The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 87, Issue 10

Scientific Articles | October 01, 2005

Indirect Reduction and Plate Fixation, without Grafting, for Periprosthetic Femoral Shaft Fractures About a Stable Intramedullary Implant

William M. Ricci, MD¹; Brett R. Bolhofner, MD²; Timothy Loftus, BA¹; Christopher Cox, BA¹; Scott Mitchell, MD³; Joseph BorrelliJr., MD¹

¹ Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, One Barnes Hospital Plaza, Suite 11300, St. Louis, MO 63110. E-mail address for W.M. Ricci: ricciw@msnotes.wustl.edu
² All Florida Orthopaedic Associates, P.O. Box 76359, St. Petersburg, FL 33734
³ Department of Orthopaedic Surgery, University of California at Los Angeles, 200 UCLA Medical Plaza, Suite 140, Los Angeles, CA 90095-6907

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A video supplement to this article will be available from the Video Journal of Orthopaedics. A video clip will be available at the JBJS web site, . The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: .

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at the Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, Missouri, and All Florida Orthopaedic Associates, St. Petersburg, Florida

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2005 Oct 01;87(10):2240-2245. doi: 10.2106/JBJS.D.01911

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Abstract

Background: The application of indirect reduction techniques has improved fracture-healing and reduced the need for bone-grafting compared with the outcomes of older, direct reduction techniques. We investigated the results of such indirect reduction techniques for the treatment of periprosthetic femoral shaft fractures.

Methods: Fifty consecutive patients with a femoral shaft fracture about a stable intramedullary implant (a Vancouver Type-B1 fracture) were treated with a protocol that included open reduction with use of indirect reduction techniques and internal fixation with a single lateral plate without structural allografting or other bone-grafting. Four patients died in the early postoperative period, and five had inadequate follow-up. The remaining forty-one patients (average age, seventy-two years) were evaluated clinically and radiographically at an average of twenty-four months.

Results: All fractures healed in satisfactory alignment at an average of twelve weeks (range, seven to twenty-three weeks) after the index procedure. One patient had one fractured cable and two others had one fractured screw, but all of the fractures healed without evidence of implant loosening or malalignment. There was one deep infection in the perioperative period. Thirty of the forty-one patients returned to their baseline ambulatory status.

Conclusions: The results of this study support the use of indirect open reduction and internal fixation with a single extraperiosteal lateral plate, without the use of allograft struts, for the treatment of a femoral shaft fracture about a stable intramedullary implant.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

As the prevalence of periprosthetic femoral fractures has increased over the last decade¹, the complications associated with their treatment have been increasingly recognized². However, optimal management strategies remain unclear. The difficulty involved in the management of these fractures is evidenced by the array of treatment options described in the literature without a clear consensus regarding the most appropriate method^1,3. Most recently, treatment has focused on open reduction with internal fixation or revision arthroplasty procedures with or without supplementary autologous or allogenic bone-grafting^4-6.

A successful approach to the management of periprosthetic femoral fractures must take into account the location of the fracture relative to the femoral component, the stability of the implant, the quality of the surrounding bone, and the medical and functional status of the patient⁷. For fractures about well-fixed femoral implants, stabilization with open reduction and internal fixation with plates and screws and/or cortical onlay allografts has been advocated^2,8-10. Plate osteosynthesis combined with a cortical strut allograft placed subperiosteally at a 90° angle from the plate requires extensive disruption of periosteal soft tissues, which can adversely affect fracture-healing⁶. Contemporary fracture-fixation techniques that have focused on minimizing soft-tissue disruption and periosteal stripping have reduced the need for supplemental bone-grafting in many anatomic areas^11,12. We studied the outcomes and complications of these modern indirect fracture-reduction techniques combined with fixation with a single lateral plate, but without the use of structural allograft, for the treatment of a periprosthetic femoral shaft fracture about a stable intramedullary implant.

