Interprosthetic femoral fractures: Morbidity and mortality in a retrospective, multicenter study

Risk of peri‑implant femoral fracture after cephalomedullary nailing in older patients with trochanteric fractures

INTRODUCTION

Despite the recent increase in the use of cephalomedullary nails for trochanteric hip fractures, factors that may be associated with peri‑implant femoral fracture (PIFF) after cephalomedullary nailing for trochanteric fractures remain unknown. We investigated the factors associated with PIFF after cephalomedullary nailing of trochanteric hip fractures in older patients.

METHODS

A nested case-control study was conducted using a database of patients aged ≥65 years who underwent surgery with cephalomedullary nails for trochanteric fractures caused by low-energy trauma during 2005-2021. The cases were defined as patients who developed PIFF after surgery, while controls were patients who did not develop PIFF and who were followed up for ≥3 years after surgery. Four controls were randomly matched to each case for sex and age. First, potential factors associated with PIFF were compared between cases and controls. Second, multivariable conditional logistic regression analysis was employed to assess factors possibly associated with PIFF, controlling for potential confounding factors.

RESULTS

Of 1531 patients who underwent surgery with cephalomedullary nails because of trochanteric fractures, we assessed 34 cases and 136 controls (N = 170; mean age 85.7 ± 7 years; and females, 94 %). PIFF was significantly associated with patients having undergone total knee arthroplasty (adjusted odds ratios [95 % confidence intervals], 4.41 [1.16-16.8]) and those with AO/OTA classification 31A3 fracture (A3 fracture) (2.3 [1.12-4.76]), after adjusting for potential confounding factors.

CONCLUSIONS

Our results showed that PIFF was more likely to develop among older patients with a clinical history of total knee arthroplasty and A3 fracture. These findings suggest that such patients may require careful follow-up with rigorous assessments after cephalomedullary nailing for trochanteric fractures.

Incidences and Outcomes of Operatively Treated Interprosthetic Femoral Fractures Compared to Vancouver Type C and Rorabeck Type II Fractures

BACKGROUND

This case-control study evaluated the incidences and outcomes of interprosthetic femoral fracture (IPFF) (Group I) and performed comparisons with Vancouver type C (Group II) and Rorabeck type II (Group III) periprosthetic femoral fractures (PPFF) occurring at similar anatomic sites.

METHODS

A retrospective analysis was performed for all patients who had a previously implanted total hip arthroplasty (THA) and total knee arthroplasty (TKA), who lived in the hospital district and had undergone surgery due to PPFF. A total of 153 PPFFs [Group I (n = 31), Group II (n = 21), and Group III (n = 108)] were included. The annual incidences of PPFFs were summarized per 100,000 individuals. The risks of complications, reoperations, and mortalities were evaluated for all groups.

RESULTS

The mean population-based annual incidence was 0.9 per 100,000 person years for Group I, 0.7 per 100,000 person years for Group II, and 3.1 per 100,000 person years for Group III. A total of 25 of 153 (16%) major complications were found and 23 of 153 (13%) cases resulted in a revision surgery. The cumulative incidence of death in Group I was 50.4% at 10 years, in Group II it was 63.8% at 10 years, and in Group III it was 74.9% at 10 years.

CONCLUSION

The annual incidence of the IPFF almost doubled while the incidence of Vancouver type C stayed stable and Rorabeck type II incidence increased 5-fold. Most of the major complications occurred in IPFF group, while Rorabeck type II patients had the worst survival.

[Treatment aspects of interprosthetic femur fractures-retrospective analysis of 70 patients]

BACKGROUND

Interprosthetic femur fractures (IFF) are rare injuries, whose surgical treatment is basically with osteosynthesis or revision arthroplasty. Various therapy algorithms have been proposed based on very small study collectives. Factors influencing the outcome are not known.

OBJECTIVES

The aim of the retrospective monocentric study is to derive a treatment algorithm based on a large number of cases and to identify factors influencing the outcome.

MATERIALS AND METHODS

Between 2006 and 2020, 70 IFF were identified. The surgical treatment comprised 38 osteosyntheses, 30 revision arthroplasties and 2 amputations. With classification and time to surgery, 69 perioperative variables were recorded. General and operative complications, as well as mortality, were determined in the follow-up period of 1 year.

