Postoperative Femoral Fractures Research Articles

Femoral Component Revision with Use of Impaction Bone-Grafting and a Cemented Polished Stem

The purpose of this study was to evaluate the clinical and radiographic outcomes of revision of the femoral component of a hip arthroplasty with use of an impaction bone-grafting technique and a cemented polished stem. Thirty-three consecutive femoral reconstructions that were performed between March 1991 and February 1996 with use of the X-change femoral revision system, fresh-frozen morselized allograft, and a cemented polished Exeter stem were followed prospectively. Femoral bone stock defects were classified according to the Endoklinik classification. The average age of the patients at the time of the femoral component revision was sixty-three years. No patient was lost to follow-up, which was performed at a minimum of eight years, but eight patients had died. None of the deaths was related to the surgery. No femoral reconstruction had been rerevised at a mean of 10.4 years postoperatively. There was one unrecognized intraoperative fracture, which healed following nonoperative treatment. There were three postoperative femoral fractures, all through cortical defects at the level of the tip of the prostheses. All fractures healed after plate fixation, and all femoral implants were left in situ. The average subsidence of the stem within the cement mantle was 3 mm; seven stems migrated 5 mm. The average Harris hip score improved from 49 points prior to surgery to 85 points (range, 68 to 100 points) at the time of this review. Subsidence did not affect the Harris hip score. Kaplan-Meier analysis, with an end point of femoral revision for any reason, showed a survival rate of 100% (one-sided 95% confidence interval, 100% to 91.3%). Femoral revision with use of an impaction bone-grafting technique and a cemented polished stem resulted in an excellent prosthetic survival rate at eight to thirteen years postoperatively. The major problem that occurred was a femoral fracture in four patients.

Peritrochanteric fractures treated with the Fixion expandable proximal femoral nail: technical note and report of early results

The theoretical advantages of intramedullary fixation for peritrochanteric fractures were lessened in practice by implant-related operative problems and postoperative complication. Forty-nine patients were treated with a newly designed expandable proximal femoral nail (EPFN) and followed thereafter for a minimum of 6 months. After experience was gained in carrying out the procedure, its mean duration was limited to 43.4+/-20.2 min and total mean fluoroscopy time to 39.8+/-16.1 s. Due to minimal extent of soft tissue trauma blood loss was negligible and rate of postoperative infections reduced. Condensation of cancellous bone in the femoral head as an alternative to reaming and the blunt cone-shaped head of the peg reduced the frequency of head peg cut-out. Homogenic load distribution along the nail interface decreased the concentration of stress and thereby eliminated the risk of postoperative femoral fracture distal to the implant stem. The EPFN may be considered as a further evolution of implants designed to stabilize peritrochanteric fractures of all grades.

Femoral Component Revision with Use of Impaction Bone-Grafting and a Cemented Polished Stem

The purpose of this study was to evaluate the clinical and radiographic outcomes of revision of the femoral component of a hip arthroplasty with use of an impaction bone-grafting technique and a cemented polished stem. Thirty-three consecutive femoral reconstructions that were performed between March 1991 and February 1996 with use of the X-change femoral revision system, fresh-frozen morselized allograft, and a cemented polished Exeter stem were followed prospectively. Femoral bone stock defects were classified according to the Endoklinik classification. The average age of the patients at the time of the femoral component revision was sixty-three years. No patient was lost to follow-up, which was performed at a minimum of eight years, but eight patients had died. None of the deaths was related to the surgery. No femoral reconstruction had been rerevised at a mean of 10.4 years postoperatively. There was one unrecognized intraoperative fracture, which healed following nonoperative treatment. There were three postoperative femoral fractures, all through cortical defects at the level of the tip of the prostheses. All fractures healed after plate fixation, and all femoral implants were left in situ. The average subsidence of the stem within the cement mantle was 3 mm; seven stems migrated > or =5 mm. The average Harris hip score improved from 49 points prior to surgery to 85 points (range, 68 to 100 points) at the time of this review. Subsidence did not affect the Harris hip score. Kaplan-Meier analysis, with an end point of femoral revision for any reason, showed a survival rate of 100% (one-sided 95% confidence interval, 100% to 91.3%). Femoral revision with use of an impaction bone-grafting technique and a cemented polished stem resulted in an excellent prosthetic survival rate at eight to thirteen years postoperatively. The major problem that occurred was a femoral fracture in four patients.