Materials and Methods

Materials and Methods | Results | Discussion | References

Inclusion and Exclusion Criteria

Fifty consecutive patients with a femoral shaft fracture about a stable intramedullary implant were treated with a protocol that included osteosynthesis with a large-fragment plate, indirect reduction techniques, and no structural allograft. Pathologic fractures and those associated with a loose prosthesis were excluded. All patients were treated by one of three surgeons at one of two trauma centers. Four patients who died prior to fracture-healing and five others with inadequate follow-up were excluded from the analysis. The forty-one remaining patients were followed prospectively. Institutional review board approval and informed consent were obtained at one center. At the second center, the study was performed prior to such requirements. Patient characteristics and injury mechanisms are summarized in Table I.

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TABLE I Patient Demographics

Variable
No. of fractures	41
Average age (range) (yr)	72 (38-98)
Male	15
Female	26
Mechanism of injury
Fall from standing height	39
Motor-vehicle accident	2

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TABLE I Patient Demographics

Variable
No. of fractures	41
Average age (range) (yr)	72 (38-98)
Male	15
Female	26
Mechanism of injury
Fall from standing height	39
Motor-vehicle accident	2

Characteristics of the Prostheses

The periprosthetic fracture was associated with a hip prosthesis in thirty-four patients, a revision knee prosthesis with a long-stem femoral component in four, and an intramedullary device that had been used to treat an intertrochanteric fracture that had subsequently healed in two; the fracture was between a stemmed total knee prosthesis and a hip prosthesis in the remaining patient (Table II). There were twenty-three cemented and eighteen uncemented intramedullary implants. All components were well-fixed according to both clinical and radiographic criteria.

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TABLE II Characteristics of the Prostheses

Implant Type	No.
Hip prosthesis	34
Uncemented primary	11
Cemented primary	17
Uncemented revision	2
Cemented revision	4
Stemmed total knee prosthesis	4
Cemented	2
Uncemented	2
Intramedullary nail	2
Stemmed uncemented total knee prosthesis and primary uncemented total hip prosthesis	1

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TABLE II Characteristics of the Prostheses

Implant Type	No.
Hip prosthesis	34
Uncemented primary	11
Cemented primary	17
Uncemented revision	2
Cemented revision	4
Stemmed total knee prosthesis	4
Cemented	2
Uncemented	2
Intramedullary nail	2
Stemmed uncemented total knee prosthesis and primary uncemented total hip prosthesis	1

Characteristics of the Fractures

As dictated by the inclusion criteria, all fractures were Orthopaedic Trauma Association (OTA) Type 32¹³ and Vancouver Type B1⁷ (Table III). Thirty-one of the fractures were centered at the tip of the intramedullary implant, seven were through native bone either distal to a hip implant or proximal to a knee implant, and three were mostly around the intramedullary implant with extension to the tip of the implant. All fractures were closed.

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TABLE III Fracture Characteristics

	No.
Fracture location
About implant with extension to tip	3
At implant tip	31
Distal to hip implant or proximal to knee implant	7
OTA classification
32A1	13
32A2	13
32A3	3
32B1	2
32B2	2
32B3	7
32C3	1

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TABLE III Fracture Characteristics

	No.
Fracture location
About implant with extension to tip	3
At implant tip	31
Distal to hip implant or proximal to knee implant	7
OTA classification
32A1	13
32A2	13
32A3	3
32B1	2
32B2	2
32B3	7
32C3	1

Fracture Management

The fractures were managed operatively with indirect reduction techniques and with internal fixation. A lateral thigh incision was used for exposure of the lateral aspect of the femur proximal and distal to the fracture site. Meticulous soft-tissue dissection was used to minimize devascularization of bone during the exposure, which was limited to what was necessary to apply the plate proximal and distal to the fracture. In some instances, a skin bridge centered at the fracture site was left to help minimize inadvertent soft-tissue stripping at the site of the fracture (Fig. 1). The plate was applied to the lateral aspect of the femur extraperiosteally and was provisionally secured around the implant with cables. Great care was taken to minimize stripping of muscle with extraperiosteal passage of the cables. The plate was provisionally centered on the native femur with use of standard reduction clamps. Fracture reduction was achieved with manipulation of the limb under fluoroscopic guidance. Once a satisfactory reduction was confirmed, the plate was definitively secured to the native bone with use of standard screws and, in the region of the intramedullary implant, with retensioning and securing of the cables. Fixation was accomplished with a laterally placed large-fragment plate in all patients. A 4.5-mm broad dynamic compression plate was used in thirty patients; a femoral condylar plate, in eight; a blade-plate, in two; and a cable-plate, in one. Postoperatively, weight-bearing was generally limited to toe-touch for six to ten weeks and then was advanced on the basis of clinical and radiographic evidence of healing.

