Periprosthetic fractures around the femoral stem: overcoming challenges and avoiding pitfalls

Vancouver type B2 periprosthetic femoral fractures: clinical and radiological outcomes from a tertiary care center

INTRODUCTION

The purpose of this study was to report mid-term clinical and radiographic results after hip arthroplasty revision in Vancouver type B2 femoral periprosthetic fractures (PPFx). Specifical focus of the paper is as follows: (1) the description of a standardized and reproducible surgical technique, (2) functional outcomes presentation and (3) type and number of complications and implants' survival rate analysis.

METHODS

We retrospectively reviewed all patients treated for hip revision with non-modular tapered fluted titanium stem in patients with Vancouver type B2 femur PPFx at a single institution. At least 18 months' follow-up period was required. Harris Hip Scores and SF-12 were obtained, and radiographical follow-up was performed. Complications were reported and analyzed.

RESULTS

The authors included 114 patients (114 hips) with a mean follow-up of 62.8 ± 30.6 months. All patients were treated with Wagner SL revision hip stem (Zimmer-Biomet), metal cerclage wires ± trochanteric plate. The mean HHS and SF-12 score at the last follow-up evaluation were respectively 81.3 ± 9.7 and 32.5 ± 7.6. Seventeen (14.9%) complications occurred. We observed five cases of dislocations, two of periprosthetic joint infections and six cases of new PPFx. The stem-related revision rate for any cause at the final FU was 1.7%, due to PJI. No patients underwent stem revision surgery for aseptic loosening. Fracture healed in all the included patients with a union-rate of 100%. The re-operation rate for any cause was 9.6%, with an implant survival rate for overall failure of 96.5%.

CONCLUSION

The presented standard and reproducible surgical technique obtains optimal clinical and radiological results with limited complication rate at mid-term follow up. Preoperative planning as well as careful intraoperative surgical technique is of a paramount importance.

Outcomes of cable fixation after Vancouver type B1 periprosthetic femoral fractures

BACKGROUND

In this study, it was aimed to evaluate the patients who underwent cable plate fixation due to a Vancouver-type B1 periprosthetic femur fracture and their clinical results.

METHODS

Vancouver-type B1 patients who were operated on for periprosthetic fractures between 2014 and 2019 were investi-gated. Age, gender, body mass index (BMI), follow-up time, operation time, bleeding amount, non-union fracture, last surgery before fracture, the time between previous surgery and fracture, implant survival, patient survival, and complications were recorded. In addi-tion, the postoperative clinical functions of these patients were compared.

RESULTS

23 patients who met the study criteria (Vancouver type B1 fracture) were identified. The mean age of the patients was 60 (49-76) years, the mean BMI was 26.3 (17.5-40.7), and the postoperative mean follow-up period was 14 (6-36) months. Considering the gender distribution, there were 5 (22%) men and 18 (78%) women. The mean time between the last surgery before the fracture and the fracture was 6 months (0-30). While the mean operation time was 95 min (60-180), the average amount of bleeding was 310 mL (150-600). Functional evaluations of patients: In total, five patients had decreased ambulatory abilities after surgery. Nonunion was observed in 2 patients during the follow-ups, and these patients underwent open surgery for treatment.

CONCLUSION

Cable and locking plate applications are successful in Vancouver type B1 fractures, which are one of the most common forms of periprosthetic fractures. In this technique, the duration of the operation can be shortened under ideal conditions, and the need for blood and blood products is reduced as blood loss is reduced. If there is a complication, you still have the chance to treat it with the option of revision arthroplasty.

Treatment Algorithm of Periprosthetic Femoral Fracturens

Introduction. The ever-expanding indications for total hip arthroplasty are leading to more implants being placed in younger as well as in older patients with high functional demand. Also, prolonged life expectancy is contributing to an overall increment of periprosthetic femoral fractures. The Vancouver classification has been the most used for guiding the surgeon choice since its proposal in 1995. Fractures occurring over a hip femoral implant can be divided into intra-operative and post-operative PFFs, and their treatment depends on factors that may severely affect the outcome: level of fracture, implant stability, quality of bone stock, patients’ functional demand, age and comorbidities, and surgeon expertise. There are many different treatment techniques available which include osteosynthesis and revision surgery or a combination of both. The goals of surgical treatment are patients’ early mobilization, restoration of anatomical alignment and length with a stable prosthesis and maintenance of bone stock. Significance. The aim of this review is to describe the state-of-the-art treatment and outcomes in the management of PFFs. We performed a systematic literature review of studies reporting on the management of PFFs around hip stems and inter-prosthetic fractures identifying 45 manuscripts eligible for the analysis. Conclusions. PFFs present peculiar characteristic that must be considered and special features that must be addressed. Their management is complex due to the extreme variability of stem designs, the possibility of having cemented or uncemented stems, the difficulty in identifying the “real” level of the fracture and the actual stability of the stem. As a result, the definition of a standardized treatment is unlikely, thereby high expertise is fundamental for the surgical management of PPFs, so this kind of fractures should be treated only in specialized centres with both high volume of revision joint arthroplasty and trauma surgery.

