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Management of peri-prosthetic fractures around total hip arthroplasty: a contemporary review of surgical options

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Introduction
There is a risk of intraoperative periprosthetic fracture
during primary hip arthroplasty (1); however, more
commonly this complication is seen post-operatively (2).
It is anticipated that the incidence of periprosthetic
fractures will increase with increasing numbers of total
hip or knee arthroplasty performed and as the numbers
of uncemented femoral stems increase (3). These injuries
often occur in older patients with more significant co-
morbidity and osteopenia (4). Management of these injuries
is often resource intensive and can present significant
socioeconomic challenges (1).
Periprosthetic fractures are challenging for the
surgeon and medical team. Surgical management can be
technically demanding (5). Historically non-operative
management of the injuries such as long leg casting or
traction has demonstrated unacceptably high rates of
morbidity and mortality (6). Multiple techniques have
been described to manage these complex injuries and
may include internal xation and/or revision of the in situ
prosthesis. Whilst internal fixation may include locking
plate, cable plating, orthogonal plating and the use of
allograft or autograft, no consensus exists on the ideal
approach. Furthermore, controversy exists over plate
type, length and distance spanning the prosthesis or the
bone. Potential complications following surgery include
blood loss, loosening, failure or bony union, further
fracture and infection (7). Boylan et al. recently described
a similar mortality rate in patients following periprosthetic
fracture when compared to neck of femur fracture up to
6 months post injury and a 1-year mortality rate of 9.7% (8)
highlighting the importance of prioritising management of
these patients.
The Vancouver classification system (9) is commonly
used to guide management decisions. This includes
Review Article
Management of peri-prosthetic fractures around total hip
arthroplasty: a contemporary review of surgical options
Dominic Davenport1, Jonathan R. Hutt1, Philip A. Mitchell1, Alex Trompeter1, Daniel Kendoff2,
Nemandra A. Sandiford1
1Department of Trauma and Orthopaedics, Complex Arthroplasty Unit, St George’s Hospital, London, UK; 2Department of Orthopaedic, ENDO-
Klinik, Hamburg, Germany
Contributions: (I) Conception and design: D Davenport, NA Sandiford; (II) Administrative support: None; (III) Provision of study materials or
patients: None; (IV) Collection and assembly of data: D Davenport, NA Sandiford; (V) Data analysis and interpretation: All authors; (VI) Manuscript
writing: All authors; (VII) Final approval of manuscript: All authors.
Correspondence to: Nemandra A. Sandiford. Department of Trauma and Orthopaedics, Complex Arthroplasty Unit, St George’s Hospital, London,
UK. Email: nemsandiford@gmail.com.
Abstract: The burden of periprosthetic fractures is increasing with increasing volumes of total hip
arthroplasty. These injuries often occur in older patients with more signicant co-morbidity and osteopenia.
Management of these injuries is often resource intensive and can present significant socioeconomic
challenges. Understanding the principles of surgical management these cases and recognising when xation
or replacement is required is critical. The aim of this article is to present a contemporary evidence-based
review of the surgical xation options for management of periprosthetic fractures in the presence of well-
xed or loose components.
Keywords: Arthroplasty; hip; periprosthetic; fracture; trauma; complications
Received: 24 June 2018; Accepted: 17 July 2018; Published: 10 August 2018.
doi: 10.21037/aoj.2018.07.03
View this article at: http://dx.doi.org/10.21037/aoj.2018.07.03
Page 2 of 6 Annals of Joint, 2018
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assessment of fracture location, stability and bone
quality (10) (Figure 1). Type A fractures involve the greater
or lesser trochanter, type B are diaphyseal starting around
the stem and may extend distally whereas type C are distal
to the stem in the femoral shaft. The Vancouver system
remains the most commonly used due to its simplicity and
its application to surgical management (11).
In general, in the context of a well fixed femoral stem
(Vancouver B1 or C) it is possible to retain the prosthesis
and treat with internal fixation methods (1,12). When
there is concern of loosening or instability around the stem
(Vancouver B2, B3) then the literature supports revision
arthroplasty surgery with or without internal xation (10).
Despite this there remains some controversies surrounding
the optimal management of peri-prosthetic fractures such as
which internal xation method is optimal in Vancouver B1
fracture (10) and identication of stable or unstable stems
when considering retention of the prosthesis (7). The aim
of this article is to present a contemporary evidence-based
review of the surgical fixation options for management
of periprosthetic fractures in the presence of well-fixed
components.
Methods of internal xation around stable stems
Fixation options in the context of a Vancouver B1 or C
fractures are limited by restricted bony xation proximally
given the presence of a femoral stem and often in
compromised bone stock. Complications following operative
intervention for periprosthetic fractures can include blood
loss, non-union, re-fracture or metalwork failure and
implant loosening (13). These issues are compounded by
the predisposition for these injuries to occur in patients of
older age with more signicant co-morbidity and reduced
physiological reserve (4). Previous studies have been
published describing the outcomes of operative intervention
of these fractures, but the treatment methods have been
heterogenous (14,15).
Plates
High failure rates and need for reoperation have previously
been described by Lindahl et al. (13) with the use of single
plate fixation for treatment of Vancouver B and C type
fractures with an overall failure rate of 33.9%. Froberg
et al. (15) described a 13% failure rate and need for
revision in cases treated exclusively with locking plate
fixation. Zhang et al. described orthogonal plating of 12
patients with Vancouver B fractures around cemented
or uncemented femoral stems and reported that all cases
had united at a mean of 12.5 weeks with no complications
of infection or deep vein thrombosis (DVT) (14). These
failures demonstrate that no single options for plate xation
of periprosthetic fractures is without risk. In addition, some
of these failures may at least in part be due to a failure to
recognise the original injury as involving a loose stem (13).
