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Ostéosynthèse mini-invasive des fractures fémorales inter-prothétiques de type B et C
Abstract
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.
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Because of an increasing life expectancy of patients and the rising number of joint replacements, peri- and interprosthetic femoral fractures are a common occurrence in most trauma centers. This study was designed to answer two primary questions. First, whether the fracture risk increases with two intramedullary implants in one femur; and second, whether a compression plate osteosynthesis is sufficient for stabilizing an interprosthetic fracture.
Twenty-four human cadaveric femurs were harvested and four groups were matched based on the basis of bone density using a peripher quantitative computer tomography (pQCT). All groups-(I) hip prosthesis with a cemented femoral stem; (II) hip prosthesis and retrograde femoral nail; (III) hip prosthesis, retrograde femoral nail, and lateral compression plate; (IV) all three implants with an additional simulated interprosthetic fracture-were biomechanically tested in a four-point bending in lateral-medial direction.
The second group with two intramedullary implants exhibited 20% lower fracture strength in comparison with group 1 with proximal femoral stem only. The stabilization of an interprosthetic fracture with a lateral compression plate (group IV) resulted in a fracture strength similar to femur with prosthesis only.
Two intramedullary implants reduce the fracture strength significantly. If an interprosthetic fracture occurs, sufficient stability can be achieved by a lateral compression plate. Because two intramedullary implants in the femur may decrease the fracture strength, the treatment of supracondylar femoral fractures with a retrograde nail in cases with preexisting ipsilateral hip prosthesis should be reconsidered.
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.
Periprosthetic fracture after total joint replacement predominantly occurs at the stem tip. In this study, the effects of gap size, stem stability and cortical thickness between two press-fit, ipsilateral intramedullary stems on the tensile stresses created in the femur were investigated using finite-element models. The findings were confirmed with strain-gauge tests using a composite Sawbone femur. Gap size did not affect the level of stress on the femur. Cortical thickness had an important effect on stress distribution: peak stresses increased as bone cortical thickness decreased. Irrespective of gap size, the tips of loose stems acted as stress risers particularly with thinner cortices; the tips of well-fixed stems, however, did not.
Fondement
Les fractures fémorales périprothétiques de type C posent des problèmes de fixation liés à la longueur de l’extension de la fracture et à la qualité du stock osseux.
Objectif
Les auteurs rapportent une série continue et prospective de fractures fémorales périprothétiques de type C afin d’évaluer la tenue mécanique de l’implant fémoral et le devenir clinique à moyen terme.
Patients et méthode
Entre avril 2004 et novembre 2006, nous avons traité 17 patients (15 femmes, deux hommes) présentant une fracture sur prothèse de hanche (12 cas), entre prothèse de hanche et de genou (un cas), sur une prothèse de genou (quatre cas). Tous les implants étaient bien fixés au moment de la fracture. L’âge moyen était de 76,7 ans (39–93 ans). L’ostéosynthèse a été effectuée avec une plaque à vis bloquée LCP (Synthes™) pontant le matériel en place afin d’éviter une zone de faiblesse. Le protocole de rééducation consistait en une remise en charge autant que possible.
Résultats
Le recul moyen de la série était de 31,5 mois (4–51). Nous avons observé quatre décès au cours du suivi. Une chirurgie mini-invasive a été réalisée 15 fois. La remise en charge totale a été possible immédiatement dix fois, un appui partiel à 20 kg trois fois et sans appui jusqu’à six semaines quatre fois. Nous déplorons deux infections et une complication mécanique à type de « pliage » de plaque secondaire à une chute. La consolidation a été obtenue dans tous les cas avec l’apparition d’un cal dès la sixième semaine.
Discussion
La technique utilisée allie le principe de l’ostéosynthèse à foyer fermé avec conservation de l’hématome fracturaire à la stabilité du matériel. En effet, les vis bloquées à la plaque permettent la réalisation d’un « fixateur interne » avec une stabilité accrue suffisante pour permettre une remise en charge précoce sans risquer de perte d’axe secondaire. Malgré cette rigidité accrue, nous n’avons pas observé de contrainte particulière sur les implants fémoraux. Nous recommandons le pontage de l’implant et un verrouillage espacé pour une meilleure répartition des contraintes lors de la remise en charge. Ce matériel avec, si possible, mise en place par voie d’abord réduite semble adapté aux fractures fémorales périprothétiques surtout chez la personne âgée.
Niveau de preuve
IV prospective non comparative.