Metallic versus Non-Metallic Cerclage Cables System in Periprosthetic Hip Fracture Treatment: Single-Institution Experience at a Minimum 1-Year Follow-Up

Metallic cerclage cables are reliable and cost-effective internal fixation devices, which are largely used in surgical practice for the treatment of periprosthetic fractures. Nevertheless, complications connected with their use have been described in the literature, including the following: third-body generation, failure and consequent migration, fraying, allergies, and injury to the surgical team. The development of new materials offers alternatives to traditional metallic cables. This study compares the outcomes between two groups of patients affected by periprosthetic hip fractures, treated with titanium cables or with ultra-high-molecular-weight polyethylene (UHMWPe) iso-elastic cables. Our retrospective study aims to compare the clinical and radiological outcomes of titanium cables and UHMWPe iso-elastic cables, isolated or associated with dedicated plates, for the surgical treatment of periprosthetic fractures with stable implants. Two groups of 30 (group A-metallic cables) and 24 (group B-UHMWPe iso-elastic cables) patients have been surgically treated in our institution for hip periprosthetic fractures, between September 2017 and June 2020. The mean age of the patients was 81 years in group A and 80 years in group B. In our study, we included fractures classified as B1 or C, according to the Vancouver postoperative fractures classification; the patients were evaluated retrospectively at 1 year postoperatively, regarding the following: surgery time, blood loss, partial weight-bearing time, radiographical healing time, Harris hip score, and postoperative complications. Comparable outcomes were observed in patients from both groups. Group A showed a higher complication rate compared to group B, at 1 year postoperatively. Non-metallic nylon fiber and ultra-high-molecular-weight polyethylene (UHMWPe) cerclage cables could represent a reliable fixation device, ensuring comparable healing and complication rates with traditional titanium cerclage cables.

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.

Multiple failures of internal fixation for treatment of periprosthetic femoral refracture: a case report and literature review

We herein report a case involving three failures of internal fixation after periprosthetic femoral fracture (Vancouver type B1). The patient had low bone mass (T-score of −1.7) and was overweight (body mass index of 28.7 kg/m²) but had no sign of femoral stem loosening. The first open reduction with internal fixation was performed according to the recommended treatment. Unexpectedly, three treatment failures subsequently occurred, after which the patient finally attained endurable walking activity. A literature review indicated that the intrinsic biomechanical problems of Vancouver B1 fractures have not been thoroughly addressed. Choosing the correct surgical strategy for Vancouver B1 fractures is essential to avoid complications and ensure healing. A sufficient locking plate and cable system should be used after the first failure if revision was not performed the first time.

Comparison of different fixation techniques for periprosthetic fractures: a biomechanical study of a new implant

INTRODUCTION

The ideal treatment method for periprosthetic fractures is controversial due to the risks of current methods. Single-cortex screw fixation in prosthesis may lead to implant failure. Therefore, we aimed to develop an implant that lowers the risk for complications. For this study, we designed and tested two new implant models. The first model was a plate with a combination of U nails and cerclage holes. The second model was a U nail plate with a screw, which combines a plate screw with U nail (staples). Our study aimed to compare the stability of two newly designed implants with classical treatment modalities. We used 27 (in 3 groups) artificial bone models and 9 different test models.

METHODS

The ISO 7206-4:2010 (E) standards were used for 27 bones in nine groups tested under laboratory conditions. In our study, we examined nine different groups. In group 1, hip the prosthesis was extracted, and a revision femoral stem was embedded. In group 2, periprosthetic fractures were repaired with a plate and cable. In group 3, periprosthetic fractures were repaired with a plate and stapler. In group 4, periprosthetic fractures were repaired with a plate and stapler cable. In group 5, periprosthetic fractures were repaired with a plate stapler and screw. Groups 6 and 7 were the control groups. Group 6 was the only artificial bone group, and group 7 was the prosthesis embedded bone group. Group 8 was periprosthetic fractures treated with unicortical screw fixation with cerclage, and group 9 was periprosthetic fractures treated with unicortical screw fixation. Axial loading was applied to the bones. The yield strength of the system was determined by loading the synthetic bone models with a constant compression speed of 5 mm/min through the centre of motion using the Geratech SH 2000 testing system. During the tests, load and displacement values were recorded, and the stiffness of the models was calculated based on those values.

