Dall–Miles cable and plate fixation for the treatment of peri-prosthetic femoral fractures-analysis of results in 13 cases
Introduction
Periprosthetic femoral fractures are increasingly common following primary uncemented as well as revision joint replacements [1], [2], [3], [4]. Previous studies have suggested an incidence of 0.1–2.5% [3], [4], [5], [6]. Intra-operative periprosthetic femoral fractures have become particularly common due to the advent of uncemented press-fit implants [2].
Management of periprosthetic femoral fractures can be challenging to the surgeon. The non-operative treatment includes traction and the use of casts and braces. If the fracture relates to a loose implant, revision of the prosthesis is a better option in a fit patient [7]. However, in the presence of a stable prosthesis, open reduction and internal fixation of the fracture is probably the better choice [8]. Several fixation devices have been described, including cerclage wires, Partridge bands [9], retrograde intramedullary devices [10], [11], and a variety of plates such as the Mennen plate [12], compression plate [13], and Dall–Miles cable and plate system [14], [15]. We present our experience and results with the Dall–Miles cable and plate fixation system.
Section snippets
Patients and methods
A retrospective review was undertaken of 13 periprosthetic femoral fractures treated with the Dall–Miles cable and plate system over a period of 4 years between 1995 and 1999. These included a supracondylar fracture proximal to the stem of the femoral component in a total knee replacement; a pathological fracture distal to the tip of the femoral stem due to secondary deposit from breast cancer; and an iatrogenic cortical window made during a revision hip procedure for a broken femoral stem.
Results
The results are summarized in Table 2. Bone healing was judged by the ability of the patient to fully weight-bear with no pain, absence of pain on stressing at the fracture site and the presence of a callus across the fracture site on the radiographs.
We had ten satisfactory results with union of the fracture achieved at an average of 4.4 months (2.5–12 months), (Fig. 1a and b); all patients returned to their full pre-fracture mobility.
Three patients had unsatisfactory results requiring further
Discussion
Treatment of periprosthetic femoral fractures is challenging. Understanding the risk factors associated with these fractures may help to prevent these difficult injuries [18]. Non-operative treatment with traction followed by cast application may be appropriate for surgically unfit patients, but it carries a high risk of complications from prolonged bed rest as well as the risk of nonunion due to the presence of bone cement [6]. Intramedullary fixation using a long stem prosthesis in fractures
Conclusion
The Dall–Miles cable and plate system is a useful method of internal fixation for periprosthetic femoral fractures. However it is not suitable in fractures with the femoral component in varus angulation of more than 6°. Revision to a long stem prosthesis is indicated in fractures with a loose femoral stem.
Acknowledgements
The authors are grateful to Mr JC D'Arcy, Mr KR Ross, Mr AV Bonnici and Mr SE James for allowing their patients to be included in this study.
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