STATE
OF THE
ART
Periprosthetic Femur Fractures William M. Ricci, MD
Summary: Successful treatment of periprosthetic femur fractures, like all fractures, requires careful attention to understand the fracture pattern nuances, identifying and executing a rational treatment approach, and providing an appropriate postoperative recovery protocol. Unlike most other fractures, modification of standard techniques is often required to obtain a stable fixation construct, and there is a greater role for revision arthroplasty in the treatment of periprosthetic fractures. Optimal indications for surgical repair versus revision arthroplasty and optimal postoperative weight-bearing protocols remain uncertain. Reported outcomes for patients with periprosthetic femoral shaft fractures are generally good and are relatively consistent. Results for periprosthetic distal femur fractures, however, are less good and more inconsistent. Both periprosthetic femoral shaft and distal femur fractures are associated with relatively high mortality rates, approaching that of patients with hip fractures. This review should provide insight into the current solutions and challenges for the treatment of patients with periprosthetic femur fractures. Key Words: periprosthetic, femur, fracture (J Orthop Trauma 2015;29:130–137)
INTRODUCTION Periprosthetic fractures continue to increase in frequency. This is due, in part, to the increasing number of primary and revision arthroplasties performed annually and also to the increasing age and fragility of patients with such implants. In each situation, the presence of an arthroplasty component either obviates the use of or increases the difficulty of standard fixation techniques. Additionally, these fractures often occur in elderly patients with osteoporotic bone, making stable fixation with traditional techniques even more problematic. Treatment of the most common periprosthetic fractures, those of the femoral shaft, and those of the femoral supracondylar region has focused on open reduction with internal fixation (ORIF) or revision arthroplasty procedures with or without supplementary autologous or allogeneic bone grafting.1–3 Most recently, Accepted for publication December 10, 2014. From the Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO. W. M. Ricci is a consultant for Smith & Nephew, Stryker, and Biomet; receives institutional support from AONA, COTA, Smith & Nephew; receives royalties from Smith & Nephew, MicroPort (Wright Medical), Biomet (expected), Stryker (expected), and LWW (expected). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions this article on the journal’s Web site (www.jorthotrauma.com). Reprints: William M. Ricci, MD, Department of Orthopaedic Surgery, Washington University School of Medicine, Campus Box 8233, 660 S Euclid Avenue, St Louis, MO 63110 (e-mail: [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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treatment strategies to accelerate weight bearing have suggested benefits with regard to mortality.4–6 Successful application of these strategies can be extrapolated to periprosthetic fractures in other anatomic locations but must also consider the fracture location relative to the arthroplasty component, the implant stability, the quality of the surrounding bone, and the patients’ medical and functional status.7
TREATMENT GOALS The goals of periprosthetic fracture care are essentially no different than the goals of treatment of any other fracture. These include uncomplicated fracture union, restoration of alignment, and return to preinjury level of function without pain. An accurate history of prefracture function should be obtained to help guide goals and prognosis. When a poorly functioning or loose prosthesis was present before fracture, return to a better functional level after fracture fixation and revision arthroplasty may be a reasonable goal. A unique consideration when treating periprosthetic rather than native periarticular fractures is consideration of prosthesis stability and the potential need for future revision arthroplasty. The additional goal therefore is to assure stability of the prosthesis and restoration of adequate bone stock to maximize the potential success of any subsequent procedures.
PERIPROSTHETIC FEMUR FRACTURES ABOUT HIP ARTHROPLASTY PROSTHESES Classification The Vancouver classification considers the location of the fracture relative to the stem, the stability of the implant, and the associated bone loss. Type A fractures are in the trochanteric region, type B fractures involve the area of the stem, and type C fractures are distant to the tip of the stem such that their treatment is considered independent of the hip prosthesis (except relating to overlap of the fixation device and the prosthesis). Type A fractures are subdivided into fractures of the greater trochanter (AG) and fractures about the lesser trochanter (AL). Type B fractures are also further subdivided: B1 fractures are associated with a stable implant, B2 fractures are associated with a loose implant, and B3 fractures are associated with bone loss and usually a loose implant. The ability to distinguish a well-fixed implant from a loose implant in the setting of periprosthetic fracture may be difficult; therefore, intraoperative testing of implant stability and preparation for dealing with a loose stem are prudent.8
Vancouver A Fractures Incidence and Risk Factors Vancouver type A fractures can occur intraoperatively or postoperatively with similar frequency. They were found to J Orthop Trauma Volume 29, Number 3, March 2015
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occur intraoperatively in 21 of 373 (5.6%) patients (all women).9 Associated fractures usually involve the metaphyseal area and can be visualized within the surgical field along the medial aspect of the neck cut. Unrecognized intraoperative metaphyseal fractures often lead to propagation and subsidence early in the postoperative period. Postoperative fracture occurred in 2.6% of 887 cases treated with a single type of uncemented prosthesis.10 These fractures typically occurred through osteolytic cysts between 4 and 11 years after total hip arthroplasty (THA).
Management The majority of periprosthetic fractures of the greater trochanter, type AG, are stable. They are usually nondisplaced or minimally displaced and are stabilized by the opposing pull and continuity of the soft-tissue sleeve connecting the abductors and the vastus lateralis.11 Stable fractures occurring postoperatively can be managed nonoperatively with symptomatic treatment with weight bearing to tolerance. Intraoperative stable fractures of the greater trochanter can be managed similarly, especially when recognized after wound closure. In a series of 30 Vancouver type A fractures treated nonoperatively, 90% had displacement of 2.5 cm or less12 Internal fixation is considered for intraoperative fractures, displaced or nondisplaced, or for a complete fracture of the greater trochanter including the abductor attachment without a stabilizing softtissue sleeve. These are generally treated with open reduction and internal fixation (ORIF), typically with a claw plate that engages the soft-tissue attachment of the gluteus medius and the bone of the greater trochanter (see Figure, Supplemental Digital Content 1, http://links.lww.com/BOT/A281). There is very little in the way of published modern series for operative treatment of acute Vancouver type AG fractures to guide treatment and establish expected outcomes. Much of the available information includes or is exclusively related to treatment of greater trochanteric osteotomies or nonunions.13–16 In a recent series of 31 cases of claw plate fixation of the greater trochanter, only 8 were for acute fracture.13 Results for these patients were not distinguished. Overall, union occurred in 28 of 31 patients, with 3 having fibrous union of the trochanter. Fractures of the lesser trochanter, Vancouver type ALT, are typically avulsion fractures that can be managed nonoperatively. However, larger fractures that involve a segment of the proximal medial femoral cortex are typically associated with tapered press-fit stem designs and are usually treated operatively with cerclage cables or wires with or without revision of the stem to one that provides fixation distal to the fracture.17 Nondisplaced fractures of this nature noted intraoperatively can be managed with cerclage cables with retention of the femoral stem if stable. Displaced medial fractures noted intraoperatively or postoperatively are managed with cables and revision to a stem with distal fixation.
