Retrograde bridging nailing of periprosthetic femoral fractures

A systematic review of the surgical outcomes of interprosthetic femur fractures

Background

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

Methods

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

Results

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

Conclusion

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

Interprosthetic Femur Fractures: A Review Article

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The prevalence of interprosthetic femur fractures (IFFs) is rising with the aging population and increased prevalence of total joint arthroplasty.

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IFFs have high rates of complications and high associated morbidity and mortality.

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The main treatment methods available for IFFs include plate fixation, intramedullary nailing, combined plate fixation and intramedullary nailing, and revision arthroplasty including partial and total femur replacement.

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There have been several proposed classification systems and at least 1 proposed treatment algorithm for IFFs; however, there is no consensus.

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Whichever treatment option is chosen, goals of surgery should include preservation of blood supply, restoration of length, alignment, rotation, and sufficient stabilization to allow for early mobilization.

Interprosthetic Femoral Fractures Surgical Treatment in Geriatric Patients

Background

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

Methods

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

Results

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

Conclusion

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

Level of Evidence

Level III, Therapeutic study.

The Effect of Age on Fracture Healing Time in Metacarpal Fractures

Background: Older patients are treated for fracture with increasing frequency. Although studies on animals suggest that older mice and rats heal fractures more slowly, the clinical implications remain unclear. A better understanding of differences in healing with age can help customize fracture treatment. Our purpose was to retrospectively evaluate metacarpal fractures for healing time looking specifically at age-related differences. Methods: A retrospective review of patients treated for metacarpal fractures was conducted. Patients with incomplete charts or inadequate follow-up were excluded. One hundred ninety-eight charts were analyzed. Demographic and other patient factors were documented. Fracture characteristics and treatment type were documented. Fracture healing was determined clinically. Plain radiographs and examination were used in decision making. Results: Age was not associated with fracture healing time as a continuous variable (P = .09). Patients above 75 years were not associated with increased healing time (P = .58). Fracture characteristics were related to healing time: minimally displaced and comminuted fractures healed faster than oblique fractures, spiral fractures, or transverse fractures (P = .048). Patients undergoing surgery healed faster than those without surgery (P = .046). Renal failure negatively affected fracture healing time (P = .03). Diabetes, hypothyroidism, and gender were not associated with healing time. Complications were not associated with age or other patient or fracture-related factors. Conclusions: Age does not affect clinical fracture healing time in adult. Therefore, older patients do not require disparate treatment. Other fracture-related factors and considerations such as functional demand and support systems might influence treatment decisions in fracture care.

Prosthesis-Engaging Retrograde Femoral Nail with Locking Plate for the Treatment of a Vancouver B1 Periprosthetic Femur Fracture Nonunion: A Case Report

CASE

Here, we describe a case of a Vancouver B1 periprosthetic femur fracture which initially went on to nonunion after open reduction and internal fixation. Union was ultimately achieved with a construct consisting of a prosthesis-engaging retrograde femoral nail and a locking compression plate.

CONCLUSIONS

This case provides evidence that a construct consisting of a prosthesis-engaging retrograde femoral nail and a locking compression plate is an option for increasing fracture site stability in Vancouver B1 periprosthetic fractures and may be useful for patients with poor bone quality or a previously established nonunion.

Interprosthetic Fractures of the Femur

As the rate of hip and knee arthroplasty procedures increases, so will the rate of interprosthetic fractures. Several factors, including bone quality, bone quantity, and stability of the prosthetic components, play a role in determining the appropriate operative treatment. Patients with stable components should undergo reduction and internal fixation, while patients with loose components should undergo either revision arthroplasty, with or without additional fixation, or conversion to total femur replacement. Despite implant and technique advances, complications remain frequent. [Orthopedics. 2018; 41(1):e1-e7.].

Periprosthetic femoral fractures after hemiarthroplasty. An analysis of 17 cases

PURPOSE

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

MATERIAL AND METHOD

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

The treatment of periprosthetic femur fractures after total knee arthroplasty

Periprosthetic femur fractures after total knee arthroplasty are a rising concern; however, when properly diagnosed, they can be managed nonoperatively or operatively in the form of locking plate fixation, intramedullary nailing, and arthroplasty. The degree of osteoporosis, stability of the femoral implant, and goals of the patient are a few critical variables in determining the ideal treatment. Despite excellent outcomes from each of these operative choices, the risk of nonunion, malunion, instability, and refracture cannot be ignored.