The potential benefits of using locking plates is the
option for unicortical screw fixation and theoretical
increased pull out strength when used in osteoporotic
bone. Furthermore, there is in vitro evidence of increased
resistance to axial load and torsion compared to non-locking
plates (16). Despite this, evidence suggests that locking
plates are associated with a higher rate of non-union and
implant failure when used to treat Vancouver B1 fracture
A B1 B2 B3 C
Figure 1 Vancouver classication for periprosthetic femoral fractures around hip implants.
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compared to non-locking plates (10) which may be a result
of changing the strain at the fracture site and reducing
healing potential while not achieving optimal compression
at the fracture site.
Cables
Cerclage wire or cable fixation is commonly employed in
the management of intra-operative periprosthetic fracture
at time of primary surgery however this technique may also
be applied to management of post-operative periprosthetic
fractures. Authors have reported the use of both open cable
xation or percutaneous cable xation but the majority of
studies describe combined plate and cable techniques rather
than cable xation in isolation. Previous reports of “cable-
only” plate xation (i.e., no screws used) showed that this
construct had high rates of failure and need for revision
surgery. In a 16-patient series which included 3 Vancouver
B1 fractures, 2 went on to non-union and metalwork failure
at 6 months post-surgery with the use of plates and cables
alone (17). A recent study demonstrated better outcomes
using the hybrid technique of percutaneous cable fixation
around the stem combined with distal locking plate xation.
In 10 cases of Vancouver B1 fracture xed with the above
construct with the mean time to union was 18 weeks and no
implant failures were observed at an average of 13 months
follow up (18).
Strut allograft
Strut allograft fixation has been described by Haddad
et al. (3). The use of cortical strut grafts is based on their
similar Young’s modulus of elasticity to the host bone
therefore theoretically reducing the impact of stress
shielding and bone resorption (19). Whilst the cortical
bone graft provides an additional biological bone stock and
structural support in the early phase of treatment some
concern remains that as the graft incorporates its loses its
mechanical strength (3). Cortical strut allografts are rarely
used in isolation. They are more often applied and used
in combination with plate fixation (10). The combination
of plate and strut allograft in combination has been
demonstrated to provide a very stable construct during in
vitro biomechanical studies when used in orthogonal planes
e.g., lateral plate fixation and anterior cortical struct graft
fixation (20). In vivo results don’t appear to confer any
added benet over plate cable or compression plate xation
despite the additional procedure burden and economic
impact of cortical strut graft use however (10) (Table 1).
The need to fix and revise—Vancouver B2 & B3
The presence of a loose stem associated with a
periprosthetic fracture requires revision arthroplasty and
fixation with the aim of achieving both a stable implant
and a healed fracture (22). Revision arthroplasty for
peri-prosthetic fractures has been described using both
uncemented and cemented implants.
When uncemented prostheses are used, tapered fluted
titanium stems can be used to achieve diaphyseal fixation
while enabling the surgeon to bypass the fracture site
and achieve fixation distal to the fracture (11). Modular
implants have previously been popular allowing more
freedom to reconstruct the anatomy; however, there is an
increasing trend towards non-modular implants which avoid
complications associated with corrosion and fatigue failure
particularly when bone stock support may be limited (23).
Controversy surrounds periprosthetic fractures in the
Table 1 Studies demonstrating outcomes of various xation constructs for Vancouver B1 or C fractures
Author Year N (fractures) Mean F/U
(months) Treatment Outcomes
Froberg et al. 2012 (15) 2012 60: B1 & C 23 Locking plate 13% revision, 72% union at 6
months
Lindahl et al. 2006 (21) 2006 90: B1 60 Non-locking plate 24% revision, 23% non-union
Zhang et al. 2013 (14) 2013 12: B1 13.3 Orthogonal plates 100% union
Tsiridis et al. 2003 (17) 2003 3: B1; 3: C 6 Dall-Miles cable plate 66% revision, 33% union
Apivatthakakul et al. 2012 (18) 2011 10 13.2 Percutaneous cables and plate 100% union at 18 weeks
Haddad et al. 2002 (3) 2002 40 28 Cortical strut graft ± plate 98% union
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presence of a cemented hip replacement and whether
the stem should be considered loose given that inherent
lack of bonding between cement and stem. Some authors
have suggested that the presence of fracture around a
cemented stem is as an absolute indication for revision
arthroplasty (22). In contrast, Goudie et al. achieved a 91%
union rate in 79 periprosthetic fractures around cemented
polished tapered stems using open reduction internal
fixation (ORIF) with a broad dynamic compression plate
(DCP) plate only suggesting that simultaneous revision
arthroplasty is not required (24). Furthermore, the
authors advocate, and had no complication from the use of
biocritical locking screws proximally, avoiding the stem but
accepting the cement mantle may be breeched. This has
also been the experience of the senior authors.
Regardless of the stem fixation there has been concern
raised that increased failure of fixation in some fracture
patterns may be due to the incorrect diagnosis of a B2
fractures (13) i.e., failure to recognise at the time of
presentation that the stem is loose. Certainly, evidence
from the Swedish Hip Arthroplasty registry suggests poor
outcomes with xation of B1 fracture compared to xation
and revision of B2 fractures and it has been proposed that
this may be an indication of mis-diagnosis of a B2 fracture
at initial presentation and failure to recognise that the loose
stem (13).