Vancouver B and C Fractures Incidence and Risk Factors The incidence of periprosthetic femur fracture after primary hip arthroplasty has been considered to be less than 1%18–20 but has been reported to be as high as 2.3%.19,21–23 In Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Periprosthetic Femur Fractures
comparison with the rate of aseptic loosening, the cumulative occurrence of periprosthetic fracture became equivalent to aseptic loosening at 17 years, indicating the relative importance of periprosthetic fracture in the long term.24 After revision arthroplasty, the incidence of periprosthetic femoral shaft fractures climbs to between 1.5% and 7.8%.18–21,25 Risk factors for periprosthetic femoral shaft fractures about hip arthroplasty femoral stems are related to the age of the patient, gender, index diagnosis, presence or absence of osteolysis, presence or absence of aseptic loosening, primary or revision status, the specific type of implant used, and whether cemented or noncemented technique was used.24,26–39 Identifying risk factors can both improve patient counseling and potentially improve efforts at fracture prevention. Intraoperative fracture has a unique subset of associated risk factors. During primary THA or hemi arthroplasty, implantation of a cementless femoral component presents a reported 3%–5.4% risk for intraoperative fracture compared with 0%–1.2% for a cemented stem.21,40–43 The force used during insertion, the relative geometry of the stem and the femur, and the strength of the bone all may influence the risk for fracture during insertion of noncemented stems. Stem design also influences fracture rate, and the surgeon must be aware of the unique aspects of each stem design and each patients’ femoral morphology, which may predispose to fracture.44 Stems with a combination of metaphyseal and diaphyseal fit with a cylindrical diaphyseal design can predispose to diaphyseal fractures if the distal press-fit is too aggressive or the reamers are not advanced to the full length of the stem. Certain bone morphology patterns have been correlated with fracture during noncemented fixation45 because of a metaphysis— diaphysis mismatch. Cemented stems may also protect against postoperative fracture in patients with poor bone quality by virtue of internal stiffening of the femoral canal.46 Patients with periprosthetic femur fractures have increased mortality.34 In multiple recent series, 7%–18% of patients with periprosthetic fractures died within 1 year after surgical treatment.47–49 In 1 study, this mortality rate approached that of patients with hip fracture (16.5%) treated during the same period and was significantly lower than the mortality of patients undergoing primary joint replacement (2.9%).48 Data from the New Zealand National Registry indicated that the 6-month mortality after revision THA associated with periprosthetic fracture (7.3%) was significantly higher than in a matched cohort undergoing revision for aseptic loosening (0.9%).49
Open Reduction and Internal Fixation
Stabilization using open reduction and internal fixation techniques with plates and screws or cortical onlay allografts or a combination of both is indicated for femoral shaft fractures about (Vancouver B) or distal to (Vancouver C) well-fixed implants (Vancouver type B1 fractures).50–53 The preferred plate construct for Vancouver type B1 fractures includes a lateral plate contoured proximally to accommodate the trochanteric flare (see Figure, Supplemental Digital Content 2, http://links.lww.com/BOT/A282). Three or more equally spaced cables are used proximally between the lesser trochanter and the tip of the stem. Isolated use of unicortical www.jorthotrauma.com |
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locked screws in the proximal fragment is not recommended because of marginal rotational control. Distally, the plate should have a minimum of 6–8 holes covering the native femur distal to the fracture or extend to the condylar region (where a distal femoral plate design may be used). A bowed plate to accommodate the sagittal bow of the femur is preferred. Screws, typically locked screws, can be placed in the trochanteric region after all cables are tensioned. For femoral shaft fractures around a loose implant, Vancouver types B2 and B3 fractures, revision of the femoral component is typically recommended (see Figure, Supplemental Digital Content 3, http://links.lww.com/BOT/A283). This strategy addresses both the loose component and the fracture and provides intramedullary (IM) stability by virtue of longer femoral stems used for revision. Fracture fixation with a lateral plate or reconstitution of bone stock with allograft strut or sometimes a combination of both plates and struts are used in addition to femoral component revision. In more severe cases of bone loss, an allograft prosthesis composite, impaction bone grafting technique, or proximal femoral replacement may be considered.54,55 ORIF remains the most applicable method of internal fixation for Vancouver type C fractures. There is almost always not enough proximal shaft bone to allow stable fixation of a retrograde nail. The mainstay of treatment of distal femur fractures in the presence of a femoral stem is open reduction internal fixation with lateral plates. Although the fracture fixation is not entirely dictated by the presence of the femoral stem, the femoral stem must be considered. The principles for lateral plating for Vancouver C fractures are similar to those for Vancouver B fractures. Locked plates are used to provide fixed-angle stability of the end segment and improved fixation in an osteoporotic shaft segment. The main deviation from standard fixation of these fractures because of the presence of the hip arthroplasty stem comes with fixation proximally. It is rarely the case a lateral plate to provide stable fixation of the distal femur fracture is short enough to avoid a stress riser effect between the top of the plate and the hip arthroplasty femoral stem. The plate should span the fracture and overlap the zone of the stem and be secured with cables in this area (see Figure, Supplemental Digital Content 4, http://links.lww.com/BOT/A284). One of the challenges for ORIF of periprosthetic femoral shaft fractures is obtaining adequate fixation in the proximal fragment around the zone of the hip stem. Cables are typically supplemented with screws into the trochanteric region or with unicortical locked screws in the zone of the stem. Relying on unicortical locked screws without cables should be avoided as these constructs have inadequate rotational control. Unexpectedly, finding a loose femoral stem can be avoided with a careful history and careful observation of prefracture and postfracture radiographs. Even when a careful preoperative evaluation indicates that the stem is stable, intraoperative evaluation of the stem should be performed for confirmation. Access to the distal aspect of the stem is through the fracture. Some authors have advocated performing a hip arthrotomy in all cases to confirm stem stability. Postoperatively, early rehabilitation is concentrated on mobilization and knee range of motion (ROM). Weight
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bearing is protected to some degree for approximately 6–8 weeks. Initial weight-bearing restrictions are typically toetouch for balance or up to 50% weight bearing if the bone quality and fixation were both optimal. Immediate weight bearing has been advocated after minimally invasive plate application56,57; however, little clinical results to support such an aggressive protocol are available. Therapy for knee ROM, transfer training, and use of assist devices are initiated immediately postoperatively. Based on progressive clinical and radiographic signs of fracture healing, weight bearing is gradually advanced. Full weight bearing is typically accomplished by 6–8 weeks postoperatively, and at this time, formal strengthening and gait training therapy are useful. Newer biologic plating techniques that maximally preserve the soft-tissue attachments about a fracture have been shown to be successful without adjuvant bone grafting for Vancouver B1 fractures. Indirect fracture reduction and a single laterally applied plate without the use of structural allograft or any other substitute were uniformly used in the series of Ricci et al.58 Union occurred after the index procedure in all of the 41 patients who lived beyond the perioperative period. All patients healed in satisfactory alignment (less than 5 degrees of malalignment). The consistent healing was attributed to care in preserving the soft-tissue envelope around the fracture. Xue et al59 and Anakwe et al47 had very similar results in smaller series, 12 and 11 cases, respectively, treated in nearly the identical manor: single lateral plate, screw fixation distally, screw and cerclage fixation proximally, and without the use of adjuvant bone grafts. All patients from both studies healed after the index procedure, with 1 patient having a delayed union and 1 with proximal screw loosening in the series by Xue et al. These results compare favorably with the treatment of similar fractures using cortical onlay grafts alone,3,50,53,60 where nonunion requiring revision surgery has been reported in 8%–10% of cases3,50,60 and where angular malunion has been reported to occur in 5%– 10% of cases.53,60 Good clinical results of isolated locked compression plating technique, without the use of cables, has been reported in small series of patients (10–13), all who accomplished union after the index procedure.61,62 It is important to recognize that in these series, all patients had bicortical fixation in the proximal fragment including bicortical locking screws anterior or posterior to the prosthesis, bicortical fixation into the lesser trochanter, or bicortical fixation into the greater trochanter, or some combination of these methods. Constructs relying on unicortical fixation, without any bicortical fixation, have poor rotational control and are not recommended. Other recent series of ORIF for Vancouver type B and C fractures using plates have not shown universally good results. Less Invasive Stabilization System plating for 19 patients yielded 2 delayed unions and 4 implant-related complications, each requiring revision ORIF.63 Another small study of 10 patients treated with ORIF reported surgeryrelated complication in 62.5% of cases.6
Revision Hip Arthroplasty Historically, there has been little role for revision arthroplasty for B1 fractures, given the stable prosthesis. However, revision of an associated well-fixed stem to a long-stem modular Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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prosthesis nail that spans the fracture has recently been advocated by several authors for Vancouver B fractures regardless of the stem stability.4–6 The earlier weight bearing and improved mobilization associated with revision arthroplasty with implants that span the fracture may provide for improved mortality rates if patients who can withstand the magnitude of such surgery are properly selected. Femoral component revision with or without adjuvant plate and/or allograft strut fixation is indicated for Vancouver types B2 (see Figure, Supplemental Digital Content 3, http://links.lww.com/BOT/A283) and B3 fractures where the femoral stem is loose. The indication for including allograft struts in the operative strategy is most clear when there is associated bone loss from long-standing component motion, type B3 fractures. The overall functional outcome based on the Oxford hip score for revision arthroplasty in the setting of periprosthetic fracture have been found, in a large comparative analysis (n = 232 revisions for fracture), to be worse than when revision is for aseptic loosening.49 Furthermore, this study demonstrated an 8-fold higher mortality rate (7.3%) seen in the patients with periprosthetic fracture. These data are consistent with the high mortality rates (11%) seen in patients treated with ORIF for periprosthetic femur fractures64 and together paint a sobering picture of the seriousness of these injuries. Langenhan et al,5 because of high mortality rates after ORIF, altered their treatment protocol in 2001 and began performing stem replacement with a distally locked modular prosthesis nail for the majority of periprosthetic femur fractures, Vancouver B and C, regardless of the stem stability. This strategy permitted immediate full weight bearing and therefore improved mobility compared with patients treated with ORIF and protected weight bearing. The authors attribute the improved mobility to the improved mortality seen in their group of 29 patients who underwent revision arthroplasty (10 died at final follow-up and 3 died early) to the 23 patients treated with ORIF (21 died at final follow-up and 7 died early). Subgroup analysis of patients with Vancouver B1 fractures showed no significant difference in 6-month mortality between groups, but this analysis was likely underpowered. Another retrospective study comparing ORIF with revision arthroplasty for Vancouver B and C fractures failed to show differences in systemic complications between groups.6 This study did, however, reveal more surgery-related complications in the ORIF group (62.5% vs. 18.8%).
PERIPROSTHETIC DISTAL FEMUR FRACTURES ABOUT TOTAL KNEE ARTHROPLASTY Incidence and Risk Factors Approximately 300,000 primary knee arthroplasties are performed annually in the United States, and this number continues to increase. It is estimated that 0.3%–2.5% of patients will sustain a periprosthetic fracture as a complication of primary total knee arthroplasty (TKA).20,65–67 The prevalence of these fractures is substantially higher (1.7%–38%) after revision TKA.20,68 Patient-specific risk factors such as rheumatoid arthritis, osteolysis, osteopenic bone, use of steroid medications, and frequent falls, all common in the elderly Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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population, and technique-specific risk factors such as anterior femoral cortical notching have been implicated as potential causes of periprosthetic fractures.69–79 In a large population-based study from Scotland that included 44,511 primary and 3222 revision TKAs, female gender, age older than 70 years, and revision arthroplasty were associated with risk for fracture.20 Anterior femoral notching has been implicated as another risk factor for periprosthetic supracondylar femur fracture. Biomechanical evaluations, including cadaveric studies and finite element models, implicate anterior notching as a risk factor for periprosthetic fracture.80,81 Despite commonsense and laboratory investigations indicating notching as a risk factor for periprosthetic supracondylar femur fractures, clinical data remain unconvincing. The lack of statistical association between notching and fracture may be due to underpowered studies and extremely small numbers of observed fractures. Lesh et al80 reviewed 164 supracondylar periprosthetic femur fractures reported in the literature and noted more than 30% were associated with notching. Many of these patients, however, were noted to have other risk factors for fracture. Three separate large retrospective studies (.200 patients) failed to find an association between notching and fracture.82–84 However, with very few fractures (3 or less) in each of these cohorts, statistical power is lacking in each to rule out an association between notching and fracture.
