Arch Orthop Trauma Surg (2014) 134:9–14 DOI 10.1007/s00402-013-1883-6

ORTHOPAEDIC SURGERY

Treatment of periprosthetic femur fractures around a well‑fixed hip arthroplasty implant: span the whole bone Gele B. Moloney · Edward R. Westrick · Peter A. Siska · Ivan S. Tarkin 

Received: 22 May 2013 / Published online: 20 November 2013 © Springer-Verlag Berlin Heidelberg 2013

Abstract  Introduction  Periprosthetic femur fractures are a growing problem in the geriatric population. This study examines Vancouver B1 periprosthetic femur fractures treated with open reduction internal fixation using a laterally based plate. Outcomes using plates which spanned the length of the femur to the level of the femoral condyles were compared to those which did not. The hypothesis was that spanning internal fixation would result in a decreased rate of refracture and subsequent reoperation. Materials and methods  Patients admitted to three affiliated academic hospitals treated with open reduction internal fixation for a periprosthetic femur fracture in the setting of a preexisting total hip arthroplasty or hemiarthroplasty stem were identified. Patient data were reviewed for age, gender, fracture classification, operative intervention, time to union, as well as complications related to treatment and need for further surgery. Results  Over a 5-year period, 58 patients were treated with open reduction internal fixation using a laterally based plate for Vancouver B1 femur fractures. Twenty-one patients were treated with plates that extended to the level of the femoral condyles. In that group there were no nonunions or subsequent periprosthetic fractures reported. Of 36 patients treated with short plates, 3 went on to nonunion resulting in plate failure and refracture and 2 sustained a subsequent fracture distal to the existing fixation.

G. B. Moloney · E. R. Westrick · P. A. Siska · I. S. Tarkin (*)  Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufmann Building, Suite 911, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA e-mail: [email protected]

Conclusions  In this series, fixation for periprosthetic femur fractures around a well-fixed arthroplasty stem which spans the length of the femur to the level of the femoral condyles is associated with a decreased rate of nonunion and refracture. By decreasing the rate of refracture and nonunion, spanning fixation decreases the morbidity and mortality associated with additional surgery in a fragile geriatric population. Keywords  Geriatric hip fracture · Periprosthetic femur fracture

Introduction With the rising incidence of total hip arthroplasty, currently over 200,000 per year [1], and the aging population, the number of periprosthetic femur fractures is expected to rise. The incidence of periprosthetic femur fracture following primary total hip arthroplasty is commonly reported around 1 % [2, 3], but has been reported as high as 2.3 % [4]. The rate following revision total hip arthroplasty is reported between 1.5 and 7.8 % [3, 4]. Traditional goals of treatment of periprosthetic fractures include timely and uncomplicated fracture union, restoration of alignment, and return to preinjury level of functionality [5]. Revision arthroplasty is a viable option using a long stem to span/stabilize the acute fracture. This technique is preferable in the setting of a loose stem. However, implant retention and ORIF is typically the optimal treatment paradigm for periprosthetic fracture with a stable femoral component. Many fixation constructs have been used for treatment of Vancouver type B1, which occur around a wellfixed stem. Large fragment laterally based plates are the