RESULTS

ASA and Charlson score correlated with 1‑year-mortality. In addition, preoperatively increased CRP levels, reduced hemoglobin and the CHA2DS2-VASc score were identified as factors influencing mortality. Surgery within 24 h showed a trend towards fewer general complications. Transferred patients indicated an increased mortality. Based on classification according to Pires et al. or Füchtmeier et al. no clear treatment decision could be made. Relevant criteria for the surgical treatment were fracture localization, implant stability, bone vitality, anchoring possibility of the revision stem, as well as general condition of the patient.

CONCLUSIONS

The identified factors influencing the outcome correspond to those of patients with hip fractures. IFF should be treated timely. A treatment path was developed on the basis of the largest patient group to date.

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

➢

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

➢

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

➢

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.

➢

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

➢

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.

The race for the classification of proximal periprosthetic femoral fractures : Vancouver vs Unified Classification System (UCS) - a systematic review

Background

Periprosthetic femoral fractures (PFFs) represent a major cause for surgical revision after hip arthroplasty with detrimental consequences for patients. The Vancouver classification has been traditionally used since its introduction in 1995. The Unified Classification System (UCS) was described in 2014, to widen the spectrum by aiming for a more comprehensive approach. The UCS also aimed to replace the Vancouver classification by expanding the idea of the Vancouver classification to the whole musculoskeletal apparatus. After introduction of the UCS, the question was raised, whether the UCS found its place in the field of analysing PFFs. Therefore, this systematic review was performed to investigate, the use of the UCS compared to the established Vancouver classification.

Methods

Medline was searched for reports published between 1 January 2016 and 31 November 2020, without language restriction. Included were original articles, irrespective of the level of evidence and case reports reporting on a PFF and using either the Vancouver or the UCS to classify the fractures. Excluded were reviews and systematic reviews.

Results

One hundred forty-six studies were included in the analysis. UCS has not been used in a single registry study, giving a pooled cohort size of 3299 patients, compared to 59,178 patients in studies using the Vancouver classification. Since 2016, one study using UCS was published in a top journal, compared to 37 studies using the Vancouver classification (p=0.29). During the study period, the number of yearly publications remained stagnant (p=0.899).

Conclusions

Despite valuable improvement and expansion of the latter UCS, to date, the Vancouver system clearly leads the field of classifying PFFs in the sense of the common use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05240-w.

Interimplant femoral fractures

The number of hip or knee arthroplasties, and internal fixations of the proximal and distal femur, is increasing in proportion to the growing and ageing population, whose life expectancy is lengthening. Thus, fractures of the femur between proximal and distal implants, although rare, are becoming more frequent. Women over the age of 70, with fragile bones and whose ends of the two implants are close to each other ("kissing implants") are particularly vulnerable to them. Reliable and reproducible fracture classifications exist when it comes to 2 prostheses, but they are less well established in the presence of one, or even two, non-prosthetic implants. Their treatment is difficult and must consider the possibility of fracture consolidation while ensuring or restoring the stability and role of the implants. Whether it is the main element of treatment or a complement to prosthesis revision, locked plating forms the basis of the treatment but it must be rigorous, considering that failures are mainly the result of technical errors. Other more invasive treatments (total femoral arthroplasty, cortical sleeves) are offered more rarely if consolidation appears compromised.

Periprosthetic femoral fracture type and location are influenced by the presence of an ipsilateral knee arthroplasty implant: A case-control study of 84 interprosthetic femoral fractures

BACKGROUND

This multicentre case-control study compares Vancouver Classification System (VCS) grade and Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) fracture type in interprosthetic femoral fractures (IPFFs) between primary total hip arthroplasty (THA) and ipsilateral total knee arthroplasty (TKA) to periprosthetic femoral fracture (PFF) without ipsilateral TKA.

METHODS

Data were collected following institutional approval. Eighty-four IPFFs were assessed for VCS grade and AO/OTA type. Each IPFF case (84) was matched to five PFF controls (360) by age, gender and stem fixation philosophy (SMD<0.1). VCS grade and AO/OTA type were compared between the IPFF and PFF groups using weighted proportions and medians.

