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.
CookREJenkinsPJWalmsleyPJPattonJTRobinsonCMRisk factors for periprosthetic fractures of the hip: a survivorship analysis.Clin Orthop Relat Res2008;466(7):1652–1656
2.
KatzJNWrightEAPolarisJJHarrisMBLosinaEPrevalence and risk factors for periprosthetic fracture in older recipients of total hip replacement: a cohort study.BMC Musculoskelet Disord2014;15(1):168
3.
GiannoudisPVKanakarisNKTsiridisEPrinciples of internal fixation and selection of implants for periprosthetic femoral fractures.Injury2007;38(6):669–687
4.
LindahlHMalchauHOdénAGarellickGRisk factors for failure after treatment of a periprosthetic fracture of the femur.J Bone Joint Surg Br2006;88(1):26–30
5.
BhattacharyyaTChangDMeigsJBEstokDMIIMalchauHMortality after periprosthetic fracture of the femur.J Bone Joint Surg Am2007;89(12):2658–2662
6.
BerryDJEpidemiology: hip and knee.Orthop Clin North Am1999;30(2):183–190
7.
DehghanNMcKeeMDNauthARistevskiBSchemitschEHSurgical fixation of Vancouver type B1 periprosthetic femur fractures: a systematic review.J Orthop Trauma2014;28(12):721–727
8.
MooreREBaldwinKAustinMSMehtaSA systematic review of open reduction and internal fixation of periprosthetic femur fractures with or without allograft strut, cerclage, and locked plates.J Arthroplasty2014;29(5):872–876
9.
DuncanCPMasriBAFractures of the femur after hip replacement.Instr Course Lect1995;44:293–304
10.
BradyOHGarbuzDSMasriBADuncanCPThe reliability and validity of the Vancouver classification of femoral fractures after hip replacement.J Arthroplasty2000;15(1):59–62
11.
NaqviGABaigSAAwanNInterobserver and intraobserver reliability and validity of the Vancouver classification system of periprosthetic femoral fractures after hip arthroplasty.J Arthroplasty2012;27(6):1047–1050
12.
DaveDJKokaSRJamesSEMennen plate fixation for fracture of the femoral shaft with ipsilateral total hip and knee arthroplasties.J Arthroplasty1995;10(1):113–115
13.
de RidderVAde LangeSKoomenARHeatleyFWPartridge osteosynthesis: a prospective clinical study on the use of nylon cerclage bands and plates in the treatment of periprosthetic femoral shaft fractures.J Orthop Trauma2001;15(1):61–65
14.
ZenniEJJrPomeroyDLCaudleRJOgden plate and other fixations for fractures complicating femoral endoprostheses.Clin Orthop Relat Res1988;(231):83–90
15.
ButtaroMAFarfalliGParedesNúñez MCombaFPiccalugaFLocking compression plate fixation of Vancouver type-B1 periprosthetic femoral fractures.J Bone Joint Surg Am2007;89(9):1964–1969
16.
MontMAMaarDCFractures of the ipsilateral femur after hip arthroplasty.A statistical analysis of outcome based on 487 patients. J Arthroplasty1994;9(5):511–519
17.
ScottRDTurnerRHLeitzesSMAufrancOEFemoral fractures in conjunction with total hip replacement.J Bone Joint Surg Am1975;57(4):494–501
18.
McElfreshECCoventryMBFemoral and pelvic fractures after total hip arthroplasty.J Bone Joint Surg Am1974;56(3):483–492
19.
NoordaRJWuismanPIMennen plate fixation for the treatment of periprosthetic femoral fractures: a multicenter study of thirty-six fractures.J Bone Joint Surg Am200284-A122211–2215
20.
HaddadFSDuncanCPBerryDJLewallenDGGrossAEChandlerHPPeriprosthetic femoral fractures around well-fixed implants: use of cortical onlay allografts with or without a plate.J Bone Joint Surg Am2002;84(6):945–950
21.
BryantGKMorshedSAgelJet al.Isolated locked compression plating for Vancouver Type B1 periprosthetic femoral fractures. Injury2009;40(11):1180–1186
22.
