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Abstract

Periprosthetic fractures after cemented hip replacement are a challenging problem to manage. Biomechanical studies have suggested the benefit of using locking screws for plate fixation, but there are concerns whether screws damage the cement mantle and promote crack propagation leading to construct failure. In this biomechanical study, different screw types were implanted into the cement mantle after pre-drilling holes of different sizes, in unicortical and bicortical configuration. The presence of cracks and the pull-out resistance of these screws were then evaluated. No unicortical screw induced cracks. Screws with a shortened tip, smaller flutes and double threads were significantly better for pull-out resistance. Bicortical screws were associated with a risk of local cement mantle damage, but also with a significantly greater holding power. By increasing the drill diameter, the onset of cracks decreased, but so does the pull-out resistance.

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... Regardless of the approach, opportunities for bicortical screw fixation around the retained femoral component are limited. In the setting of a cemented stem, bicortical screw fixation typically requires drilling through the cement mantle and some surgeons have raised concerns that this may result in prosthesis loosening or particle induced osteolysis [2][3][4][5][6][7][8]. However, the clinical implications of drilling through the cement mantle around a femoral stem during fracture fixation remain unknown. ...
... Surgical fixation of periprosthetic femur fractures around a cemented hip arthroplasty often requires screw placement into the cement mantle to optimize fixation. Biomechanical research has offered mixed results regarding the safety of placing screws into the cement [6,10], but clinical outcomes have not previously been reported. In this retrospective cohort study, we compared reoperation and overall complication rates between patients with periprosthetic diaphyseal femur fractures who had screws placed into the cement mantle of their prosthesis (CD) with patients who had screws placed around an uncemented arthroplasty (PF) and found no differences. ...
... In a simplified cement mantle model, Kampshoff et al. found that 5.0 mm unicortical screws were not associated with crack formation, but that 5.0 mm bicortical screws induced cracks in 62.5% of cases. Crack formation could be reduced significantly by overdrilling relative to the recommended drill bit, although this unsurprisingly resulted in decreased pull-out strength, and is not a practical clinical recommendation when construct stability is paramount [6]. Kampshoff's results conflicted with a study by Giesinger et al., who found no signs of cement mantle damage when 36 standard 5.0-mm cortical screws were placed bicortically through the cement mantle immediately after drilling in a composite bone model of a Vancouver C periprosthetic fracture [10]. ...
Article
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Objective To determine if screw fixation across a cement mantle is safe and effective during plate fixation of well-fixed periprosthetic femur fractures. Design Retrospective cohort study. Setting Academic Level I Trauma Center. Patients Twenty-eight patients with AO/OTA 32A[B1] or 32A[C] periprosthetic femur fractures treated with open reduction and internal plate and screw fixation after cemented or uncemented hip arthroplasty. Intervention Screw placement into the cement mantle during internal fixation. Outcome Measurements Primary outcome was revision arthroplasty for aseptic loosening. Secondary outcomes included radiographic evidence of aseptic loosening, infection, nonunion, implant failure, and overall reoperation rate. Results There were 28 patients who met inclusion criteria. A total of 9 patients had screws placed in the cement mantle while the remaining 19 patients had screws placed around an uncemented stem. At a mean of 3.7-year follow-up, there were no cases of revision arthroplasty or aseptic loosening in either group. There were no significant differences in rates of infection, nonunion, implant failure, or reoperation rate between patients who had screw placement into a cement mantle vs around an uncemented stem. Conclusion Drilling into the cement mantle during fixation of a periprosthetic femur fracture around a well-fixed cemented hip stem appears safe and effective. When possible, surgeons can consider bicortical screws around a cemented stem, given the biomechanical advantages over unicortical screw or cerclage fixation. Larger prospective trials confirming the safety of this technique are warranted prior to routine implementation. Level of Evidence III.
... Our current orientation for the treatment of femoral peri-prosthetic fractures with a stable implant (A, B1, C) is the use of the new Zimmer NCB (Non-Contact Bridging), poly-axial angular stability plates (10,12,13). ...
... When the proximal femoral plate was selected and compared with a LCP Broad Curved Femur Shaft Plate, 1 million load cycles were applied in the Materials Laboratory: the NCB PP Proximal Femur Plate broke at a load of 500 N (24.5 Nm bending moment), showing almost double the resistance to the LCP Broad Curved Plate Femur Shaft Plate which broke at a load of 240 N (11.8 Nm bending moment) (6,10,12,14). ...
... NCB plates, compared to the means of synthesis used in the past, are technologically innovative tools, much more resistant, conceptually better, and easier to apply in the operating field. Their flexibility helps to solve practically all the technical problems that are typical of their osteosynthesis (5,10,12). ...
Article
Background and aim of the work: The incidence of periprostethic femur fractures has increased over the last years; the treatment includes an open reduction and internal fixation or revision implant. The treatment of these fractures can be complex, expensive and associated with risks of systemic and local complications. Methods: We evaluated clinical and radiological results in patients treated in our department for periprosthetic femoral fractures from 2011 to 2017. We included 52 cases of periprosthetic fractures regardless of their classification with a mean follow-up of 2 years. The analisys of the result was performed using Harris Hip Score and searching for radiographic signs of loosening, infections or mechanical failure of the implants. Results: There was no evidence of septic complications or mechanical failure in cases treated. The average HHS was equal to 92 points with a certificate pain relief and a sufficient independence in daily living activities. Conclusions: The treatment of periprosthetic fractures is complex: it depends on type of fracture, on stability of the stem and on the bone quality. A right classification of the fractures, a good experience of the surgeon in prosthetic and trauma surgery is the basis for the best treatment.
... A clinical concern regarding the way that a construct fixation is applied is the potential breach of cement mantle integrity; in particular, cortical screw tips infringing the cement mantle and potentially leading to substantial cement fracture and eventual hip implant loosening (Lever et al., 2010). Two authors (Kampshoff et al., 2010;Konstantinidis et al., 2017) studied the role of cement mantle integrity and screws in PFF. Konstantinidis et al. (2017) deliberately made a more brittle mantle by using hand-mixed rather than the advised vacuum mixed cement, and Kampshoff et al. (2010) forgoed typical plate fixation setup and investigated the effect of different screw implantation techniques by directly drilling different screws in the cement. ...
... Two authors (Kampshoff et al., 2010;Konstantinidis et al., 2017) studied the role of cement mantle integrity and screws in PFF. Konstantinidis et al. (2017) deliberately made a more brittle mantle by using hand-mixed rather than the advised vacuum mixed cement, and Kampshoff et al. (2010) forgoed typical plate fixation setup and investigated the effect of different screw implantation techniques by directly drilling different screws in the cement. Brand et al. (2014) proposed and investigated a novel fixation methodintraprosthetic fixation; where screws that fixed the fracture plate to the bone were also drilled and fixed to the cemented hip implant. ...
... Screws (Kampshoff et al., 2010) Effect of different screw implantation techniques on the integrity of local cement mantle and fixation strength of the screw. Using different kinds of locking screws. ...
Article
Full-text available
Background: Periprosthetic femoral fracture is a severe complication of total hip arthroplasty. A previous review published in 2011 summarised the biomechanical studies regarding periprosthetic femoral fracture and its fixation techniques. Since then, there have been several commercially available fracture plates designed specifically for the treatment of these fractures. However, several clinical studies still report failure of fixation treatments used for these fractures. Methods: The current literature on biomechanical models of periprosthetic femoral fracture fixation since 2010 to present is reviewed. The methodologies involved in the experimental and computational studies of periprosthetic femoral fracture fixation are described and compared with particular focus on the recent developments. Findings: Several issues raised in the previous review paper have been addressed by current studies; such as validating computational results with experimental data. Current experimental studies are more sophisticated in design. Computational studies have been useful in studying fixation methods or conditions (such as bone healing) that are difficult to study in vivo or in vitro. However, a few issues still remain and are highlighted. Interpretation: The increased use of computational studies in investigating periprosthetic femoral fracture fixation techniques has proven valuable. Existing protocols for testing periprosthetic femoral fracture fixation need to be standardised in order to make more direct and conclusive comparisons between studies. A consensus on the 'optimum' treatment method for periprosthetic femoral fracture fixation needs to be achieved.