Encouraging outcomes have been reported following
treatment of Vancouver B2 and B3 fractures with revision
of the stem and reduction and cable xation of the fractured
proximal femur. The rate of union reported with this
technique has been reported to be 98% union and 11%
revision rates at a mean follow up for 4.5 years (11).
Vancouver B3 fractures present unique surgical challenges
as there is a loose prosthesis in the presence of poor bone
quality and often poor bone stock. While a fix and revise
approach may be effective we would recommend having
other options available such as impaction bone grafting (25)
or reconstruction using megaprosthesis (26). These patients
often have significant co morbidities therefore techniques
which facilitate expedient reconstruction and with minimal
anaesthetic time and surgical burden should be considered
and a single surgical episode is preferable to need for
revision surgery.
Discussion
In a recent systematic review of internal fixation methods
for Vancouver B1 fractures (10), four groups were separated
based on the type of construct used including ORIF with
cortical strut allograft, ORIF with cable or compression
plate, ORIF with plate and strut graft and ORIF with
locking plates. The final analysis included 333 patients of
which 46% were fixed with cable or compression plate,
36% with locking plates, 13% with plating and cortical
strut graft and 6% with cortical strut graft only. The union
rate was 95% for all types of fixation and when grouped
complications included non-union (5%), metal work failure
(4%), infection (5%) and need for reoperation (9%). In
particular locking plate fixation demonstrated a more
signicant complication rate for non-union 9% vs. 3% and
metalwork failure 7% vs. 2% therefore supporting the use of
cable plate or compression plating techniques. In addition,
the authors highlight the fact that in this complex highly
comorbid population the reoperation rate of 9% represents
a signicant burden with high risk for the patients involved.
In this often-challenging group of patients we suggest that
the main surgical priorities should focus on achieving a
stable reduction with a solid xation, a stable implant and
allowing early mobilisation and full weight bearing.
We retrospectively reviewed the outcomes of total
femoral plating of periprosthetic fractures around stable
hip or knee replacements to consider whether a spanning
plate from trochanter to distal femur may reduce the risk of
further periprosthetic fracture or metalwork failure whilst
allowing our patients to fully weight bear immediately
following surgery. We followed up 17 patients at a mean
duration of 24 months post-op who had undergone total
femoral plating for a periprosthetic fracture of the femur
(unpublished data). Nine cases involved only a total hip
replacement (THR), 6 cases only a total knee replacement
(TKR) and 2 cases were interprosthetic. Average age was
72.5 years (range, 42–88 years), 88% were female, 12%
female. Median ASA grade was 3.
Three patients were excluded from outcome scores as
they were unable to complete the questionnaires due to
dementia. Of the remaining 14 patients the mean Oxford
Hip or Knee score was 50.25 (range, 23–60), EQ-5D scores
were 4.0, 4.3, 4.1, 4.3 and 4.1 out of 5 for mobility, self-care,
activity, pain and anxiety respectively. Visual Analogue Scale
for general health was 64.4/100. At 6 months follow up
76% had achieved clinical and radiographic union. There
were no other implant or patient related complications
observed when using total femoral plating suggesting that
this is a safe option. Moloney et al. 2014 also describe
a similar technique by ensuring their plating technique
extended from trochanter down to the femoral condyles
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around well-fixed stems. In 21 patients treated using this
xation method mean time to union was 19 weeks and there
were no cases of non-union and metalwork failure unlike a
comparable shorter plate fixation cohort (27). Therefore,
we propose that the technique of plate application may be
as important as the choice of internal xation construct and
future studies should also aim to compare “spanning” or
“total femoral plating” outcomes.
Conclusions
In the presence of a well-fixed stem there are various
options for retaining the implant and reduction and
xation of the fracture, but loose implants require revision
arthroplasty and internal xation. We have described some
of the potential pitfalls of internal xation of periprosthetic
fractures including non-union, metalwork failure and
discussed the important relationship to the physiologic
health of the patient. Future large-scale randomised trials
are needed to determine the optimum xation option with
an aim to reduce these complications.
Acknowledgements
None.
Footnote
Conicts of Interest: The authors have no conicts of interest
to declare.
References
1. Chakravarthy J, Bansal R, Cooper J. Locking plate
osteosynthesis for Vancouver Type B1 and Type C
periprosthetic fractures of femur: a report on 12 patients.
Injury 2007;38:725-33.
2. Katz JN, Wright EA, Polaris JJ, et al. Prevalence and risk
factors for periprosthetic fracture in older recipients of
total hip replacement: a cohort study. BMC Musculoskelet
Disord 2014;15:168.
3. Haddad FS, Duncan CP, Berry DJ, et al. Periprosthetic
femoral fractures around well-xed implants: use of
cortical onlay allografts with or without a plate. J Bone
Joint Surg Am 2002;84-A:945-50.
4. Bhattacharyya T, Chang D, Meigs JB, et al. Mortality after
periprosthetic fracture of the femur. J Bone Joint Surg Am
2007;89:2658-62.
5. Birch CE, Blankstein M, Chlebeck JD, et al. Orthogonal
plating of Vancouver B1 and C-type periprosthetic femur
fracture nonunions. Hip Int 2017;27:578-83.
