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Treatment of periprosthetic femoral fractures after femoral revision using a long stem.

Kim Y, Tanaka C, Tada H, Kanoe H, Shirai T - BMC Musculoskelet Disord (2015)

Bottom Line: The average follow-up was 58.9 months (8 to 180).This failed case had a bone defect at the fracture site, and revision surgery using a cementless long stem and allografts was successful.These findings suggest that most cases of type B1 fracture after revision using a long stem have been treated successfully with open reduction and internal fixation.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, Kyoto City Hospital, 1-2 Mibu,higashitakada-cho, Nakagyo, Kyoto, 604-8845, Japan. woochan76@hotmail.co.jp.

ABSTRACT

Background: Periprosthetic femoral fractures are becoming increasingly common and are a major complication of total hip arthroplasty and hemiarthroplasty. The treatment of periprosthetic femoral fracture after femoral revision using a long stem is more complex and challenging. The purpose of this study was to identify the clinical and radiographical features of periprosthetic femoral fractures after revision using a long stem.

Methods: We report a retrospective review of the outcomes of treatment of 11 periprosthetic fractures after femoral revision using a long stem. Eleven female patients with a mean age of 79.2 years (70 to 91) were treated for a Vancouver type B1 fracture between 1998 and 2013. The mean numbers of previous surgeries were 3.1 (2 to 5).

Results: The average follow-up was 58.9 months (8 to 180). We found several important features that might influence the outcome of treatment for periprosthetic femoral fractures after femoral revision using a long stem: 1) all cases were classified as Vancouver type B1. 2) 6 patients (55%) had a transverse fracture around the tip of the long stem. 3) 7 patients (64%) had a history of previous fracture of the ipsilateral femur. The type B1 fractures were treated with open reduction and internal fixation in 9 hips, 6 of which were reinforced with bone grafts. Two other periprosthetic fractures were treated with femoral revision. One was revised because of stem breakage, and the other was a transverse fracture associated with poor bone quality, which received a femoral revision with a long stem and a plate. All fractures except one achieved primary union. This failed case had a bone defect at the fracture site, and revision surgery using a cementless long stem and allografts was successful.

Conclusions: These findings suggest that most cases of type B1 fracture after revision using a long stem have been treated successfully with open reduction and internal fixation. However, a transverse fracture with very poor bone quality might be considered as a type B3 fracture, and femoral revision might be a treatment of choice.

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Case 3, A seventy-three-years-old woman who sustained a Vancouver type-B1 periprosthetic femoral fracture seventy five months after revision surgery using a long stem. A Anteroposterior radiograph of the right hip showing the loosening of long stem. B Anteroposterior radiograph of the right hip made just after revision surgery using a standard stem with impaction bone grafting. C Anteroposterior radiograph of the right hip showing the Vancouver type B1 fracture pattern six months after revision surgery. D Anteroposterior radiograph of the right hip made one year after operation. Incorporation of the fracture site can be observed.
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Fig1: Case 3, A seventy-three-years-old woman who sustained a Vancouver type-B1 periprosthetic femoral fracture seventy five months after revision surgery using a long stem. A Anteroposterior radiograph of the right hip showing the loosening of long stem. B Anteroposterior radiograph of the right hip made just after revision surgery using a standard stem with impaction bone grafting. C Anteroposterior radiograph of the right hip showing the Vancouver type B1 fracture pattern six months after revision surgery. D Anteroposterior radiograph of the right hip made one year after operation. Incorporation of the fracture site can be observed.

Mentions: The mean time of the radiographic and clinical follow-up was 58.9 months (8 to 180 months). All fractures were classified as Vancouver type B1. The fracture pattern was a transverse fracture in 6 hips and an oblique fracture in 5 hips (Table 2). The mean time from the revision arthroplasty using a long stem to the fracture was 106.5 months (12 to 240 months). The mean cortical index was 20.5% (13.8 to 34.0%). In this study, the type B1 fractures were fixed with a plate in 9 patients. Seven patients were treated with a locking compression plate and cerclage wiring and, 2 patients were treated with a Dall–Miles system (Howmedica, Rutherford, NJ). Six patients were treated with bone allografts or autografts to facilitate fracture healing. In the other 2 patients, revision arthroplasty was performed with a cemented long stem using an impaction bone grafting technique. In one of them, femoral revision was necessary because of stem breakage (Case 4). In this case, cortical index was 15.3%. Another patient required reinforcement with a locking compression plate fixation (Case3, Figure 1). This patient was a 73-year-old female who had undergone revision surgery using impaction bone grafting because of aseptic loosening of the long stem after hemiarthroplasty. Six months after revision, this patient sustained a periprosthetic femoral fracture and had required revision arthroplasty using long stem because of very poor bone quality (cortical index; 13.8%) and had required reinforcement with a locking compression plate fixation because the length of the long stem available seemed to be insufficient and the reduction of the fracture was not ideal (in valgus alignment).Table 2


Treatment of periprosthetic femoral fractures after femoral revision using a long stem.