... Il faut choisir un implant peu encombrant, adapté à la courbure du fémur, permettant la synthèse par câbles ou par vis en s'affranchissant des difficultés liées à la présence de l'implant fémoral. Différentes études biomécaniques montrent qu'il n'y a pas de différence de solidité de montage entre l'utilisation de câbles proximaux ou de vis proximales (27)(28)(29)(30)(31)(32).Il faut au minimum trois câbles ou trois vis bicorticales au-dessus de la fracture et au minimum trois vis bicorticales ou deux vis bicorticales et un câble en dessous de la fracture. Le montage par câblage seul est moins solide, il faut l'associer à l'utilisation de vis en distal pour supprimer les déplacements en translation et en rotation. ...
... De plus, les vis bi corticales ont une meilleure tenue que les vis mono corticales. Le vissage endommagerait pour certains le manteau de ciment ce qui conduirait à une défaillance de la vis à long terme (30,32). Les études montrent aussi que l'amincissement des corticales, les fractures instables ainsi que les fractures descendant en dessous de l'extrémité distale de la prothèse conduisent à des montages moins solides (31). ...
... The results and findings are variable (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30). Biomechanical studies show that proximal mono cortical and distal bi cortical screw fixations or proximal cerclage and distal bi cortical screw fixations ensure good stabilization in axial compression, lateral compression in 4 points (anterior-posterior and medio-lateral) and in torsion (31)(32)(33). In addition, bi cortical screws have a better resistance than mono cortical screws. ...
Thesis
Introduction : La fracture péri prothétique du fémur (FPF) est une complication fréquente chez les personnes âgées, souvent dépendantes avec une espérance de vie limitée. Leur prise en charge est difficile et le choix entre ostéosynthèse et changement prothétique est toujours sujet à discussion. A ce jour, il n’existe aucune étude concernant une plaque non verrouillée avec cerclages intégrés et crochet trochantérien pour cette indication. Les objectifs de cette étude étaient d’analyser la consolidation des fractures, le taux de complication et le résultat fonctionnel. Notre hypothèse est que cette technique permet un fort taux de consolidation et un retour à l’état antérieur en terme d’autonomie et de lieu de résidence. Matériels et méthodes : Nous avons réalisé une étude rétrospective multicentrique (Nancy, Metz, Thionville et Remiremont) entre 2010 et 2015. Les critères d’inclusion étaient : patients présentant une FPF de type A et B selon la classification de Vancouver, avec ostéosynthèse par plaque à crochet. L’évaluation a porté sur le délai de consolidation, les complications et les scores de Parker et de Katz en pré et post-opératoire. Etaient considérées comme des complications majeures : décès, pseudarthrose, luxation, infection, faillite de l’ostéosynthèse. Résultats : Quarante-cinq patients satisfaisaient aux critères d’inclusion et ont été évalués au recul moyen de 20 mois (6-72). Toutes les fractures ont consolidé au délai moyen de 7 semaines (6-10), sauf une qui n’a pas fait l’objet d’une reprise chirurgicale en l’absence de retentissement fonctionnel. Un lavage précoce a été réalisé pour un écoulement sur cicatrice à 3 semaines avec une bonne évolution. Le score de Parker a diminué de 6.4 à 4.9 (p=0.03) et le score de Katz de 4.8 à 4.3 (p=0.045). Cinq patients sont décédés dans l’année suivant l’opération. Cinq patients vivant à domicile en pré opératoire ont été institutionnalisés, les autres ont pu retrouver leur maison de retraite ou leur EHPAD. Conclusion : Cette plaque permet une prise en charge rapide et efficace des patients ayant une FPF. Le faible taux de complication et le très bon taux de consolidation nous poussent à utiliser cette plaque même pour les fractures classées B2 ou B3 chez certains patients à l’état général précaire ne pouvant pas tolérer une chirurgie lourde de reprise : âgé, score ASA>3, en perte d’autonomie, score de Katz<4.
... However, it may compromise the cement mantle, and various authors [12][13][14] have concerns that this may lead to cement fragmentation and subsequent failure. Kampshoff et al. [15] showed in a simplified cement mantle model that screw placement initiated cracks around the screw holes in 60% using a standard drill bit. ...
... Both groups showed no cracks in the cement mantle or signs of cement mantle failure. This in vitro study does not confirm the concerns of other authors [13][14][15]. Differently to Kampshoff et al. [15] we did not find any cracks around the screw holes. Drill bit size and screws were identical therefore the different findings may well be due to the fact that Kampshoff et al. [15] inserted the screws once the cement mantle had fully cooled down. ...
... This in vitro study does not confirm the concerns of other authors [13][14][15]. Differently to Kampshoff et al. [15] we did not find any cracks around the screw holes. Drill bit size and screws were identical therefore the different findings may well be due to the fact that Kampshoff et al. [15] inserted the screws once the cement mantle had fully cooled down. ...
... Methods including single-and double-plating, single-and double-allograft struts, and combinations thereof are possible. [65][66][67][68][69] Biomechanical studies have attempted to determine the strongest constructs, although validation with clinical studies is rare. [65][66][67][68][69][70] A cadaveric study showed that dual fixation with a plate and strut graft or strut grafts only was significantly more stable than a plate-only construct when loaded at 1.5 times the body weight. ...
... [65][66][67][68][69] Biomechanical studies have attempted to determine the strongest constructs, although validation with clinical studies is rare. [65][66][67][68][69][70] A cadaveric study showed that dual fixation with a plate and strut graft or strut grafts only was significantly more stable than a plate-only construct when loaded at 1.5 times the body weight. 69 In contrast, a similarly conducted cadaveric study reported that plate fixation with cables proximally and screws distally (Ogden system) was significantly stronger than 2 allograft struts with cables. ...
Article
Full-text available
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.
... Locking-plate fixation via a minimally invasive approach has been proven effective for the treatment of periprosthetic femoral fractures [7,11,[21][22][23][24][25]. Periprosthetic screw fixation produces a highly secure construct but can damage the cement mantle [26]. In patients with interprosthetic fractures, the main objective is protection of the entire femur to avoid the creation of stress riser zones [18,20,27], thereby preventing the occurrence of secondary fractures, which can be life threatening in elderly patients [3][4][5]. ...
Article
Les fractures fémorales inter-prothétiques sont rares, et leur traitement est discuté notamment sur la longueur de l’ostéosynthèse. L’apport des plaques verrouillées par voie mini-invasive est peu connu et peut contribuer à améliorer le taux de succès de l’ostéosynthèse.
... Für die Versorgung von periprothetischen Frakturen bei festem zementiertem Schaft sollten die leicht überdimensionierten Bohrer und Bohrführungen benutzt werden, um die Gefahr von Rissen im Zementmantel beim Positionieren von bikortikalen Schrauben zu reduzieren. In einer biomechanischen Studie konnten Kampshoff et al. [19] . 1, 2). ...
Article
Full-text available
Periprosthetic fractures are increasing not only due to the demographic development with high life expectancy, the increase in osteoporosis and increased prosthesis implantation but also due to increased activity of the elderly population. The therapeutic algorithms are manifold but general valid rules for severe fractures are not available. The most commonly occurring periprosthetic fractures are proximal and distal femoral fractures but in the clinical routine fractures of the tibial head, ankle, shoulder, elbow and on the borders to other implants (peri-implant fractures) and complex interprosthetic fractures are being seen increasingly more. It is to be expected that in the mid-term further options, such as cement augmentation of cannulated polyaxial locking screws will extend the portfolio of implants for treatment of periprosthetic fractures. The aim of this review article is to present the new procedures for osteosynthesis of periprosthetic fractures.
... This is consistent with a biomechanical study showing that use of a non-locking plate around a stable femoral stem was better than use of a locking plate [27]. Moreover, it has been reported that when type B1 fractures are treated with locking plates, not placing locking screws at the fracture site reduces the construct's stiffness, which helps to increase callus formation and reduce the risk of complications [37]. In the current study, union occurred in all patients in an average of 2.4 months and only one patient had a mal-union; this is comparable to studies with locking plates [20][21][22][23][24]. ...
Article
Periprosthetic femur fracture (PFF) is a serious complication after total hip arthroplasty that can be treated using different internal fixation devices. However, the outcomes with curved non-locking plates with eccentric holes in this indication have not been reported previously. The objectives of this study were to determine: (1) the union rate; (2) the complication rate; (3) autonomy in a group of patients with a Vancouver type B PFF who were treated with this plate. Use of this plate results in a high union rate with minimal mechanical complications. Forty-three patients with a mean age of 79 years±13 (41-98) who had undergone fixation of Vancouver type B PFF with this plate between 2002 and 2007 were included in the study. The time to union and Parker Mobility Score were evaluated. The revision-free survival (all causes) was calculated using Kaplan-Meier analysis. The average follow-up was 42 months±20 (16-90). Union was obtained in all patients in a mean of 2.4 months±0.6 (2-4). One patient had varus malunion of the femur. The Parker Mobility Score decreased from 5.93±1.94 (2-9) to 4.93±1.8 (1-9) (P=0.01). Two patients required a surgical revision: one for an infection after 4.5 years and one for stem loosening. The survival of the femoral stem 5 years after fracture fixation was 83.3%±12.6%. Use of a curved plate with eccentric holes for treating type B PFF led to a high union rate and a low number of fixation-related complications. However, PFF remains a serious complication of hip arthroplasty that is accompanied by high morbidity and mortality rates. Retrospective study, level IV. Copyright © 2015. Published by Elsevier Masson SAS.