Classification The Lewis and Rorabeck classification scheme for periprosthetic femur fractures about TKAs accounts for fracture displacement and prosthesis stability.85,86 Type I are stable fractures essentially nondisplaced, and the bone– prosthesis interface remains intact. Type II fractures are displaced with a well-fixed prosthesis. Type III fractures have a loose or failing prosthesis regardless of the fracture displacement. This classification does not account for the fracture location relative to the prosthesis, a factor that has the potential to dictate treatment. The classification scheme of Su et al87 divides fractures into 3 types according to the fracture location relative to the proximal border of the femoral component: type I fractures are proximal to the femoral component; type II originate at the proximal end of the component and extend proximally; and type III extend distal to the proximal border of the femoral component.
Management Nonoperative Nonoperative treatment of periprosthetic supracondylar femur fractures is reserved for nondisplaced fractures or for displaced fractures where patient-based results of nonoperative treatment would be at least as good as operative treatment. For displaced fractures, nonoperative treatment is indicated for nonambulatory patients or those patients who are not like to survive surgery because of medical comorbidities.
Open Reduction and Internal Fixation Operative treatment of patients with supracondylar femur fractures associated with TKA prostheses present www.jorthotrauma.com |
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unique challenges. The presence of a TKA prosthesis can complicate operative treatment of these fractures by interfering with or precluding the use of standard fixation methods. A TKA prosthesis with a narrow or closed intracondylar space either limits the diameter for a retrograde nail or completely obviates its use.88 Traditional nonlocked plate fixation is prone to varus collapse.67 Fixed-angle implants such as blade plates or condylar screws have limited applicability for very distal fractures or when associated with a TKA prosthesis that has a deep intracondylar box but may be used successfully when adequate bone above the femoral prosthesis is available.89 Locked plating has become the treatment method of choice for many surgeons, as this device offers many theoretic advantages (see Figure, Supplemental Digital Content 5, http://links.lww.com/BOT/A285). The multiple locked distal screws provide both a fixed angle to prevent varus collapse and the ability to address distal fractures90 even when associated with a deep intracondylar box. The provision for locked screw insertion into the diaphyseal fragment theoretically improves fixation. These devices can also be inserted with relative ease and familiarity. A simple fracture pattern amenable to compression plating techniques will require an anatomic reduction and rigid fixation, whereas a comminuted fracture is treated with indirect reduction techniques and bridge plating. Use of multiple locking screws and the largest diameter screws available will minimize loss of distal fixation. Proximal fixation is optimized with the use of relatively long plates, 8 or more holes covering the proximal fragment secured with at least 4 screws. Locked screws are used in the proximal fragment when bone stock is poor. One of the most common pitfalls during ORIF of distal femur fractures is reduction in valgus. True anteroposterior radiographs and comparison with the contralateral limb should be used to assure proper alignment. In the sagittal plane, apex posterior malreduction is common. Joysticks or clamps in the distal fragment can be used to manipulate the articular segment into proper alignment. Early rehabilitation is concentrated on patient mobilization and knee ROM. Weight bearing is protected to some degree for approximately 6–8 weeks. Initial weight-bearing restrictions are toe-touch for balance or up to 50% weight bearing if the bone quality and fixation were both optimal. Therapy for knee ROM, transfer training, and use of assist devices are initiated immediately postoperatively. Based on progressive clinical and radiographic signs of fracture healing, weight bearing is gradually advanced. Full weight bearing is typically accomplished by 6–8 weeks postoperatively, and at this time, formal strengthening and gait training therapy are useful. The initial enthusiasm for locked plating of distal femur fractures is being tempered by the inability to obtain consistently high union rates.91–95 Results of locked plating of periprosthetic distal femur fractures are consistent with those of other series of locked plate fixation of native distal femur fractures,96,97 indicating that the presence of the TKA femoral component has little effect on outcomes. Although locked plate fixation has become the de-facto standard method for ORIF at many centers, nonunion and implant failure rates for this method of fixation remain a concern.
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Hoffmann et al,98 in a series of 36 periprosthetic fractures treated with locked plates at 2 trauma centers, reported nonunion in 22.2% of cases and implant failure in 8.3%. Ricci et al,92 in a series of 22 patients treated with locked distal femoral plates, also showed a relatively high nonunion rate of 14%. The 3 patients with nonunion were insulin-dependent diabetics who were also obese. Fulkerson et al99 also had a high complication rate (33%) after treatment of 18 supracondylar femur fractures above a TKA with a first-generation locking plate. These included plate failure (n = 1), delayed union (n = 2), nonunion (n = 2), and component loosening (n = 1). In contrast, Anakwe et al47 and Large et al100 had no nonunions among a total of 40 patients treated with locked plating, and Kolb et al101 reported just 1 nonunion among 19 patients at mid term follow-up of 46 months.
IM Nailing IM nailing represents another viable option for a subset of periprosthetic distal femur fractures.93,102–104 The associated femoral component must accommodate the diameter of the driving end of a retrograde nail, and sufficient distal bone is required. Published galleries of radiographic profiles and reference lists that include intercondylar dimensions of various prostheses are helpful to avoid unanticipated problems when documentation of the component type is unavailable.105 This fixation method is advantageous because of the indirect nature of the fracture reduction and associated minimization of soft-tissue disruption about the fracture. However, problems obtaining stable fixation with IM nails in patients with wide metaphyseal areas, with osteopenia, or both can lead to loss of fixation and malalignment.103 Patients are mobilized as soon as possible postoperatively. Weight bearing is typically protected for 4–6 weeks after retrograde nailing of comminuted distal femur fracture in osteoporotic patients, the typical scenario for periprosthetic distal femur fractures. A careful history of prefracture knee function helps identify reasonable goals for postoperative ROM and function. Weight bearing is advanced based on clinical and radiographic evidence of progressive fracture healing. One of the most disheartening potential pitfalls of retrograde nailing of periprosthetic distal femur fractures is unexpectedly finding a closed or a narrow intercondylar box of the femoral component that prevents passage of the retrograde nail. Prevention of this situation is certainly preferred to managing it intraoperatively. In the absence of accurate documentation of the knee arthroplasty design, an intraoperative notch view can be used to confirm an open intercondylar notch. Obtaining and maintaining satisfactory fracture alignment is often difficult in the setting of a periprosthetic fracture. Even when the staring guide wire and opening portal are perfectly aligned, the nail often migrates to a different trajectory, leading to malalignment of the fracture. In such cases, placement of blocking screws helps obtain and maintain proper position of the nail, centered along the long axis of the distal fragment, and in turn results in a satisfactory fracture reduction. Blocking screws on both sides of the nail, medial and lateral to control varus/valgus and anterior and Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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posterior to control flexion/extension, can help maintain reduction. It is also recommended to place as many interlocking screws as possible (typically 3 or 4 depending on the nailing system selected) in various planes to support distal fixation in osteoporotic bone. A true lateral of the knee should be used to judge nail position relative to the knee prosthesis to avoid a nail that protrudes into the knee joint. Most studies of periprosthetic supracondylar femur fractures treated with retrograde nailing are small retrospective series. Reported union rates are generally favorable. However, the risk for malunion after retrograde nailing is high. Four small series (14 or less patients) of periprosthetic supracondylar femur fractures treated with retrograde nailing each reported 100% union.102,106,107 Alignment at healing is variable, as this is one of the main technical challenges of this treatment method. Han et al106 had no malalignment greater than 10 degrees. Malunion of 35-degree valgus requiring revision to a stemmed TKA was occurred in 1 of 10 cases reported by Gliatis et al.102 Another study of 14 patients reported valgus of 8–12 degrees in 3 cases, 15-degree extension in one, and 50% posterior translation in another.107 The malalignment seen in these series may, in part, be related to the use of short nails, which, because they do not benefit from the stability and alignment control that comes from passing the nail across the femoral isthmus, are not currently recommended for the treatment of distal femur fractures.