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Fig. 1: Intraoperative photograph demonstrating the minimally invasive technique used for fixation of a distal femoral shaft fracture about the tip of a long-stem revision femoral prosthesis. The surgical exposure is proximal and distal to the fracture, and the plate is placed submuscularly.

Follow-up

Patients were followed postoperatively at regular intervals with clinical and radiographic examinations. Union was defined as weight-bearing without pain at the fracture site associated with bridging callus across at least one cortex of the fracture on both the anteroposterior and the lateral radiograph. Nonunion was defined as the absence of progressive fracture-healing over a three-month period extending beyond six months from the date of the initial fracture management. Malunion was defined as =5° of deformity at the fracture site in either the frontal or the sagittal plane. Complications including hardware failure, infection, and any reoperation were recorded. The patient's baseline ambulatory status (prior to the fracture), defined as community, household, or unable to walk, and the need for assistive devices were recorded during the initial hospitalization, and these factors were reassessed at the final postoperative visit.

Results

Materials and Methods | Results | Discussion | References

Healing

The average duration of follow-up was twenty-four months (range, eleven to 170 months), with eighteen patients followed for more than twenty-four months. All fractures united in satisfactory alignment after the index procedure (Figs. 2-A and 2-B). The average time (and standard deviation) from the fracture repair to union was 12 ± 3.7 weeks (range, seven to twenty-three weeks), and the average time from the fracture repair to weight-bearing as tolerated was 12 ± 4.2 weeks (range, seven to twenty-three weeks).

Hardware Failure

One patient had a fracture of one cable (the most proximal cable), and two patients had a fracture of one distal screw. The fractures healed without evidence of implant loosening or malalignment at ten, eleven, and twelve weeks in those patients.

Infectious Complications

One early and two late infections occurred. The early infection was a postoperative infected wound hematoma, distant from the fracture site, which resolved after a single irrigation-and-débridement procedure. Antibiotic cement beads were inserted and were never removed. This fracture in this patient healed at eleven weeks. In another patient, in whom the fracture healed at sixteen weeks, an infected hematoma developed in the lateral part of the thigh two years after the index procedure. The hematoma was associated with over-anticoagulation because of atrial fibrillation, and the infection developed simultaneously with a bout of pneumonia. It resolved after one irrigation-and-débridement procedure, without removal of any implants. In the third patient, an infection developed at the site of an ipsilateral total hip arthroplasty two years after the fracture fixation. The infection was treated with irrigation and débridement with retention of the hip prosthesis, and it did not appear to involve the fracture site or fracture-fixation devices.

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Figs. 2-A and 2-B: Anteroposterior (Fig. 2-A) and lateral (Fig. 2-B) radiographs demonstrating healing after lateral plate fixation, without use of strut allograft, of a midshaft femoral fracture about the tip of a well-fixed primary cemented femoral stem.

Other Complications

A deep venous thrombosis developed in one patient and was treated successfully with low-molecular-weight heparin. One patient sustained a fracture distal to the plate three years after the index procedure. The fracture was treated successfully with removal of the plate and revision plate osteosynthesis.

Functional Outcome

Thirty patients returned to their baseline ambulatory status, whereas eleven patients had either a decline in their ambulatory status and/or a need for additional assistive devices at their last follow-up visit. Five patients who had been able to walk about the community at baseline were able to only walk about the house at the time of follow-up. Two patients who had been able to walk about the house at baseline were no longer able to walk. Four patients who had not required assistive devices for walking at baseline required a cane at their most recent follow-up visit. Five patients who required a walker at baseline ultimately required a wheelchair either occasionally (three patients) or consistently (two).