... Locking-plate fixation via a minimally invasive approach has been proven effective for the treatment of periprosthetic femoral fractures [7,11,[21][22][23][24][25]. Periprosthetic screw fixation produces a highly secure construct but can damage the cement mantle [26]. In patients with interprosthetic fractures, the main objective is protection of the entire femur to avoid the creation of stress riser zones [18,20,27], thereby preventing the occurrence of secondary fractures, which can be life threatening in elderly patients [3][4][5]. ...
Article
Introduction Le verrouillage des clous permet le contrôle de la longueur et de la rotation mais expose aux rayonnements. Récemment un viseur externe adapté au Clou Gamma Long® (Stryker®) a été développé. L’objectif de cette étude de pratique observationnelle était d’évaluer sa fiabilité. Notre hypothèse était que l’utilisation du viseur est systématique et ce sans conversion et sans complication. Matériel et méthode Tous les Clous Gamma Longs® posés entre 11/2011 et 10/2012 ont été colligés soit 91 clous (59F/32H, âge moyen 73,5 ans) pour 68 fractures traumatiques, 14 enclouages préventifs et 9 fractures pathologiques. Quarante-cinq fois l’opérateur était junior et 46 fois il était senior. Le nombre d’utilisation de l’ancillaire, les difficultés et complications, le temps de scopie et la dose d’irradiation étaient notés. Des facteurs de risque étaient recherchés. Résultats Le viseur était utilisé 79 fois (11 fois il n’a pas été utilisé par choix de l’opérateur et 1 fois il était indisponible) Une fois une erreur de mesure est survenue, soit 78 enclouages exploitables. Trois fausses routes étaient observées. Aucun facteur de risque statistique n’était mis en évidence. Le temps du verrouillage correspondait à 18 % de l’ensemble de la procédure de l’enclouage et la dose à 7,44 % (ils étaient plus importants pour les clous titanes et les fractures pathologiques). La durée de scopie totale pour l’ensemble de l’intervention était plus importante pour les opérateurs juniors que pour les seniors mais la durée et la dose du verrouillage n’étaient pas différents. Discussion L’hypothèse formulée n’était pas vérifiée. L’utilisation n’était pas systématique et les complications non nulles. Aucun facteur péjoratif n’est apparu. Le verrouillage distal reste une étape délicate mais l’utilisation du viseur permet de limiter la dose d’irradiation. Cet ancillaire est efficace et son utilisation permet aux opérateurs juniors d’effectuer un verrouillage distal sans surcroît d’irradiation par rapport aux opérateurs seniors. Niveau de preuve IV, étude de cohorte, suivi prospectif observationnel.
... The possibility of a cement mantle failure during screw insertion has also been investigated. [53][54][55] The occlusion of the femoral canal (implant/cement mantle), prior reaming, cement exothermic reaction, and pressurization all have a negative impact on the intramedullary blood supply. 56 Further periosteal devascularization during the procedure contributes to further biologic compromise of the local environment. ...
Article
Full-text available
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;6:955-972. DOI: 10.1302/2058-5241.6.200050
... Locking-plate fixation via a minimally invasive approach has been proven effective for the treatment of periprosthetic femoral fractures [7,11,[21][22][23][24][25]. Periprosthetic screw fixation produces a highly secure construct but can damage the cement mantle [26]. In patients with interprosthetic fractures, the main objective is protection of the entire femur to avoid the creation of stress riser zones [18,20,27], thereby preventing the occurrence of secondary fractures, which can be life threatening in elderly patients [3][4][5]. ...
Article
Introduction: Interprosthetic femoral fractures are rare and raise unresolved treatment issues such as the length of the fixation material that best prevents secondary fractures. Awareness of the advantages of locked-plate fixation via a minimally invasive approach remains limited, despite the potential of this method for improving success rates. Hypothesis: Femur-spanning (from the trochanters to the condyles) locked-plate fixation via a minimally invasive approach provides high healing rates with no secondary fractures. Materials and methods: From January 2004 to May 2011, all eight patients seen for interprosthetic fractures were treated with minimally invasive locked-plate fixation. Mean time since hip arthroplasty was 47.5 months and mean time since knee arthroplasty was 72.6 months. There were 12 standard primary prostheses and four revision prostheses; 11 prostheses were cemented and a single prosthesis showed femoral loosening. Classification about the hip prostheses was Vancouver B in one patient and Vancouver C in seven patients; about the knee prosthesis, the fracture was SoFCOT B in three patients and SOFCOT C in five patients, and a single fracture was SoFCOT D. Minimally invasive locking-plate fixation was performed in all eight patients, with installation on a traction table in seven patients. Results: Healing was obtained in all eight patients, after a mean of 14 weeks (range, 12-16 weeks). One patient had malalignment with more than 5° of varus. There were no general or infectious complications. One patient died, 32 months after surgery. The mean Parker-Palmer mobility score decreased from 6.2 pre-operatively to 2.5 at last follow-up. Early construct failure after 3 weeks in one patient required surgical revision. There was no change in implant fixation at last follow-up. No secondary fractures were recorded. Discussion: In patients with type B or C interprosthetic fractures, femur-spanning fixation not only avoids complications related to altered bone stock and presence of prosthetic material, but also decreases the risk of secondary fractures by eliminating stress riser zones. The minimally invasive option enhances healing by preserving the fracture haematoma. Thus, healing was obtained consistently in our patients, with no secondary fractures, although the construct failed in one patient. Level of evidence: Level IV.
... Other studies demonstrated good results with the use of locking plates for reconstruction of Vancouver type B1 and C periprosthetic fractures. [22][23][24] The present study is not without limitations. Firstly, it was conducted in vitro. ...
Article
Full-text available
Objectives: To biomechanically compare the cable, trochanteric grip plate and locking plate in Vancouver type AG fracture model in an in-vitro test environment. Materials-Methods: Fifteen pieces of 4th generation synthetic femora were seperated to 3 groups 5 models in each. A greater trochanteric fracture model was created after femoral stem implantation. First group was fixated with only cable, second group was fixated with a trochanteric grip plate and third group was fixated with a locking plate. Samples were placed on a testing machine, horizontal stiffness, axial stiffness and failure loads were measured. Results: In horizontal compression tests, Group 3 had the highest values but the only statistically significant difference was between locking plate group and cable group. Axial distraction test results revealed that the mean stiffness of group 1 was 94.6 ± 9.44 N/mm, Group 2 was 174.8 ± 28.64 N/mm and Group 3 was 185.6 ± 71.64 N/mm. Locking plate versus cable fixation and grip plate fixation versus cable fixation showed statistically significant difference (p<0.05), however, comparison of locking plate versus grip plate fixation (p>0.05) showed no statistically significant difference In axial failure load test Group 3 had the highest results. The only significant difference was between locking plate and cable groups (p<0.05). Conclusion: Stable fixation of Vancouver type AG fractures are critical to not to face related complications and to obtain better functional results. For such cases grip plate fixation and locking plates provide better and safer fixation with the former promising more stable osteosynthesis. DOI: 10.3944/AOTT.2015.15.0298 This abstract belongs to the un-edited version of the article and is only for informative purposes. Published version may differ from the current version.
... Für die Versorgung von periprothetischen Frakturen bei festem zementiertem Schaft sollten die leicht überdimensionierten Bohrer und Bohrführungen benutzt werden, um die Gefahr von Rissen im Zementmantel beim Positionieren von bikortikalen Schrauben zu reduzieren. In einer biomechanischen Studie konnten Kampshoff et al. [19] . 1, 2). ...
Article
Full-text available
Periprosthetic fractures are increasing not only due to the demographic development with high life expectancy, the increase in osteoporosis and increased prosthesis implantation but also due to increased activity of the elderly population. The therapeutic algorithms are manifold but general valid rules for severe fractures are not available. The most commonly occurring periprosthetic fractures are proximal and distal femoral fractures but in the clinical routine fractures of the tibial head, ankle, shoulder, elbow and on the borders to other implants (peri-implant fractures) and complex interprosthetic fractures are being seen increasingly more. It is to be expected that in the mid-term further options, such as cement augmentation of cannulated polyaxial locking screws will extend the portfolio of implants for treatment of periprosthetic fractures. The aim of this review article is to present the new procedures for osteosynthesis of periprosthetic fractures.