Distal Femoral Replacement Distal femoral replacement also has a role in certain subsets of patients with periprosthetic distal femur fractures.108–110 This treatment method is gaining in popularity, and indications are expanding from primarily those patients with loose TKA prostheses to also include patients with wellfixed and well-functioning prosthesis, when the prolonged period of protected weight bearing associated with internal fixation methods is undesirable or impractical. Revision of femoral components typically requires metal augmentation because of the inevitable bone deficiency associated with component removal. Stems should be used routinely, and it is recommended that the stems engage the femoral diaphysis both for alignment and fixation reasons. Most of the clinical data evaluating the outcomes of a simultaneous revision arthroplasty with IM stem fixation of a supracondylar fracture have been gathered from the treatment of distal femoral nonunion. Kress et al111 reported a small series of nonunions about the knee treated successfully with revision and uncemented femoral stems with bone grafting and achieved union in 6 months. Davila et al112 have reported a small series of supracondylar distal femoral nonunions treated with megaprostheses in elderly patients. They have shown that a cemented megaprosthesis in this patient population permits early ambulation and return to activities of daily living. Freedman et al113 performed distal femoral replacement in 5 elderly patients with acute fractures and reported 4 good results and 1 poor result secondary to infection. The 4 patients with good results regained ambulation in less than 1 month and had an average arc of motion of 99 degrees. All patients had some degree of extension lag. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Periprosthetic Femur Fractures
REFERENCES 1. Haddad FS, Marston RA, Muirhead-Allwood SK. The Dall-Miles cable and plate system for periprosthetic femoral fractures. Injury. 1997;28: 445–447. 2. Radcliffe SN, Smith DN. The Mennen plate in periprosthetic hip fractures. Injury. 1996;27:27–30. 3. Chandler HP, Tigges RG. The role of allografts in the treatment of periprosthetic femoral fractures. Instr Course Lect. 1998;47; 257–264. 4. Pavlou G, Panteliadis P, Macdonald D, et al. A review of 202 periprosthetic fractures—stem revision and allograft improves outcome for type B fractures. Hip Int. 2011;21:21–29. 5. Langenhan R, Trobisch P, Ricart P, et al. Aggressive surgical treatment of periprosthetic femur fractures can reduce mortality: comparison of open reduction and internal fixation versus a modular prosthesis nail. J Orthop Trauma. 2012;26:80–85. 6. Laurer HL, Wutzler S, Possner S, et al. Outcome after operative treatment of Vancouver type B1 and C periprosthetic femoral fractures: open reduction and internal fixation versus revision arthroplasty. Arch Orthop Trauma Surg. 2011;131:983–989. 7. Duncan CP, Masri BA. Fractures of the femur after hip replacement. Instr Course Lect. 1995;44:293–304. 8. Rayan F, Dodd M, Haddad FS. European validation of the Vancouver classification of periprosthetic proximal femoral fractures. J Bone Joint Surg Br. 2008;90:1576–1579. 9. Hendel D, Yasin M, Garti A, et al. Fracture of the greater trochanter during hip replacement: a retrospective analysis of 21/372 cases. Acta Orthop Scand. 2002;73:295–297. 10. Hsieh PH, Chang YH, Lee PC, et al. Periprosthetic fractures of the greater trochanter through osteolytic cysts with uncemented MicroStructured Omnifit prosthesis: retrospective analyses pf 23 fractures in 887 hips after 5-14 years. Acta Orthop. 2005;76:538–543. 11. Tsiridis E, Spence G, Gamie Z, et al. Grafting for periprosthetic femoral fractures: strut, impaction or femoral replacement. Injury. 2007;38:688–697. 12. Pritchett JW. Fracture of the greater trochanter after hip replacement. Clin Orthop Relat Res. 2001;390:221–226. 13. Lindahl H, Oden A, Garellick G, et al. The excess mortality due to periprosthetic femur fracture. A study from the Swedish national hip arthroplasty register. Bone. 2007;40:1294–1298. 14. Lindahl H. Epidemiology of periprosthetic femur fracture around a total hip arthroplasty. Injury. 2007;38:651–654. 15. Lindahl H, Malchau H, Herberts P, et al. Periprosthetic femoral fractures classification and demographics of 1049 periprosthetic femoral fractures from the Swedish National Hip Arthroplasty Register. J Arthroplasty. 2005;20:857–865. 16. Guidera KJ, Borrelli J Jr, Raney E, et al. Orthopaedic manifestations of Rett syndrome. J Pediatr Orthop. 1991;11:204–208. 17. Van Houwelingen AP, Duncan CP. The pseudo A(LT) periprosthetic fracture: it’s really a B2. Orthopedics. 2011;34:e479–e481. 18. Kavanagh BF. Femoral fractures associated with total hip arthroplasty. Orthop Clin North Am. 1992;23:249–257. 19. Lewallen DG, Berry DJ. Periprosthetic fracture of the femur after total hip arthroplasty: treatment and results to date. Instr Course Lect. 1998; 47:243–249. 20. Meek RM, Norwood T, Smith R, et al. The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement. J Bone Joint Surg Br. 2011;93:96–101. 21. Berry DJ. Epidemiology: hip and knee. Orthop Clin North Am. 1999; 30:183–190. 22. Fredin HO, Lindberg H, Carlsson AS. Femoral fracture following hip arthroplasty. Acta Orthop Scand. 1987;58:20–22. 23. Garcia-Cimbrelo E, Munuera L, Gil-Garay E. Femoral shaft fractures after cemented total hip arthroplasty. Int Orthop. 1992; 16:97–100. 24. Streit MR, Merle C, Clarius M, et al. Late peri-prosthetic femoral fracture as a major mode of failure in uncemented primary hip replacement. J Bone Joint Surg Br. 2011;93:178–183. 25. Morrey BF, Kavanagh BF. Complications with revision of the femoral component of total hip arthroplasty. Comparison between cemented and uncemented techniques. J Arthroplasty. 1992;7:71–79.
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26. Singh JA, Jensen MR, Lewallen DG. Patient factors predict periprosthetic fractures after revision total hip arthroplasty. J Arthroplasty. 2012;27:1507–1512. 27. Singh JA, Jensen MR, Harmsen SW, et al. Are gender, comorbidity, and obesity risk factors for postoperative periprosthetic fractures after primary total hip arthroplasty? J Arthroplasty. 2013;28:126–131. 28. Wu CC, Au MK, Wu SS, et al. Risk factors for postoperative femoral fracture in cementless hip arthroplasty. J Formos Med Assoc. 1999;98: 190–194. 29. Sarvilinna R, Huhtala H, Pajamaki J. Young age and wedge stem design are risk factors for periprosthetic fracture after arthroplasty due to hip fracture. A case-control study. Acta Orthop. 2005;76:56–60. 30. Beals RK, Tower SS. Periprosthetic fractures of the femur. An analysis of 93 fractures. Clin Orthop Relat Res. 1996;327:238–246. 31. Bethea JS III, DeAndrade JR, Fleming LL, et al. Proximal femoral fractures following total hip arthroplasty. Clin Orthop Relat Res. 1982;170:95–106. 32. Johansson JE, McBroom R, Barrington TW, et al. Fracture of the ipsilateral femur in patients with total hip replacement. J Bone Joint Surg Am. 1981;63:1435–1442. 33. Whittaker RP, Sotos LN, Ralston EL. Fractures of the femur about femoral endoprostheses. J Trauma. 1974;14:675–694. 34. Franklin J, Malchau H. Risk factors for periprosthetic femoral fracture. Injury. 2007;38:655–660. 35. Sarvilinna R, Huhtala HS, Sovelius RT, et al. Factors predisposing to periprosthetic fracture after hip arthroplasty: a case (n = 31)-control study. Acta Orthop Scand. 2004;75:16–20. 36. Dhawan RK, Mangham DC, Graham NM. Periprosthetic femoral fracture due to Biodegradable Cement Restrictor. J Arthroplasty. 2012;27:1581. 37. Incavo SJ, Beard DM, Pupparo F, et al. One-stage revision of periprosthetic fractures around loose cemented total hip arthroplasty. Am J Orthop (Belle Mead NJ). 1998;27:35–41. 38. Tsiridis E, Haddad FS, Gie GA. The management of periprosthetic femoral fractures around hip replacements. Injury. 2003;34:95–105. 39. Harris B, Owen JR, Wayne JS, et al. Does femoral component loosening predispose to femoral fracture?: an in vitro comparison of cemented hips. Clin Orthop Relat Res. 2010;468:497–503. 40. Taylor MM, Meyers MH, Harvey JP Jr. Intraoperative femur fractures during total hip replacement. Clin Orthop Relat Res. 1978;137:96–103. 41. Schwartz JT Jr, Mayer JG, Engh CA. Femoral fracture during noncemented total hip arthroplasty. J Bone Joint Surg Am. 1989;71:1135–1142. 42. Foster AP, Thompson NW, Wong J, et al. Periprosthetic femoral fractures—a comparison between cemented and uncemented hemiarthroplasties. Injury. 2005;36:424–429. 43. Hailer NP, Garellick G, Kärrholm J. Uncemented and cemented primary total hip arthroplasty in the Swedish Hip Arthroplasty Register. Acta Orthop. 2010;81:34–41. 44. Chana R, Mansouri R, Jack C, et al. The suitability of an uncemented hydroxyapatite coated (HAC) hip hemiarthroplasty stem for intra-capsular femoral neck fractures in osteoporotic elderly patients: the MetaphysealDiaphyseal Index, a solution to preventing intra-operative periprosthetic fracture. J Orthop Surg Res. 2011;6:59. 45. Cooper HJ, Rodriguez JA. Early Post-operative Periprosthetic Femur Fracture in the Presence of a Non-cemented Tapered Wedge Femoral Stem. HSS J. 2010;6:150–154. 46. Thomsen MN, Jakubowitz E, Seeger JB, et al. Fracture load for periprosthetic femoral fractures in cemented versus uncemented hip stems: an experimental in vitro study. Orthopedics. 2008;31:653. 47. Anakwe RE, Aitken SA, Khan LA. Osteoporotic periprosthetic fractures of the femur in elderly patients: outcome after fixation with the LISS plate. Injury. 2008;39:1191–1197. 48. Bhattacharyya T, Chang D, Meigs JB, et al. Mortality after periprosthetic fracture of the femur. J Bone Joint Surg Am. 2007;89:2658–2662. 49. Young SW, Walker CG, Pitto RP. Functional outcome of femoral peri prosthetic fracture and revision hip arthroplasty: a matched-pair study from the New Zealand Registry. Acta Orthop. 2008;79:483–488. 50. Wong P, Gross AE. The use of structural allografts for treating periprosthetic fractures about the hip and knee. Orthop Clin North Am. 1999;30:259–264. 51. Brady OH, Garbuz DS, Masri BA, et al. The treatment of periprosthetic fractures of the femur using cortical onlay allograft struts. Orthop Clin North Am. 1999;30:249–257.