RESULTS

According to our results, the greatest durability was found in the revision hip prosthesis group (1511 N), and the weakest performance was found in the plate with the stapler implant group (163N). When comparing the data of groups according to compression, significant differences were found in group 2 with groups 1, 4, 5, and 7; group 3 with group 1; group 8 with groups 1 and 5; and group 9 with 1, 5, 7, and according to breakage, significant differences were found in group2 with groups 1, 3, 5, and 7; group 3 with group 1; group 8 with groups 1 and 5; and group 9 with groups 1, 5, and 7 (p<0.001).

DISCUSSION

The revision hip prosthesis treatment for periprosthetic fractures showed the best performance, followed by the plate with stapler screw. In older patients, U nail-augmented implants may be a good alternative for periprosthetic fractures. Unicortical screw and cerclage wire combination fixation results were unsatisfactory results in this study.

CONCLUSION

This is an experimental study, so further studies, especially patient-specific studies, should be made to expand the findings of this study.

The clinical and economic burden of proximal femur periprosthetic fractures

BACKGROUND

The number of hip replacements is constantly and progressively increasing, resulting in an increase in periprosthetic fractures. The main aim of this study is to analyze costs and outcomes of surgical treatment for those fractures.

MATERIALS AND METHODS

A retrospective study was performed on periprosthetic proximal femur fracture presented a single-level I trauma center. Medical records were reviewed in terms of demographic data, diagnosis (according to Vancouver classification), type of surgical treatment, hospitalization length and follow-up. Patients were interviewed about number of consultations after discharge, medications and physiotherapy sessions. Clinical outcome was evaluated with WOMAC score at the last follow-up, and patient health status was evaluated with the EQ5D5L score pre-trauma and at the last follow-up. Patients were divided into two groups according to surgical treatment: reduction and internal fixation alone and revision plus fixation. A further group was also considered: patients underwent a Girdlestone procedure. Global costs for each group were calculated.

RESULTS

We initially recruited 117 patients, 17 of them were lost at follow-up. Furthermore, 19 patients (19%) died during the follow-up, and 81 of them were therefore included in the study. Mean follow-up was 26.5 months. Mean postoperative WOMAC score was 39.44, and EQ5D5L score was 9.12 for the preoperative period and 12.35 at the last follow-up. A significant worsening of clinical conditions was found comparing the period before fracture to the last follow-up (p < 0.01). Quality of life after surgery resulted to be poor or fair in 40% of the patients at a mean follow-up of 26.5 months. No significant differences between groups were found according to patients' health status. Mean global costs for mayor surgeries were 18,822 Euros; mean costs for fixation alone were 17,298 Euros while for fixation and revision were 20,966 Euros, but no statistically difference was found between these two groups. Mean cost for Girdlestone group was 12,664 Euros.

CONCLUSIONS

In proximal femur periprosthetic fractures, either fixation or revision plus fixation presents high costs but patients' postoperative quality of life is poor.

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

High Failure Rates of Locking Compression Plate Osteosynthesis with Transverse Fracture around a Well-Fixed Stem Tip for Periprosthetic Femoral Fracture

This study investigated the incidence of failure after locking compression plate (LCP) osteosynthesis around a well-fixed stem of periprosthetic femoral fractures (PFFs). We retrospectively evaluated outcomes of 63 Vancouver type B1 and C PFFs treated with LCP between May 2001 and February 2018. The mean follow-up duration was 47 months. Only patients with fracture fixation with a locking plate without supplemental allograft struts were included. We identified six periprosthetic fractures of proximal Vancouver B1 fractures with spiral pattern (Group A). Vancouver B1 fractures around the stem tip were grouped into seven transverse fracture patterns (Group B) and 38 other fracture patterns such as comminuted, oblique, or spiral (Group C). Vancouver C fractures comprised 12 periprosthetic fractures with spiral, comminuted, or oblique patterns (Group D). Fracture healing without complications was achieved in all six cases in Group A, 4/7 (57%) in Group B, 35/38 (92%) in Group C, and 11/12 (92%) in Group D, respectively. The failure rates of transverse Vancouver type B1 PFFs around the stem tip were significantly different from those of Vancouver type B1/C PFFs with other patterns. For fracture with transverse pattern around the stem tip, additional fixation is necessary because LCP osteosynthesis has high failure rates.