... In Löcher schädigte den Mantel in keinem Fall, Insertion von Schrauben in bikortikaler Konfiguration, induzierten in dieser Untersuchung jedoch vermehrt Risse im Zementmantel[38]. In Kongruenz zu den vorliegenden Ergebnissen (63%) verband die Ausweichmöglichkeiten sollte in diesem Modell spürbar höher sein als ein Widerstand, den man bei der Platzierung der Schraube in vivo vorfinden würde. ...
Thesis
Steigende Fallzahlen in allen Bereichen der Endoprothetik gehen mit erhöhten Inzidenzen der periprothetischen Fraktur einher. So auch bei Hüft-Totalendoprothesen. Bei fehlenden Zeichen einer Lockerung der Prothese wird im Zuge der Versorgung der Erhalt des Implantats angestrebt. Die osteosynthetische Versorgung mittels Schrauben und Platten hat nach der Einführung der Winkelstabilität in der Unfallchirurgie zunehmende Akzeptanz gefunden. Die vorliegende Untersuchung beschäftigte sich darum mit der Fragestellung, welche Faktoren bei der osteosynthetischen Versorgung einer periprothetischen Femurfraktur Einfluss auf die Integrität des Zementmantels bei einliegender Hüft-Totalendoprothese haben. Dazu wurden Leichenfemora (n=20) mit zementierten Endoprothesen versorgt und pro Femur eine Osteosyntheseplatte mit je vier Schrauben (n=80) im Bereich der Prothese fixiert. Anschließend folgten je 20.000 zyklische Belastungen mit 2100 Newton und abschließend die makro- und mikroskopische Untersuchung auf Schäden an den vom Knochen befreiten Zementmänteln. Die Analyse zeigte, dass mit abnehmender Entfernung der Schraube zum Schaft die Wahrscheinlichkeit der Beschädigung des Zementmantels signifikant steigt (p= 0,019 Exakter Test nach Fischer). Typ (winkelstabile Schraube oder Kompressionsschraube) und Konfiguration (mono- oder bikortikal) der Schraube (p=0,52 – Exakter Test nach Fischer), Morphologie des Knochens (p=0,68 – Exakter Test nach Fischer) und Dicke des Zementmantels (p=0,36 – Exakter Test nach Fischer) stehen nicht in Zusammenhang mit Beschädigungen am Zementmantel. Die Ergebnisse weisen darauf hin, dass bei der Platzierung von Osteosyntheseschrauben eine Güterabwägung zwischen mechanischer Stabilität (Versorgung der Fraktur) und größtmöglichem Abstand der Schrauben zum Metallschaft des Implantates (Erhalt der Prothese) erfolgen muss. Die Verwendung von Schrauben in bikortikaler Konfiguration erhöht das Risiko einer Beschädigung des Zementmantels nicht.
... Another reason for the improved outcomes in the present study might be the smaller drill diameter (4.3 mm), which maintained the pull-out resistance. This is in line with the results of Kampshoff et al. [25], who conducted a biomechanical study of PPF utilizing various locking screws and reported that the greater was the drill diameter, the lower was its pull-out resistance. ...
Article
Full-text available
To promote rapid bone healing, an adequate stable fixation implant with a percutaneous reduction instrument should be used for Vancouver type B1 or C fractures. The objective of this study was to describe radiographic and clinical outcomes of patients with periprosthetic fracture (PPF) around a stable femoral stem, treated with a distal femoral locking plate alone or with a cerclage cable. A total of 21 patients with PPF amenable to either a reverse distal femoral locking plate (LCP DF®) alone or with a cerclage cable, with a mean age of 75.7 years, were included. In these patients, ten fractures were treated with a reverse LCP DF® alone and were classified as group I, and 11 additionally received a cerclage cable and were classified as group II. Group II had a significantly longer operation time (P = 0.019) than group I and included one patient with nonunion at the final 24-month follow-up visit after the initial fracture reduction. However, this difference in nonunion rate for the two groups is more likely to inappropriate indications than surgical techniques. When comparing the stability of the fractures in both groups, there was no statistically significant difference, which might be attributed to the stable fixed-angle implant.
... Lever et al. utilized 12 pairs of human cadaveric femurs for 3 different plate fixation systems and concluded that screw plate fixation systems provided more mechanical stability compared to cable plate systems (23). Kampshoff et al. assessed the cement mantle integrity after screw insertion and concluded that bicortical screws passing through the cement cause cracks and further can destabilize the stem (24). The authors noted that the use of a unicortical screw is a much safer option with lower pullout resistance. ...
Article
he goal of our preliminary report is to investigate hip stem stability and intra-operative cement mantle integrity after screw insertion in plate fixation of periprosthetic Vancouver B1 femur fractures. From a cohort of 50 patients with a periprosthetic femur fracture treated in our department from February 2012 until February 2017, we included in our study patients with a periprostethic Vancouver B1 femoral fracture in cemented hip arthroplasty and hemiarthroplasty, operated with ORIF using a 4.5/5.0 LCP Proximal Femoral Hook Plate ® (Synthes, Switzerland) with at least one screw perforating the cement mantle. Anteroposterior and lateral femur views and pelvis X-rays were performed preoperatively. The stability of the hip implant and the cemented mantle integrity was evaluated intra-operatively in a macroscopic way and with a post-operative X-ray in anteroposterior and lateral views. Only 7 patients satisfied the inclusion criteria; no lesion/break of the cement mantle occurred intra-operatively at any step during drilling or screw insertion, also confirmed with C-arm assessment. No cases of stem mobilization were found and cement mantle integrity was maintained in every case. Insertion of screws around a cemented stem for plate fixation in periprosthetic femur fractures Vancouver type B1 could be considered a safe procedure. However, further and more extended studies are necessary for proving additional knowledge at the evaluation of the cement mantle in osteosynthesis procedures.
... Bicortical screws were associated with a risk of local cement mantle damage but also with significantly greater holding capacity. 18 If proximal screw fixation is prohibited by the hip stem or cannot provide adequate fixation because of poor bone quality, the addition of cerclage cable around the plate allows for proximal fixation, stability, and fracture control. The theoretical advantage of spanning the entire interprosthetic zone with a plate construct effectively eliminates any remaining stress riser zone in the femur. ...
Article
The treatment of interprosthetic femoral fractures is challenging because of several factors. Poor bone stock, advanced age, potential prosthetic instability, and limited fracture fixation options both proximally and distally can complicate standard femur fracture treatment procedures. The purpose of this report was to describe our experience treating interprosthetic femoral fractures, providing an emphasis on treatment principles and specific intraoperative management. All patients with fractures occurring between ipsilateral hip and knee prostheses between 2004 and 2010 were identified from a comprehensive database and included in this study. Patients had been treated using principles adapted from two isolated periprosthetic fracture classification systems, the Vancouver and Su classifications. The electronic medical record (including inpatient medical records, operative notes, outpatient medical records, and all radiographs) was reviewed for each patient and demographic and treatment-related variables as well as complications and outcomes were recorded. Thirteen consecutive patients with interprosthetic fractures were included. Four fractures occurred around a clearly loose prosthesis, which were subsequently treated with long-stemmed revisions. The remaining 12 fractures were treated with a locked-plate construct. Two of nine patients (22.2%) died before fracture union. Follow-up averaged 28 months ± 4 months, with fracture union achieved at an average of 4.7 months ± 0.3 months. All patients returned to their self-reported preoperative ambulatory status except one who developed a loose hip prosthesis at 3-year follow-up after fracture union. The principles for treatment of isolated periprosthetic fractures are useful to guide the fixation of interprosthetic fractures. Locked plating is an effective method for the treatment of interprosthetic femoral fractures. Bypassing the adjacent prosthesis by a minimum of two femoral diameters is a necessary technique to prevent a stress riser.
... Für die Versorgung von periprothetischen Frakturen bei festem zementiertem Schaft sollten die leicht überdimensionierten Bohrer und Bohrführungen benutzt werden, um die Gefahr von Rissen im Zementmantel beim Positionieren von bikortikalen Schrauben zu reduzieren. In einer biomechanischen Studie konnten Kampshoff et al. [19] . 1, 2). ...