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52. Tower SS, Beals RK. Fractures of the femur after hip replacement: the Oregon experience. Orthop Clin North Am. 1999;30:235–247. 53. Haddad FS, Duncan CP, Berry DJ, et al. Periprosthetic femoral fractures around well-fixed implants: use of cortical onlay allografts with or without a plate. J Bone Joint Surg Am. 2002;84-A:945–950. 54. Mukundan C, Rayan F, Kheir E, et al. Management of late periprosthetic femur fractures: a retrospective cohort of 72 patients. Int Orthop. 2010;34:485–489. 55. Lee GC, Nelson CL, Virmani S, et al. Management of periprosthetic femur fractures with severe bone loss using impaction bone grafting technique. J Arthroplasty. 2010;25:405–409. 56. Ehlinger M, Adam P, Moser T, et al. Type C periprosthetic fractures treated with locking plate fixation with a mean follow up of 2.5 years. Orthop Traumatol Surg Res. 2010;96:44–48. 57. Ehlinger M, Bonnomet F, Adam P. Periprosthetic femoral fractures: the minimally invasive fixation option. Orthop Traumatol Surg Res. 2010;96:304–309. 58. Ricci WM, Bolhofner BR, Loftus T, et al. Indirect reduction and plate fixation, without grafting, for periprosthetic femoral shaft fractures about a stable intramedullary implant. J Bone Joint Surg Am. 2005; 87:2240–2245. 59. Xue H, Tu Y, Cai M, et al. Locking compression plate and cerclage band for type B1 periprosthetic femoral fractures preliminary results at average 30-month follow-up. J Arthroplasty. 2011;26:467–471. 60. Chandler HP, King D, Limbird R, et al. The use of cortical allograft struts for fixation of fractures associated with well-fixed total joint prostheses. Semin Arthroplasty. 1993;4:99–107. 61. Ebraheim NA, Gomez C, Ramineni SK, et al. Fixation of periprosthetic femoral shaft fractures adjacent to a well-fixed femoral stem with reversed distal femoral locking plate. J Trauma. 2009;66:1152–1157. 62. Bryant GK, Morshed S, Agel J, et al. Isolated locked compression plating for Vancouver Type B1 periprosthetic femoral fractures. Injury. 2009;40:1180–1186. 63. Muller M, Kaab M, Tohtz S, et al. Periprosthetic femoral fractures: outcome after treatment with LISS internal fixation or stem replacement in 36 patients. Acta Orthop Belg. 2009;75:776–783. 64. Talbot M, Zdero R, Schemitsch EH. Cyclic loading of periprosthetic fracture fixation constructs. J Trauma. 2008;64:1308–1312. 65. Mont MA, Maar DC. Fractures of the ipsilateral femur after hip arthroplasty. A statistical analysis of outcome based on 487 patients. J Arthroplasty. 1994;9:511–519. 66. Ayers DC. Supracondylar fracture of the distal femur proximal to a total knee replacement. Instr Course Lect. 1997;46:197–203. 67. Davison BL. Varus collapse of comminuted distal femur fractures after open reduction and internal fixation with a lateral condylar buttress plate. Am J Orthop. 2003;32:27–30. 68. Parvizi J, Jain N, Schmidt AH. Periprosthetic knee fractures. J Orthop Trauma. 2008;22:663–671. 69. Aaron RK, Scott R. Supracondylar fracture of the femur after total knee arthroplasty. Clin Orthop Relat Res. 1987;219:136–139. 70. Cain PR, Rubash HE, Wissinger HA, et al. Periprosthetic femoral fractures following total knee arthroplasty. Clin Orthop Relat Res. 1986; 208:205–214. 71. Culp RW, Schmidt RG, Hanks G, et al. Supracondylar fracture of the femur following prosthetic knee arthroplasty. Clin Orthop Relat Res. 1987;222:212–222. 72. Merkel KD, Johnson EW Jr. Supracondylar fracture of the femur after total knee arthroplasty. J Bone Joint Surg Am. 1986;68:29–43. 73. Cracchiolo A. Stress fractures of the pelvis as a cause of hip pain following total hip and knee arthroplasty. Arthritis Rheum. 1981;24: 740–742. 74. Hardy DC, Delince PE, Yasik E, et al. Stress fracture of the hip. An unusual complication of total knee arthroplasty. Clin Orthop Relat Res. 1992;281:140–144. 75. Kumm DA, Rack C, Rutt J. Subtrochanteric stress fracture of the femur following total knee arthroplasty. J Arthroplasty. 1997;12:580–583. 76. Lesniewski PJ, Testa NN. Stress fracture of the hip as a complication of total knee replacement. Case report. J Bone Joint Surg Am. 1982;64: 304–306. 77. Palance MD, Albareda J, Seral F. Subcapital stress fracture of the femoral neck after total knee arthroplasty. Int Orthop. 1994;18: 308–309.
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J Orthop Trauma Volume 29, Number 3, March 2015 78. Rawes ML, Patsalis T, Gregg PJ. Subcapital stress fractures of the hip complicating total knee replacement. Injury. 1995;26:421–423. 79. Peters CL, Hennessey R, Barden RM, et al. Revision total knee arthroplasty with a cemented posterior-stabilized or constrained condylar prosthesis: a minimum 3-year and average 5-year follow-up study. J Arthroplasty. 1997;12:896–903. 80. Lesh ML, Schneider DJ, Deol G, et al. The consequences of anterior femoral notching in total knee arthroplasty. A biomechanical study. J Bone Joint Surg Am. 2000;82-A:1096–1101. 81. Zalzal P, Backstein D, Gross AE, et al. Notching of the anterior femoral cortex during total knee arthroplasty characteristics that increase local stresses. J Arthroplasty. 2006;21:737–743. 82. Ritter MA, Thong AE, Keating EM, et al. The effect of femoral notching during total knee arthroplasty on the prevalence of postoperative femoral fractures and on clinical outcome. J Bone Joint Surg Am. 2005; 87:2411–2414. 83. Ritter MA, Faris PM, Keating EM. Anterior femoral notching and ipsilateral supracondylar femur fracture in total knee arthroplasty. J Arthroplasty. 1988;3:185–187. 84. Gujarathi N, Putti AB, Abboud RJ, et al. Risk of periprosthetic fracture after anterior femoral notching. Acta Orthop. 2009;80:553–556. 85. Rorabeck CH, Taylor JW. Classification of periprosthetic fractures complicating total knee arthroplasty. Orthop Clin North Am. 1999;30: 209–214. 86. Lewis PL, Rorabeck CH. In: Engh GA, Rorabeck CH, eds. Revision Total Knee Arthroplasty. Williams & Wilkins; 1997:275–295. 87. Su ET, DeWal H, Di Cesare PE. Periprosthetic femoral fractures above total knee replacements. J Am Acad Orthop Surg. 2004;12:12–20. 88. Maniar RN, Umlas ME, Rodriguez JA, et al. Supracondylar femoral fracture above a PFC posterior cruciate-substituting total knee arthroplasty treated with supracondylar nailing. A unique technical problem. J Arthroplasty. 1996;11:637–639. 89. Kolb K, Koller H, Lorenz I, et al. Operative treatment of distal femoral fractures above total knee arthroplasty with the indirect reduction technique: a long-term follow-up study. Injury. 2009;40:433–439. 90. Streubel PN, Gardner MJ, Morshed S, et al. Are extreme distal periprosthetic supracondylar fractures of the femur too distal to fix using a lateral locked plate? J Bone Joint Surg Br. 2010;92:527–534. 91. Ricci WM, Borrelli J Jr. Operative management of periprosthetic femur fractures in the elderly using biological fracture reduction and fixation techniques. Injury. 2007;38(suppl 3):S53–S58. 92. Ricci WM, Loftus T, Cox C, et al. Locked plates combined with minimally invasive insertion technique for the treatment of periprosthetic supracondylar femur fractures above a total knee arthroplasty. J Orthop Trauma. 2006;20:190–196. 93. Herrera DA, Kregor PJ, Cole PA, et al. Treatment of acute distal femur fractures above a total knee arthroplasty: systematic review of 415 cases (1981-2006). Acta Orthop. 2008;79:22–27. 94. Pressmar J, Macholz F, Merkert W, et al. Results and complications in the treatment of periprosthetic femur fractures with a locked plate system [in German]. Unfallchirurg. 2010;113:195–202. 95. Tharani R, Nakasone C, Vince KG. Periprosthetic fractures after total knee arthroplasty. J Arthroplasty. 2005;20:27–32. 96. Schütz M, Müller M, Krettek C, et al. Minimally invasive fracture stabilization of distal femoral fractures with the LISS: a prospective
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OF THE
ART
Periprosthetic Femur Fractures William M. Ricci, MD
Summary: Successful treatment of periprosthetic femur fractures, like all fractures, requires careful attention to understand the fracture pattern nuances, identifying and executing a rational treatment approach, and providing an appropriate postoperative recovery protocol. Unlike most other fractures, modification of standard techniques is often required to obtain a stable fixation construct, and there is a greater role for revision arthroplasty in the treatment of periprosthetic fractures. Optimal indications for surgical repair versus revision arthroplasty and optimal postoperative weight-bearing protocols remain uncertain. Reported outcomes for patients with periprosthetic femoral shaft fractures are generally good and are relatively consistent. Results for periprosthetic distal femur fractures, however, are less good and more inconsistent. Both periprosthetic femoral shaft and distal femur fractures are associated with relatively high mortality rates, approaching that of patients with hip fractures. This review should provide insight into the current solutions and challenges for the treatment of patients with periprosthetic femur fractures. Key Words: periprosthetic, femur, fracture (J Orthop Trauma 2015;29:130–137)
INTRODUCTION Periprosthetic fractures continue to increase in frequency. This is due, in part, to the increasing number of primary and revision arthroplasties performed annually and also to the increasing age and fragility of patients with such implants. In each situation, the presence of an arthroplasty component either obviates the use of or increases the difficulty of standard fixation techniques. Additionally, these fractures often occur in elderly patients with osteoporotic bone, making stable fixation with traditional techniques even more problematic. Treatment of the most common periprosthetic fractures, those of the femoral shaft, and those of the femoral supracondylar region has focused on open reduction with internal fixation (ORIF) or revision arthroplasty procedures with or without supplementary autologous or allogeneic bone grafting.1–3 Most recently, Accepted for publication December 10, 2014. From the Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO. W. M. Ricci is a consultant for Smith & Nephew, Stryker, and Biomet; receives institutional support from AONA, COTA, Smith & Nephew; receives royalties from Smith & Nephew, MicroPort (Wright Medical), Biomet (expected), Stryker (expected), and LWW (expected). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions this article on the journal’s Web site (www.jorthotrauma.com). Reprints: William M. Ricci, MD, Department of Orthopaedic Surgery, Washington University School of Medicine, Campus Box 8233, 660 S Euclid Avenue, St Louis, MO 63110 (e-mail: [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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treatment strategies to accelerate weight bearing have suggested benefits with regard to mortality.4–6 Successful application of these strategies can be extrapolated to periprosthetic fractures in other anatomic locations but must also consider the fracture location relative to the arthroplasty component, the implant stability, the quality of the surrounding bone, and the patients’ medical and functional status.7