RESULTS

Median (IQR) age of IPFF patients was 81.75 (76.57-85.33) years and 61 (72.6%) were female. The commonest VCS grade was B1 (34, 40.5%). The commonest AO/OTA type was spiral (51.8% of VCS B fractures; 50.0% of VCS C fractures). A greater proportion of fractures occurred distal to the stem in IPFF patients versus PFF patients (33.3% versus 18.2%, p = 0.003). VCS grade was significantly different between groups (p = 0.015). For VCS C fractures, twice as many AO/OTA transverse and wedge fractures occurred in the IPFF group compared to the PFF group (25.0% versus 12.6% and 7.1% versus 3.3%, respectively) although the overall difference was not statistically significant (p = 0.407).

CONCLUSION

The presence of an ipsilateral TKA affects the location of PFF with more fractures occurring distal to the stem. A greater proportion of bending type fractures occurred when an ipsilateral TKA was present. These unstable fractures often require more complex surgery.

Outcomes of operatively treated interprosthetic femoral fractures

AIMS

The prevalence of ipsilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA) is rising in concert with life expectancy, putting more patients at risk for interprosthetic femur fractures (IPFFs). Our study aimed to assess treatment methodologies, implant survivorship, and IPFF clinical outcomes.

METHODS

A total of 76 patients treated for an IPFF from February 1985 to April 2018 were reviewed. Prior to fracture, at the hip/knee sites respectively, 46 femora had primary/primary, 21 had revision/primary, three had primary/revision, and six had revision/revision components. Mean age and BMI were 74 years (33 to 99) and 30 kg/m² (21 to 46), respectively. Mean follow-up after fracture treatment was seven years (2 to 24).

RESULTS

Overall, 59 fractures were classified as Vancouver C (Unified Classification System (UCS) D), 17 were Vancouver B (UCS B). In total, 57 patients (75%) were treated with open reduction and internal fixation (ORIF); three developed nonunion, three developed periprosthetic joint infection, and two developed aseptic loosening. In all, 18 patients (24%) underwent revision arthroplasty including 13 revision THAs, four distal femoral arthroplasties (DFAs), and one revision TKA: of these, one patient developed aseptic loosening and two developed nonunion. Survivorship free from any reoperation was 82% (95% confidence interval (CI) 66.9% to 90.6%) and 77% (95% CI 49.4% to 90.7%) in the ORIF and revision groups at two years, respectively. ORIF patients who went on to union tended to have stemmed knee components and greater mean interprosthetic distance (IPD = 189 mm (SD 73.6) vs 163 mm (SD 36.7); p = 0.546) than nonunited fractures. Patients who went on to nonunion in the revision arthroplasty group had higher medullary diameter: cortical width ratio (2.5 (SD 1.7) vs 1.3 (SD 0.3); p = 0.008) and lower IPD (36 mm (SD 30.6) vs 214 mm (SD 32.1); p < 0.001). At latest follow-up, 95% of patients (n = 72) were ambulatory.

CONCLUSION

Interprosthetic femur fractures are technically and biologically challenging cases. Individualized approaches to internal fixation versus revision arthroplasty led to an 81% (95% CI 68.3% to 88.6%) survivorship free from reoperation at two years with 95% of patients ambulatory. Continued improvements in management are warranted. Cite this article: Bone Joint J 2021;103-B(7 Supple B):122-128.

Interprosthetic femoral fractures managed with modern distal femoral locking plates: 10 years' experience at a UK major trauma centre

INTRODUCTION

Interprosthetic femoral fractures (IFF) are rare but increasing with an ageing population. Operative management is challenging and there is currently a paucity of outcome data in literature. The purpose of this study was to evaluate outcomes of IFFs managed with modern distal femoral locking plates, in a larger sample size than previously published.

METHOD

This retrospective study reviewed 49 closed IFFs in 48 patients at a major trauma center from 2009 to 2019 occurring between previous total hip arthroplasty (n=38), hemi hip arthroplasty (n=3), dynamic hip screw (n=6) or cephalomedullary nail (n=2) and total knee arthroplasty. They were managed with Minimally Invasive Plate Osteosynthesis (MIPO) employing modern biological fixation techniques and stabilised with VA-LCP Condylar (Synthes; n=28) or Peri-Loc (S&N; n=21) plate. Clinical and radiographic outcomes were measured.