Chapter
Die Prävalenz dieser Frakturen ist steigend, und sie sind daher bereits der dritthäufigste Grund für die Revision einer Hüftprothese. Periprothetische Frakturen werden in peri- und postoperative Frakturen unterteilt. Unzementierte Schäfte sind mit einem großen Risiko für eine periprothetische Fraktur verbunden. Daten aus der Mayo-Klinik zeigen ein Risiko für eine intraoperative Fraktur von 0,3 % für zementierte Schäfte und von 5,4 % für unzementierte Schäfte. Das Risiko einer postoperativen Fraktur für zementierte und unzementierte Schäfte wird mit 1,1 % angegeben. Das Risiko einer intraoperativen Fraktur steigt bei einer Wechseloperation auf 3,6 % für zementierte und 20,9 % für unzementierte Schäfte (Berry 1999). Das Gesamtrisiko für eine periprothetische Fraktur beträgt nach den Daten der Mayo-Klinik 4,1 %. Daten aus dem schwedischen Prothesenregister zeigen für das Gesamtkollektiv ein 10-Jahres- Risko von 0,64 % (Lindahl 2007). Die Einjahresmortalität des Gesamtkollektivs beträgt 13,1 % (Lindahl et al. 2006a).
Article
Demographic changes and rising numbers of implanted prostheses accompanied by increasing demands on mobility and activities of the elderly will lead to an increasing number of periprosthetic fractures in the future. Poor bone quality, geriatric comorbidities and multiple prostheses result in an increased risk for this type of fracture in the old patient. Management of these patients is challenging and demanding and needs an interdisciplinary approach. The present work describes the different aspects of periprosthetic fractures in the geriatric patient with regard to epidemiology, risk factors, prevention and treatment options.
Article
Trochanteric osteotomies (TO) facilitate exposure and "true hip reconstruction" in complex primary and revision total hip arthroplasty (THA). However, non-union represents a clinically relevant complication. The purpose of the present study was to identify risk factors for trochanteric non-union. All cases of THA approached by TO during the past 10 years were analyzed with respect to potential risk factors for non-union. In 298 cases complete data were available for analysis. Trochanteric union occurred in 80.5%, fibrous union in 5.4% and non-union 14.1%. Risk factor analysis revealed a four times higher risk for non-union in anterior trochanteric slide osteotomies compared to extended trochanteric osteotomies and a three times higher risk in cemented versus non-cemented stems. Multiple logistic regression analysis revealed patient's age and use of cement to be independent risk factors for non-union. Femoral cementation and increasing age negatively influence the union of trochanteric osteotomies.
Article
Résumé Introduction La fracture périprothétique du fémur (FPF) est une complication sérieuse des arthroplasties de hanche pour laquelle différents matériels d’ostéosynthèse sont proposés. Toutefois, aucune étude n’a rapporté les résultats obtenus avec une plaque anatomique non verrouillée avec des trous excentrés. Les objectifs de ce travail étaient de présenter sur une population de FPF du groupe B selon Vancouver : (1) le taux de consolidation des FPF traitées par cet implant, (2) le taux de complications et (3) les résultats en termes d’autonomie. Hypothèse L’utilisation de cette plaque permet d’obtenir un taux élevé de consolidation avec un minimum de complications mécaniques. Matériels et méthodes Quarante-trois patients, d’âge moyen 79 ans ± 13 (41–98), qui ont été traités pour une ostéosynthèse d’une FPF de type B selon Vancouver avec cette plaque entre 2002 et 2007 ont été inclus. Le délai de consolidation et le score de Parker ont été évalués. La survie sans révision (toutes causes confondues) a été calculée par la méthode de Kaplan-Meier. Le recul moyen était de 42 mois ± 20 (16–90). Résultats La consolidation a été obtenue chez tous les patients avec un délai moyen de 2,4 mois ± 0,6 (2–4). Nous déplorons 1 patient avec un cal vicieux en varus. Le score de Parker a diminué de 5,93 ± 1,94 (2–9) à 4,93 ± 1,8 (1–9) (p = 0,01). Deux révisions chirurgicales ont été nécessaires sur la série (une infection survenue à 4,5 ans et un descellement fémoral). Le taux de survie à 5 ans des prothèses après ostéosynthèse était de 83,3 ± 12,6 %. Conclusion Cette plaque anatomique avec trous excentrés permet le traitement des FPF du type B et garantit une consolidation de la fracture avec un faible taux de complications liées à l’ostéosynthèse. Toutefois, les FPF représentent une complication sérieuse des arthroplasties de hanche assortie d’un fort taux de morbidités et de mortalité. Niveau de preuve Étude rétrospective thérapeutique niveau IV.
Article
There is an increasing number of patients who have undergone stemmed total knee arthroplasty and total hip arthroplasty in the same leg. These patients may be at increased risk of periprosthetic and interprostethic fracture. Etiology and the potential therapy strategies are not well represented in the current literature. Determination of the risk factors for interprosthetic fractures and possible prevention. We performed a review of the literature and additionally a survey among experts (members of the German Association for Arthroplasty [AE]) to investigate the risk and the necessity for a preventive internal fixation. There are only a few biomechanical studies. The interprosthetic distance seems to have little influence on the fracture risk, but the thickness of the cortex and the cortical area at the diaphysis seems to be important. The value of a bridging osteosynthesis remains uncertain. Ninety experts took part in the survey. The risk of fracture risk was estimated to be only slight to medium. Opinions regarding the necessity of preventive internal fixation were heterogeneous. The indication for preventive internal fixation could be derived neither from the literature nor from the survey of experts. The thickness of the cortex and co-morbidities (osteoporosis, tendency to fall, and medication) seem to be more important than the interprosthetic distance.
Article
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. 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. 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. 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.
Article
The aim of this study was to biomechanically evaluate the Locking attachment plate (LAP) construct in comparison to a Cable plate construct, for the fixation of periprosthetic femoral fractures after cemented total hip arthroplasty. Each construct incorporated a locking compression plate with bi-cortical locking screws for distal fixation. In the Cable construct, 2 cables and 2 uni-cortical locking screws were used for proximal fixation. In the LAP construct, the cables were replaced by a LAP with 4 bi-cortical locking screws. The LAP construct was significantly stiffer than the cable construct under axial load with a bone gap (P=0.01). The LAP construct offers better axial stiffness compared to the cable construct in the fixation of comminuted Vancouver B1 proximal femoral fractures. Copyright © 2015. Published by Elsevier Inc.
Article
Periprosthetic fractures of the femur are increasing due to the increase of arthroplasties and the aging population. They concern a population that is often elderly and with important comorbidities that complicate managing this already complex pathology. Usual complications of classic osteosynthesis are numerous, including infections and nonunions and the need for delayed weight bearing after surgery. The development of locking plates has allowed complication avoidance. When used in minimally invasive surgery, they combine the biological advantages of closed-wound surgery to the mechanical advantages of locking plates, which have better stability in fragile bones. We propose a technical update on handling such fractures by using locking plates under minimally invasive surgery. In our experience, under certain guidelines, this allows for immediate post-operative full weight bearing, which is beneficial to these often elderly patients.
Article
Die Inzidenz periprothetischer Frakturen am proximalen Femur bei liegender Huftgelenksprothese nimmt aufgrund der demografischen Entwicklung und der damit verbundenen hoheren Lebenserwartung, der steigenden Zahl der implantierten Prothesen sowie des vermehrten Auftretens von Osteoporose und des hoheren Aktivitatsniveaus der alteren Bevolkerung zu. Neben der Lokalisation der Fraktur und der Stabilitat der Prothese sind insbesondere auch patientenspezifische individuelle Faktoren fur die Planung des therapeutischen Vorgehens zu berucksichtigen. Fur diese Frakturform hat sich in den letzten Jahren die Vancouver-Klassifikation nach Duncan und Masri im klinischen Alltag durchgesetzt. Sie berucksichtigt neben der Lokalisation der Fraktur und der Stabilitat der Prothese auch die Knochenqualitat und liefert so Hinweise fur die Auswahl des richtigen Behandlungsverfahrens. Die Therapie der proximalen periprothetischen Femurfraktur ist sehr differenziert und reicht von der konservativen Therapie uber die operative Stabilisierung bis hin zum totalen endoprothetischen Femurersatz, und sollte unter optimaler Vorbereitung und besten Operationsbedingungen an spezialisierten Zentren erfolgen. Neue interdisziplinare multimodale Therapieansatze konnen helfen, der zu erwartenden weltweiten Zunahme der periprothetischen Frakturen zu begegnen.