Purpose of the study
We report a consecutive prospective series of femoral fractures on previous implants. The purpose was to assess treatment with locking compression plates and total weight-bearing.
Material and method
From June 2002 to December 2005, we treated 21 patients (16 women, five men) for fractures on previous implants: total hip arthroplasty (n = 11), total knee arthroplasty (n = 1), unicompartmental prosthesis (n = 1), gamma nail (n = 4), hip screw (n = 1). Mean patient age was 75.8 years (range 39–90). Osteosynthesis was performed on an orthopedic table or on a standard table using a minimally-invasive approach for fixation with a locking compression plate (Synthes® LCP) to bridge the implants in place and avoid any zone of weakness. The rehabilitation protocol included immediate total weight bearing.
Results
At last follow-up there were three deaths and one failure so that there were 17 patients with a mean follow-up of 15.9 months (range 6–45 months). The following outcomes were noted. Minimally-invasive surgery was used in 18 cases, access to the fracture focus in three. Total weight bearing was possible immediately after surgery in 12 patients and partial weight bearing (20 kg) for two. There were two infections, two general complications and one early displacement. Healing was achieved at 6–10 weeks. Misalignment greater than 10° was noted in three cases.
Discussion
This work illustrates the use of locking plates for minimally-invasive repair of fractures on previous implants with total weight bearing. This technique combines the principles of closed fixation and preservation of the fracture hematoma with material stability. In this form, use developed progressively. It is now common practice to use plate fixation for femoral fractures. The LISS system was then developed progressively for minimally-invasive repair of distal fractures. We widened the concept to include more proximal approaches. The use of the locking screws in the plate corresponds to what could be called an internal external fixator with three pins (two corresponding to the cortical screws plus the plate), which enable a solid fixation. Screw hold seems to be sufficient to allow early weight bearing.
Conclusion
Locking plates have been shown to be an effective treatment for femoral fractures on previous implants allowing a stable fixation sufficient for early weight bearing.
Type C periprosthetic femoral fractures present fixation problems related to the extent of the fracture and the quality of the bone stock.
The authors report a continuous and prospective series of type C periprosthetic femoral fractures to assess the mechanical stability of the femoral implant and the clinical outcome at the medium term.
Between April 2004 and November 2006, we treated 17 patients (15 females, two males) presenting a prosthetic hip fracture (12 cases), between the hip prosthesis and the knee (one case), and with a knee prosthesis (four cases). All the implants had no sign of loosening at the time of fracture. The patients' mean age was 76.7 years (range, 39-93 years). Internal fixation was obtained with a locking compression plate (LCP) Synthes bridging the implant in place to prevent a weak zone. The rehabilitation protocol consisted in full weight bearing as much as possible.
The mean follow-up of the series was 31.5 months (range, 4-51 months). Four deaths were recorded during the follow-up. Minimally invasive surgery was performed in 15 patients.Total loading was possible immediately in 10 patients, partial loading at 20 kg in three patients,and no loading was possible until 6 weeks in four patients. Two infections and a bending-type mechanical complication of the plate secondary to a fall were observed. Consolidation was obtained in all cases with the appearance of callus formation beginning in the 6th week.
The technique used allies the principle of closed internal fixation (with preservation of the fracture hematoma) with mechanical stability. The screws locking to the plate warrant an internal fixator with increased stability that is sufficient for early loading with no risk of losing the secondary axis. Despite this increased rigidity, we did not observe any particular stress on the femoral implants. We recommend bridging the implant and spaced locking for better distribution of the stresses during loading. This hardware, with, if possible, insertion using a reduced approach, seems adapted to periprosthetic femoral fractures, particularly in the elderly.
Level IV, prospective therapeutic study.
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.
Interprosthetic fracture is a rare but serious entity, impairing consolidation and stability due to adverse mechanical conditions related to bone fragility and implant volume.
The present study highlights the difficulties involved in managing such fractures, details treatment options and reports findings leading to a proposed additional grade in the comparable Vancouver (hip) and French Orthopedic and Traumatologic Surgery Society (Société française de chirurgie orthopédique et traumatologique: SoFCOT) (knee) classification systems.
A multicenter retrospective series included 14 interprosthetic femoral fractures: eight type double C (typeC for both hip and knee), five type C for hip and B for knee, and one type double B (type B for both hip and knee) on the Vancouver and SoFCOT classifications. Fracture occurred on standard (n=15) or revision (n =13) implants. Six cases involved a femoral shaft encumbered by a total knee replacement (TKR) femoral extension stem and eight cases TKR without femoral long stem, assimilable to type C fracture.