Periprosthetic fractures of the proximal femur within first year of the index hip prosthesis

Introduction:

Periprosthetic fractures are a serious complication of implants prosthetic. The aim of this review is to analyze incidence and predisposing factors of periprosthetic fractures of the proximal femur within first year of the index hip prosthesis.

Materials and methods:

Between 1998 and 2017 we have performed 4240 hip replacements (F 2661, M 1579): 2877 total hip arthroplasties (67,9%) and 1363 hemiartrhoplasties (32,1%). Hip replacements with cemented stem were 2173 (51,2%), while cementless ones were 2067 (48,8%). In the same period we admitted 121 hip periprosthetic fractures, 26 of which (0,6%) within the first year of the index surgery. We examined the medical and radiographic records of this last cohort of patients (F 19, M 7) following the Vancouver System, Dorr Classification and Stem Size Index.

Results:

The cause was a low-energy trauma in 25 cases (96.1%); the primary diagnosis was hip fracture in 20 patients (76.9%); 8 patients were taking chronic osteoporosis medication (30.7%); 14 patients were affected by neuropsychiatric disease (53.8%); cementless stems were found in 18 cases, 12 of which were oversized (SSI < 0,8). According to Vancouver System, fractures were classified as follows: 10 type B1, 14 type B2 and 2 type C. As far as the proximal femoral shape, 2 cases were Dorr type A, 7 Dorr type B and 17 Dorr type C.

Conclusions:

The incidence of periprosthetic fractures in the aftermath of stem implant is twice as high with uncemented stems. The Vancouver type B1/B2 is the most common. Predisposing factors are: female sex, hip fracture, chronic osteoporosis medication, neuropsychiatric disease and oversized uncemented stem (SSI < 0.8).The evidence level is IV. (www.actabiomedica.it)

Effectiveness of circular external fixator in periprosthetic fractures around the knee

Background

The incidence of periprosthetic fractures after total joint arthroplasty (TJA) is rising due to an increasing number of TJAs performed annually and the growing elderly population. In many elderly patients with periprosthetic fractures, the bone strength is lowered due to the deterioration of bone quality and a decrease in bone quantity; rigid fixation of the fracture is difficult. It is a challenging operation for orthopedic surgeons. The usefulness of circular external fixation for periprosthetic fractures has been reported in several case studies. The aim of this study was to investigate the rate of union and complications associated with circular external fixation in periprosthetic fractures around the knee.

Methods

We included 19 patients with periprosthetic femur and tibial fractures who underwent osteosynthesis using a circular external fixator and had at least 2 years of follow-up. All patients had comorbidities and high risks associated with anesthesia. Tourniquets were not used in any of the patients. There were no cases in which the skin incision was placed, and the closed reduction technique was used in all cases.

Results

A 100% union rate was achieved with no serious complications. All fractures healed after a mean time of 14.3 ± 5.2 weeks (range, 8–38 weeks). The walking ability was the same level as before the injury in 13 cases.

Discussion

There are many comorbidities associated with periprosthetic fractures in elderly patients. Double-plate or revision surgery were largely invasive and had high risks associated with anesthesia. Circular external fixation is a feasible and effective treatment option because it provides stable fixation, prompt postoperative mobilization, and has no major complications, especially in elderly patients who are treated for periprosthetic fractures.

Conclusion

Circular external fixation is a safe and reliable method for periprosthetic fractures around the knee in elderly patients.

Level of evidence

Level IV, retrospective case series.

A case-control study of 30-day mortality in periprosthetic hip fractures and hip fractures

INTRODUCTION

There are increasing numbers of periprosthetic femoral fractures, which have high mortality rates. These fractures occur in a similar demographic to hip fractures. There has been limited research on mortality following these fractures. This study compared 30-day mortality in periprosthetic hip fractures with case-matched hip fractures.

MATERIALS AND METHODS

Case notes of periprosthetic hip fractures between 1 January 2009 and 31 December 2015 were reviewed retrospectively at a single institution. There were 173 periprosthetic hip fractures over the seven years of the study. All hip fractures attending the same institution have data collected prospectively for the National Hip Fracture Database. Data were analysed from the Hip Fracture Database. A power calculation was undertaken; 173 periprosthetic hip fractures were matched to 865 hip fractures individually for age, sex, American Society of Anesthesiologists grade and capacity.