Article
Osteosynthesis of periprosthetic femur fractures by screw fixation around the implanted prosthetic stem is currently regarded as the biomechanically superior option compared with cerclage. The aim of this biomechanical study was damage analysis of the cement mantle after revision screw insertion. A prosthetic stem (Bicontact) was implanted in 20 cadaveric femora in cemented technique. A locking compression plate (Synthes) was then applied to the lateral femur at the level of the prosthetic stem. The method of plate fixation to the femur was assigned randomly to three groups: bicortical non-locking screws, monocortical locking screws, and bicortical locking screws. This was followed by applying a fluctuating axial load (2100 N, 0.5 Hz) for 20,000 cycles. After testing, macroscopic and microscopic evaluations of the cement mantle were conducted. Cracks formed in the cement mantle in 14% of the 80 screw holes. The type of screw (bicortical or monocortical; locking or non-locking) had no significant effect on the number of cracks (p = 0.52). The relationship between manifestation of crack damage and cement mantle thickness was not significant (p = 0.36), whereas the relationship between crack formation and screw position was significant (p = 0.019). Those screws whose circumference was only partially within the cement mantle yielded a significantly lower number of cracks compared with screws positioned completely within the cement mantle or even touching the prosthetic stem. In order to reduce the incidence of crack formation in the cement mantle during plate osteosynthesis of periprosthetic femur fractures, the screws should not be either placed within the cement mantle or make direct contact with the stem.
Article
With the increasing number of total knee arthroplasties (TKAs) being performed, the incidence of periprosthetic fractures adjacent to a TKA is rising. Minimally invasive plate osteosynthesis (MIPO) has proven to be successful for the biological fixation of many fractures. Advances in surgical instrumentation and techniques made MIPO possible for more complex fractures. Periprosthetic fractures are always complicated by problems of soft tissue incisions, scarring, and, of course, the arthroplasty components. MIPO techniques may be particularly suited to these injuries and may make the surgical repair of these fractures safer and more reliable. In this review, case examples are used to define the indications, preoperative planning, implant selection, complications, limitations, and challenges of MIPO for the treatment of periprosthetic fractures about the knee. When considering MIPO for any fracture, we recommend prioritizing an acceptable reduction with biological fixation and resorting to mini-open or open approach when necessary to achieve it. Awareness of the learning curve of the surgical technique, advances in implant designs, the tips and tricks involved, and the limitations of the MIPO is of paramount importance from the orthopaedic surgeon's perspective.
Article
Periprosthetic fractures (PPFx) are becoming an increasingly important topic in orthopedics and trauma surgery due to the rising number of endoprosthetic joint replacements. The recently published unified classification system (UCS) has replaced numerous historical classification systems and can be applied to all PPFx regardless of the bone or joint involved. The treatment of PPFx requires individual therapeutic concepts taking patient-dependent and patient-independent factors into consideration. The conservative treatment of PPFx is only justified in exceptional situations. In contrast, the choice between operative treatment and deciding between osteosynthesis or revision arthroplasty is particularly based on the assessment of the implant stability. In order to achieve fracture consolidation and also a good functional outcome, knowledge of the basic biomechanical principles of operative (osteosynthesis or endoprosthesis) treatment of periprosthetic fractures is necessary.
Article
Background Periprosthetic femur fractures (PPFF) distal to a femoral stem are traditionally treated with open reduction and internal fixation (ORIF) with plate and screws. To our knowledge, no studies exist comparing outcomes following ORIF vs retrograde intramedullary nails (RIMN) for this injury.Methods This is a retrospective comparison of PPFFs distal to a femoral stem treated by ORIF (n = 17) vs RIMN (n = 13). The primary outcome was unplanned re-operation.ResultsThere was no difference in unplanned re-operation (17.6 vs 23.1%, p > 0.99), infection, nonunion, refracture, and alignment between groups. The RIMN group had shorter surgical time (89 vs 157 min, p < 0.01), less blood loss (137 vs 291 ml, p = 0.03), and greater obesity.ConclusionRIMN is a potential option for operative fixation of PPFF distal to a femoral stem worthy of additional study.
Article
Demographic changes and rising numbers of implanted prostheses accompanied by increasing demands on mobility and activities of the elderly will lead to an increasing number of periprosthetic fractures in the future. Poor bone quality, geriatric comorbidities and multiple prostheses result in an increased risk for this type of fracture in the old patient. Management of these patients is challenging and demanding and needs an interdisciplinary approach. The present work describes the different aspects of periprosthetic fractures in the geriatric patient with regard to epidemiology, risk factors, prevention and treatment options.
Article
Full-text available
The goal of total hip replacement is to provide a pain-frce, iiwll-fixcd, stable, long-lasting nrflioplasty. Len^fli of hospital stay, recoveij fiiue, and incision lengtli an' iniportanf factors related to the success oftliepiva'dnrc. As tin' procedure has erolreci, the iw of liniilcd incision snr^ciy IKIS givu'n. A uniform classification system for less iinvsiw approaches to total hip replacement will nlloip similar approaches to be grouped together and lic'lp snrceons to srlccf tin' best approacli. Instr Course Lect 2006;55:195-197. The goal of total hip replncemcnt is to provide tlic patient with a pain-free, well-fixcd, stable, ni-throplasty that will last fur many years. Ideally, tliis procedure should be associated with the shortest possible recovery time and should expose the patient to the lowest possible risk. When tot ;il liip replacement was first intro-ducfd, the emphasis was on using a wide expo.surc to ensure neurovas-culnr protection and precise implant placement to achieve maximum implant longevity. Length of liospital stay, recovery time, and incision length were not important factors. Minimally invasive surgery has been introduced in many surgical fields and has revolutionized the surgical management of many conditions. The use of minimally invasive surgery has often resulted in faster recovery times, lower postoperative morbidity rates, and reduced costs.
Article
Full-text available
This study evaluated 5 currently used periprosthetic femoral shaft fracture fixation techniques to determine which technique provided the greatest fixation stability. Periprosthetic fractures in 30 synthetic femurs were fixed with a plate with cables, plate with proximal cables and distal bicortical screws (Ogden concept), plate with proximal unicortical screws and distal bicortical screws, plate with proximal unicortical screws and cables and distal bicortical screws, or 2 allograft cortical strut grafts with cables. These specimens were then tested in 3 physiologic loading modes. The plate constructs with proximal unicortical screws and distal bicortical screws or with proximal unicortical screws, proximal cables, and distal bicortical screws were significantly more stable in axial compression, lateral bending, and torsional loading than the other fixation constructs studied.
Article
Total hip replacement is sometimes associated with a fracture of the ipsilateral femur8, 9, 11, 12, 15, 18, 19, 23, 24 and 26 and rarely a fracture of the acetabulum.1, 5, 16, 19, 22 and 26 Although uncommon, they present a major challenge to the orthopedic surgeon. They can occur either during or after total hip replacement.15, 17 and 27 The lifetime hip as yet does not exist, and with hip arthroplasty routinely being performed in ever-younger patient populations, this ideal arthroplasty seems even further away.9 As expected patient longevity and the number of primary and revision arthroplasty procedures continue to increase, so too does the incidence of periprosthetic fracture. The management of these fractures is usually difficult, often complex, and always expensive. Technologic advances as well as the prohibitive cost of prolonged immobilization make surgical intervention the preferred option in most cases. The patient can receive appropriate treatment only if the surgeon has appropriate training, adequate resources, and an in-depth knowledge of the outcomes of surgical intervention. Consequently, it is mandatory that a clear plan of action exist before embarking on the surgical treatment of such a case because an inappropriate decision may prove costly not only from the point of view of exhausting valuable hospital resources but also in terms of patient morbidity. In fact, an inappropriate surgical decision may result in an unsalvageable situation in which further reconstruction may no longer be a consideration. Classification systems are widely used in all branches of orthopedics because they have the potential to guide treatment and enable comparison of results after different interventions for the same pathology in different centers. Ultimately, this classification should allow one to choose the most appropriate reconstructive procedure for each specific case scenario. If a classification is to be useful and germane to clinical practice, it should also be reliable and valid. Reliability refers to the consistency between users of the classification system, whether between the same user on different occasions (intraobserver reliability) or different users on the same occasion (interobserver reliability). Validity is the degree to which the abnormality as described in the classification system actually represents the true abnormality. The incidence of acetabular periprosthetic fractures has increased since the introduction of cementless press-fit acetabular components.1, 5 and 26 Despite this, there are still only a few reports in the orthopedic literature to date.16, 19 and 22 These fractures are associated with a poor outcome for the acetabular component of a total hip arthroplasty.21 Peterson and Lewallen21 have simply classified these fractures into two types. Type 1 indicates that the acetabular component is both clinically and radiologically stable. In type 2, the acetabular component is unstable. Because the acetabular periprosthetic fracture is so rarely encountered, the rest of this article discusses periprosthetic fractures of the femur.