None of the six fractures proximal to a constrained TKR with stem-achieved union by primary intention, whereas seven of the eight type-C fractures did so. Finally, 12 cases showed favorable evolution, with three secondary total femur replacements (TFR) and one death at 6 months without bony union or revision and one patient waiting for TFR.
To describe the status of the intermediate femur and its medullary canal encumbrance, we propose adding a category D to the SoFCOT and Vancouver classifications, corresponding to interprosthetic fracture on TKR with diaphyseal extension stem. Interprosthetic fracture internal fixation should begin with long devices bridging the two prostheses. When the implant is loose, it may be replaced; in case of diaphyseal extension, however, the residual femur between the two extensions should be protected against peak stress by a plate extending upward and downward. In case of limited bone stock, due to osteolysis or initial femoral medullary canal compromise, especially if one or both implants are loose, TFR may be indicated as consolidation, is jeopardized by the uncertain mechanical situation.
We report a continuous series of periprosthetic femoral fractures after knee arthroplasty treated with a locking plate. We hypothesize that minimally invasive surgery and immediate weight-bearing improve functional recovery.
From June 2002 to December 2008, 15 patients with 16 fractures were treated. Median age was 81 years. The autonomy level according to the mobility score of Parker and Palmer showed a median of 5 (0-9). Osteosynthesis was performed mainly through a minimally invasive approach using a locking compression plate. The rehabilitation protocol consisted of immediate mobilization and, whenever possible, immediate unrestricted weight-bearing.
Five patients died during follow-up, more than 1 year after osteosynthesis. Their results were included. Autonomy and mobility were preserved with a median postoperative score of 4 (0-9) according to Parker and Palmer. The consolidation rate was 93.8%, which was obtained within 10 weeks. There were no mechanical or infectious complications. Fourteen cases were treated with minimally invasive surgery without fracture exposition; the remaining 2 required a slightly more extended approach. Full weight-bearing occurred 10 times; 20-kg partial weight-bearing was advised twice; and on 4 occasions, no weight-bearing was allowed for 6 weeks.
Osteosynthesis with a minimally invasive bridge-plating technique is effective in the treatment of periprosthetic, distal femoral fractures without component loosening. Immediate full weight-bearing is possible if certain rules are respected. The surgical management presented herein is beneficial for these challenging fractures, and it may help reduce the complication rate and improve functional outcome.
Introduction:
Interprosthetic femoral fractures following ipsilateral hip and knee arthroplasty are a rare but serious complication in clinical practice. In most cases, adequate management of these injuries might constitute a challenging problem. However, the literature provides only few data regarding the treatment and outcome of interprosthetic femoral fractures, and there are only few classifications available, which might assist in finding an appropriate treatment concept. The purpose of this study was to analyse our experience in the management of interprosthetic femoral fractures following ipsilateral hip and knee joint replacement.
Materials and methods:
We reviewed the clinical and radiographic records of 23 patients (15 female and eight male, average age: 79.2 years) with an interprosthetic fracture after ipsilateral hip and knee joint replacement between 1992 and 2008. For the classification of interprosthetic femoral fractures, the fractures were divided into three types, depending on the fracture site and the adjacency to the prostheses. All patients underwent operative stabilisation, either by lateral plate fixation (n=19), by revision arthroplasty using a long stem (n=2) or by plate fixation and revision arthroplasty (n=2).
Results:
Referring to the clinical outcome, 16 patients returned to their pre-injury activity level and were satisfied with their clinical outcome. In six patients, we saw a relevant decrease of hip or knee function and severe limitations in gait and activities of daily living. We had a mean Harris Hip Score (HHS) of 78.4 points, and a mean Knee injury and Osteoarthritis Outcome Score (KOOS) of 71.8 points. Relating to the radiographic outcome, successful fracture healing was achieved in 19 of 22 patients (86%) within 6 months. Failures of reduction and fixation were noted in four (18%) of 22 patients.
Conclusion:
We had a satisfactory outcome following individualised treatment of interprosthetic femoral fractures following ipsilateral hip and knee joint replacement. Compared to the rare data in current literature, we had promising functional result and high rate of bony fusion. Regarding the complexity and challenges in many of these cases, interprosthetic fractures require an adequate analysis of the fracture aetiology and a suitable transfer into the best possible treatment concept.
