Elsevier

Injury

Volume 38, Issue 6, June 2007, Pages 688-697
Injury

Grafting for periprosthetic femoral fractures: Strut, impaction or femoral replacement

https://doi.org/10.1016/j.injury.2007.02.046Get rights and content

Summary

Peri-prosthetic fractures are technically demanding to treat, as they require the skills of revision arthroplasty as well as those of trauma surgery. [Lindahl H, Malchau H, Herberts P, Garellick G. Periprosthetic femoral fractures classification and demographics of 1049 periprosthetic femoral fractures from the Swedish National Hip Arthroplasty Register. J Arthroplasty 2005;20:857–65.] reporting on 1049 periprosthetic femoral fractures found that the annual incidence varied between 0.045% and 0.13% for all THAs performed in Sweden and that the accumulated incidence for the primary hip arthroplasties was 0.4% while for the revision arthroplasties was 2.1% [Lindahl H, Malchau H, Herberts P, Garellick G. Periprosthetic femoral fractures classification and demographics of 1049 periprosthetic femoral fractures from the Swedish National Hip Arthroplasty Register. J Arthroplasty 2005;20:857–65.]. 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 recognized limitations and allograft represents the gold standard of bone augmentation in the majority of the cases. Allograft can be used as morselised in the form of impaction grafting, reconstructing the bone from within out, or in the form of structural allograft. 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. Immune reaction and disease transmission along with delayed revascularization of the cortical allograft can cause failure of the construct in the long term; however, the results to date from their use are promising. We here present an overview of the literature on the use of available bone grafts in the treatment of periprosthetic femoral fractures.

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.

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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.

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