The Effect of Femoral Notching During Total Knee Arthroplasty on the Prevalence of Postoperative Femoral Fractures and on Clinical Outcome

The treatment of a supracondylar femoral fracture following total knee arthroplasty is complicated by the presence of the prosthetic components. Anterior femoral notching during arthroplasty has been implicated as a contributing risk factor for femoral fracture. We retrospectively reviewed the effect of anterior femoral notching on the subsequent occurrence of a periprosthetic supracondylar fracture of the distal aspect of the femur and the outcomes of primary total knee arthroplasty in such patients. The prevalence and depth of femoral notching were determined on a review of the lateral radiographs by observers blinded to the clinical results of 1089 consecutive total knee replacements performed in 1997 and 1998. Linear and logistic regression modeling was used to analyze the relationship between femoral notching and the prevalence of supracondylar femoral fracture, postoperative range of motion, the Knee Society score, and the Knee Society functional and pain scores. Femoral notching was performed in 325 (29.8%) of the 1089 knees in our series. During an average follow-up period of 5.1 years, only two supracondylar femoral fractures occurred, both in femora treated without notching. Femoral notching was not associated with an increased rate of fracture (p = 1.000) or with significant differences in the measures of outcome (range of motion [p = 0.117], knee score [p = 0.967], functional score [p = 0.861], need for a lateral release [p = 0.234], or postoperative pain [p = 0.948]). This study demonstrated no difference in knees managed with or without notching of the anterior distal aspect of the femur with respect to the occurrence of a supracondylar fracture, range of motion, Knee Society score, Knee Society function, or pain.

Periprosthetic Femoral Fractures: Classification and Demographics of 1049 Periprosthetic Femoral Fractures from the Swedish National Hip Arthroplasty Register

Postoperative femoral periprosthetic fracture is an uncommon complication of total hip arthroplasty surgery, but several centers worldwide have recently reported an increase in total numbers of such fractures. This severe complication is costly for society and results in high morbidity. Our analysis of 1049 periprosthetic fractures occurring in Sweden between 1979 and 2000 and recorded in the Swedish National Hip Arthroplasty Register focuses on patient- and implant-related factors, fracture classification, and fracture frequency. These were our 3 major findings: (1) a majority of the patients who sustained a late periprosthetic femoral fracture had a loose stem. (2) Implant-related factors are significantly associated with occurrence of a periprosthetic fracture. (3) Since the 1980s in Sweden, treatment results for periprosthetic fractures have been poor, with low long-term survivorship and a high frequency of complications. We have initiated further studies of this important problem.

Femoral Neck Fractures Complicating Metal-on-Metal Resurfaced Hips: A Report of 2 Cases

Metal-on-metal hip resurfacing arthroplasty is increasingly popular for younger patients with advanced hip disease. Intra-operative or immediate postoperative femoral neck fracture after metal-on-metal hip resurfacing is a well-described technical complication, ranging from 0% to 1.5%. We report 2 cases of late femoral neck fracture occurring 8 and 15 months following the index operation, with a review of the literature. We recommend that patient selection should be of prime importance before embarking on metal-on-metal surface hip replacement to avoid such complications.