TREATMENT GOALS The goals of periprosthetic fracture care are essentially no different than the goals of treatment of any other fracture. These include uncomplicated fracture union, restoration of alignment, and return to preinjury level of function without pain. An accurate history of prefracture function should be obtained to help guide goals and prognosis. When a poorly functioning or loose prosthesis was present before fracture, return to a better functional level after fracture fixation and revision arthroplasty may be a reasonable goal. A unique consideration when treating periprosthetic rather than native periarticular fractures is consideration of prosthesis stability and the potential need for future revision arthroplasty. The additional goal therefore is to assure stability of the prosthesis and restoration of adequate bone stock to maximize the potential success of any subsequent procedures.
PERIPROSTHETIC FEMUR FRACTURES ABOUT HIP ARTHROPLASTY PROSTHESES Classification The Vancouver classification considers the location of the fracture relative to the stem, the stability of the implant, and the associated bone loss. Type A fractures are in the trochanteric region, type B fractures involve the area of the stem, and type C fractures are distant to the tip of the stem such that their treatment is considered independent of the hip prosthesis (except relating to overlap of the fixation device and the prosthesis). Type A fractures are subdivided into fractures of the greater trochanter (AG) and fractures about the lesser trochanter (AL). Type B fractures are also further subdivided: B1 fractures are associated with a stable implant, B2 fractures are associated with a loose implant, and B3 fractures are associated with bone loss and usually a loose implant. The ability to distinguish a well-fixed implant from a loose implant in the setting of periprosthetic fracture may be difficult; therefore, intraoperative testing of implant stability and preparation for dealing with a loose stem are prudent.8
Vancouver A Fractures Incidence and Risk Factors Vancouver type A fractures can occur intraoperatively or postoperatively with similar frequency. They were found to J Orthop Trauma Volume 29, Number 3, March 2015
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J Orthop Trauma Volume 29, Number 3, March 2015
occur intraoperatively in 21 of 373 (5.6%) patients (all women).9 Associated fractures usually involve the metaphyseal area and can be visualized within the surgical field along the medial aspect of the neck cut. Unrecognized intraoperative metaphyseal fractures often lead to propagation and subsidence early in the postoperative period. Postoperative fracture occurred in 2.6% of 887 cases treated with a single type of uncemented prosthesis.10 These fractures typically occurred through osteolytic cysts between 4 and 11 years after total hip arthroplasty (THA).
Management The majority of periprosthetic fractures of the greater trochanter, type AG, are stable. They are usually nondisplaced or minimally displaced and are stabilized by the opposing pull and continuity of the soft-tissue sleeve connecting the abductors and the vastus lateralis.11 Stable fractures occurring postoperatively can be managed nonoperatively with symptomatic treatment with weight bearing to tolerance. Intraoperative stable fractures of the greater trochanter can be managed similarly, especially when recognized after wound closure. In a series of 30 Vancouver type A fractures treated nonoperatively, 90% had displacement of 2.5 cm or less12 Internal fixation is considered for intraoperative fractures, displaced or nondisplaced, or for a complete fracture of the greater trochanter including the abductor attachment without a stabilizing softtissue sleeve. These are generally treated with open reduction and internal fixation (ORIF), typically with a claw plate that engages the soft-tissue attachment of the gluteus medius and the bone of the greater trochanter (see Figure, Supplemental Digital Content 1, http://links.lww.com/BOT/A281). There is very little in the way of published modern series for operative treatment of acute Vancouver type AG fractures to guide treatment and establish expected outcomes. Much of the available information includes or is exclusively related to treatment of greater trochanteric osteotomies or nonunions.13–16 In a recent series of 31 cases of claw plate fixation of the greater trochanter, only 8 were for acute fracture.13 Results for these patients were not distinguished. Overall, union occurred in 28 of 31 patients, with 3 having fibrous union of the trochanter. Fractures of the lesser trochanter, Vancouver type ALT, are typically avulsion fractures that can be managed nonoperatively. However, larger fractures that involve a segment of the proximal medial femoral cortex are typically associated with tapered press-fit stem designs and are usually treated operatively with cerclage cables or wires with or without revision of the stem to one that provides fixation distal to the fracture.17 Nondisplaced fractures of this nature noted intraoperatively can be managed with cerclage cables with retention of the femoral stem if stable. Displaced medial fractures noted intraoperatively or postoperatively are managed with cables and revision to a stem with distal fixation.
Vancouver B and C Fractures Incidence and Risk Factors The incidence of periprosthetic femur fracture after primary hip arthroplasty has been considered to be less than 1%18–20 but has been reported to be as high as 2.3%.19,21–23 In Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Periprosthetic Femur Fractures
comparison with the rate of aseptic loosening, the cumulative occurrence of periprosthetic fracture became equivalent to aseptic loosening at 17 years, indicating the relative importance of periprosthetic fracture in the long term.24 After revision arthroplasty, the incidence of periprosthetic femoral shaft fractures climbs to between 1.5% and 7.8%.18–21,25 Risk factors for periprosthetic femoral shaft fractures about hip arthroplasty femoral stems are related to the age of the patient, gender, index diagnosis, presence or absence of osteolysis, presence or absence of aseptic loosening, primary or revision status, the specific type of implant used, and whether cemented or noncemented technique was used.24,26–39 Identifying risk factors can both improve patient counseling and potentially improve efforts at fracture prevention. Intraoperative fracture has a unique subset of associated risk factors. During primary THA or hemi arthroplasty, implantation of a cementless femoral component presents a reported 3%–5.4% risk for intraoperative fracture compared with 0%–1.2% for a cemented stem.21,40–43 The force used during insertion, the relative geometry of the stem and the femur, and the strength of the bone all may influence the risk for fracture during insertion of noncemented stems. Stem design also influences fracture rate, and the surgeon must be aware of the unique aspects of each stem design and each patients’ femoral morphology, which may predispose to fracture.44 Stems with a combination of metaphyseal and diaphyseal fit with a cylindrical diaphyseal design can predispose to diaphyseal fractures if the distal press-fit is too aggressive or the reamers are not advanced to the full length of the stem. Certain bone morphology patterns have been correlated with fracture during noncemented fixation45 because of a metaphysis— diaphysis mismatch. Cemented stems may also protect against postoperative fracture in patients with poor bone quality by virtue of internal stiffening of the femoral canal.46 Patients with periprosthetic femur fractures have increased mortality.34 In multiple recent series, 7%–18% of patients with periprosthetic fractures died within 1 year after surgical treatment.47–49 In 1 study, this mortality rate approached that of patients with hip fracture (16.5%) treated during the same period and was significantly lower than the mortality of patients undergoing primary joint replacement (2.9%).48 Data from the New Zealand National Registry indicated that the 6-month mortality after revision THA associated with periprosthetic fracture (7.3%) was significantly higher than in a matched cohort undergoing revision for aseptic loosening (0.9%).49
Open Reduction and Internal Fixation
Stabilization using open reduction and internal fixation techniques with plates and screws or cortical onlay allografts or a combination of both is indicated for femoral shaft fractures about (Vancouver B) or distal to (Vancouver C) well-fixed implants (Vancouver type B1 fractures).50–53 The preferred plate construct for Vancouver type B1 fractures includes a lateral plate contoured proximally to accommodate the trochanteric flare (see Figure, Supplemental Digital Content 2, http://links.lww.com/BOT/A282). Three or more equally spaced cables are used proximally between the lesser trochanter and the tip of the stem. Isolated use of unicortical www.jorthotrauma.com |