Discussion

Materials and Methods | Results | Discussion | References

The results of traditional plate-and-screw fixation of periprosthetic femoral shaft fractures with use of older, direct reduction techniques have been varied^2,14-17. Newer, indirect fracture-reduction techniques have more favorable biologic features. Minimizing soft-tissue disruption preserves the vascular supply to healing bone and has been shown to enhance healing and decrease the prevalence of nonunion of many fractures¹⁸, perhaps obviating the need for supplemental bone-grafting. Abhaykumar and Elliott¹⁹ used this percutaneous fixation method in seven patients with a femoral fracture around a stable implant, and six of them were observed to have fracture-healing and pain-free mobilization at six months.

The use of cortical onlay allograft struts has also been successful in the management of periprosthetic fractures. In a recent report on forty patients, Haddad et al.¹⁰ concluded that such struts should be used routinely to augment fixation and healing of periprosthetic femoral fractures around well-fixed implants. Treatment methods varied in that study and included either cortical onlay strut allograft alone, a plate and one cortical strut, or a plate and two strut grafts. The use of adjuvant bone-grafting materials increased the heterogeneity of the treatment methods: eight patients received autograft, twenty-nine received morselized allograft, and fifteen received demineralized bone matrix. That study, in which the rate of healing was 100%, suggests that the use of strut allografts as well as adjuvant bone-graft material achieves good results.

In the current study, all patients had stable intramedullary implants and were treated with indirect fracture reduction and a single laterally applied plate without the use of structural allograft. Union occurred after the index procedure in all forty-one patients who lived beyond the perioperative period and had adequate follow-up. The average time required for healing was relatively short (twelve weeks), and the times were very homogeneous, with a standard deviation of ±4 weeks. Care in preserving the soft-tissue envelope around the fracture is probably responsible for these consistent healing times. Our results with regard to healing compare favorably with those of treatment with cortical onlay grafts alone^6,8,10,20, after which the rate of nonunion requiring revision surgery has been reported to be 8% to 10%^6,8,20. Although implant-related complications occurred in three patients in the current series, they did not appear to complicate the healing process. Each of these three fractures healed in ten to twelve weeks and in satisfactory alignment, without the need for another operation.

All of the fractures in the current series healed in satisfactory alignment (<5° of malalignment). This result is more favorable than the outcomes of treatment with allograft struts alone, following which the rate of angular malunion has been reported to be 5% to 10%^10,20. The reason for the higher malunion rate following allograft strut fixation may be that the struts cannot be bent or contoured as plates can. Fracture alignment, therefore, cannot be adjusted with struts as precisely as it can with plates.

As was expected in a group of elderly patients with a lower-extremity fracture, the ability to return to the preinjury ambulatory status after healing was variable in our study, and the utility of high-intensity rehabilitation for these patients is being investigated.

Several inherent limitations of the current study should be considered. The type, number, and position of the cables and screws were not subject to experimental control. The type of intramedullary implant varied, as did the implant fixation pattern. However, each of the patients in our study presented a very similar surgical problem, and our treatment protocol was successful regardless of the type of intramedullary implant. Furthermore, we know of no data suggesting that healing of a periprosthetic fracture of the femoral shaft depends on the type of intramedullary implant. Although fracture-healing is a primary goal of the treatment of periprosthetic femoral shaft fractures, longevity of the hip prosthesis is an additional concern, and longer follow-up is required to determine the fate of the prosthetic stem. We believe, however, that the outcomes in this series justify the continued use of this treatment method for Vancouver Type-B1 periprosthetic fractures. ?

