Grafting for periprosthetic femoral fractures: Strut, impaction or femoral replacement☆
Introduction
Periprosthetic femoral fractures are becoming an increasing and complex problem for orthopaedic surgeons. The incidence increases with the aging of the population and the popularity of hip arthroplasty.82 Management requires the combined skills of revision arthroplasty and trauma surgery.82 Periprosthetic fractures occur intraoperatively in about 1% of uncemented hip arthroplasty cases32, 82 and in 3–18% of cemented cases.2, 13, 61, 76 During revision surgery the figures are higher and have been estimated at around 6.3% and 17.6% in uncemented and cemented cases, respectively.2, 31 Periprosthetic fractures also occur postoperatively and reports indicate an incidence of about 1% in primary hip arthroplasty cases and 4% of revision hip arthroplasty cases.55, 62 The elderly population is particularly vulnerable to low-energy periprosthetic fractures attributed to osteopenia or osteoporosis, leaving limited reconstruction options to the hip revision surgeon. Bone grafting in the form of autograft has well recognised limitations and allograft represents the gold standard of bone augmentation in the majority of these cases.34, 46 Allograft can be used in a morselised form for impaction grafting, reconstructing the bone from within, or in the form of structural allograft.24 In the latter case, strut onlay plates or whole proximal femoral allografts can be used to augment the deficient bone or to totally replace it, respectively.37 Immune reaction and disease transmission together with delayed revascularisation of the cortical allograft can cause failure of the construct in the long term; however, the results to date from their use are promising.37, 38, 48 We present an overview of the literature on the use of available bone grafts in the treatment of periprosthetic femoral fractures.
Section snippets
Autograft
Autogenous bone graft is osteoconductive, osteoinductive and provides osteogenic bone cells.30 Animal models have been used to study the processes that occur when the graft is incorporated into the host bone.30 The graft is initially invaded by inflammatory cells and is rapidly revascularised. Osteoprogenitor cells and osteoclasts are able to migrate from the host to the autograft and begin bone remodelling. This has been divided into two phases: (1) an early phase, in which formation and
Conclusion
The management of periprosthetic femoral fractures can be complex and the associated bone loss commonly requires the use of structural allografts.3, 5, 10, 11, 12, 13, 22, 23, 24, 30, 31, 32, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 50, 55, 56, 57, 58, 59, 60, 61, 62, 64, 68, 69, 77, 78, 79, 80, 81, 82, 83, 84, 85
When the stem is stable and the bone quality is good (Vancouver type B1 fracture), a double plating technique using two long struts, or strut with plate bypassing the most distal
Conflict of interest statement
All authors state that no financial or personal relationships with other people, or organisations has inappropriately influenced this work, within 3 years of beginning the work submitted.
References (93)
- et al.
Classification of the hip
Orthop Clin North Am
(1999) - et al.
The use of osteogenic protein-1 in reconstructive surgery of the hip
J Arthroplasty
(2001) - et al.
The effect of demineralized bone matrix gel on bone ingrowth and fixation of porous implants
J Arthroplasty
(2002) - 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.
The Dall-Miles cable and plate system for periprosthetic femoral fractures
Injury
(1997) - et al.
Onlay cortical allografting for the femur
Orthop Clin North Am
(1998) - et al.
Restoration of femoral bone stock in revision total hip arthroplasty
Orthop Clin North Am
(1993) - et al.
Bone graft and total hip replacement. A review
J Arthroplasty
(1992) Femoral fractures associated with total hip arthroplasty
Orthop Clin North Am
(1992)- et al.
