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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, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.
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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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.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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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 “because these cases were co-mingled, we have been unable to extract valid conclusions from the study”. 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 Narvani’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 “cable fixation may preserve bone and cement; however, it does not provide the strongest possible construct”. 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 “argue that (we) 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 100% success rate”. Unfortunately, Drs. Tsiridis and Narvani have again failed to accurately comprehend our message. We clearly state that our results “support the use of indirect open reduction and internal fixation with a single extraperiosteal lateral plate, without the use of allograft struts.” Since no direct comparison of our method was made to any other, we were very careful not to claim superiority of our method.


    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


    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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