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locked screws in the proximal fragment is not recommended because of marginal rotational control. Distally, the plate should have a minimum of 6–8 holes covering the native femur distal to the fracture or extend to the condylar region (where a distal femoral plate design may be used). A bowed plate to accommodate the sagittal bow of the femur is preferred. Screws, typically locked screws, can be placed in the trochanteric region after all cables are tensioned. For femoral shaft fractures around a loose implant, Vancouver types B2 and B3 fractures, revision of the femoral component is typically recommended (see Figure, Supplemental Digital Content 3, http://links.lww.com/BOT/A283). This strategy addresses both the loose component and the fracture and provides intramedullary (IM) stability by virtue of longer femoral stems used for revision. Fracture fixation with a lateral plate or reconstitution of bone stock with allograft strut or sometimes a combination of both plates and struts are used in addition to femoral component revision. In more severe cases of bone loss, an allograft prosthesis composite, impaction bone grafting technique, or proximal femoral replacement may be considered.54,55 ORIF remains the most applicable method of internal fixation for Vancouver type C fractures. There is almost always not enough proximal shaft bone to allow stable fixation of a retrograde nail. The mainstay of treatment of distal femur fractures in the presence of a femoral stem is open reduction internal fixation with lateral plates. Although the fracture fixation is not entirely dictated by the presence of the femoral stem, the femoral stem must be considered. The principles for lateral plating for Vancouver C fractures are similar to those for Vancouver B fractures. Locked plates are used to provide fixed-angle stability of the end segment and improved fixation in an osteoporotic shaft segment. The main deviation from standard fixation of these fractures because of the presence of the hip arthroplasty stem comes with fixation proximally. It is rarely the case a lateral plate to provide stable fixation of the distal femur fracture is short enough to avoid a stress riser effect between the top of the plate and the hip arthroplasty femoral stem. The plate should span the fracture and overlap the zone of the stem and be secured with cables in this area (see Figure, Supplemental Digital Content 4, http://links.lww.com/BOT/A284). One of the challenges for ORIF of periprosthetic femoral shaft fractures is obtaining adequate fixation in the proximal fragment around the zone of the hip stem. Cables are typically supplemented with screws into the trochanteric region or with unicortical locked screws in the zone of the stem. Relying on unicortical locked screws without cables should be avoided as these constructs have inadequate rotational control. Unexpectedly, finding a loose femoral stem can be avoided with a careful history and careful observation of prefracture and postfracture radiographs. Even when a careful preoperative evaluation indicates that the stem is stable, intraoperative evaluation of the stem should be performed for confirmation. Access to the distal aspect of the stem is through the fracture. Some authors have advocated performing a hip arthrotomy in all cases to confirm stem stability. Postoperatively, early rehabilitation is concentrated on mobilization and knee range of motion (ROM). Weight
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bearing is protected to some degree for approximately 6–8 weeks. Initial weight-bearing restrictions are typically toetouch for balance or up to 50% weight bearing if the bone quality and fixation were both optimal. Immediate weight bearing has been advocated after minimally invasive plate application56,57; however, little clinical results to support such an aggressive protocol are available. Therapy for knee ROM, transfer training, and use of assist devices are initiated immediately postoperatively. Based on progressive clinical and radiographic signs of fracture healing, weight bearing is gradually advanced. Full weight bearing is typically accomplished by 6–8 weeks postoperatively, and at this time, formal strengthening and gait training therapy are useful. Newer biologic plating techniques that maximally preserve the soft-tissue attachments about a fracture have been shown to be successful without adjuvant bone grafting for Vancouver B1 fractures. Indirect fracture reduction and a single laterally applied plate without the use of structural allograft or any other substitute were uniformly used in the series of Ricci et al.58 Union occurred after the index procedure in all of the 41 patients who lived beyond the perioperative period. All patients healed in satisfactory alignment (less than 5 degrees of malalignment). The consistent healing was attributed to care in preserving the soft-tissue envelope around the fracture. Xue et al59 and Anakwe et al47 had very similar results in smaller series, 12 and 11 cases, respectively, treated in nearly the identical manor: single lateral plate, screw fixation distally, screw and cerclage fixation proximally, and without the use of adjuvant bone grafts. All patients from both studies healed after the index procedure, with 1 patient having a delayed union and 1 with proximal screw loosening in the series by Xue et al. These results compare favorably with the treatment of similar fractures using cortical onlay grafts alone,3,50,53,60 where nonunion requiring revision surgery has been reported in 8%–10% of cases3,50,60 and where angular malunion has been reported to occur in 5%– 10% of cases.53,60 Good clinical results of isolated locked compression plating technique, without the use of cables, has been reported in small series of patients (10–13), all who accomplished union after the index procedure.61,62 It is important to recognize that in these series, all patients had bicortical fixation in the proximal fragment including bicortical locking screws anterior or posterior to the prosthesis, bicortical fixation into the lesser trochanter, or bicortical fixation into the greater trochanter, or some combination of these methods. Constructs relying on unicortical fixation, without any bicortical fixation, have poor rotational control and are not recommended. Other recent series of ORIF for Vancouver type B and C fractures using plates have not shown universally good results. Less Invasive Stabilization System plating for 19 patients yielded 2 delayed unions and 4 implant-related complications, each requiring revision ORIF.63 Another small study of 10 patients treated with ORIF reported surgeryrelated complication in 62.5% of cases.6
Revision Hip Arthroplasty Historically, there has been little role for revision arthroplasty for B1 fractures, given the stable prosthesis. However, revision of an associated well-fixed stem to a long-stem modular Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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prosthesis nail that spans the fracture has recently been advocated by several authors for Vancouver B fractures regardless of the stem stability.4–6 The earlier weight bearing and improved mobilization associated with revision arthroplasty with implants that span the fracture may provide for improved mortality rates if patients who can withstand the magnitude of such surgery are properly selected. Femoral component revision with or without adjuvant plate and/or allograft strut fixation is indicated for Vancouver types B2 (see Figure, Supplemental Digital Content 3, http://links.lww.com/BOT/A283) and B3 fractures where the femoral stem is loose. The indication for including allograft struts in the operative strategy is most clear when there is associated bone loss from long-standing component motion, type B3 fractures. The overall functional outcome based on the Oxford hip score for revision arthroplasty in the setting of periprosthetic fracture have been found, in a large comparative analysis (n = 232 revisions for fracture), to be worse than when revision is for aseptic loosening.49 Furthermore, this study demonstrated an 8-fold higher mortality rate (7.3%) seen in the patients with periprosthetic fracture. These data are consistent with the high mortality rates (11%) seen in patients treated with ORIF for periprosthetic femur fractures64 and together paint a sobering picture of the seriousness of these injuries. Langenhan et al,5 because of high mortality rates after ORIF, altered their treatment protocol in 2001 and began performing stem replacement with a distally locked modular prosthesis nail for the majority of periprosthetic femur fractures, Vancouver B and C, regardless of the stem stability. This strategy permitted immediate full weight bearing and therefore improved mobility compared with patients treated with ORIF and protected weight bearing. The authors attribute the improved mobility to the improved mortality seen in their group of 29 patients who underwent revision arthroplasty (10 died at final follow-up and 3 died early) to the 23 patients treated with ORIF (21 died at final follow-up and 7 died early). Subgroup analysis of patients with Vancouver B1 fractures showed no significant difference in 6-month mortality between groups, but this analysis was likely underpowered. Another retrospective study comparing ORIF with revision arthroplasty for Vancouver B and C fractures failed to show differences in systemic complications between groups.6 This study did, however, reveal more surgery-related complications in the ORIF group (62.5% vs. 18.8%).
PERIPROSTHETIC DISTAL FEMUR FRACTURES ABOUT TOTAL KNEE ARTHROPLASTY Incidence and Risk Factors Approximately 300,000 primary knee arthroplasties are performed annually in the United States, and this number continues to increase. It is estimated that 0.3%–2.5% of patients will sustain a periprosthetic fracture as a complication of primary total knee arthroplasty (TKA).20,65–67 The prevalence of these fractures is substantially higher (1.7%–38%) after revision TKA.20,68 Patient-specific risk factors such as rheumatoid arthritis, osteolysis, osteopenic bone, use of steroid medications, and frequent falls, all common in the elderly Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Periprosthetic Femur Fractures
population, and technique-specific risk factors such as anterior femoral cortical notching have been implicated as potential causes of periprosthetic fractures.69–79 In a large population-based study from Scotland that included 44,511 primary and 3222 revision TKAs, female gender, age older than 70 years, and revision arthroplasty were associated with risk for fracture.20 Anterior femoral notching has been implicated as another risk factor for periprosthetic supracondylar femur fracture. Biomechanical evaluations, including cadaveric studies and finite element models, implicate anterior notching as a risk factor for periprosthetic fracture.80,81 Despite commonsense and laboratory investigations indicating notching as a risk factor for periprosthetic supracondylar femur fractures, clinical data remain unconvincing. The lack of statistical association between notching and fracture may be due to underpowered studies and extremely small numbers of observed fractures. Lesh et al80 reviewed 164 supracondylar periprosthetic femur fractures reported in the literature and noted more than 30% were associated with notching. Many of these patients, however, were noted to have other risk factors for fracture. Three separate large retrospective studies (.200 patients) failed to find an association between notching and fracture.82–84 However, with very few fractures (3 or less) in each of these cohorts, statistical power is lacking in each to rule out an association between notching and fracture.