Periprosthetic femoral fractures classification and demographics of 1049 periprosthetic femoral fractures from the Swedish National Hip Arthroplasty Register
J Arthroplasty
(2005)
The use of OP-1 in femoral impaction grafting in a sheep model
J Orthop Res
Finite-element modelling of femoral shaft fracture fixation techniques post total hip arthroplasty
J Biomech
Complications with revision of the femoral component of total hip arthroplasty: comparison between cemented and uncemented techniques
J Arthroplasty
Biomechanical aspects of bone autografts and allografts
Orthop Clin North Am
Surgical management of intra- and postoperative fractures of the femur about the tip of the stem in total hip arthroplasty
J Arthroplasty
Biology of bone grafts
Orthop Clin North Am
Fractures of the femur after hip replacement: the Oregon experience
Orthop Clin North Am
Enhancing the osteoinductive properties of hydroxyapatite by the addition of human mesenchymal stem cells, and recombinant human osteogenic protein-1 (BMP-7) in vitro
Injury
Mal-united femoral fractures adjacent to loose total hip arthroplasties salvage with impaction grafting
Injury
Dall-Miles plates for periprosthetic femoral fractures. A critical review of 16 cases
Injury
The management of periprosthetic femoral fractures around hip replacements
Injury
Immunological responses to bone soluble proteins in recipients of bone allografts
J Orthop Res
A biomechanical study comparing cortical onlay allograft struts and plates in the treatment of periprosthetic femoral fractures
Clin Biomech (Bristol Avon)
The use of structural allograft for treating periprosthetic fractures about the hip and knee
Orthop Clin North Am
Comparison of anterior and posterior iliac crest bone grafts in terms of harvest-site morbidity and functional outcomes
J Bone Joint Surg Am
Total hip arthroplasty complications
Proximal femoral fractures following total hip arthroplasty
Clin Orthop
Immune responses of rats to frozen bone allografts
J Bone Joint Surg Am
Nonallograft osteoconductive bone graft substitutes
Clin Orthop Relat Res
The biology of bone graft repair
Clin Orthop Relat Res
Studies in the transplantation of bone. V. The capacity of fresh and treated homografts of bone to evoke transplantation immunity
J Bone Joint Surg Br
Sterilization of HIV by gamma irradiation: a bone allograft model
Int Orthop
Reconstruction of major segmental loss of the proximal femur in revision total hip replacement
Orthopaedics
The use of cortical allograft struts for fixation of fractures associated with well-fixed total joint prostheses
Semin Arthroplasty
The role of allograft in the treatment of periprosthetic femoral fractures
Instr Course Lect
Management of intraoperative femur fractures associated with revision hip arthroplasty
Clin Orthop
Transmission of the hepatitis C virus by tissue transplantation
J Bone Joint Surg Am
Recombinant human bone morphogenetic protein-7 induces healing in a canine long-bone segmental defect model
Clin Orthop Relat Res
The effect of recombinant human osteogenic protein-1 on healing of large segmental bone defects
J Bone Joint Surg Am
In vivo evaluation of recombinant human osteogenic protein (rhOP-1) implants as a bone graft substitute for spinal fusions
Spine
Fixation of periprosthetic femoral shaft fractures: a biomechanical comparison of two techniques
J Orthop Trauma
Fractures of the femur after hip replacement
Instr Course Lect
Basic science of onlay allografts: a review
Instr Course Lect
Cortical strut allografts in the reconstruction of the femur in revision total hip arthroplasty: a basic science and clinical study
Clin Orthop
Effects of gamma irradiation on the human immunodeficiency virus. A study in frozen human bone-patellar ligament-bonegrafts obtained from infected cadaver
J Bone Joint Surg Am
Bone-grafting and bone-graft substitutes
J Bone Joint Surg Am
Cited by (41)
Impaction Bone Grafting or Uncemented Modular Stems for the Treatment of Type B3 Periprosthetic Femoral Fractures? A Complication Rate Analysis
2019, Journal of ArthroplastyCitation Excerpt :Median grade of Endo-Klinik femoral bone defect was similar between both groups (P = .11). All surgeries were performed in laminar flow theaters following the general principles that have been described for both original techniques (Table 2) [4,7]. Under epidural hypotensive anesthesia, an extended posterolateral approach was performed in 29 patients of group A and all patients of group B.
Periprosthetic femoral fractures: When i use strut grafts and why?
2015, InjuryCitation Excerpt :However, cortical struts are technically demanding to apply and their use have some concerns, such as if the soft tissue stripping required for the application may lead into a delayed bone healing or increase the infection rate. Other concerns are the role as disease carrier, immune reactions, incorporation to the host bone in the long term and, in some centres, the availability and costs [27]. Another question without clear current answer, is the need nowadays of cortical struts combined with the locking and periprosthetic plate and screw technology that allows better purchase to the proximal fragment around the stem, compared with conventional plates, increasing, theoretically, the stability of the fixation by itself.
Interprosthetic femoral fractures: Analysis of 14 cases. Proposal for an additional grade in the Vancouver and SoFCOT classifications
2011, Orthopaedics and Traumatology: Surgery and ResearchCitation Excerpt :We therefore prefer open plate osteosynthesis, with a plate long enough to bridge the fracture and adequate periprosthetic anchorage by cerclages and screws, away from the implant and combating avulsion [16]. A graft (cancellous autograft and/or allograft rod) improves consolidation [20,22], when associated to stable osteosynthesis, which is a prerequisite. The LISS® technique respects the fracture site environment and consolidation factors [16–18], and may also be indicated in comminutive fracture if not extensive.
Management and outcome of interprosthetic femoral fractures
2011, InjuryCitation Excerpt :With a complication rate of 16% and re-operation in one patient, we can recommend this technique for the stabilisation of interprosthetic femoral fractures with stable prosthetic components. The use of additional fixation devices, such as cables or cerclages, adjacent to the angular stable plate systems, has been subject to controversy.10,22,24 A number of authors argue against these constructs, as additional circumferential soft-tissue dissection is necessary for cerclage placement, more likely leading to local necrosis and bony nonunion.7,10,22
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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. No funds were received in support of this study.