References

Materials and Methods | Results | Discussion | References

Lewallen DG, Berry DJ. Periprosthetic fracture of the femur after total hip arthroplasty: treatment and results to date. Instr Course Lect.1998;47: 243-9.47243 1998 [PubMed]

Tower SS, Beals RK. Fractures of the femur after hip replacement: the Oregon experience. Orthop Clin North Am.1999;30: 235-47.30235 1999 [CrossRef]

Kolstad K. Revision THR after periprosthetic femoral fractures. An analysis of 23 cases. Acta Orthop Scand.1994;65: 505-8.65505 1994 [CrossRef]

Haddad FS, Marston RA, Muirhead-Allwood SK. The Dall-Miles cable and plate system for periprosthetic femoral fractures. Injury.1997;28: 445-7.28445 1997 [PubMed][CrossRef]

Radcliffe SN, Smith DN. The Mennen plate in periprosthetic hip fractures. Injury.1996;27: 27-30.2727 1996 [PubMed][CrossRef]

Chandler HP, Tigges RG. The role of allografts in the treatment of periprosthetic femoral fractures. Instr Course Lect.1998;47: 257-64.47257 1998

Duncan CP, Masri BA. Fractures of the femur after hip replacement. Instr Course Lect.1995;44: 293-304.44293 1995 [PubMed]

Wong P, Gross AE. The use of structural allografts for treating periprosthetic fractures about the hip and knee. Orthop Clin North Am.1999;30: 259-64.30259 1999 [PubMed][CrossRef]

Brady OH, Garbuz DS, Masri BA, Duncan CP. The treatment of periprosthetic fractures of the femur using cortical onlay allograft struts. Orthop Clin North Am.1999;30: 249-57.30249 1999 [PubMed][CrossRef]

Haddad FS, Duncan CP, Berry DJ, Lewallen DG, Gross AE, Chandler HP. Periprosthetic femoral fractures around well-fixed implants: use of cortical onlay allografts with or without a plate. J Bone Joint Surg Am.2002;84: 945-50.84945 2002

Müller ME, Allgower M, Schneider R, Willinegger H, editors. Manual of internal fixation: techniques recommended by the AO-ASIF group. 3rd ed. New York: Springer; 1991. 1991

Ruedi TP, Murphy WM, editors. AO principles of fracture management. New York: Thieme; 2000. 2000

Committee of Coding and Classification of the Orthopaedic Trauma Association. Fracture and dislocation compendium. J Orthop Trauma.1996;10 Suppl 1: 1-154.101 1996 [CrossRef]

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: 511-9.9511 1994 [PubMed][CrossRef]

Tadross TS, Nanu AM, Buchanan MJ, Checketts RG. Dall-Miles plating for periprosthetic B1 fractures of the femur. J Arthroplasty.2000;15: 47-51.1547 2000 [PubMed][CrossRef]

Venu KM, Koka R, Garikipati R, Shenava Y, Madhu TS. Dall-Miles cable and plate fixation for the treatment of peri-prosthetic femoral fractures—analysis of results in 13 cases. Injury.2001;32: 395-400.32395 2001 [PubMed][CrossRef]

Zenni EJ Jr, Pomeroy DL, Caudle RJ. Ogden plate and other fixations for fractures complicating femoral endoprostheses. Clin Orthop Relat Res.1988;231: 83-90.23183 1988 [PubMed]

Holden CE. The role of blood supply to soft tissue in the healing of diaphyseal fractures. An experimental study. J Bone Joint Surg Am.1972;54: 993-1000.54993 1972 [PubMed]

Abhaykumar S, Elliott DS. Percutaneous plate fixation for periprosthetic femoral fractures—a preliminary report. Injury.2000;31: 627-30.31627 2000 [PubMed][CrossRef]

Chandler HP, King D, Limbird R, Hedley A, McCarthy J, Penenberg B, Danylchuk K. The use of cortical allograft struts for fixation of fractures associated with well-fixed total joint prostheses. Semin Arthroplasty.1993;4: 99-107.499 1993 [PubMed]

Topics

fracture ; bone plates ; transplantation ; femoral shaft fracture ; allografting

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William M. Ricci, M.D.