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

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

Primary versus secondary distal femoral arthroplasty for treatment of total knee arthroplasty periprosthetic femur fractures

Current methods of fixing periprosthetic fractures after total knee arthroplasty (TKA) are variable, and include open reduction and internal fixation (ORIF) via plating, retrograde nailing, or revision using standard revision TKA components or a distal femoral arthroplasty (DFA). The purpose of this study is to compare patients who failed plating techniques requiring subsequent revision to DFA to patients who underwent primary DFA. Of the 13 patients (9.2%) who failed primary ORIF, causes included nonunion (53.8%), infection (30.8%), loosening (7.7%), and refracture (7.7%). There were significantly more surgical procedures for ORIF revision to DFA compared to primary DFA. Complications for patients who underwent primary reconstruction with DFAs included extensor mechanism disruption (8.3%), infection (5.6%), and dislocation (2.8%). Primary reconstruction via ORIF is beneficial for preserving bone stock, but primary DFA may be preferred in osteopenic patients, or those at high risk for nonunion.

Extension malunion of the femoral component after retrograde nailing: no sequelae at 6 years

OBJECTIVES

Supracondylar femoral fracture is a complex complication after total knee arthroplasty (TKA). One potential complication of retrograde locked nailing is malunion in extension of the femoral prosthetic component--produced by an overly posterior nail entry point in the intercondylar notch. The aim of this study was to determine the repercussion of this deformity on the midterm radiological and functional outcomes of TKA.

DESIGN

Retrospective review.

METHODS

From 2001 to 2006, 30 patients were treated for supracondylar femoral fracture above TKA with a retrograde locked nail. In 7 patients (6 women and 1 man) with a mean age of 78.8 years (range, 74-84 years), more than 10 degrees of hyperextension (mean of 18.5 degrees) of the femoral component on the sagittal plane was observed without any significant misalignment on the coronal plane. Functional outcomes were assessed using the Knee Society Score.

RESULTS

After a mean follow-up of 68.5 months (range, 48-111 months), all patients' fractures with a hyperextension of the femoral component had consolidated with no clinical or radiological signs of TKA loosening. These patients presented "good" functional outcomes at final follow-up.

CONCLUSIONS

These results should be interpreted with caution. However, isolated hyperextension of the femoral component of a TKA after placing a retrograde nail for a periprosthetic fracture does not seem to significantly affect the functional or radiological outcomes at ∼6-years follow-up.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Peptic ulcer disease and heart disease are associated with periprosthetic fractures after total hip replacement

BACKGROUND AND PURPOSE

There have been no published studies assessing the possible association of medical comorbidities with periprosthetic fracture risk. We therefore assessed whether medical comorbidity is associated with risk of periprosthetic fractures after total hip replacement (THR).

MATERIAL AND METHODS

We used prospectively collected data from 1989-2008 in the Mayo Clinic Total Joint Registry for 2 cohorts: primary THR and revision THR. The main variables of interest were Deyo-Charlson comorbidities at the time of surgery. Outcome of interest was p ostoperative periprosthetic fracture at postoperative day 1 onwards. Multivariable Cox regression models were additionally adjusted for age, sex, body mass index, American Society of Anesthesiology (ASA) class, and operative diagnosis.

RESULTS

We identified 14,065 primary THRs and 6,281 revision THRs with mean follow-up times of 6.3 and 5.6 years, respectively. There were 305 postoperative periprosthetic fractures in the primary THR cohort and 330 in the revision THR cohort. In patients who underwent primary THR, 2 comorbidities were associated with higher risk of periprosthetic fracture: peptic ulcer disease with adjusted hazard ratio of 1.5 (95% CI: 1.1-2.2) and heart disease with adjusted hazard ratio of 1.7 (CI: 1.2-2.4). In patients with revision THR, peptic ulcer disease was associated with a higher adjusted risk of periprosthetic fracture, 1.6 (CI: 1.1-2.3).

INTERPRETATION

Peptic ulcer disease and heart disease in primary THR patients and peptic ulcer disease in revision THR patients were associated with higher postoperative periprosthetic fracture risk. Further studies are needed to understand whether disease severity or specific medications used for treatment, or both, are responsible for this association. This may allow identification of modifiable factors.