Classification The Lewis and Rorabeck classification scheme for periprosthetic femur fractures about TKAs accounts for fracture displacement and prosthesis stability.85,86 Type I are stable fractures essentially nondisplaced, and the bone– prosthesis interface remains intact. Type II fractures are displaced with a well-fixed prosthesis. Type III fractures have a loose or failing prosthesis regardless of the fracture displacement. This classification does not account for the fracture location relative to the prosthesis, a factor that has the potential to dictate treatment. The classification scheme of Su et al87 divides fractures into 3 types according to the fracture location relative to the proximal border of the femoral component: type I fractures are proximal to the femoral component; type II originate at the proximal end of the component and extend proximally; and type III extend distal to the proximal border of the femoral component.
Management Nonoperative Nonoperative treatment of periprosthetic supracondylar femur fractures is reserved for nondisplaced fractures or for displaced fractures where patient-based results of nonoperative treatment would be at least as good as operative treatment. For displaced fractures, nonoperative treatment is indicated for nonambulatory patients or those patients who are not like to survive surgery because of medical comorbidities.
Open Reduction and Internal Fixation Operative treatment of patients with supracondylar femur fractures associated with TKA prostheses present www.jorthotrauma.com |
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unique challenges. The presence of a TKA prosthesis can complicate operative treatment of these fractures by interfering with or precluding the use of standard fixation methods. A TKA prosthesis with a narrow or closed intracondylar space either limits the diameter for a retrograde nail or completely obviates its use.88 Traditional nonlocked plate fixation is prone to varus collapse.67 Fixed-angle implants such as blade plates or condylar screws have limited applicability for very distal fractures or when associated with a TKA prosthesis that has a deep intracondylar box but may be used successfully when adequate bone above the femoral prosthesis is available.89 Locked plating has become the treatment method of choice for many surgeons, as this device offers many theoretic advantages (see Figure, Supplemental Digital Content 5, http://links.lww.com/BOT/A285). The multiple locked distal screws provide both a fixed angle to prevent varus collapse and the ability to address distal fractures90 even when associated with a deep intracondylar box. The provision for locked screw insertion into the diaphyseal fragment theoretically improves fixation. These devices can also be inserted with relative ease and familiarity. A simple fracture pattern amenable to compression plating techniques will require an anatomic reduction and rigid fixation, whereas a comminuted fracture is treated with indirect reduction techniques and bridge plating. Use of multiple locking screws and the largest diameter screws available will minimize loss of distal fixation. Proximal fixation is optimized with the use of relatively long plates, 8 or more holes covering the proximal fragment secured with at least 4 screws. Locked screws are used in the proximal fragment when bone stock is poor. One of the most common pitfalls during ORIF of distal femur fractures is reduction in valgus. True anteroposterior radiographs and comparison with the contralateral limb should be used to assure proper alignment. In the sagittal plane, apex posterior malreduction is common. Joysticks or clamps in the distal fragment can be used to manipulate the articular segment into proper alignment. Early rehabilitation is concentrated on patient mobilization and knee ROM. Weight bearing is protected to some degree for approximately 6–8 weeks. Initial weight-bearing restrictions are toe-touch for balance or up to 50% weight bearing if the bone quality and fixation were both optimal. Therapy for knee ROM, transfer training, and use of assist devices are initiated immediately postoperatively. Based on progressive clinical and radiographic signs of fracture healing, weight bearing is gradually advanced. Full weight bearing is typically accomplished by 6–8 weeks postoperatively, and at this time, formal strengthening and gait training therapy are useful. The initial enthusiasm for locked plating of distal femur fractures is being tempered by the inability to obtain consistently high union rates.91–95 Results of locked plating of periprosthetic distal femur fractures are consistent with those of other series of locked plate fixation of native distal femur fractures,96,97 indicating that the presence of the TKA femoral component has little effect on outcomes. Although locked plate fixation has become the de-facto standard method for ORIF at many centers, nonunion and implant failure rates for this method of fixation remain a concern.
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Hoffmann et al,98 in a series of 36 periprosthetic fractures treated with locked plates at 2 trauma centers, reported nonunion in 22.2% of cases and implant failure in 8.3%. Ricci et al,92 in a series of 22 patients treated with locked distal femoral plates, also showed a relatively high nonunion rate of 14%. The 3 patients with nonunion were insulin-dependent diabetics who were also obese. Fulkerson et al99 also had a high complication rate (33%) after treatment of 18 supracondylar femur fractures above a TKA with a first-generation locking plate. These included plate failure (n = 1), delayed union (n = 2), nonunion (n = 2), and component loosening (n = 1). In contrast, Anakwe et al47 and Large et al100 had no nonunions among a total of 40 patients treated with locked plating, and Kolb et al101 reported just 1 nonunion among 19 patients at mid term follow-up of 46 months.
IM Nailing IM nailing represents another viable option for a subset of periprosthetic distal femur fractures.93,102–104 The associated femoral component must accommodate the diameter of the driving end of a retrograde nail, and sufficient distal bone is required. Published galleries of radiographic profiles and reference lists that include intercondylar dimensions of various prostheses are helpful to avoid unanticipated problems when documentation of the component type is unavailable.105 This fixation method is advantageous because of the indirect nature of the fracture reduction and associated minimization of soft-tissue disruption about the fracture. However, problems obtaining stable fixation with IM nails in patients with wide metaphyseal areas, with osteopenia, or both can lead to loss of fixation and malalignment.103 Patients are mobilized as soon as possible postoperatively. Weight bearing is typically protected for 4–6 weeks after retrograde nailing of comminuted distal femur fracture in osteoporotic patients, the typical scenario for periprosthetic distal femur fractures. A careful history of prefracture knee function helps identify reasonable goals for postoperative ROM and function. Weight bearing is advanced based on clinical and radiographic evidence of progressive fracture healing. One of the most disheartening potential pitfalls of retrograde nailing of periprosthetic distal femur fractures is unexpectedly finding a closed or a narrow intercondylar box of the femoral component that prevents passage of the retrograde nail. Prevention of this situation is certainly preferred to managing it intraoperatively. In the absence of accurate documentation of the knee arthroplasty design, an intraoperative notch view can be used to confirm an open intercondylar notch. Obtaining and maintaining satisfactory fracture alignment is often difficult in the setting of a periprosthetic fracture. Even when the staring guide wire and opening portal are perfectly aligned, the nail often migrates to a different trajectory, leading to malalignment of the fracture. In such cases, placement of blocking screws helps obtain and maintain proper position of the nail, centered along the long axis of the distal fragment, and in turn results in a satisfactory fracture reduction. Blocking screws on both sides of the nail, medial and lateral to control varus/valgus and anterior and Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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posterior to control flexion/extension, can help maintain reduction. It is also recommended to place as many interlocking screws as possible (typically 3 or 4 depending on the nailing system selected) in various planes to support distal fixation in osteoporotic bone. A true lateral of the knee should be used to judge nail position relative to the knee prosthesis to avoid a nail that protrudes into the knee joint. Most studies of periprosthetic supracondylar femur fractures treated with retrograde nailing are small retrospective series. Reported union rates are generally favorable. However, the risk for malunion after retrograde nailing is high. Four small series (14 or less patients) of periprosthetic supracondylar femur fractures treated with retrograde nailing each reported 100% union.102,106,107 Alignment at healing is variable, as this is one of the main technical challenges of this treatment method. Han et al106 had no malalignment greater than 10 degrees. Malunion of 35-degree valgus requiring revision to a stemmed TKA was occurred in 1 of 10 cases reported by Gliatis et al.102 Another study of 14 patients reported valgus of 8–12 degrees in 3 cases, 15-degree extension in one, and 50% posterior translation in another.107 The malalignment seen in these series may, in part, be related to the use of short nails, which, because they do not benefit from the stability and alignment control that comes from passing the nail across the femoral isthmus, are not currently recommended for the treatment of distal femur fractures.
Distal Femoral Replacement Distal femoral replacement also has a role in certain subsets of patients with periprosthetic distal femur fractures.108–110 This treatment method is gaining in popularity, and indications are expanding from primarily those patients with loose TKA prostheses to also include patients with wellfixed and well-functioning prosthesis, when the prolonged period of protected weight bearing associated with internal fixation methods is undesirable or impractical. Revision of femoral components typically requires metal augmentation because of the inevitable bone deficiency associated with component removal. Stems should be used routinely, and it is recommended that the stems engage the femoral diaphysis both for alignment and fixation reasons. Most of the clinical data evaluating the outcomes of a simultaneous revision arthroplasty with IM stem fixation of a supracondylar fracture have been gathered from the treatment of distal femoral nonunion. Kress et al111 reported a small series of nonunions about the knee treated successfully with revision and uncemented femoral stems with bone grafting and achieved union in 6 months. Davila et al112 have reported a small series of supracondylar distal femoral nonunions treated with megaprostheses in elderly patients. They have shown that a cemented megaprosthesis in this patient population permits early ambulation and return to activities of daily living. Freedman et al113 performed distal femoral replacement in 5 elderly patients with acute fractures and reported 4 good results and 1 poor result secondary to infection. The 4 patients with good results regained ambulation in less than 1 month and had an average arc of motion of 99 degrees. All patients had some degree of extension lag. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Periprosthetic Femur Fractures
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