Periprosthetic femoral fractures: When I use strut grafts and why?

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

INTRODUCTION

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

SIGNIFICANCE

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

RESULTS

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

CONCLUSION

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

The biology and treatment of acute long-bones diaphyseal fractures: Overview of the current options for bone healing enhancement

Diaphyseal fractures represent a complex biological entity that could often end into impaired bone-healing, with delayed union and non-union occurring up to 10% of cases. The role of the modern orthopaedic surgeon is to optimize the fracture healing environment, recognize and eliminate possible interfering factors, and choose the best suited surgical fixation technique. The impaired reparative process after surgical intervention can be modulated with different surgical techniques, such as dynamization or exchange nailing after failed intramedullary nailing. Moreover, the mechanical stability of a nail can be improved through augmentation plating, bone grafting or external fixation techniques with satisfactory results. According to the "diamond concept", local therapies, such as osteoconductive scaffolds, bone growth factors, and osteogenic cells can be successfully applied in "polytherapy" for the enhancement of delayed union and non-union of long bones diaphyseal fractures. Moreover, systemic anti-osteoporosis anabolic drugs, such as teriparatide, have been proposed as off-label treatment for bone healing enhancement both in fresh complex shaft fractures and impaired unions, especially for fragility fractures. The article aims to review the biological and mechanical principles of failed reparative osteogenesis of diaphyseal fractures after surgical treatment. Moreover, the evidence about the modern non-surgical and pharmacological options for bone healing enhancement will discussed.

The Treatment of Acute Diaphyseal Long-bones Fractures with Orthobiologics and Pharmacological Interventions for Bone Healing Enhancement: A Systematic Review of Clinical Evidence

BACKGROUND

The healing of long bones diaphyseal fractures can be often impaired and eventually end into delayed union and non-union. A number of therapeutic strategies have been proposed in combination with surgical treatment in order to enhance the healing process, such as scaffolds, growth factors, cell therapies and systemic pharmacological treatments. Our aim was to investigate the current evidence of bone healing enhancement of acute long bone diaphyseal fractures.

METHODS

A systematic review was conducted by using Pubmed/MEDLINE; Embase and Ovid databases. The combination of the search terms "long-bones; diaphyseal fracture; bone healing; growth factors; cell therapies; scaffolds; graft; bone substitutes; orthobiologics; teriparatide".

RESULTS

The initial search resulted in 4156 articles of which 37 papers fulfilled the inclusion criteria and were the subject of this review. The studies included 1350 patients (837 males and 513 females) with a mean age of 65.3 years old.

CONCLUSIONS

General lack of high-quality studies exists on the use of adjuvant strategies for bone healing enhancement in acute shaft fractures. Strong evidence supports the use of bone grafts, while only moderate evidence demineralized bone matrix and synthetic ceramics. Conflicting results partially supported the use of growth factors and cell therapies in acute fractures. Teriparatide showed promising results, particularly for atypical femoral fractures and periprosthetic femoral fractures.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

The challenge of non-union in subtrochanteric fractures with breakage of intramedullary nail: evaluation of outcomes in surgery revision with angled blade plate and allograft bone strut

PURPOSE

Subtrochanteric fractures have a bimodal age distribution. They usually require open reduction and internal fixation. Closed reduction and intramedullary nail fixation rate are increased for this type of fracture. As a result, the hardware breakage and non-union rate is high among such patients. Our purpose is to evaluate the outcomes of the role of blade plate and bone strut allograft in the management of subtrochanteric non-union by femoral nailing.

MATERIALS AND METHODS

We reported a group of 22 patients with subtrochanteric non-union, associated with breakage of the intramedullary nail with medial femoral allograft bone and lateral blade plate and wire (PS) s; and a group of 13 patients with subtrochanteric non-union, associated with breakage of the intramedullary nail treated with lateral blade plate and screws (CG). The chosen criteria to evaluate the two group during the clinical and radiological follow-up were the quality of life, measured by The Short Form (12) Health Survey (SF-12), the hip function and quality of life related to it, measured by the Harris Hip Score (HHS), bone healing, measured by Radiographic Union Score (RUS) by XR and CT at 1 year after the surgery, and postoperative complications. The evaluation endpoint was set at 12 months.