[Periprosthetic fractures after total hip arthroplasty : classification, diagnosis and therapy strategies]

The number of periprosthetic fractures following hip replacement is increasing due to longer life expectancy and the rising number of joint replacements. The main causes of periprosthetic fractures include trauma, implant specific factors or loosening of the endoprosthesis. When planning therapy, surgeons should consider specific and general implant- and patient-related risk factors to ensure the best possible treatment. Established classification systems can facilitate preoperative planning. At present, the Vancouver classification system probably comes closest to the ideal, as it considers fracture configuration, stability of the implant and quality of the bone stock. Depending on these factors, therapeutic options include conservative treatment, fracture stabilisation or replacement of the endoprosthesis. The problems associated with periprosthetic fractures of varying etiology and the available treatment options are discussed against the background of the established classification systems.

[Replacement of femoral hip prostheses]

Femoral revision of total hip arthroplasty is a technically demanding procedure. Therefore, accurate preoperative planning is essential for good clinical results. With many reconstruction methods available, the decision-making process can be complex. Well established classification systems can facilitate preoperative planning. At the time of revision surgery appropriate implants and instruments have to be available ensuring the possibility of managing operative complications. Primary goals of revision arthroplasty are restoration of the physiological joint biomechanics and primary stable fixation of the revision implant. In consideration of possible repeat revision surgery, cementless stem fixation should be preferred. Modular stems provide significant flexibility in restoring the center of rotation. Depending on the pre-existing femoral defect, osseous grafts can be necessary.The scope and classification systems of femoral osseous defects in revision arthroplasty will be discussed and different treatment options will be outlined, which guide the surgeon in selecting an appropriate method of reconstruction.

Are extreme distal periprosthetic supracondylar fractures of the femur too distal to fix using a lateral locked plate?

It is unclear whether there is a limit to the amount of distal bone required to support fixation of supracondylar periprosthetic femoral fractures. This retrospective multicentre study evaluated lateral locked plating of periprosthetic supracondylar femoral fractures and compared the results according to extension of the fracture distal with the proximal border of the femoral prosthetic component. Between 1999 and 2008, 89 patients underwent lateral locked plating of a supracondylar periprosthetic femoral fracture, of whom 61 patients with a mean age of 72 years (42 to 96) comprising 53 women, were available after a minimum follow-up of six months or until fracture healing. Patients were grouped into those with fractures located proximally (28) and those with fractures that extended distal to the proximal border of the femoral component (33). Delayed healing and nonunion occurred respectively in five (18%) and three (11%) of more proximal fractures, and in two (6%) and five (15%) of the fractures with distal extension (p = 0.23 for delayed healing; p = 0.72 for nonunion, Fisher's exact test). Four construct failures (14%) occurred in more proximal fractures, and three (9%) in fractures with distal extension (p = 0.51). Of the two deep infections that occurred in each group, one resolved after surgical debridement and antibiotics, and one progressed to a nonunion. Extreme distal periprosthetic supracondylar fractures of the femur are not a contra-indication to lateral locked plating. These fractures can be managed with internal fixation, with predictable results, similar to those seen in more proximal fractures.

Retrograde bridging nail in periprosthetic femoral fracture treatment which allows direct weight bearing

The bridging nail is a retrograde intramedullary femoral nail designed to stabilize periprosthetic femoral fractures. It offers a minimal invasive surgical approach in combination with early mobilization. The goal of this study was to evaluate the osteosynthesis under full weight-bearing conditions. Three groups of five composite fibreglass femora were prepared with a cemented hip stem. Group 1 underwent cyclic axial loading with 1500 N during 150 000 cycles. After completion, linear loading to failure was conducted. Groups 2 and 3 were submitted to linear increased torsional loading with and without an axial load respectively. Failure was defined as rotational movement of the connection (slippage). In the axial cyclic loading configuration, one specimen failed after 122 000 cycles. Four specimens passed 150 000 cycles and failed after linearly increasing the axial loading of 1940–2600 N (mean, 2408 N ± 313 standard deviation (SD)). Slippage was first detected at a torque varying between 2.5 and 8.2 N m (mean, 5.1 N m ± 2.1 SD) in group 2 and between 10.0 and 15.4 N m (mean, 13.0 N m ± 2.3 SD) in group 3. In conclusion the bridging nail offers a stable connection with the stem of a hip arthroplasty which can resist high repetitive loads, representative of direct full axial weight bearing. The biomechanical results support the clinical experience of a stable osteosynthesis enabling early post-operative mobilization.