ChakravarthyJBansalRCooperJLocking plate osteosynthesis for Vancouver Type B1 and Type C periprosthetic fractures of femur: a report on 12 patients.Injury2007;38(6):725–733
23.
ChandlerHPKingDLimbirdRet al.The use of cortical allograft struts for fixation of fractures associated with well-fixed total joint prostheses. Semin Arthroplasty1993;4(2):99–107
24.
CrockarellJRJrBerryDJLewallenDGNonunion after periprosthetic femoral fracture associated with total hip arthroplasty.J Bone Joint Surg Am1999;81(8):1073–1079
25.
PatelAARicciWMMcDonaldDJBorrelliJClohisyJCTreatment of periprosthetic femoral shaft nonunion.J Arthroplasty2006;21(3):435–442
26.
WestrichGHGellerDSOMalleyMJDelandJTHelfetDLAnterior iliac crest bone graft harvesting using the corticocancellous reamer system.J Orthop Trauma2001;15(7):500–506
27.
Falck-YtterYFrancisCWJohansonNAPrevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.Chest20121412 Supple278S–325S
28.
ZderoRWalkerRWaddellJPSchemitschEHBiomechanical evaluation of periprosthetic femoral fracture fixation.J Bone Joint Surg Am2008;90(5):1068–1077
29.
WilsonDFreiHMasriBAOxlandTRDuncanCPA biomechanical study comparing cortical onlay allograft struts and plates in the treatment of periprosthetic femoral fractures.Clin Biomech (Bristol, Avon)2005;20(1):70–76
30.
DennisMGSimonJAKummerFJKovalKJDi CesarePEFixation of periprosthetic femoral shaft fractures: a biomechanical comparison of two techniques.J Orthop Trauma2001;15(3):177–180
31.
RicciWMBolhofnerBRLoftusTCoxCMitchellSBorrelliJJrIndirect reduction and plate fixation, without grafting, for periprosthetic femoral shaft fractures about a stable intramedullary implant.J Bone Joint Surg Am2005;87(10):2240–2245
32.
KumarVKanabarPOwenPJRushtonNLess invasive stabilization system for the management of periprosthetic femoral fractures around hip arthroplasty.J Arthroplasty2008;23(3):446–450
33.
ChoiJKGardnerTRYoonEMorrisonTAMacaulayWBGellerJAThe effect of fixation technique on the stiffness of comminuted Vancouver B1 periprosthetic femur fractures.J Arthroplasty2010256Suppl124–128
34.
ChapmanMWFinkemeierCGTreatment of supracondylar nonunions of the femur with plate fixation and bone graft.J Bone Joint Surg Am1999;81(9):1217–1228
35.
JazrawiLMKummerFJSimonJAet al.New technique for treatment of unstable distal femur fractures by locked double-plating: case report and biomechanical evaluation. J Trauma2000;48(1):87–92
36.
SandersRSwiontkowskiMRosenHHelfetDDouble-plating of comminuted, unstable fractures of the distal part of the femur.J Bone Joint Surg Am1991;73(3):341–346
37.
ZiranBHRohdeRHWhartonARLateral and anterior plating of intra-articular distal femoral fractures treated via an anterior approach.Int Orthop2002;26(6):370–373
38.
KhalilA-SAyoubMAHighly unstable complex C3-type distal femur fracture: can double plating via a modified Olerud extensile approach be a standby solution?J Orthop Traumatol2012;13(4):179–188
39.
MüllerFJGallerMFüchtmeierBClinical and radiological results of patients treated with orthogonal double plating for periprosthetic femoral fractures.Int Orthop2014;38(12):2469–2472
40.
KanakarisNKGiannoudisPVThe health economics of the treatment of long-bone non-unions.Injury200738Suppl 2S77–S84
41.
GiannoudisPVKanakarisNKDimitriouRGillIKolimaralaVMontgomeryRJThe synergistic effect of autograft and BMP-7 in the treatment of atrophic nonunions.Clin Orthop Relat Res2009;467(12):3239–3248