RESULTS

The majority of fractures were in female patients (80%), who were elderly (average 83 years), and comorbid (55% ASA grade 3 or 4). Most fractures were Pires type IIA and OTA/AO type 33A. Average plate spanning femur was 16 holes, with average working length of 6 holes. 86% had unrestricted weight bearing immediately post operatively. 31 fractures reached radiological (n=25) or clinical (n=6) union. 13 patients died with 2 lost to follow up. There were 3 non-unions, with implant failure occurring before 4 months in all 3. We present a union rate of 91% (n=31/34).

CONCLUSION

IFFs are occurring with increasing frequency in a frail elderly population. In patients with IFFs, MIPO and biological fixation techniques using modern distal femoral locking plates can achieve high rate of union when combined with immediate unrestricted weight bearing postoperatively.

Periprosthetic hip fractures: an update into their management and clinical outcomes

The Vancouver classification is still a useful tool of communication and stratification of periprosthetic fractures, but besides the three parameters it considers, clinicians should also assess additional factors.

Combined advanced trauma and arthroplasty skills must be available in departments managing these complex injuries.

Preoperative confirmation of the THA (total hip arthroplasty) stability is sometimes challenging. The most reliable method remains intraoperative assessment during surgical exploration of the hip joint.

Certain B1 fractures will benefit from revision surgery, whilst some B2 fractures can be effectively managed with osteosynthesis, especially in frail patients.

Less invasive osteosynthesis, balanced plate–bone constructs, composite implant solutions, together with an appropriate reduction of the limb axis, rotation and length are critical for a successful fixation and uneventful fracture healing.

Cite this article: EFORT Open Rev 2021;6:75-92. DOI: 10.1302/2058-5241.6.200050

Postoperative periprosthetic femoral fracture around total hip replacements: current concepts and clinical outcomes

The rising incidence of postoperative periprosthetic femoral fracture (PFF) presents a significant clinical and economic burden.

A detailed understanding of risk factors is required in order to guide preventative strategies.

Different femoral stems have unique characteristics and management strategies must be tailored appropriately.

Consensus regarding treatment of PFFs around well-fixed stems is lacking, but revision surgery may provide more predictable outcomes for unstable fracture patterns and fractures around polished taper-slip stems.

Future research should focus on implant-related risk factors, treatment of concurrent metabolic bone disease and the use of large endoprostheses.

Cite this article: EFORT Open Rev 2020;5:558-567. DOI: 10.1302/2058-5241.5.200003

Factors associated with mortality due to trochanteric fracture. A cross-sectional study

OBJECTIVE

To explore factors associated with mortality in patients with trochanteric fracture.

METHODS

A cross-sectional study was performed in patients with trochanteric fracture treated at Clinica Las Vegas, in Medellín, Colombia, during the period going from January 2008 to December 2015. Information was collected on demographic, clinical variables, surgical complications and mortality. Telephone follow-up was performed up to 6months postoperatively. An exploratory analysis to identify possible factors associated with mortality was conducted. The Chi² test was used; the strength of the association was assessed through odds ratio (OR) and its respective confidence interval (CI) of 95%.

RESULTS

A total of 275 patients diagnosed with trochanteric fracture were included; 16.0% of patients died within 6months following surgery. We found a higher risk of death in patients with surgery after 48hours OR 2.3 (95% CI: 1.0-5.1); acute renal failure featuring OR: 3.4 (95% CI: 1.3-8.8); patients who received blood transfusions in the intraoperative featuring OR: 4.4 (95% CI: 1.7-11.8); with urinary tract infection in the postoperative 7.1 (2.1-24.5); and patients with surgical site infection featuring OR: 5.6 (95% CI: 1.1-28.5).

CONCLUSIONS

Trochanteric fracture mortality is associated with acute renal failure, blood transfusion, urinary tract infection and patients with surgical site infection.

Interprosthetic femoral fractures: management challenges

Interprosthetic femur fractures are a rare but serious complication following total hip and knee arthroplasty. Classification systems have focused not only on diagnosis but also on treatment algorithm. Critical to the evaluation of patients with these fractures are an assessment of fracture location, bone quality, and the presence of stemmed implants. The gold standard for fracture fixation is locked plating with bicortical and unicortical screws, supplemented with wires or cables as needed. For patients with compromised bone stock or insufficient bony area for fixation, allograft augmentation with struts or interprosthetic sleeves may be used. For fractures with severe bone loss, conversion to a megaprosthesis or total femur replacement may be warranted.