Percutaneous plate fixation for periprosthetic femoral fractures — a preliminary report
Introduction
With the increasing incidence of hip arthroplasty surgery, periprosthetic fractures of the proximal femur are more commonly encountered [1], [2]. These fractures are challenging to treat, especially in a situation where the fracture has occurred through osteoporotic bone or areas of focal bone deficiency and where there is a cement mantle. The aim of the treatment is to allow early mobilisation and avoid the complications of prolonged recumbency. Non-operative management fails to achieve this, with attendant complications from lengthy periods of immobilisation, and introduces potential complications of non-union secondary to the presence of bone cement [3], [4].
Early results of the Dall–Miles cable and plate system for open reduction and fixation for these fractures are encouraging [5], [6]. However, open reduction and plating, with or without cerclage wiring, involves a lengthy operation, compromises periosteal blood supply and is associated with a significant failure rate [7], [8], [9]. If the bone–cement interface is intact, revision using a long stemmed prosthesis is technically demanding with the potential for further loss of bone stock [10].
A minimally invasive technique of percutaneous plating has been described for femoral fractures [11], [12]. Cadaveric injection studies have demonstrated compromise of the blood supply believed to be essential for fracture healing during conventional plating, whereas the blood supply is well preserved when a minimally invasive percutaneous plating technique is used [13]. In addition, percutaneous plating preserves the fracture haematoma, minimizes the soft tissue stripping and reduces wound problems, increasing the overall chances of early healing and mobilisation.
We have extended the application of percutaneous plating to seven patients with periprosthetic fractures of the femur in which the prosthesis was secure.
Section snippets
Patients and method
Seven patients presented with periprosthetic femoral fractures in 1996 and 1997. Five were female and two were male, the youngest being 78 years old. All patients were previously mobile. Radiological examination showed no obvious loosening of the femoral component in each of the patients. Using the Vancouver classification of periprosthetic femoral fractures, there were five type II fractures (around the stem of the prosthesis) (Fig. 1) and one type III (beyond the tip of the prosthesis) (Table
Results
Fracture reduction was deemed adequate in all cases. The average operative time was 55 min, the longest being 75 min in the patient with a comminuted fracture above the long stem of the Total Knee Replacement (TKR) (Fig. 3). In comminuted fractures adequate bridging was obtained (Fig. 2, Fig. 3, Fig. 4).
All seven patients made unremarkable recoveries in the immediate post-operative period. Blood loss was minimal and no patient required blood tranfusion. One patient suffered a stroke 4 weeks
Discussion
Reports suggest that the incidence of periprosthetic femoral fractures following total hip arthroplasty is increasing [1], [2]. If fractures occurring around a hemiarthroplasty in previously mobile patients are taken into account, the numbers may be even higher. Early mobilisation can be achieved by open reduction and fixation of the fracture. However, the extensive incision, soft tissue stripping and disruption of periosteal blood supply during conventional plating are known to increase
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