Interprosthetic femoral fractures, ones occurring between ipsilateral total hip and total knee arthroplasties, are an increasingly common and challenging problem for orthopaedic surgeons. The purpose of this study was to report specific fracture locations and treatment outcomes associated with a protocol of femoral plate fixation that spanned the interprosthetic zone applied with modern soft tissue preserving reduction techniques without adjuvant bone grafts.
Retrospective cohort study.
One Level I and one Level II trauma center.
A consecutive cohort of 25 patients with 26 interprosthetic femur fractures surgically treated by one of four orthopaedic traumatologists were retrospectively reviewed. There were nine fractures of the femoral shaft (Orthopaedic Trauma Association [OTA] 32) about hip arthroplasty prostheses and 17 supracondylar fractures (OTA 33) about total knee prostheses. Five patients with six fractures were excluded as a result of lack of follow up (n = 4) or deviation from the treatment protocol (n = 2). The remaining 20 fractures were all low-energy closed injuries in elderly patients (average age 80 years; range, 56-98 years; 14 females and six males).
A common surgical treatment protocol included plate fixation that spanned the entire interprosthetic zone (overlapping the stem proximally and knee component distally) and the use of biologic tissue-preserving plating techniques without use of supplemental bone grafts of any kind.
Fracture healing, time to full weightbearing, malunion, nonunion, and the presence of any hardware failure.
Supracondylar interprosthetic fracture patterns (OTA 33A) were two times more common than proximal diaphyseal fractures (OTA 32) (Vancouver B), 65% versus 35%. All 20 fractures healed after the index procedure. The average time to weightbearing as tolerated was 13 weeks (range, 6-22 weeks). There were three malunions (one 10° valgus, one 9° extension, and one 10° flexion), two cases of painful implants (one required removal), and one loose long-stem revision hip prosthesis (required total femur replacement). All other implants remained well-fixed. All complications occurred in patients with supracondylar fracture patterns. There were no additional associated peri-implant fractures.
Interprosthetic femoral fractures tend to occur more frequently in the supracondylar region about total knee arthroplasty components than in the diaphysis about hip stems. Modern biologic plating techniques that span the entire interprosthetic zone to eliminate additional stress risers show reliable union rates without the use of adjuvant bone graft while maintaining limb alignment and implant survivorship.
Unlabelled:
Increasingly frequent periprosthetic fractures are affecting the elderly; this patients group often suffers from significant co-morbidities that make it particularly difficult to manage these already complex injuries. The classic pitfalls of conservative treatment are many, including infections, pseudarthrosis and the growing necessity of different postoperative supports. We present an internal fixation technique by minimally invasive surgery to manage periprosthetic fractures. The hardware used is a locking plate, with manufacturers' recommendations usually allowing immediate weight bearing. This minimally invasive method provides optimal stability to the fixation, while avoiding the open approach shortcomings.
Level of evidence:
IV: retrospective or historical series.
The purpose of this observational study was to determine the clinical results of the operative treatment of periprosthetic femoral fractures over a long period of time.
The medical records of patients treated between 1993 and 2006 for a periprosthetic femoral fracture were obtained after a survey in two major hospitals. Radiographic evaluation was performed according to the Vancouver classification. All patients were contacted to fill out the Oxford hip score.
A total of 80 PPFs were identified in 79 patients. For 71 patients with 71 fractures, medical records and radiographs were available. The mean age at the time of fracture was 73.4 years (range: 38-95 years). The mean interval between initial arthroplasty and the time of fracture was 6.3 years. As many as 44 fractures occurred in patients with primary hip arthroplasty (62%) and 27 fractures in patients with revision implants (38%). All but two patients were treated operatively and 34 patients (48%) suffered from a complication, leading to a re-operation in 22 cases (33%). The most frequent indication for re-operation was re-fracture or implant failure. Vancouver type-C fractures lead to re-operations in 52% of the cases (11 of 20). A total of 36 patients (51%) were able to complete an Oxford hip score after a mean period of 64.9 months (range: 16-157 months). The other patients were lost to follow-up (45% were deceased and 4% were mentally impaired). The mean Oxford hip score was 27.8 (range: 12-57) and was significantly higher in patients suffering from a complication (p=0.02) and in patients with a periprosthetic fracture (PPF) after revision surgery (p=0.02).
The treatment of periprosthetic femoral fractures has a high complication rate and a large number of re-operations occur. The long-term clinical results are compromised by the event of a complication. The clinical results of treated fractures after a primary arthroplasty were better than after multiple arthroplasty procedures. Particularly, Vancouver type-C fractures showed high complication rates. This high complication rate should be taken into account for future studies in PPFs.
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.