Kim Y, Tanaka C, Tada H, Kanoe H, Shirai T - BMC Musculoskelet Disord (2015)

Case 3, A seventy-three-years-old woman who sustained a Vancouver type-B1 periprosthetic femoral fracture seventy five months after revision surgery using a long stem. A Anteroposterior radiograph of the right hip showing the loosening of long stem. B Anteroposterior radiograph of the right hip made just after revision surgery using a standard stem with impaction bone grafting. C Anteroposterior radiograph of the right hip showing the Vancouver type B1 fracture pattern six months after revision surgery. D Anteroposterior radiograph of the right hip made one year after operation. Incorporation of the fracture site can be observed.
© Copyright Policy - open-access
Related In: Results  -  Collection

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Fig1: Case 3, A seventy-three-years-old woman who sustained a Vancouver type-B1 periprosthetic femoral fracture seventy five months after revision surgery using a long stem. A Anteroposterior radiograph of the right hip showing the loosening of long stem. B Anteroposterior radiograph of the right hip made just after revision surgery using a standard stem with impaction bone grafting. C Anteroposterior radiograph of the right hip showing the Vancouver type B1 fracture pattern six months after revision surgery. D Anteroposterior radiograph of the right hip made one year after operation. Incorporation of the fracture site can be observed.
Mentions: The mean time of the radiographic and clinical follow-up was 58.9 months (8 to 180 months). All fractures were classified as Vancouver type B1. The fracture pattern was a transverse fracture in 6 hips and an oblique fracture in 5 hips (Table 2). The mean time from the revision arthroplasty using a long stem to the fracture was 106.5 months (12 to 240 months). The mean cortical index was 20.5% (13.8 to 34.0%). In this study, the type B1 fractures were fixed with a plate in 9 patients. Seven patients were treated with a locking compression plate and cerclage wiring and, 2 patients were treated with a Dall–Miles system (Howmedica, Rutherford, NJ). Six patients were treated with bone allografts or autografts to facilitate fracture healing. In the other 2 patients, revision arthroplasty was performed with a cemented long stem using an impaction bone grafting technique. In one of them, femoral revision was necessary because of stem breakage (Case 4). In this case, cortical index was 15.3%. Another patient required reinforcement with a locking compression plate fixation (Case3, Figure 1). This patient was a 73-year-old female who had undergone revision surgery using impaction bone grafting because of aseptic loosening of the long stem after hemiarthroplasty. Six months after revision, this patient sustained a periprosthetic femoral fracture and had required revision arthroplasty using long stem because of very poor bone quality (cortical index; 13.8%) and had required reinforcement with a locking compression plate fixation because the length of the long stem available seemed to be insufficient and the reduction of the fracture was not ideal (in valgus alignment).Table 2

Bottom Line: The average follow-up was 58.9 months (8 to 180).This failed case had a bone defect at the fracture site, and revision surgery using a cementless long stem and allografts was successful.These findings suggest that most cases of type B1 fracture after revision using a long stem have been treated successfully with open reduction and internal fixation.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, Kyoto City Hospital, 1-2 Mibu,higashitakada-cho, Nakagyo, Kyoto, 604-8845, Japan. woochan76@hotmail.co.jp.

ABSTRACT

Background: Periprosthetic femoral fractures are becoming increasingly common and are a major complication of total hip arthroplasty and hemiarthroplasty. The treatment of periprosthetic femoral fracture after femoral revision using a long stem is more complex and challenging. The purpose of this study was to identify the clinical and radiographical features of periprosthetic femoral fractures after revision using a long stem.

Methods: We report a retrospective review of the outcomes of treatment of 11 periprosthetic fractures after femoral revision using a long stem. Eleven female patients with a mean age of 79.2 years (70 to 91) were treated for a Vancouver type B1 fracture between 1998 and 2013. The mean numbers of previous surgeries were 3.1 (2 to 5).

Results: The average follow-up was 58.9 months (8 to 180). We found several important features that might influence the outcome of treatment for periprosthetic femoral fractures after femoral revision using a long stem: 1) all cases were classified as Vancouver type B1. 2) 6 patients (55%) had a transverse fracture around the tip of the long stem. 3) 7 patients (64%) had a history of previous fracture of the ipsilateral femur. The type B1 fractures were treated with open reduction and internal fixation in 9 hips, 6 of which were reinforced with bone grafts. Two other periprosthetic fractures were treated with femoral revision. One was revised because of stem breakage, and the other was a transverse fracture associated with poor bone quality, which received a femoral revision with a long stem and a plate. All fractures except one achieved primary union. This failed case had a bone defect at the fracture site, and revision surgery using a cementless long stem and allografts was successful.

Conclusions: These findings suggest that most cases of type B1 fracture after revision using a long stem have been treated successfully with open reduction and internal fixation. However, a transverse fracture with very poor bone quality might be considered as a type B3 fracture, and femoral revision might be a treatment of choice.

Show MeSH
Related in: MedlinePlus