Article
Between 1984 and 1986, 10 patients who sustained a femur fracture about a hip prosthesis were treated with open reduction and internal fixation using compression plating. Nine of the 10 fractures healed in an average time of 5 months. Other than one nonunion, no significant complications were noted. Follow-up study, ranging from 13 to 44 months (average, 26 months), was obtained on all 10 patients. One had a loose femoral component, which was attributed to inadequate stem size. None of the other patients had either clinical or radiographic evidence of loosening. Based on Harris hip scores, there was no indication that plating significantly interfered with hip function. The authors believe that these results demonstrate that plating can be an effective method of treating femoral fractures about hip prostheses.
Article
We have reviewed the results of treating 75 fractures of the proximal femoral shaft in the presence of a cemented femoral prosthesis. A simple radiographic classification into four types is proposed, and suggestions are made on the appropriate management of each. Comminuted fractures around the implant need early revision, whilst spiral fractures in this region may be treated conservatively or by operation. Transverse fractures at the level of the tip of the prosthesis are difficult to manage, and may require open reduction and internal fixation.
Article
Thirty-one postoperative fractures around the femoral component of previous total hip arthroplasties were reviewed retrospectively until healing occurred. This type of injury seemed to be associated with either high-velocity trauma or weakening of bony stock secondary to stress risers from prior surgery or loosening. These fractures were classified as Type A at the stem tip, Type B spiralling around the stem, and Type C comminuted around the stem. Type A fractures have a significant incidence of nonunion in the face of multiple previous proximal femoral surgeries, but, after healing, usually show no loosening. Type B fractures usually will heal without operative intervention but have a high incidence of associated eventual component loosening. Type C fractures need immediate surgery to allow mobilization of the elderly patient. When postfracture revision surgery with long-stem component or plating is required, the technical order of priority should be adequate bony apposition of fracture fragments, good cement technique at the proximal femur, bone grafting.
Article
Six techniques for the surgical management of fractures of the femur about the tip of the stem of a total hip arthroplasty were evaluated. Seven embalmed human femurs were prepared to receive the correct-size femoral component of a total hip system. A transverse osteotomy was performed at the level of the tip of the stem. Stability and strength of each reconstruction were tested on each femur under semidynamic loading conditions. This study showed that cementless revision to a long-stem prosthesis does not provide adequate stability. The highest strength and stability were achieved by supplementing the long-stem conversion with allograft struts and cable cerclage. Good results were obtained by lateral compression plating with unicortical screws proximally. Failure was due to pull-out of the proximal screws.
Article
A number of classification systems have been proposed for periprosthetic fractures of the femur following total hip replacement. Most of these rely purely on the site and pattern of the fracture. However, it is only after consideration of other important factors, including the stability of the prosthesis as well as the quality of the surrounding bone stock, that appropriate management can be instituted. The authors have developed a new classification system that addresses these other important factors. The authors believe that only after classifying a periprosthetic fracture with specific reference to fracture site, stability of the implant, and quality of the surrounding bone stock, can one make a rational decision towards a treatment algorithm.
Article
This article reviews the epidemiologic features of periprosthetic fractures around total hip arthroplasty and total knee arthroplasty according to the site of fracture occurrence. The frequency and cause of intraoperative and postoperative periprosthetic fractures vary by anatomic site. For each anatomic site, unique risk factors, some demographic and some technical, appear to be related to risk of fracture. For several anatomic sites, excellent articles that collate large numbers of series are available to the reader to provide aggregate information concerning the epidemiology of these fractures.
Article
This study assessed the reliability and validity of a new classification system for fractures of the femur after hip arthroplasty. Forty radiographs were evaluated by 6 observers, 3 experts and 3 nonexperts. Each observer read the radiographs on 2 separate occasions and classified each case as to its type (A, B, C) and subtype (B1, B2, B3). Reliability was assessed by looking at the intraobserver and interobserver agreement using the kappa statistic. Validity was assessed within the B group by looking at the agreement between the radiographic classification and the intraoperative findings. Our findings suggest that this classification system is reliable and valid. Intraobserver agreement was consistent across observers, ranging from 0.73 to 0.83. There was a negligible difference between experts and nonexperts. Interobserver agreement was 0.61 for the first reading and 0.64 for the second reading by kappa analysis, indicating substantial agreement between observers. Validity analysis revealed an observed agreement kappa value of 0.78, indicating substantial agreement. This study has shown that this classification is reliable and valid.
Article
To determine the effect of the number and length of cutting flutes on the insertion torque and pullout strength for self-tapping 4.5-millimeter cortical bone screws. Screws were self-tapped in the diaphysis of human cadaver femurs. Each of the six screw types studied had different designs with varying cutting flute lengths and numbers. Bone mineral density, insertion torque, and pullout strength were measured. The study was conducted at an experimental biomechanics laboratory associated with a university medical center. Insertion torque and pullout strength were normalized by the local bone mineral density. The mean normalized insertion torque of the design with four full-length cutting flutes was less than the design with three full-length flutes and the two designs with one-third length flutes (p < 0.05). The mean normalized pullout strength of the screw with four full-length flutes was significantly greater than that of all screws with fewer than three flutes (p < 0.05). Priorities for a cutting flute design should ideally include ease of screw insertion, minimal soft tissue irritation, and maximal screw holding power. Screws with more than two flutes were easier to insert and did not cause cortical damage during insertion. The screw with four full-length flutes showed a trend toward being the easiest to insert and having the greatest holding strength.
Article
The management of nonunion of femoral fractures around a total hip prosthesis is difficult. It is associated with a high risk of complications and a relatively poor outcome. Prevention of the nonunion by appropriate treatment of the initial fracture is mandatory. Most peritrochanteric periprosthetic fractures can be treated conservatively. Markedly displaced fractures and those associated with osteolysis require surgery. This usually involves removing the cause of the osteolysis followed by appropriate bone grafting and cerclage fixation. The excellent results of the treatment of type-B1 fractures reported by Haddad et al from a multicentre review are encouraging. Of interest, however, are two studies which compared various different configurations of fixation of periprosthetic fractures biomechanically. Dennis et al showed that a plate, proximal cables and distal bicortical screws gave a stronger and more rigid fixation than that provided by two cortical allograft struts fixed by cables. In a similar model with a transverse fracture, Schmotzer, Tchejeyan and Dall demonstrated that allograft struts fixed by wires did not provide adequate strength and stability. However, the use of cerclage cables and crimpsleeves increased the interfragmentary compression and thus the frictional resistance between graft and bone, which resulted in a marked improvement of the strength and stability of the fixation. Strut grafts should not make contact with each other since tensioning of any cerclage device will result in compression of one strut against the other rather than that of the strut against host bone. Cortical strut grafts are invaded by osteoclast cutting cones and subsequent revascularisation renders the graft at its weakest at four to six months. It would therefore seem logical to combine a plate, with distal bicortical screw fixation and proximal unicortical screw fixation supplemented by cables, with an onlay cortical strut allograft fixed by cables. This provides the biological benefit of a strut allograft with enhanced fixation which is not potentially compromised during revascularisation and remodelling of the graft. It is appropriate to apply the plate and strut graft at right angles to each other, usually anterior and lateral, in order to resist the forces in both planes. Type-132 fractures should be treated by revision to a long stem with adequate distal fixation and supplemental proximal grafting as required. In type-B3 fractures the osteogenic potential of vascularised fragments of the proximal femur should be carefully preserved in order to augment whatever major proximal femoral reconstruction is carried out. Figures 7 and 8 give management algorithms for type-A and type-B fractures. Type-C fractures should be treated in the same manner as any other fracture in the distal femur. Periprosthetic fractures are difficult to treat. The vascularity of the involved limb has often been compromised by previous surgery. autograft or allograft should be freely used. The radiographs will often underestimate the extent of bone loss. The surgeon should be prepared to consider and to cater for all alternatives in reconstruction since the definitive treatment often depends on the findings at operation.
Article
This article reports a prospective series of periprosthetic femur fractures in 33 patients treated with a modernized fracture treatment protocol. Some form of operative treatment was selected prospectively based on the categorization of the fracture by the Duncan-Vancouver and Beals-Tower Oregon classification systems. Fractures in which the prosthesis-bone interface was stable were treated with open reduction and internal fixation of the fracture around the stable implant. Unstable prosthesis-bone interfaces required removal of the primary prosthesis and revision to an uncemented long-stem prosthesis after stabilization of the femoral fracture with plates or allograft struts. Complications were minimal over an average follow-up period of 28.3 months; restoration of function was predictable.
