Locking plate osteosynthesis for Vancouver Type B1 and Type C periprosthetic fractures of femur: A report on 12 patients
Introduction
The treatment of periprosthetic fractures is complex and challenging and requires the skills of both trauma surgery and revision arthroplasty. The management is made more difficult by co-morbid factors such as osteoporosis, previous surgery, and frailty of the patients. Total hip arthroplasty (THA) is becoming more commonplace and the prevalence of periprosthetic fractures is bound to rise.
The incidence of post-operative periprosthetic fractures has remained relatively constant.14, 17 Intra-operatively, they are estimated to occur in about 1% of cemented10 and 3–18% of uncemented primary hip replacements.21, 23 During revision surgery, the incidence is higher, occurring in 6.3% of cemented4 and 17.6% of uncemented replacements.9 Post-operatively, the incidence is estimated to be <1% after primary hip replacement and about 4% following revision.7
Various attempts have been made to classify these fractures. We use the Vancouver6 classification (Table 1) as it considers the fracture anatomy, quality of bone stock and stability of implant, all of which are useful in planning a management strategy. In the presence of a loose prosthesis (Type B2, B3) most arthroplasty surgeons would elect to revise the prosthesis, with or without augmentation with internal fixation or strut graft. The management of fractures around a well-fixed femoral prosthesis is less clear. Though there is little doubt that fractures around or below the tip of a stable prosthesis (Type B1 and Type C) should be fixed, the optimum fixation technique is still unclear. The challenge in managing these fractures is in achieving adequate proximal fixation, without compromising the cement mantle or the prosthesis.
The Mennen paraskeletal clamp has been described but is now losing favour in view of the poor results quoted in literature.2, 15 Strut allograft alone or in conjunction with internal fixation can be used. In a multi-centre trial of 40 patients, Haddad and Duncan11 reported union in 39 patients using strut grafts alone or in conjunction with plates. However, the use of allografts is not without disadvantages; there is a risk of transmitting disease and they are not readily available to most surgeons.
Devices like the Dall-Miles plate, which apply the ‘Ogden method’22 of using cables for proximal fixation, are popular because they do not interfere with the cement mantle. The results are encouraging.19, 25 Failures reported in most series19, 24, 25 are related to varus placement of the femoral stem. Tadross et al.24 reported only three good results from nine fractures treated with the Dall-Miles plate, and they did not recommend its use in the presence of femoral component loosening or more than 6° varus.
The introduction of ‘internal external fixators’ like the locking compression plate (LCP) [Synthes USA]18 and less invasive stabilisation system (LISS) [Synthes USA]20 has provided another method of treating these fractures. Many of these plates allow for minimally invasive insertion and therefore respect the soft tissues. The screws lock onto the plate, providing better angular stability. This allows these plates to be used as a bridging construct with minimal disruption of the fracture fragments’ blood supply.
We present our experience with the use of the LCP and distal femur LISS in periprosthetic fractures with well-fixed femoral prosthesis (Vancouver Type B1 and Type C).
Section snippets
Patients and methods
All patients presenting to our unit with periprosthetic fractures of the femur were reviewed. The fractures were classified using the Duncan and Masri/Vancouver classification (Table 1). Only Type B1 or Type C fractures were considered for fixation. The decision to fix the fractures was made following consultations with our arthroplasty colleagues. Between January 2004 and March 2005, 12 consecutive patients underwent internal fixation with a locking plate (LCP or distal femur LISS). We
Results
Locking plate osteosynthesis was performed on 12 patients between January 2004 and March 2005 (see Table 2). All suffered their fracture following falls. Ten were female and two male. The mean age of the patients was 80.2 years (range 72–86). The mean time from the primary total hip arthroplasty was 10 years (range 5–15 years). One patient underwent fixation after two prior operations for periprosthetic fracture (Patient 5). The initial revision failed in 2 weeks and required stabilisation with
Discussion
The management of femoral fractures following total hip arthroplasty is influenced by various factors including bone quality, stem loosening, health of the patient and experience of the surgeon. Fractures around a stable stem usually benefit from internal fixation. The challenge in fixing these fractures is in finding an implant that provides adequate proximal fixation without damaging the cement mantle and at the same time provides good fixation in osteoporotic bone.
Conventional plating with
Conclusion
The angular stability of locking screws makes these devices suitable for unicortical fixation. Specially designed periprosthetic screws further allow good fixation into the cement mantle. The instrumentation facilitates minimally invasive fixation. Our initial success encourages us to propose that locking plate implants have a role to play, with due care to details of the technique, in the future management of periprosthetic fractures around the stable cemented femoral stem.
Conflicts of interest
There are no conflicts of interest.
References (26)
- et al.
Percutaneous plate fixation for periprosthetic femoral fractures—a preliminary report
Injury
(2000) - et al.
The Mennen femoral plate for fixation of periprosthetic femoral fractures following hip arthroplasty
Injury
(2002) - et al.
Operative stabilization of supracondylar femur fractures above total knee arthroplasty: a comparison of four treatment methods
J Arthroplasty
(2003) - et al.
Fixation of periprosthetic femoral shaft fractures occurring at the tip of the stem: a biomechanical study of 5 techniques
J Arthroplasty
(2000) - et al.
A prospective, modernised treatment protocol for periprosthetic femur fractures
Orthop Clin North Am
(2004) - et al.
Dynamic compression plate fixation for post-operative fractures around the tip of a hip prosthesis
Injury
(2005) - et al.
The Mennen plate: unsuitable for elderly femoral peri-prosthetic fractures
Injury
(1999) - et al.
Peri-prosthetic femoral shaft fractures treated with plate and cable fixation
Injury
(1999) Femoral fractures associated with total hip arthroplasty
Orthop Clin North Am
(1992)- et al.
Dall-Miles cable and plate fixation for the treatment of peri-prosthetic femoral fractures-analysis of results in 13 cases
Injury
(2001)