6. Mont MA, Maar DC. Fractures of the ipsilateral femur
after hip arthroplasty. A statistical analysis of outcome
based on 487 patients. J Arthroplasty 1994;9:511-9.
7. Giannoudis PV, Kanakaris NK, Tsiridis E. Principles
of internal xation and selection of implants for
periprosthetic femoral fractures. Injury 2007;38:669-87.
8. Boylan MR, Riesgo AM, Paulino CB, et al. Mortality
Following Periprosthetic Proximal Femoral Fractures
Versus Native Hip Fractures. J Bone Joint Surg Am
2018;100:578-85.
9. Duncan CP, Masri BA. Fractures of the femur after hip
replacement. Instr Course Lect 1995;44:293-304.
10. Dehghan N, McKee MD, Nauth A, et al. Surgical xation
of Vancouver type B1 periprosthetic femur fractures: a
systematic review. J Orthop Trauma 2014;28:721-7.
11. Abdel MP, Cottino U, Mabry TM. Management of
periprosthetic femoral fractures following total hip
arthroplasty: a review. International Orthopaedics
(SICOT) 2015;39:2005-10.
12. Bryant GK, Morshed S, Agel J, et al. Isolated locked
compression plating for Vancouver Type B1 periprosthetic
femoral fractures. Injury 2009;40:1180-6.
13. Lindahl H, Malchau H, Odén A, et al. Risk factors for
failure after treatment of a periprosthetic fracture of the
femur. J Bone Joint Surg Br 2006;88:26-30.
14. Zhang Y, Fan X, Liu Y, et al. Limited open reduction
and double plates internal xation for treatment of
Vancouver type B1 periprosthetic femoral fracture after
hip arthroplasty. Zhongguo Xiu Fu Chong Jian Wai Ke Za
Zhi 2013;27:1428-31.
15. Froberg L, Troelsen A, Brix M. Periprosthetic Vancouver
type B1 and C fractures treated by locking-plate
osteosynthesis: fracture union and reoperations in 60
consecutive fractures. Acta Orthop 2012;83:648-52.
16. Fulkerson E, Egol KA, Kubiak EN, et al. Fixation
of diaphyseal fractures with a segmental defect: a
biomechanical comparison of locked and conventional
plating techniques. J Trauma 2006;60:830-35.
17. Tsiridis E, Haddad FS, Gie GA. Dall-Miles plates for
periprosthetic femoral fractures. A critical review of 16
cases. Injury 2003;34:107-10.
18. Apivatthakakul T, Phornphutkul C, Bunmaprasert
T, et al. Percutaneous cerclage wiring and minimally
invasive plate osteosynthesis (MIPO): a percutaneous
reduction technique in the treatment of Vancouver type
Page 6 of 6 Annals of Joint, 2018
© Annals of Joint. All rights reserved. Ann Joint 2018;3:65aoj.amegroups.com
B1 periprosthetic femoral shaft fractures. Arch Orthop
Trauma Surg 2012;132:813-22.
19. Mihalko WM, Beaudoin AJ, Cardea JA, et al. Finite-
element modelling of femoral shaft fracture xation
techniques post total hip arthroplasty. J Biomech
1992;25:469-76.
20. Zdero R, Walker R, Waddell JP, et al. Biomechanical
evaluation of periprosthetic femoral fracture xation. J
Bone Joint Surg Am 2008;90:1068-77.
21. Lindahl H, Garellick G, Regnér H, et al. Three Hundred
and twenty-one periprosthetic femoral fractures. J Bone
Joint Surg Am 2006;88:1215-22.
22. Grammatopoulos G, Pandit H, Kambouroglou G, et al.
A unique peri-prosthetic fracture pattern in well xed
femoral stems with polished, tapered, collarless design of
total hip replacement. Injury 2011;42:1271-6.
23. Sandiford NA, Garbuz DA, Masri BA, et al. Nonmodular
Tapered Fluted Titanium Stems Osseointegrate Reliably
at Short Term in Revision THAs. Clin Orthop Relat Res
2017;475:186-92.
24. Goudie ST, Patil S, Patton JT, et al. Outcomes
following osteosynthesis of periprosthetic hip
fractures around cemented tapered polished stems.
Injury 2017;48:2194-200.
25. Wimmer MD, Randau TM, Deml MC, et al. Impaction
grafting in the femur in cementless modular revision
total hip arthroplasty: a descriptive outcome analysis of
243 cases with the MRP-TITAN revision implant. BMC
Musculoskelet Disord 2013;14:19.
26. Parvizi J, Sim FH. Proximal femoral replacements
with megaprostheses. Clin Orthop Relat Res
2004;(420):169-75.
27. Moloney GB, Westrick ER, Siska PA, et al. Treatment
of periprosthetic femur fractures around a well-xed hip
arthroplasty implant: span the whole bone. Arch Orthop
Trauma Surg 2014;134:9-14.
doi: 10.21037/aoj.2018.07.03
Cite this article as: Davenport D, Hutt JR, Mitchell PA,
Trompeter A, Kendoff D, Sandiford NA. Management of
peri-prosthetic fractures around total hip arthroplasty: a
contemporary review of surgical options. Ann Joint 2018;3:65.
... PPF is of concern due to the significant impact on the patient and cost to the health care system. 5 Several studies have shown poor long term functional outcome and slower return to prefracture mobility after periprosthetic femoral fractures, 6 in addition to an increased mortality risk. 7,8 The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) provides a tool to assist in interpretation of local arthroplasty revision rates. ...