RESULTS

The median wait to surgery was 88 hours for periprosthetic fractures and 23 hours for hip fractures (p < 0.00001); 22.5% of patients with periprosthetic fractures underwent surgery within 36 hours compared with 68.2% of those with hip fractures (p < 0.0001). The median length of stay was 16 days for periprosthetic fractures and 10 days for hip fractures (p < 0.00001). The 30-day mortality was 6.4% for periprosthetic hip fractures and 3.1% for case-matched hip fractures (odds ratio 2.11, 95% confidence interval 1.03-4.36; p = 0.043).

CONCLUSIONS

Periprosthetic hip fractures have a significantly higher mortality than hip fractures. Further research should aim to improve outcomes in these patients.

Correlations between Vancouver type of periprosthetic femur fracture and treatment outcomes

Objective

Periprosthetic femur fractures are one of the most severe complications of total hip arthroplasty.

Methods

The aim of this study was to assess outcomes of periprosthetic femur fractures based on the Vancouver classifications of fractures.

Results

Sixty-four patients were enrolled into the study. Type B1 fractures were the most common - 33 cases. In comparison to patients with type B3 fracture, patients with type B1 fracture significantly less often experienced postoperative pain.

Conclusion

Study shown that in the context of both objective outcomes of the operation and patient satisfaction, the most unfavourable prognosis is after type B3.

The value of a standardized and reproducible surgical technique in treatment of Vancouver B2 periprosthetic fractures: our experience

PURPOSE

To retrospectively review results and complications of our standardized surgical technique addressed exclusively to Vancouver B2 fractures.

METHODS

From January 2006 to July 2016, we treated 235 consecutive patients, 47 males and 188 females, mean age at surgery of 71 ± 10 years, with periprosthetic B2 fractures. Exclusion criteria were other kind of periprosthetic fractures and other femoral fractures. The patients were assessed clinically and radiographically following our standard protocol at the last available follow-up. The mean follow-up time was 6.4 years. Radiographic evaluation was performed according to Beals and Tower's criteria and clinical evaluation was performed using the Harris Hip Score and clinical exam.

RESULTS

From the starter cohort of 235, 207 patients (88.1%) were fully evaluated, while 28 were lost to follow-up. According to Beal and Tower's criteria, we found excellent results in 72 patients (34.8%), good results in 133 patients (64.3%), and poor results in 2 patients (0.9%). Mean HHS was 75 ± 9 points, with a statistically significant correlation between good functional results and better radiographic assessment (p = 0.001). The use of support plate (p = 0.008) and the acetabular revision (p = 0.002) showed a statistically significant distribution with worse radiographic results. Late complications detected were ten dislocations.

CONCLUSION

Our experience suggests that using a standardized and reproducible surgical technique, as our technique proposed, can surely reduce surgical time, the complication rate, and the mortality rate. During acetabular evaluation, the choice of performing a cup revision must be weighed on overall patient's assessment.

Mortality in patients sustaining a periprosthetic fracture following a hemiarthroplasty

Periprosthetic fractures of the proximal femur after hip hemiarthroplasty are an increasing concern. The aim of this study was to analyse the 30 day mortality of periprosthetic fractures around a hip hemiarthroplasty. A retrospective case review at a single institution. 32 patients. Mean age 76.5, 16 males and 16 females. 13% underwent non-operative treatment, 50% open reduction internal fixation and 38% revision arthroplasty. 30 day mortality was 12.5% and 1 year mortality 28.1%. Time to surgery was the only significant risk factor for 30 day mortality Periprosthetic fractures following a hip hemiarthroplasty have high 30 day mortality.

Intriguing Periprosthetic Fracture of Hip Stem and Proximal Femoral Replacement

Lateral femoral prosthesis perforation is an uncommon periprosthetic fracture. Periprosthetic fractures may be fixed with open reduction and internal fixation, or with revision arthroplasty, depending on the type of fracture, the condition of the host bone in the proximal femur, the stability of the implant, and occasionally the medical co-morbidities of the patient. Proximal femoral replacement is a complex and challenging procedure but provides a better chance of early mobilisation. We describe a case of treating a 71-year-old woman who presented with an unusual type of periprosthetic fracture, treated with a revision arthroplasty procedure using a proximal femur replacement.

Distal radius re-fracture with bending of implant and neurovascular compromise

Peri-implant fractures of the wrist are uncommon, and usually present as stress fractures distal to the site of the implant. We report an unusual case where the radius has fractured beneath a plate, causing bending and deformity of the implant. This prevented reduction of the fracture under sedation, so urgent intervention became necessary due to neurovascular compromise.