Scientific Article   |    
Periprosthetic Femoral Fractures Around Well-Fixed Implants:Use of Cortical Onlay Allografts with or without a Plate
Fares S. Haddad, BSc, FRCS(Orth); Clive P. Duncan, MD, FRCS(C); Daniel J. Berry, MD; David G. Lewallen, MD; Allan E. Gross, MD, FRCS(C); Hugh P. Chandler, MD
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Investigation performed at Vancouver General Hospital, Vancouver, British Columbia, Canada; Mayo Clinic, Rochester, Minnesota;Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; and Massachusetts General Hospital, Boston, Massachusetts

Fares S. Haddad, BSc, FRCS(Orth)
46b Hanover Gate Mansions, Park Road, London NW1 4SN, United Kingdom. E-mail address: fareshaddad@compuserve.com

Clive P. Duncan, MD, FRCS(C)
Department of Orthopaedics, Pattison Pavilion North, Vancouver General Hospital, 910 West Tenth Avenue, Room 3114, Vancouver, BC V5Z 4E3, Canada

Daniel J. Berry, MD
David G. Lewallen, MD
Department of Orthopaedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905

Allan E. Gross, MD, FRCS(C)
Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Suite 476A, Toronto, ON M5G 1X5, Canada

Hugh P. Chandler, MD
Massachusetts General Hospital, Wang Ambulatory Care Center, 15 Parkman Street, Level 5, Boston, MA 02114

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. One of the authors (F.S.H.) was supported by the John Charnley and BOA (British Orthopaedic Association)/Wishbone Trusts and by the Norman Capener Travelling Fellowship.

J Bone Joint Surg Am, 2002 Jun 01;84(6):945-950
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Background: Periprosthetic femoral fractures around hip replacements are increasingly common. When the femoral component is stable, open reduction and internal fixation is recommended in all but exceptional cases. The purpose of this study was to evaluate the outcome of treatment of fractures around stable implants with cortical onlay strut allografts with or without a plate.

Methods: A survey of our four centers identified forty patients with a fracture around a well-fixed femoral stem treated with cortical onlay strut allografts without revision of the femoral component. There were fourteen men and twenty-six women, with an average age of sixty-nine years. Nineteen patients were treated with cortical onlay strut allografts alone, and twenty-one were managed with a plate and one or two cortical struts. All of the patients were followed until fracture union or until a reoperation was done. The mean duration of follow-up was twenty-eight months for thirty-nine patients. One patient, who was noncompliant with treatment recommendations, had a failure at two months because of a fracture of the plate and graft. The primary end point of the evaluation was fracture union; secondary end points included strut-to-host bone union, the amount of final bone stock, and postoperative function.

Results: Thirty-nine (98%) of the forty fractures united, and strut-to-host bone union was typically seen within the first year. There were four malunions, all of which had <10° of malalignment, and one deep infection. There was no evidence of femoral loosening in any patient. All but one of the surviving patients returned to their preoperative functional level within one year.

Conclusions: Cortical onlay strut allografts act as biological bone plates, serving both a mechanical and a biological function. The use of cortical struts, either alone or in conjunction with a plate, led to a very high rate of fracture union, satisfactory alignment, and an increase in femoral bone stock at the time of short-term follow-up. Although this study did not address the potential for later allograft remodeling, our findings suggest that cortical strut grafts should be used routinely to augment fixation and healing of a periprosthetic femoral fracture.

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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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