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Aim: The Anatomique Benoist Girard (ABG) II femoral implant was a commonly used stem for primary total hip replacement (THR) at our institution (Launceston, Tasmania Australia). We identified peri-prosthetic fracture as the main cause of late failure. Methods: The late periprosthetic fracture rate for ABG II implants was reviewed with national statistics, using Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) data. National revision rates for periprosthetic fracture were used to compare ABG II with all other cementless femoral stems. Result: ABG II stems accounted for 1% (2719 implants) of all femoral stem implants in Australia during the 12-year review period, compared to 23% (587 implants) in Launceston Hospitals. Although the Launceston cumulative percent revision rate for the ABG II stem was lower than the National rate at all time points, the reasons for revision were similar. The most common reason for revision of ABG II was fracture (56.8%), followed by loosening (15.3%). This differs from the reasons for revision in other cementless prostheses (loosening 23.9%, fracture 20.8%, dislocation 18.7%). Cumulative percent revision rates from late periprosthetic fracture, were higher for the ABG II stem than other cementless femoral prostheses. Conclusion: This review of the AOANJRR has confirmed a local and national higher revision rate of the ABG II stem due to late periprosthetic fracture compared with other cementless stems. Stem design must be considered to reduce the risk of late periprosthetic fracture.
... The fractures are devastating complications that result in functional limitations, increase overall mortality, and pose great burdens on trauma and orthopaedic surgeons. The injury usually occurs in patients with multiple comorbidities, and the management tends to be difficult [29]. ...
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Purpose The aim of this retrospective study was to investigate the treatment of traumatic periprosthetic femoral fractures with open reduction and internal fixation. The outcomes with the use of the surgical techniques were also reported. Methods Between September 2017 and September 2019, 25 patients with traumatic periprosthetic femoral fractures were managed by open reduction and internal fixation in Ain Shams University Hospital, Egypt. The fixation methods were selected based on the surgeon’s preference. Outcomes were assessed using the Harris Hip Score, visual analogue score (VAS) for pain, and EuroQol 5 Dimensions – 5 Level (EQ5D-5L) prior to and after surgery. Patients were regularly followed up for one year. A P value < 0.05 was considered to be statistically significant. Results The mean age at surgery was 77 years (range, 51 to 95 years), 64% ( n = 16) were females. According to the Vancouver classification, there were 1 type AG, 15 type B1, and 9 type C fractures. Postoperative complications included wound site infection ( n = 2) and non-union ( n = 1). The mean pre-trauma Harris Hip Score was 77.44 ± 8.63 (range, 65 to 90), and the mean Harris Hip Score collected at the final follow-up was 72.47 ± 8.85 (range, 60 to 86) ( P < 0.05). The mean pre-trauma VAS was 2.20 ± 1.21 (range, 0 to 4), and the mean VAS recorded at the final follow-up was 3.00 ± 1.41 (range, 0 to 5) ( P < 0.05). According to the EQ5D-DL assessed at the final follow-up, no patient felt that their daily life and activities became more problematic. Conclusion This study provided added validation of the current management of periprosthetic femoral fractures after total hip arthroplasty. Using the proper fixation and implant can achieve a reliable fixation and good functional recovery. Level of evidence IVa
... Therefore, it is perhaps not surprising that low preoperative BMD is a risk factor for periprosthetic fracture [44,45]. Periprosthetic fracture represents a severe clinical challenge due to the relatively complicated and expensive surgical care [46]. The complications following surgical Fig. 1 Representation of the prevalence of osteoporosis [4] and TJR surgery [7,8] in the USA based on the 2010 estimates. ...
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Purpose of review: The purpose of this review is to critically evaluate the current literature regarding implant fixation in osteoporotic bone. Recent findings: Clinical studies have not only demonstrated the growing prevalence of osteoporosis in patients undergoing total joint replacement (TJR) but may also indicate a significant gap in screening and treatment of this comorbidity. Osteoporosis negatively impacts bone in multiple ways beyond the mere loss of bone mass, including compromising skeletal regenerative capacity, architectural deterioration, and bone matrix quality, all of which could diminish implant fixation. Recent findings both in preclinical animal models and in clinical studies indicate encouraging results for the use of osteoporosis drugs to promote implant fixation. Implant fixation in osteoporotic bone presents an increasing clinical challenge that may be benefitted by increased screening and usage of osteoporosis drugs.
... The aim of surgery is to stabilize and bridge the insufficient bone area with an osteosynthesis plate and cerclages. 7 For cortical defects the use of an allogenic bone grafting combined with a long revision implant seems to represent an useful stabilization of insufficient bone conditions of the femur. ...
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Cortical bone loss in revision hip arthroplasty requires an adequate stabilization to achieve a durable implant fixation. This case series shall illustrate possible indications for the use of allogenic grafts in revision hip arthroplasty. Twelve patients with femoral bone loss were treated with allografts. In addition to established clinical scores, the radiological follow-ups were analyzed for hints of implants loosening and the osteointegration of the allografts. After a mean follow-up of 3.0 years the mHHS was 61.3 points and the UCLA 3.8. One patient showed a non-progressive radiolucency around the hip implant. The osteointegration of all allogenic grafts happened on time. Up to the last follow-up no revision surgery of the hip implants and the associated femoral bone graft was observed. Allogenic bone grafts present a method for biological stabilization in situations of large femoral cortical bone defects in revision hip arthroplasty.