Posted on November 23, 2005

Dr. Ricci, et al respond to Drs. Tsiridis and Narvani

Washington University School of Medicine, Dept. of Orthopaedic Surgery, St. Louis, MO 63110

To The Editor:

We appreciate the interest expressed in our manuscript by Drs. Tsiridis and Narvani. We would like to respond to their expressed concerns. Applying the Vancouver classification to fractures around stemmed knee arthroplasties and intramedullary femoral implants for hip fracture fixation may not have been the originally intended use of this classification, but we believe it represents an accurate description of the fracture patterns in our study population. Furthermore, we disagree with their statement that â€œbecause these cases were co-mingled, we have been unable to extract valid conclusions from the studyâ€. Although fractures about total hip arthroplasty stems, total knee replacement stems and intramedullary implants for hip fracture fixation were all included in our manuscript, the specific number of each of these cases was clearly stated and the results for each subpopulation was the same--100% union. Furthermore, the specific type of implant was specified for each of the described complications; therefore, it should not be difficult to extract valid information from our study with regard to each of these subpopulations. As stated in the manuscript, each of these clinical situations presents a similar problem for the surgeon and therefore we felt it was reasonable to include all of these patients in one manuscript.

Contrary to Drs. Tsiridis and Narvaniâ€™s interpretation, all fractures in our study population were indeed Vancouver B1 type fractures, as they all extended to the tip of the prosthesis. We supplied additional information about the fracture characteristics such as whether the fracture was around the prothesis with extension to the tip, or was at the tip and extend just distal to the prosthesis.

We thank Drs. Tsiridis and Narvani for pointing out that our 100% healing rate does not reflect the current literature for plate fixation of these fractures. Our series is the first, to our knowledge, to specifically apply biologic plating techniques to periprosthetic femoral shaft fractures. Relative to a traditional direct plating technique, biologic plating techniques offer an improved physiologic environment for fracture healing. We believe this is largely responsible for the higher union rate seen in our series compared to others that utilized more traditional plating methods, including those reported in the article that Drs. Tsiridis and Narvani published (and referenced in their letter) that reported only a 57% union rate.

Drs. Tsiridis and Narvani also point out that â€œcable fixation may preserve bone and cement; however, it does not provide the strongest possible constructâ€. We would agree that the addition of a structural allograft perpendicular to a plate would increase the strength of the construct. However, their statement reflects a general problem with extrapolation of biomechanical analysis of fracture repair techniques to the clinical setting. Strength and rigidity of fracture fixation techniques are not synonymous with better results. Intramedullary nail techniques and bridge plating techniques are proven and reliable methods of fracture fixation that are certainly not the most rigid. The construct utilized for each case in our series was not the strongest and most stable construct available, but our 100% union rate indicates that, at the very least, this construct provides adequate stability for reliable fracture healing and may be preferable to more rigid constructs that require greater soft tissue stripping.

Drs. Tsiridis and Narvani point out that they have experienced failures with cable/plate constructs alone for Vancouver Type B1 fractures and advocate augmenting fixation with allograft struts. We would agree that when using older direct reduction techniques, healing rates appear to be higher when allograft struts are used as an adjust to plate fixation. The message of our manuscript is that when modern biologic plating techniques are utilized, struts are not mandatory.

Drs. Tsiridis and Narvani â€œargue that (we) the authors have not shown that single plate fixation with cables and screws, even when biologically applied, is the â€œbest solutionâ€ for the treatment of B1 fractures, even if presented with 100% success rateâ€. Unfortunately, Drs. Tsiridis and Narvani have again failed to accurately comprehend our message. We clearly state that our results â€œsupport the use of indirect open reduction and internal fixation with a single extraperiosteal lateral plate, without the use of allograft struts.â€ Since no direct comparison of our method was made to any other, we were very careful not to claim superiority of our method.

Sincerely,

William M. Ricci, M.D.

Brett Bolhofner, M.D.

Tim Loftus, BA

Christopher Cox, BA

Scott Mitchell, M.D.

Joseph Borelli, M.D.

Eleftherios Tsiridis

Posted on November 03, 2005

Single Plate Fixation for B1 Periprosthetic Femoral Fractures. A Cause for Concern?