Interprosthetic fractures of the femur, those between an ipsilateral hip and knee arthroplasty, are challenging to treat secondary to limited bone available for fixation, osteopenic bone, a compromised intramedullary blood supply, and an often elderly patient population. From 2002 to 2006, 22 consecutive patients with an interprosthetic femur fracture were treated with a single-locking plate. Follow-up averaged 17.7 months, with fracture union achieved an average of 13.8 weeks postoperatively. All patients regained their preoperative ambulatory status and subjectively reported unchanged function of their hip and knee arthroplasties. Single-locked plating is an effective method of treatment of interprosthetic fractures of the femur. Emphasis on preservation of the soft tissue envelope and sufficient cortical purchase both above and below the fracture is of paramount importance.
We assessed 882 patients presenting with a proximal femoral fracture by a new mobility score and by a mental test score, to determine which was of the most value in forecasting mortality at one year. Both scores gave a highly significant prediction, but the mobility score had a greater predictive value and is easier to perform.
Experience in the management of a complication of ipsilateral hip and knee arthroplasty is described. The cases of four female patients who sustained a femoral shaft fracture after ipsilateral hip and knee arthroplasty are reported. All fractures were treated operatively, and in all cases internal fixation devices failed. This complication of multiple joint arthroplasty presents a difficult management problem. Rigid fixation has a high failure rate for this type of fracture. Surface knee arthroplasty provides a better opportunity for internal fixation than a knee arthroplasty with a stemmed femoral component.
Proximal and distal femur fractures have traditionally been treated with open reduction and internal fixation through a standard lateral approach. New, "minimally invasive" internal fixation techniques, however, have been developed in an effort to devascularize the bone less than the traditional method. The purpose of this study was to determine whether a minimally invasive percutaneous plating technique better preserves bone vascularity relative to the traditional method by comparing the effect of the two approaches on the blood supply of the distal femur using silicone arterial dye injection in a cadaveric model.
Ten fresh human cadavers underwent lateral conventional plate osteosynthesis (CPO) through a standard lateral approach on one side and minimally invasive plate osteosynthesis (MIPO) through two three-centimeter incisions on the contralateral side. After injection of silicone dye, a dissection was performed bilaterally to identify the femoral perforating and nutrient arteries.
All MIPO specimens showed intact perforating and nutrient arteries, whereas the CPO specimens had a variable incidence of vessel disruption. The MIPO group demonstrated better periosteal perfusion in each of the cadavers and improved medullary perfusion in 70 percent of the MIPO specimens compared with the CPO specimens.
A percutaneous minimally invasive plating technique disrupts the femoral blood supply less than the traditional open method. Such minimally invasive methods may be more advantageous biologically than the traditional method.
Supracondylar femoral fractures above total knee arthroplasty remain a treatment challenge. Complication rates as high as 30% are associated with both nonoperative and operative treatment. Conventional plate fixation and rigid intramedullary nail fixation has improved the treatment of these fractures. However, problems still exist in the setting of a short distal femoral block and/or significant osteoporosis. Less Invasive Stabilization System (L.I.S.S.) fixation has been utilized for the treatment of supracondylar femoral fractures above total knee arthroplasty. Multiple fixed angle screws give optimal fixation around the femoral component. Advantages appear to include maintenance of distal femoral fixation, low infection, and low need for bone grafting.
The advent of 'biological internal fixation' is an important development in the surgical management of fractures. Locked nailing has demonstrated that flexible fixation without precise reduction results in reliable healing. While external fixators are mainly used today to provide temporary fixation in fractures after severe injury, the internal fixator offers flexible fixation, maintaining the advantages of the external fixator but allowing long-term treatment. The internal fixator resembles a plate but functions differently. It is based on pure splinting rather than compression. The resulting flexible stabilisation induces the formation of callus. With the use of locked threaded bolts, the application of the internal fixator foregoes the need of adaptation of the shape of the splint to that of the bone during surgery. Thus, it is possible to apply the internal fixator as a minimally invasive percutaneous osteosynthesis (MIPO). Minimal surgical trauma and flexible fixation allow prompt healing when the blood supply to bone is maintained or can be restored early. The scientific basis of the fixation and function of these new implants has been reviewed. The biomechanical aspects principally address the degree of instability which may be tolerated by fracture healing under different biological conditions. Fractures may heal spontaneously in spite of gross instability while minimal, even non-visible, instability may be deleterious for rigidly fixed small fracture gaps. The theory of strain offers an explanation for the maximum instability which will be tolerated and the minimal degree required for induction of callus formation. The biological aspects of damage to the blood supply, necrosis and temporary porosity explain the importance of avoiding extensive contact of the implant with bone. The phenomenon of bone loss and stress protection has a biological rather than a mechanical explanation. The same mechanism of necrosis-induced internal remodelling may explain the basic process of direct healing.