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Objective The aim of this study was to report outcomes in dogs with periprosthetic femoral fractures associated with a press-fit cementless femoral total hip replacement implant. Methods Electronic medical records and digital radiographs were used to identify dogs with periprosthetic femoral fractures associated with press-fit cementless total hip replacement. Data collected included signalment, weight, time of fracture, cause of fracture, presence of intra-operative fissure, fracture type, repair technique, and clinical and radiographic outcomes. Long-term patient outcome was assessed by communication with owners or referring veterinarians. Results Twenty-eight dogs with femoral fracture repair associated with cementless press-fit total hip replacement were identified. Eight of the fractures occurred intraoperatively and 20 occurred at a median of 2 days postoperatively. An oblique or spiral configuration was noted in 19 cases and 15 occurred at the distal end of the femoral stem (type B), with thirteen type B1, one type B2 and one type B3 fractures. Fractures were repaired with non-locking (18/28) or locking-plate fixation (10/28). Cerclage wire was applied around the plate and proximal bone segment in 17/28 dogs. Major complications occurred in 7/28 cases (five deep infection, two mechanical failures). Bone healing was noted in 21/23 cases, for which follow-up radiographic interpretation was available. Return to function was complete in 17 cases, acceptable in 8 cases and unacceptable in 3 cases. Conclusions While cementless total hip replacement periprosthetic femoral fractures can be successfully repaired with lateral plate fixation, the risk of infection appears to be high.
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Background: The ideal femoral component for revision THA is undecided. Cylindrical nonmodular stems have been associated with stress shielding, whereas junctional fractures have been reported with tapered fluted modular titanium stems. We have used a tapered fluted nonmodular titanium femoral component (Wagner Self-locking [SL] femoral stem) to mitigate this risk. This component has been used extensively in Europe by its designer surgeons, but to our knowledge, it has not been studied in North America. Added to this, the design of the component has changed since early reports. Questions/purposes: We asked: (1) Does the Wagner SL stem have low rates of rerevision and other complications at a minimum 2 years after surgery? (2) Is the Wagner SL stem associated with high levels of patient function and pain relief at a minimum 2 years after surgery? (3) Does the Wagner SL stem have low rates of subsidence at a minimum 2 years after surgery? (4) Is the Wagner SL stem associated with proximal femoral bone remodeling at a minimum 2 years after surgery? Method: Between May 2011 and December 2012, we performed 198 femoral revisions, of which 104 (53%) were performed using the Wagner SL femoral stem; during that period, our institution gradually shifted toward increasing use of these stems for all but the most severe revisions, in which modular fluted stems and proximal femoral replacements still are used on an occasional basis. Median followup in this retrospective study was 32 months (range, 24-46 months), and one patient was lost to followup before the 2-year minimum. The femoral deformities in this series were Paprosky Type I (10 hips), Paprosky Type II (26), Paprosky Type IIIA (52), Paprosky Type IIIB (nine), and Paprosky Type IV (two). Functional assessment was performed using the Oxford Hip Score (OHS), WOMAC, SF-12, and the University of California Los Angeles (UCLA) activity score. All complications and cases of revision were documented. All patients had radiographs performed within 1 year of the latest followup. These were assessed by two surgeons for signs of proximal femoral bone remodeling and subsidence. Results: Complete preoperative scores were available for 98 patients (98 of 104; 94%). The mean OHS preoperatively and at final followup were 39 (SD, 15) and 87 (SD, 19), respectively (p < 0.001; mean difference, 48; 95% CI, 43-53). Average WOMAC scores were 44 (SD, 15) and 87 (SD, 20), respectively (p < 0.001; mean difference, 43; 95% CI, 38-48). At final followup, signs of restoration of proximal femoral bone stock was noted in 45 of 103 hips (44%). Six (six of 104; 6%) patients had subsidence of 10 mm to 15 mm. In the remainder (98 of 104; 94%), the mean subsidence was 2 mm (range, 0-9 mm). One revision was performed for loosening associated with infection. Conclusions: The Wagner SL stem is a viable option for patients with Paprosky Types II and III defects undergoing revision THA. This component provides high levels of patient function with low revision rates and low rates of subsidence during the early postoperative phase. They provide a viable alternative to modular components for treatment of Types II and III defects without the risk of junctional fractures. They can be used for very selected Type IV defects, however this extent of bone loss is most easily addressed with other techniques such as a proximal femoral replacement. Level of evidence: Level IV, therapeutic study.
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Background The growing utilization of total joint replacement will increase the frequency of its complications, including periprosthetic fracture. The prevalence and risk factors of periprosthetic fracture require further study, particularly over the course of long-term follow-up. The objective of this study was to estimate the prevalence and risk factors for periprosthetic fractures occurring in recipients of total hip replacement. Methods We identified Medicare beneficiaries who had elective primary total hip replacement (THR) for non-fracture diagnoses between July 1995 and June 1996. We followed them using Medicare Part A claims data through 2008. We used ICD-9 codes to identify periprosthetic femoral fractures occurring from 2006–2008. We used the incidence density method to calculate the annual incidence of these fractures and Cox proportional hazards models to identify risk factors for periprosthetic fracture. We also calculated the risk of hospitalization over the subsequent year. Results Of 58,521 Medicare beneficiaries who had elective primary THR between July 1995 and June 1996, 32,463 (55%) survived until January 2006. Of these, 215 (0.7%) developed a periprosthetic femoral fracture between 2006 and 2008. The annual incidence of periprosthetic fracture among these individuals was 26 per 10,000 person-years. In the Cox model, a greater risk of periprosthetic fracture was associated with having had a total knee replacement (HR 1.82, 95% CI 1.30, 2.55) or a revision total hip replacement (HR1.40, 95% CI 0.95, 2.07) between the primary THR and 2006. Compared to those without fractures, THR recipients who sustained periprosthetic femoral fracture had three-fold higher risk of hospitalization in the subsequent year (89% vs. 27%, p < 0.0001). Conclusion A decade after primary THR, periprosthetic fractures occur annually in 26 per 10,000 persons and are especially frequent in those with prior total knee or revision total hip replacements.