Acadaemic Orthopaedic Dept., St. James' University Hospital, Beckett St., Leeds LS9 7TF, UK

To the Editor:

We read with interest the article by Ricci, et al,(1)and we would like to congratulate the authors for fixing these very difficult and technically demanding fractures with the biological plating technique. Recently, we published our experience in the treatment of periprosthetic femoral fractures (2,3) and we wish to raise some concerns regarding the message that the paper by Ricci, et al conveys to the readership.

The Vancouver classification was developed for periprosthetic fractures around THAs and its extension to describe fractures around TKA is not necessarily valid.(4) We believe the authors should have reported those cases separately as the biomechanics of each implant and each joint differ. Because these cases were co-mingled, we have been unable to extract valid conclusions from the study.

According to the Vancouver treatment algorithm, fractures distal to the tip of the implant are classified as type C. These are however the only fractures than can reliably be treated with a plate. In the presented series there were 7 cases located in this area. Type C fractures are different from B1 fractures.(5).

We can understand how percutaneous screw fixation around the fracture site can be accomplished with a stab incision, but it is difficult to visualize cable fixation through a limited incision close to the fracture site as demonstrated in figure 2.

A 100% healing rate for the 41 patients in this case series is an excellent result but does not reflect the current literature regarding plate fixation of periprosthetic B1 femoral fractures.(6)

Cable fixation may preserve bone and cement however it does not provide the strongest possible constract.(7)

We have experienced failures with the use of either DCP alone(2) or Dall Miles (cable plate) plates alone(3) for the treatment of Vancouver B1 fractures and we have concluded that augmentation with strut graft and or autograft may be of great importance for successful healing in accordance with the current literature.(6,7)

We would argue that the authors have not shown that single plate fixation with cables and screws, even when biologically applied, is the best solution for the treatment of B1 fractures, even if presented with a 100% success rate.

E. Tsiridis M.D., MSc, PhD, FRCS

A. A. Narvani MBBS, BSc, MSc, MRCS

References:

1. Ricci WM, Bolhofner BR, Loftus T, Cox C, Mitchell S, Borrelli J Jr. Indirect reduction and plate fixation, without grafting, for periprosthetic femoral shaft fractures about a stable intramedullary implant. J Bone Joint Surg Am. 2005;87:2240-5.

2. Tsiridis E, Narvani AA, Timperley JA, Gie GA. Dynamic compression plates for Vancouver type B periprosthetic femoral fractures: a 3-year follow-up of 18 cases. Acta Orthop. 2005;76:531-7.

3. Tsiridis E, Haddad FS, Gie GA. Dall-Miles plates for periprosthetic femoral fractures. A critical review of 16 cases. Injury. 2003;34:107-10.

4. Brady OH, Garbuz DS, Masri BA, Duncan CP. The reliability and validity of the Vancouver classification of femoral fractures after hip replacement. J Arthroplasty. 2000;15:59-62.

5 Masri BA, Meek RM, Duncan CP. Periprosthetic fractures evaluation and treatment. Clin Orthop Relat Res. 2004;(420):80-95.

6. Lindahl H, Malchau H, Herberts P, Garellick G. Periprosthetic femoral fractures classification and demographics of 1049 periprosthetic femoral fractures from the Swedish national hip arthroplasty register. J Arthroplasty. 2005;20:857-65.

7. Wilson D, Frei H, Masri BA, Oxland TR, Duncan CP. A biomechanical study comparing cortical onlay allograft struts and plates in the treatment of periprosthetic femoral fractures. Clin Biomech (Bristol, Avon). 2005;20:70-6.

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William M. Ricci, Brett R. Bolhofner, Timothy Loftus, Christopher Cox, Scott Mitchell, Joseph BorrelliJr.; Indirect Reduction and Plate Fixation, without Grafting, for Periprosthetic Femoral Shaft Fractures About a Stable Intramedullary Implant. The Journal of Bone & Joint Surgery. 2005 Oct;87(10):2240-2245.

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