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“workhorse”. Standard and locking technology is available. Further, cables and/or supplementary strut grafting is commonplace. Many studies exist to evaluate different laterally based plating constructs, both biomechanically and relative to clinical outcomes and no one method has emerged as superior [6–8]. Although laterally based plating is an accepted widespread technique for the management of B1 periprosthetic fractures, fracture nonunion and refracture occur all too commonly. This primarily geriatric, osteopenic, and fragile patient population often will not tolerate complication without significant morbidity and even mortality [9]. One recent series found an 11 % mortality rate within 1 year following surgical treatment of periprosthetic femur fracture compared to 16.5 % after surgery for hip fracture and 2.9 % following primary total joint replacement [10]. The alarming rate of refracture and/or fracture nonunion is generously reported in the literature. In a retrospective review of 1,049 periprosthetic hip fractures, Lindahl and colleagues [11] found a 6.6 % rate of refracture (17/256) in patients treated with ORIF. Five out of 15 patients treated by Wood and colleagues [12] were being treated for failure of previous fixation or a refracture after treatment for a periprosthetic femur fracture. Chakravathy and colleagues [13] reported on 12 fractures treated with locked plates and found 1 patient who had a refracture at the distal tip of the implant 2 months after fracture union. Given the high rate of mortality and morbidity associated with treatment failure for periprosthetic femur fractures, it becomes increasingly important to optimize the treatment strategy. One proposed method to promote fracture union and prevent refracture is to apply fixation that spans the entire bone. Theoretically, the plate working length is maximized to encourage bone union. Further, implant-related stress riser leading to refracture is minimized. An initial study of this periprosthetic fracture concept was evaluated by Bryant and colleagues [14] with encouraging results. They reported a case series of ten patients who underwent isolated locked compression plating which spanned the femur to the level of the femoral condyles for Vancouver type B1 periprosthetic femur fractures without cortical onlay allografts or cerclage wires. No cases of fracture nonunion or refracture with a mean time to fracture union of 17 weeks (range 12–27 weeks) and no hardware failures or complications requiring reoperation were reported. The purpose of this study was to investigate whether femoral fixation for B1 periprosthetic fractures that spans the entire bone is a more effective treatment paradigm then usage of shorter fixation constructs. We hypothesized that the rate of union would be superior, while the rate of refracture would be minimized. Further, improved survival rates after periprosthetic fracture could be realized with

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Arch Orthop Trauma Surg (2014) 134:9–14

uncomplicated fracture care using more reliable fixation that extends to the femoral condyles.

Materials and methods After institutional review board approval, a retrospective review of all patients admitted to three affiliated academic hospitals from October 1, 2005 to September 30, 2010 was conducted. Current procedural terminology (CPT) codes for open treatment of femur fracture with plate and screws (27,507), open treatment of condylar fracture of the femur (27,511), open treatment of intertrochanteric or subtrochanteric fracture with plate fixation (27,244), open fixation of proximal femur fracture (27,236) and open treatment of distal femur fracture (27,514) were searched. The CPT codes were crossed with the ICD-9 code for periprosthetic fracture around a joint (99,644). Patients with total hip arthroplasty or hemiarthroplasty including primary and revision components and cemented or uncemented stems were included. Patients treated with revision arthroplasty for periprosthetic fracture were excluded. Patients not followed to union were included only for the purposes of assessing mortality and excluded from analysis of fracture fixation. Patient data were reviewed for age, gender, fracture classification, preexisting implants, fixation construct and implants used, operative time, blood loss, and time to union. Time to union was defined clinically and radiographically. Union was determined by a single author based on the medical record once painless weight bearing was achieved, correlated with bridging bone radiographically on three of four cortices on anterior–posterior and lateral images. Postoperative complications including superficial or deep infection, hematoma, DVT, and death were recorded. The Social Security Death Index was used as an adjunct to hospital records. Nonunion, hardware failure, and subsequent fractures were also recorded. Fisher’s exact test was used to statistically compare outcome differences between the two groups with regard to refracture as a primary outcome measure. Refracture was defined as nonunion or periprosthetic fracture adjacent to plate construct used for ORIF. An alpha level of 0.05 was used. Patients included in this statistical analysis were at least followed with serial office visits until union.

Results Fifty-eight patients were treated with open reduction internal fixation for Vancouver B1 periprosthetic femur fractures in the 5 year period investigated (Table 1). For the purpose of this analysis, they were divided into two groups; patients

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Arch Orthop Trauma Surg (2014) 134:9–14

Table 1  A summary of preexisting implants and fixation constructs in patients followed to union after treatment of Vancouver B1 periprosthetic femur fractures Total Preexsisting implant patients Cemented Uncemented stem stem (proximal fit/distal fit

Fixation construct Plate length Working length Locked (# cortical widths (mm) ** plates distal) mean ± SD

# Patients with cerclage wires

Strut Screw allograft density

Short plate fixation

27

6

21 (16/5)

4.5 ± 1.5

105 ± 40

16

25

5

0.8  ± 0.2

Spanning plate fixation

14

4

10 (5/5)

6 ± 2

149 ± 65

14

12

0

0.7 ± 0.2

** p 

Treatment of periprosthetic femur fractures around a well-fixed hip arthroplasty implant: span the whole bone.

Periprosthetic femur fractures are a growing problem in the geriatric population. This study examines Vancouver B1 periprosthetic femur fractures trea...
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