Article
Background: The number of periprosthetic proximal femoral fractures is expected to increase with the increasing prevalence of hip arthroplasties. While native hip fractures have a well-known association with mortality, there are currently limited data on this outcome among the subset of patients with periprosthetic proximal femoral fractures. Methods: Using the New York Statewide Planning and Research Cooperative System, we identified patients from 60 to 99 years old who were admitted to a hospital in the state with a periprosthetic proximal femoral fracture (n = 1,655) or a native hip (femoral neck or intertrochanteric) fracture (n = 97,231) between 2006 and 2014. Within the periprosthetic fracture cohort, the indication for the existing implant was not available in the data set. We used mixed-effects regression models to compare mortality at 1 and 6 months and 1 year for periprosthetic compared with native hip fractures. Results: The risk of mortality for patients who sustained a periprosthetic proximal femoral fracture was no different from that for patients who sustained a native hip fracture at 1 month after injury (3.2% versus 4.6%; odds ratio [OR], 0.90; 95% confidence interval [CI], 0.68 to 1.19; p = 0.446), but was lower at 6 months (3.8% versus 6.5%; OR, 0.74; 95% CI, 0.57 to 0.95; p = 0.020) and 1 year (9.7% versus 15.9%; OR, 0.71; 95% CI, 0.60 to 0.85; p < 0.001). Among periprosthetic proximal femoral fractures, factors associated with a significantly increased risk of mortality at 1 year included advanced age, male sex, and higher Deyo comorbidity scores. Conclusions: In the acute phase, any type of hip fracture appears to confer a similar risk of death. Over the long term, however, periprosthetic proximal femoral fractures are associated with lower mortality rates than native hip fractures, even after accounting for age and comorbidities. Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Article
We retrospectively reviewed outcomes of 79 patients with periprosthetic hip fractures around cemented tapered polished stem (CTPS) implants treated with osteosynthesis between January 1997 and July 2011. All patients underwent open reduction and fixation using a broad dynamic compression plate (DCP). Seventy two (91%) of fractures united. There were seven (9%) non-unions with failure of metal work, three (4%) as a result of infection and four (5%) due to mechanical failure. Significant subsidence (>5 mm) of the implant was seen in seven (9%) of cases. Ten (13%) cases developed post-operative infection. Non-anatomic reduction and infection were identified as predictors of poor outcome. This is the largest series of a very specific group of periprosthetic fractures treated with osteosynthesis. Open reduction internal fixation with a broad dynamic compression plate for patients with periprosthetic hip fractures around the tip of cemented tapered polished stems is a suitable treatment provided there is no bone loss and the fracture can be precisely, anatomically, reduced and adequately fixed.
Article
Background: Periprosthetic femoral shaft fractures are a significant complication after total hip arthroplasty (THA). Plate osteosynthesis has been the mainstay of treatment around well-fixed stems. Nonunions are a rare and challenging complication of this fixation method. We report the outcomes of a novel orthogonal plating surgical technique for Vancouver B1 and C-type periprosthetic fractures that previously failed open reduction internal fixation (ORIF). Methods: A retrospective review identified all patients with Vancouver B1/C THA periprosthetic femoral nonunions from 2010 to 2015. Exclusion criteria included open fractures and periprosthetic infections. The technique utilised a mechanobiologic strategy of atraumatic exposure, resection of necrotic tissue, bone grafting with adjuvant bone morphogenetic protein (BMP) and revision open reduction internal fixation with orthogonal plate osteosynthesis. Results: 6 Vancouver B1/C periprosthetic femoral nonunions were treated. 5 patients were female with an average age of 80.3 years (range 72-91 years). The fractures occurred at a mean of 5.8 years (range 1-10 years) from their initial arthroplasty procedure. No patients underwent further revision surgery; there were no perioperative complications. All patients had a minimum of 11 months follow-up (mean 18.6, range 11-36 months). All fractures achieved osseous union, defined as solid bridging callus over at least 2 cortices and pain free, independent ambulation, at an average of 24.4 weeks (range 6.1-39.7 weeks). Conclusions: This is the 1st series describing orthogonal locked compression plating using modern implants for periprosthetic femoral nonunions. This technique should be considered in periprosthetic femur fracture nonunions around a well-fixed stem.
Article
As the number of total hip arthroplasties (THAs) is increasing, the expected number of periprosthetic femur fractures is also expected to increase. As such, a thorough grasp of the evaluation and management of patients with periprosthetic femur fractures is imperative, and discussed in this review. This review discusses the epidemiology, classification, and management of periprosthetic femur fractures in an evidence-based fashion. Periprosthetic fracture management starts with assessing stem stability and bone quality. Well-fixed stems require fracture fixation without stem revision, while loose stems require revision THA. Periprosthetic femoral fractures after primary total hip arthroplasty are a complex and clinically challenging issue. The treatment must be based on the fracture, the prosthesis, and the patient (Table 1). The Vancouver classification is not only helpful in classifying the fractures, but also in guiding the treatment. In general, well-fixed stems require open reduction and internal fixation, whereas loose stems require revision arthroplasty.
