Elsevier

Injury

Volume 34, Issue 2, February 2003, Pages 107-110
Injury

Dall-Miles plates for periprosthetic femoral fractures: A critical review of 16 cases

https://doi.org/10.1016/S0020-1383(02)00161-4Get rights and content

Abstract

Fourteen patients with 16 periprosthetic femoral fractures around hip replacement were treated with Dall-Miles plates between June 1996 and February 2000.

There were 10 Vancouver B3, three B1 and three type C fractures. In addition to a Dall-Miles plate, two of the fractures (one B3 and one C type) were also stabilised with one strut graft and nine B3 fractures were revised with impaction grafting.

Of the three B1 fractures treated with plates, two failed through fracture of the plate. A further two patients with B3 fractures treated with plates also failed with fracture of the plate. Failure of these plates occurred within 6 months of surgery.

All non-unions and fixation failures in this series were in cases where the femoral component did not bypass the most distal fracture line by at least two cortical diameters.

The Dall-Miles plates and cable system alone is insufficient for the treatment for periprosthetic femoral fractures. It must be supplemented with additional intramedullary or extramedullary fixation.

Introduction

The treatment of periprosthetic femoral fractures presents orthopaedic surgeons with increasingly complex problems [1].

Periprosthetic fractures occur intraoperatively following technical errors or post-operatively when they are frequently associated with loosening and/or osteolysis. Intraoperatively they are estimated to occur in about 1% of cemented [2], [3] and 3–18% of uncemented [4], [5], [6] primary hip operations. In revision surgery, the rate is generally higher for cemented procedures at 6.3 [7] and 17.6% for uncemented prostheses [8].

The incidence of late fractures has been estimated to be less than 1% after primary arthroplasty and up to 4% following revision surgery [9], [10].

Most reports describe a variety of treatment options and are associated with high complication and failure rates. Closed treatment is associated with the well-recognised complications of prolonged bedrest, and may result in mal-union. Mal-union, in turn, may lead to functional problems, and makes subsequent revisions more difficult. Revision of the stem poses problems as removal of a well-fixed implant is technically challenging, and can result in considerable bone loss. Attention has therefore centred on the use of internal fixation to treat periprosthetic femoral fractures. Screws, cerclage wires, cables or bands on their own are insufficient, and conventional plates commonly fail because of the difficulty in obtaining proximal fixation. Moreover, proximal screws may violate the bone prosthesis interface, may lead to cement fracture and loosening, and will act as stress risers increasing the risk of later fractures. Alternatives have included combinations of plates and cables, Partridge bands with a variety of plates, Mennen plates and compression plates, some of which are associated with high failure rates.

The aim of this study was to review the results of plating of periprosthetic femoral fractures using the Dall-Miles system in a specialist unit.

Section snippets

Patients and methods

Fourteen patients with 16 periprosthetic femoral fractures were treated with Dall-Miles plates between June 1996 and February 2000 in our unit. The average age at the time of fixation was 80.4 years (range 70–87 years). Seven fractures occurred in the left femur and nine in the right. All the fractures were around cemented implants. Seven occurred after a primary total hip replacement and nine after revision procedures. Thirteen fractures were at the tip or within one-third of the femoral stem

Results

The results are summarised in Table 1.

There were seven cases where the stem was not revised and a Dall-Miles plate was the only form of fixation (one B3, three C and three B1 fractures). Three of these cases (42.8%) were complicated by plate fracture (one B3 and two B1).

Nine cases were treated with plating with associated intramedullary or strut graft support. Only one case (one B3) was complicated by a plate fracture.

Of the three B1 fractures (stable stem and adequate bone stock) treated with

Discussion

The principle underlying the surgical management of periprosthetic fractures is that consideration needs to be given to the location of the fracture, to the stability of the prosthesis and to the available bone stock. In this series, open reduction and internal fixation was used around stable and around loose implants but was associated with impaction allograft revision in a number of cases.

In cases of loose femoral prostheses, most authors would recommend revision with a long stem prosthesis

Conclusion

This study suggests that Dall-Miles plates used on their own for the treatment of periprosthetic femoral fractures run a considerable risk of failure. Their use must continue but in association with long stem revision if the stem is unstable, and in association with cortical strut allografting if the stem is well fixed.

References (29)

  • G. Löwenhielm et al.

    Fracture of the lower extremity after total hip replacement

    Arch. Orthop. Trauma Surg.

    (1989)
  • M.A. Mont et al.

    Hoop-stress fractures of the proximal femur during hip arthroplasty: management and results in 19 cases

    J. Bone Joint Surg. Br.

    (1992)
  • S.A. Stuchin

    Femoral shaft fracture in porous and press-fit total hip arthroplasty

    Orthop. Rev.

    (1990)
  • Berry DJ, Garvin KL, Sang-Hong Lee, Maloney WJ, Paprosky WG, Steinberg ME, et al. Total hip arthroplasty complications....
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