The basic principles of an internal fixation procedure using a conventional plate and screw system (compression method) are direct, anatomical reduction and stable internal fixation of the fracture. Wide exposure of the bone is usually necessary to gain access to and provide good visibility of the fracture zone to allow reduction and plate fixation to be performed. This procedure requires pre-contouring of the plate to match the anatomy of the bone. The screws are tightened to fix the plate onto the bone, which then compresses the plate onto the bone. The actual stability results from the friction between the plate and the bone. Anatomical reduction of the fracture was the goal of conventional plating technique, but over time a technique for bridging plate osteosynthesis has been developed for multifragmentary shaft fractures that, thanks to a reduction of vascular damage to the bone, permits healing with callus formation, as seen after locked nailing. Since the damage to the soft tissues and the blood supply is less extensive, more rapid fracture healing can be achieved. The newly developed, so-called locked internal fixators (e.g.PC-Fix and Less Invasive Stabilization System (LISS)), consist of plate and screw systems where the screws are locked in the plate. This locking minimizes the compressive forces exerted by the plate on the bone. This method of screw-plate fixation means that the plate does not need to touch the bone at all, which is of particular advantage in so-called Minimal Invasive Percutaneous Osteosynthesis (MIPO). Precise anatomical contouring of a plate is no longer necessary thanks to these new screws and because the plate does not need to be pressed on to the bone to achieve stability. This prevents primary dislocation of the fracture caused by inexact contouring of a plate. The LISS plates are precontoured to match the average anatomical form of the relevant site and, therefore, do not have to be further adapted intraoperatively. The development of the locked internal fixator method has been based on scientific insights into bone biology especially with reference to its blood supply. The basic locked internal fixation technique aims at flexible elastic fixation to initiate spontaneous healing, including its induction of callus formation. This technology supports what is currently known as MIPO. The development of the Locking Compression Plate (LCP) has only been possible based on the experience gained with the PC-Fix and LISS. With reference to the mechanical, biomechanical and clinical results, the new AO LCP with combination holes can be used, depending on the fracture situation, as a compression plate, a locked internal fixator, or as an internal fixation system combining both techniques. The LCP with combination holes can also be used, depending on the fracture situation, in either a conventional technique (compression principle), bridging technique (internal fixator principle), or a combination technique (compression and bridging principles). A combination of both screw types offers the possibility to achieve a synergy of both internal fixation, methods. If the LCP is applied as a compression plate, the operative technique is much the same as conventional technique, in which existing instruments and screws can be used. The internal fixator method can be applied through an open but less invasive or an MIPO approach. An indirect closed reduction is necessary when using the LCP in the internal fixator method bridging the fracture zone. A combination of both plating techniques is possible and valuable, depending on the indication. It is important to command a knowledge of both techniques and their different features.
To summarize the complications and early clinical results of 123 distal femur fractures treated with the Less Invasive Stabilization System (LISS; Synthes, Paoli, PA).
Retrospective analysis of prospectively enrolled patients.
Two academic level I trauma centers. SUBJECTS AND PARTICIPANTS: One hundred nineteen consecutive patients with 123 distal femur fractures (OTA type 33 and distal type 32 fractures) treated by 3 surgeons. One hundred three fractures (68 closed fractures and 35 open fractures) in 99 patients were followed up at least until union (mean follow-up = 14 months, range: 3-50 months).
Surgical reduction and fixation of distal femur fractures.
Perioperative complications, radiographic union, infection rate, loss of fixation, alignment, and range of motion.
Ninety-six (93%) of 103 fractures healed without bone grafting. All fractures eventually healed with secondary procedures, including bone grafting (1 of 68 closed fractures and 6 of 35 open fractures). There were 5 losses of proximal fixation, 2 nonunions, and 3 acute infections. No cases of varus collapse or screw loosening in the distal femoral fragment were observed. Malreductions of the femoral fracture were seen in 6 fractures (6%). The mean range of knee motion was 1 degrees to 109 degrees .
Treatment of distal femur fractures with the LISS is associated with high union rates without autogenous bone grafting (93%), a low incidence of infection (3%), and maintenance of distal femoral fixation (100%). No loss of fixation in the distal femoral condyles was observed despite the treatment of 30 patients older than 65 years. The LISS is an acceptable surgical option for treatment of distal femoral fractures.