Article
Vancouver Type B1 periprosthetic femur fractures occur around a stable implant and are typically treated with open reduction and internal fixation (ORIF). Different fixation techniques are described in the literature, and there is a lack of consensus with regards to the best operative fixation strategy. The purpose of this investigation was to systematically review and compare the most commonly used fixation strategies for these fractures. A database search was performed using Pubmed, Medline and Cochrane databases to identify studies published in English language from 1985-2013. Manuscripts with a minimum of five patients with type B1 periprosthetic femur fractures and containing outcome data regarding non-union, mal-union, infection, and re-operation rate, were included. Studies were analyzed and categorized into four groups: Group 1) ORIF with cortical strut allografts alone, Group 2) ORIF with cable-plate/compression plates alone, Group 3) ORIF with cable-plate/compression plates and cortical strut allograft, Group 4) ORIF with locking plates alone. Individual patient outcomes were extracted for each study, and pooled for each of the four groups. Data analysis was performed comparing rates of non-union, malunion, hardware failure, infection, and re-operation. Data was analyzed with the use of Review Manager, and SAS 9.3. In total 333 patients identified, with an overall rate of 5% nonunion, 6% malunion, 5% infection, 4% hardware failure, 9% reoperation and 15% total complications. When comparing outcomes for different modes of fixation, compared to cable-plate/compression plate systems, locking plates had a significantly higher rate of nonunion (3% vs 9% p=0.02) and a trend towards a higher rate of hardware failure (2% vs 7%, P=0.07). There are limitations to this study, and further investigation with high quality randomized controlled trials is needed to effectively compare treatment strategies.
Article
To evaluate the effectiveness of limited open reduction and double plates internal fixation in the treatment of Vancouver type B1 periprosthetic femoral fracture after hip arthroplasty. A retrospective analysis was made on the clinical data of 12 patients with Vancouver type B1 periprosthetic femoral fracture after hip arthroplasty between May 2007 and October 2012, who underwent limited open reduction and double plates internal fixation. Of 12 patients, 4 were male and 8 were female, aged 76-85 years (mean, 81.6 years); the left side was involved in 5 patients and the right side in 7 patients. The cement prosthesis was used in 3 cases and cementless prosthesis in 9 cases; double acting head of hip arthroplasty was performed in 4 cases and total hip arthroplasty in 8 cases. The median time from first hip arthroplasty to re-fracture was 13 months (range, 5 months-5 years). The causes of injury were traffic accident in 2 cases and falling in 10 cases. Combined fractures included contralateral tibial and fibular fractures and ipsilateral distal humeral fracture (1 case), ipsilateral proximal humeral fracture (2 cases), ipsilateral distal radial fracture (1 case), and rib fracture (1 case). The time from injury to operation was 5.6 days on average (range, 3-10 days). The incisions all healed by first intention, and no infection or deep venous thrombosis of lower extremity occurred. Twelve cases were followed up 6-24 months (mean, 13.3 months). One female patient died of acute myocardial infarction at 16 months after operation. All the fractures were healed, with X-ray healing time of 12.5 weeks on average (range, 10-16 weeks). The time of full weight bearing was 13 weeks on average (range, 10-18 weeks). Ten cases could walk freely after operation, and 2 cases could walk by the aid of walking aid appliance. At last follow-up, the Harris score of hip function was 87.3 on average (range, 75-93). The method of limited open reduction and double plates internal fixation for Vancouver type B1 periprosthetic femoral fracture after hip arthroplasty is effective in maintaining stability, protecting blood supply, promoting fracture healing, and doing functional exercise early. The long-term effectiveness needs further observation.
Article
Periprosthetic femur fractures are a growing problem in the geriatric population. This study examines Vancouver B1 periprosthetic femur fractures treated with open reduction internal fixation using a laterally based plate. Outcomes using plates which spanned the length of the femur to the level of the femoral condyles were compared to those which did not. The hypothesis was that spanning internal fixation would result in a decreased rate of refracture and subsequent reoperation. Patients admitted to three affiliated academic hospitals treated with open reduction internal fixation for a periprosthetic femur fracture in the setting of a preexisting total hip arthroplasty or hemiarthroplasty stem were identified. Patient data were reviewed for age, gender, fracture classification, operative intervention, time to union, as well as complications related to treatment and need for further surgery. Over a 5-year period, 58 patients were treated with open reduction internal fixation using a laterally based plate for Vancouver B1 femur fractures. Twenty-one patients were treated with plates that extended to the level of the femoral condyles. In that group there were no nonunions or subsequent periprosthetic fractures reported. Of 36 patients treated with short plates, 3 went on to nonunion resulting in plate failure and refracture and 2 sustained a subsequent fracture distal to the existing fixation. In this series, fixation for periprosthetic femur fractures around a well-fixed arthroplasty stem which spans the length of the femur to the level of the femoral condyles is associated with a decreased rate of nonunion and refracture. By decreasing the rate of refracture and nonunion, spanning fixation decreases the morbidity and mortality associated with additional surgery in a fragile geriatric population.