RESULTS

The Bone healing measured by RUS occurred and also the full recovery before the first trauma measured by SF-12 and HHS are better in PS group. We only had three unimportant complications in PS while four breakage hardware in CG.

CONCLUSION

We conclude that in complicated non-unions, the use of blade plate and bone strut allograft has a definite positive role in the management of such cases.

Managing Vancouver B1 fractures by cerclage system compared to locking plate fixation - a biomechanical study

With increasing life expectancy and number of total hip arthroplasties (THA), the need for revision surgery is increasing too. The aim of this study was to evaluate the optimal fracture treatment for a clinically characteristic Vancouver B1 fracture. We hypothesized that locking plate fixation has biomechanical advantages over fixation with a simple cerclage system. Additionally, we hypothesized that removal of the primary short stem and revision with a long stem would show biomechanical benefit. The biomechanical testing was performed with a static and a dynamic loading protocol on twenty 4th Generation sawbones. These were divided into four different groups (n = 5 each). In group 1, the primary uncemented short stem remained and the fracture was stabilized with a locking plate. In group 2, the primary stem remained and the fracture was stabilized with a cerclage stabilization system containing two stabilizers and four cerclages. In group 3, the primary stem was replaced by an uncemented long revision stem and the fracture was fixed with a locking plate. In group 4, the short stem was replaced by a long revision stem and the fracture was fixed with the cerclage system. Static testing revealed that the revision of the short stem with the long stem caused a 2-fold (p < 0.001, ANOVA) increase of axial stiffness. In dynamic testing, the number of cycles to failure was 4 times (p < 0.001, ANOVA) higher with the long revision stem. Compared to locked plating cerclage wiring demonstrated a 26% more cycles to failure (p = 0.031, ANOVA). The load to failure was 91% larger (p < 0.001, ANOVA) with the long revision stem and 11% smaller with locked plating (p < 0.001, ANOVA). In conclusion, the present biomechanical study indicates that periprosthetic Vancouver B1 fractures can be sufficiently fixed by simple cerclage systems. Revision with a long replacement stem provides a superior mechanical stability regardless of type of osteosynthesis fixation and is therefore a viable method in Vancouver B1 cases. A disadvantage of the cerclage system compared to plating is that an increased subsidence of the short stem was observed.

Periprosthetic fracture fixation in osteoporotic bone

Fixation techniques of periprosthetic fractures are far from ideal although the number of this entity is rising. The presence of an intramedullary implant generates its own fracture characteristics since stiffness is altered along the bone shaft and certain implant combinations affect load resistance of the bone. Influencing factors are cement fixation of the implant, intramedullary locking and extramedullary or intramedullary localization of the implant and the cortical thickness of the surrounding bone. Cerclage wires are ideally suited to fix radially displaced fragments around an intramedullary implant but they are susceptible to axial and torsional load. Screws should be added if these forces have to be neutralized. Stability of the screw fixation itself can be enhanced by embracement configuration around the intramedullary implant. Poor bone stock quality, often being present in metaphyseal areas limits screw fixation. Cement augmentation is an attractive option in this field to enhance screw purchase.

The Biological Metallic versus Metallic Solution in Treating Periprosthetic Femoral Fractures: Outcome Assessment

Introduction. The periprosthetic fracture of the femur is, in order of frequency, the fourth leading cause (5.9%) of surgical revision. Our study aims to demonstrate how the grafting of bone splint betters the outcomes. Materials. We treated 15 periprosthetic femoral fractures divided into two groups: PS composed of 8 patients treated with plates and splints and PSS involving 7 patients treated only with plates. The evaluation criteria for the two groups during the clinical and radiological follow-up were the quality of life measured by the Short Form (36) Health Survey (SF-36), Harris Hip Score (HHS), Modified Cincinnati Rating System Questionnaire (MCRSQ), bone healing measured by the Radiographic Union Score (RUS), postoperative complications, and mortality. The evaluation endpoint was set at 24 months for both groups (p < 0.05). Results. The surgery lasted an average of 124.5 minutes for the PS group and 112.6 minutes for the PSS. At 24 months all clinical and radiographic scores were p < 0.05 for the PS group. During follow-up 4 patients (2 in each group) died of causes not related to surgery. Conclusions. The use of the metal plate as opposed to cortical allogenic splint should be taken into consideration as a noteworthy point for periprosthetic femoral fractures.