. Eleven percent (n=9) died within 1 month of periprosthetic fracture, 23% had died by 3 months, 34% by 1 year and 49% by 2 years. Nineteen patients (24%) died before fracture union had occurred. Fracture union occurred in 97% of the remaining cases (58/60). Two patients developed nonunion requiring revision surgery (3%), and three patients developed deep infection requiring debridement (4%), one patient had an infection at the time of the periprosthetic fracture requiring a planned two-stage revision, one patient sustained a second periprosthetic fracture and two patients underwent superficial wound debridement (3%). The incidence of periprosthetic fracture at our institution since 1999 is 1.7% (62 of 3611 patients). The incidence rate after uncemented Austin Moore stem was 2.3% (54/2378) and cemented Exeter stem was 0.5% (4/812); Fisher's exact test p=0.004.

CONCLUSIONS

This article reports satisfactory outcomes in this complex group of patients. We have established the incidence of 1.7%, with relatively low rates of nonunion, infection and other complications. The mortality rate has been established, and survivorship analysis has identified an increased rate of fracture around the Austin Moore prosthesis.

Locking plate fixation for Vancouver B1 periprosthetic femoral fractures: a critical analysis of 135 cases

PURPOSE

The overall incidence of periprosthetic femoral fractures (PPF) is between 0.1 and 6 % of all total hip arthroplasties. Locking compression plates (LCP) have been used for the treatment of Vancouver B1 PPFs with variable results. The aim of this study is to examine the literature on locking plate failure rates, mode and reasons for failure.

METHODOLOGY

A literature search was conducted for studies reporting the management of PPF of the femur with LCP fixation. The primary medical search engines used for the study were Ovid MEDLINE and EMBASE databases up to August 2012.

RESULTS

Twelve studies were identified, reporting overall union rates of 91 % in 135 fractures. Only 7 (5 %) fractures required revision surgery due to plate fracture (5) or pull out (2). Important trends in plate complications included: stress riser at the end of the plate, stress concentration in the fracture area due to rigid fixation, early loading and absence of cortical strut grafting for biological support when needed.

CONCLUSION

LCP has been used successfully in the management of Vancouver B1 PPF. However, potential areas of improvement include, leaving the fracture site free of locking screws, therefore, not disturbing the soft tissue envelope around the fracture and also reducing plate stiffness. Adding cortical strut allografts to improve stability and bone quality, if needed, may also improve outcome. Limitations in the use of strut grafts or transverse fractures below the tip of the stem that cannot be controlled with single or double plating may require long stem revision to achieve axial stability.

A review of periprosthetic femoral fractures associated with total hip arthroplasty

Periprosthetic fractures of the femur in association with total hip arthroplasty are increasingly common and often difficult to treat. Patients with periprosthetic fractures are typically elderly and frail and have osteoporosis. No clear consensus exists regarding the optimal management strategy because there is limited high-quality research. The Vancouver classification facilitates treatment decisions. In the presence of a stable prosthesis (type-B1 and -C fractures), most authors recommend surgical stabilization of the fracture with plates, strut grafts, or a combination thereof. In up to 20% of apparent Vancouver type-B1 fractures, the femoral stem is loose, which may explain the high failure rates associated with open reduction and internal fixation. Some authors recommend routine opening and dislocation of the hip to perform an intraoperative stem stability test to rule out a loose component. Advances in plating techniques and technology are improving the outcomes for these fractures. For fractures around a loose femoral prosthesis (types B2 and 3), revision using an extensively porous-coated uncemented long stem, with or without additional fracture fixation, appears to offer the most reliable outcome. Cement-in-cement revision using a long-stem prosthesis is feasible in elderly patients with a well-fixed cement mantle. It is essential to treat the osteoporosis to help fracture healing and to prevent further fractures. We provide an overview of the causes, classification, and management of periprosthetic femoral fractures around a total hip arthroplasty based on the current best available evidence.

New surgical treatment using a docking nail for postoperative periprosthetic femoral fracture after total hip arthroplasty

We report 2 cases of patients (75 and 81 years old) who had a femoral shaft fracture around the femoral prosthesis after total hip arthroplasty. Using information on the implanted stem and the preoperative radiographs, we cut and trimmed an ordinary supracondylar type intramedullary nail, after which we have termed a "docking nail." We then performed osteosynthesis using the docking nail, which is connected to the tip of the implanted stem to ensure proper alignment. Within 3 months, bony union with good alignment was observed in both patients without malunion or infection. Clinical and radiographic examination during the follow-up period showed good results. The advantages of this method are that it is less invasive and simpler compared with the conventional methods.