Article
Periprosthetic fractures can be discussed in many formats. In this article, epidemiology, classification, and treatment are divided into the following three categories of periprosthetic fracture: intraoperative fractures detected at the time of surgery; intraoperative fractures undetected at the time of surgery, but detected postoperatively; and postoperative fractures occurring late after the arthroplasty procedure.
Article
Postoperative femoral periprosthetic fracture is an uncommon complication of total hip arthroplasty surgery, but several centers worldwide have recently reported an increase in total numbers of such fractures. This severe complication is costly for society and results in high morbidity. Our analysis of 1049 periprosthetic fractures occurring in Sweden between 1979 and 2000 and recorded in the Swedish National Hip Arthroplasty Register focuses on patient- and implant-related factors, fracture classification, and fracture frequency. These were our 3 major findings: (1) a majority of the patients who sustained a late periprosthetic femoral fracture had a loose stem. (2) Implant-related factors are significantly associated with occurrence of a periprosthetic fracture. (3) Since the 1980s in Sweden, treatment results for periprosthetic fractures have been poor, with low long-term survivorship and a high frequency of complications. We have initiated further studies of this important problem.
Article
Periprosthetic fracture of the femur is an uncommon complication after total hip replacement, but appears to be increasing. We undertook a nationwide observational study to determine the risk factors for failure after treatment of these fractures, examining patient- and implant-related factors, the classification of the fractures and the outcome. Between 1979 and 2000, 1049 periprosthetic fractures of the femur were reported to the Swedish National Hip Arthroplasty Register. Of these, 245 had a further operation after failure of their initial management. Data were collected from the Register and hospital records. The material was analysed by the use of Poisson regression models. It was found that the risk of failure of treatment was reduced for Vancouver type B2 injuries (p = 0.0053) if revision of the implant was undertaken (p = 0.0033) or revision and open reduction and internal fixation (p = 0.0039) were performed. Fractures classified as Vancouver type B1 had a significantly higher risk of failure (p = 0.0001). The strongest negative factor was the use of a single plate for fixation (p = 0.001). The most common reasons for failure in this group were loosening of the femoral prosthesis, nonunion and re-fracture. It is probable that many fractures classified as Vancouver type B1 (n = 304), were in reality type B2 fractures with a loose stem which were not recognised. Plate fixation was inadequate in these cases. The difficulty in separating type B1 from type B2 fractures suggests that the prosthesis should be considered as loose until proven otherwise.
Article
To determine which of 2 techniques for the treatment of periprosthetic femoral shaft fractures is of greater stiffness. A laboratory study using 8 pairs of matched, embalmed femurs. Femurs implanted with a cemented total hip prosthesis had a simulated periprosthetic femur fracture created distal to the implant. Fractures were fixed with a plate with locked screws or a plate with cables (Ogden construct). Fixation stability was compared in various loading modalities before and after cycling. Failure in torsional loading was then determined. The cement mantle was tested for crack propagation that may have occurred secondary to locked screw insertion and loading. Fixation stiffness (the ratio of applied load to displacement at the fracture site), torsional strength, mode of failure for each system, and cement mantle evaluation for cracks after screw insertion. Locked plating was stiffer than the Ogden construct in pre- and post-cyclic axial loading and torsion. There was no difference in lateral bending stability or torsional failure loads. Locked plating constructs were stiffer than the Ogden construct in axial loading and torsion. Although no differences in loads to failure during torsion were noted, locked plating constructs exhibited catastrophic failure not observed with the Ogden construct.
Article
The purpose of this study was to determine the demographics, incidence, and results of treatment of periprosthetic fractures in a nationwide observational study. In the years 1999 and 2000, 321 periprosthetic fractures were reported to the Swedish National Hip Arthroplasty Register. All of the associated hospital records were collected. At the time of follow-up, the Harris hip score, a health-related quality-of-life measure (the EuroQol-5D [EQ-5D] index), and patient satisfaction were used as outcome measurements. A radiologist performed the radiographic evaluation. Ninety-one patients, with a mean age of 73.8 years, sustained a fracture after one or several revision procedures, and 230 patients, with a mean age of 77.9 years, sustained a fracture after a primary total hip replacement. Minor trauma, including a fall to the floor, and a spontaneous fracture were the main etiologies for the injuries. A high number of patients had a loose stem at the time of the fracture (66% in the primary replacement group and 51% in the revision group). Eighty-eight percent of the fractures were classified as Vancouver type B; however, there was difficulty with preoperative categorization of the fractures radiographically. There was a high failure rate resulting in a low short to mid-term prosthetic survival rate. The sixty-six-month survival rate for the entire fracture group, with reoperation as the end point, was 74.8% +/- 5.0%. One factor associated with fracture risk was implant design. On the basis of these findings, we believe that high-risk patients should have routine radiographic follow-up. Such a routine could identify a loose implant and make intervention possible before a fracture occurred. Furthermore, we recommend an exploration of the joint to test the stability of the implant in patients with a Vancouver type-B fracture in which the stability of the stem is uncertain.
Article
Periprosthetic femoral fractures (PFF) are increasing as a result of changes in population demographics and the increase in the number of total hip replacements performed. The overall incidence has been reported to range from 0.1% to 6% of all total hip arthroplasties. Management of these fractures is often particularly demanding, complex and expensive. In many cases, the surgeon has to solve the simultaneous problems of implant loosening, bone loss and fracture. A thorough understanding of the unique characteristics of the different fracture types, the principles of PFF treatment and a familiarity with the various fixation devices, grafts and prosthetic implants are all of paramount importance. Internal fixation is used either alone or as an adjunct to stem revision. The stability of the original implant and the configuration of the fracture itself are the basic factors that influence the decision-making process. The current study reviews the existing literature on internal fixation of femoral periprosthetic fractures.
Article
The management of periprosthetic fracture following a total hip arthroplasty is difficult, requiring expertise in both trauma and revision surgery. With rising numbers of patients in the population living with hip prostheses in situ, the frequency of these fractures is increasing, and controversy remains over their ideal management. The objective of this study was to review all periprosthetic fractures at a single institution to identify injury and treatment patterns and their associated clinical outcomes. Fifty-four periprosthetic fractures in 50 patients were reviewed to determine the relative frequency of fracture types, their complication rates and the clinical outcomes. Patient data were obtained through review of the clinical notes and individual patient follow up. Clinical outcomes were evaluated using the Oxford Hip Score and Harris Hip Score. The 54 fractures were classified using the Vancouver system, most of which were type B1 (20) or type B2 (10). The mean time to union for all fracture types was 4.6 months. A high non-union rate was seen among fractures fixed operatively. Fifteen per cent of fractures went on to develop loosening following treatment, suggesting an underrecognition at the time of injury. The average Harris Hip Score was 73.1 and Oxford Hip Score 30.3 for all fracture types at a mean follow up of 3.3 years. In the 15 patients treated with revision surgery, the most common complication was dislocation (27%). Treatment of patients with periprosthetic fractures requires recognition of the challenging nature of these injuries, the associated poor prognosis and the high complication rate.
with or without a Xattened tip Yates Department of Orthopaedic Surgery, Fremantle Hospital, P.O. Box 480, Fremantle, WA 6160, Australia e-mail: KampshoV@gmail
  • Synthes
  • Oberdorf
  • Ncb Switzerland
  • Zimmer
  • Warsaw
  • In
  • Usa
LCS (Synthes, Oberdorf, Switzerland) and NCB (Zimmer, Warsaw, IN, USA), with or without a Xattened tip, were J. KampshoV (&) · P. J. Yates Department of Orthopaedic Surgery, Fremantle Hospital, P.O. Box 480, Fremantle, WA 6160, Australia e-mail: KampshoV@gmail.com J. B. Erhardt · M. S. Kuster Department of Orthopaedic Surgery, Kantonsspital St. Gallen, Rohrschacher Strasse, 9007 St. Gallen, Switzerland K. K. StoVel Department of Orthopaedic Surgery, Kantonsspital Graubunden, Loestrasse 170, 7000 Chur, Switzerland J. KampshoV · K. K. StoVel · P. J. Yates · M. S. Kuster The University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia References
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Brady OH et al (1999) ClassiWcation of the hip. Orthop Clin North Am 30(2):215–220
Fixation of periprosthetic femoral shaft fractures occurring at the tip of the stem: a biomechanical study of 5 techniques
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