New locked plate devices offer theoretical advantages for the treatment of supracondylar femur fractures associated with a total knee arthroplasty (TKA). These devices also can be inserted with relative ease by using minimally invasive techniques, provide a fixed angle construct, and improve fixation in osteoporotic bone. The purpose of this study was to evaluate the results and complications of treating periprosthetic supracondylar femur fractures above a TKA with a locked plate designed for the distal femur.
Prospective, consecutive case series.
Level I trauma center.
Twenty-two consecutive adult patients with 24 (2 bilateral) supracondylar femur fractures (OTA 33A) above a well-fixed non-stemmed TKA were treated with the Locking Condylar Plate. One patient who died before fracture healing and 1 who was lost to follow-up were excluded from analysis. All remaining patients (5 males, 15 females, average age, 73 (range, 50-95) years) were available for follow-up at an average of 15 (range, 6-45) months. According to the OTA classification, there were three 33A1, eight 33A2, and eleven 33A3 fractures. All fractures were closed. Indirect reduction methods without bone graft were used in all cases.
Nineteen of 22 fractures healed after the index procedure (86%). All 3 patients with healing complications were insulin-dependent patients with diabetes who also were obese (body mass index >30). Two developed infected nonunions and 1 an aseptic nonunion. Postoperative alignment was satisfactory (within 5 degrees ) for 20 of 22 fractures. Fracture of screws in the proximal fragment occurred in 4 patients. In 3 of these cases, there was progressive coronal plane deformity. There was no change in alignment in any other patient. Fifteen of 17 patients who healed returned to their baseline ambulatory status, with 5 requiring additional ambulatory support compared with baseline.
Fixation of periprosthetic supracondylar femur fractures with a locking plate provided satisfactory results in nondiabetic patients. Diabetic patients seem to be at high risk for healing complications and infection.
Unlabelled:
Fractures of the femur after a knee or hip arthroplasty historically have been plagued with high complication rates. The Less Invasive Stabilization System (LISS) has theoretical advantages of improved biomechanics and limited insult to the bone's vascular supply. We theorized that the LISS would have a lower complication rate than historical controls for these fractures. Patients who were treated with a LISS at two Level I trauma centers from July 2001 to July 2003 were prospectively followed up. The inclusion criteria were an acute fracture of the femur treated with a LISS in a patient with a stable ipsilateral total knee prosthesis and/or hip pros- thesis. There were 24 patients in the study group. The injury mechanism was a low-energy fall for all patients. All patients were females with an average age of 79.5 years (range. 64-93 years). Ten patients had ipsilateral hip arthroplasties, nine patients had ipsilateral total knee arthroplasties, and five patients had knee and hip arthroplasties. Followup was at an average of 48 weeks (range, 17-101 weeks). Eighteen of the 19 fractures in the surviving patients with followup healed uneventfully for a complication rate of 5.2%. One fracture was complicated by hardware pullout and was revised to a longer LISS that healed uneventfully. We think our data show that our patients had a low complication rate compared with that of historical controls, and we suggest that the LISS may be an appropriate treatment alternative for femur fractures associated with stable hip or knee prostheses.
Level of evidence:
Therapeutic, Level IV.
Osteoporosis is a well-known phenomenon in rheumatoid arthritis (RA) that is characterized by marked loss of peripheral bone. It was found that the frequency of osteoporosis in RA can be increased significantly compared with the reference population, which implies a higher risk of fracture in this group of patients. Osteoporosis makes the treatment of fracture in RA patients more challenging, including the difficulty of fracture fixation, delayed union, secondary loss of reduction, and fixation failure. The locking compression plate was designed using the concept of "internal fixator," which provides a new solution for the fixation of osteoporotic fractures. The fixed angle between the screw and the plate increases the pull-out strength of the system, so the stability of the fixation no longer depends totally on the quality of the bone. The other benefits of this system include the fact that no accurate contouring is required, it protects the local blood supply, and it supports minimally invasive plate osteosynthesis.
Periprosthetic femoral fractures associated with well-fixed total hip or total knee prostheses present a challenging management problem as these injuries typically occur in osteoporotic bone. Conventional management entails extensive periosteal stripping to allow for plate fixation. We reviewed a consecutive series of patients who sustained fractures associated with a well fixed total knee prosthesis, a total hip prosthesis, or both. Twenty four patients with a mean age of 69.4 years were included. All patients underwent fixation via percutaneous insertion techniques with a first generation locking plate and screws (LISS--Less Invasive Skeletal Stabilization, Synthes, Paoli, PA). Three patients sustained fractures distal to a well-fixed total hip prosthesis, eighteen fractures occurred above a well-fixed total knee femoral component, and three were interprosthetic. The mean length of time from the index procedure to fracture was 76 months, range (2-172 months). Blood loss was minimal in each case, with a mean operative time of 90 min (range 60-120 min). Twenty one of twenty four went on to unite at a mean 6.2 months (range 3-19 months). Three patients underwent further surgery. One failure of fixation was encountered. Percutaneous fixation is technically demanding as it requires stable fixation without direct visualisation of the fracture site or the entire fixation device. Our results suggest percutaneous fixation with the LISS plate is an effective although technically demanding method of treatment. Complication rates were comparable to existing reports of this treatment method, and appear to be improved over traditional methods of fixation.
Management of periprosthetic femoral fractures is often complex, and few studies have documented its associated mortality.
We retrospectively identified from our trauma and surgical registries 106 patients who underwent surgery for a periprosthetic femoral fracture. We then identified a contemporaneous age and sex-matched control cohort of 309 patients who had a hip fracture (femoral neck or intertrochanteric) and 311 patients who underwent primary hip or knee replacement. Mortality at one year was identified with use of the Social Security database.
Twelve (11%) of 106 patients died within one year following surgical treatment of a periprosthetic fracture. During the same follow-up period, fifty-one (16.5%) of 309 patients died following surgery for a hip fracture and nine (2.9%) of 311 patients died following primary joint replacement. The mortality rate after a periprosthetic femoral fracture was significantly higher (p < 0.0001) compared with that for matched patients who had undergone primary joint replacement, and it was similar to the mortality rate after a hip fracture. For periprosthetic fractures, a delay of greater than two days from admission to the time of surgery was associated with an increased mortality rate at one year (p < 0.0007). Forty-nine patients underwent revision arthroplasty for the treatment of a Vancouver type-B periprosthetic fracture, and six (12%) died. In contrast, twenty-four patients with a Vancouver type-B periprosthetic fracture were treated with open reduction and internal fixation and eight (33%) died. The difference was significant (p < 0.03).
The mortality rate within one year following surgical treatment of periprosthetic femoral fractures is high and is similar to that after treatment for hip fractures. Because revision arthroplasty for the treatment of type-B periprosthetic fractures was associated with a one-year mortality rate that was significantly less than that after surgical treatment with open reduction and internal fixation, in instances when either treatment option is feasible, revision arthroplasty may be the preferred option.
We report a consecutive prospective series of femoral fractures on previous implants. The purpose was to assess treatment with locking compression plates and total weight-bearing.
From June 2002 to December 2005, we treated 21 patients (16 women, five men) for fractures on previous implants: total hip arthroplasty (n=11), total knee arthroplasty (n=1), unicompartmental prosthesis (n=1), gamma nail (n=4), hip screw (n=1). Mean patient age was 75.8 years (range 39-90). Osteosynthesis was performed on an orthopedic table or on a standard table using a minimally-invasive approach for fixation with a locking compression plate (Synthes) LCP) to bridge the implants in place and avoid any zone of weakness. The rehabilitation protocol included immediate total weight bearing.
At last follow-up there were three deaths and one failure so that there were 17 patients with a mean follow-up of 15.9 months (range 6-45 months). The following outcomes were noted. Minimally-invasive surgery was used in 18 cases, access to the fracture focus in three. Total weight bearing was possible immediately after surgery in 12 patients and partial weight bearing (20 kg) for two. There were two infections, two general complications and one early displacement. Healing was achieved at 6-10 weeks. Misalignment greater than 10 degrees was noted in three cases.
This work illustrates the use of locking plates for minimally-invasive repair of fractures on previous implants with total weight bearing. This technique combines the principles of closed fixation and preservation of the fracture hematoma with material stability. In this form, use developed progressively. It is now common practice to use plate fixation for femoral fractures. The LISS system was then developed progressively for minimally-invasive repair of distal fractures. We widened the concept to include more proximal approaches. The use of the locking screws in the plate corresponds to what could be called an internal external fixator with three pins (two corresponding to the cortical screws plus the plate), which enable a solid fixation. Screw hold seems to be sufficient to allow early weight bearing.
Locking plates have been shown to be an effective treatment for femoral fractures on previous implants allowing a stable fixation sufficient for early weight bearing.
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