Dynamic compression plates for Vancouver type B periprosthetic femoral fractures

Background There is no consensus on the best surgical treatment of periprosthetic femoral fractures. We report our experience with a dynamic compression plate.Patients and methods We reviewed the results of 18 periprosthetic femoral fractures treated with open reduction and internal fixation using the dynamic compression plate (DCP). There were 7 Vancouver type B1, 2 type B2 and 9 type B3 fractures. 16 cases had previously undergone at least one revision procedure. In addition to a DCP plate, all B2 and B3 fractures were revised to cemented prostheses, and all B3 fractures were revised with impaction grafting. Mean follow-up was 39 months.Results The mean healing time for those 11 cases that united was 13 months. One B1-type and one B3-type fracture with plate fracture within 8 months of surgery failed to heal. Furthermore, one B1-type fracture and one B2-type fracture failed and developed nonunion. 3 patients died, from causes not related to surgery, within 8 months after surgery without signs of healing.Interpretation Open reduction and internal fixation using DCPs seems to be a valid method for the treatment of postoperative periprosthetic femoral fractures with stable stem in place. If the stem is unstable, we suggest that DCPs may be used in association with femoral revision using a long stem. In cases with stable stem (B1), we are inclined to agree with other authors that additional fixation using an extramedullary cortical strut graft may be necessary to improve stability and promote final healing.

Impacted cancellous graft plus cement in hip revision.

Revision of the femoral component is difficult in the presence of large cavitary defects of the femur. Impaction cancellous grafting used in conjunction with a cemented prosthesis has been recommended as a means of restoring bone stock while providing excellent and durable clinical results. Fifty-seven consecutive femoral revisions were done between 1993 and 1997 in 54 patients (24 men and 30 women) using the impaction grafting technique and a collarless, tapered, polished stem. Strut allografts were used for femoral reinforcement in 40 hips. No patient was lost to followup. One patient had an infection develop and had a resection arthroplasty. Three patients died of causes unrelated to the hip. After 6.3 years the clinical results were excellent. Radiographic evaluation showed no evidence of loosening in any of the 53 surviving hips. Subsidence of 1 to 3 mm was seen in 40 hips and subsidence of 4 to 6 mm was seen in two hips. Cancellous remodeling was observed in 42 hips. The most common complications were postoperative femoral fractures. All six fractures occurred at the distal end of the prosthesis, were not associated with prosthetic loosening, and were treated successfully with open reduction and internal fixation without prosthetic revision. These satisfactory results and the limited subsidence observed in our patients radiographs could be explained by the careful attention to the technical details of the procedure. However, even with the generous use of strut graft augmentation, postoperative femoral fractures remain our most serious complication.

Percutaneous treatment of peritrochanteric fractures using the gamma nail. 2000.

The goal of the current study was to analyze patients treated with the Gamma nail, and to describe techniques that prevent commonly reported complications. One hundred patients with closed peritrochanteric femur fractures were treated by one surgeon using the Gamma nail. Ninety patients met the minimum 6 month followup requirement. Eighty-eight of the 90 fractures (98%) healed after the index procedure. There were nine (10%) complications (nine patients) with four patients (4%) requiring surgical intervention. One patient required total hip arthroplasty because of nonunion, and one patient required cerclage wiring of a postoperative femoral fracture. The third patient had an infection develop which resolved after debridement and a course of antibiotics. The fourth patient complained of thigh pain, which resulted in hardware removal. In the five remaining patients with complications, one patient had multi-infarct dementia and the family refused additional treatment, two patients with intraoperative femur fractures did not require treatment and two patients with thigh pain did not require additional treatment. Surgical time averaged 53 minutes and blood loss averaged 104 cc. Percutaneous fixation using the Gamma nail is effective in treating patients with peritrochanteric fractures. Surgical time and blood loss were minimized, early weightbearing was initiated, and previously reported complications were decreased.

大腿骨頚部骨折後に生じた大腿骨遠位部骨折の治療経験

Ipsilateral distal femoral fracture after postoperative femoral neck fracture is a rare complication and treatment is often difficult. We treated three cases in which retrograde supracondylar intramedullary nails were used for internal fixation. The patients consisted of three females with ages ranging from 75 to 89. Two patients underwent hemiarthroplasty and another underwent Gamma nailing. According to AO classification, they were classified into A1 (2 cases) and C1 (1 case), respectively. All patients tended to fall down easily after postoperative femoral neck fracture.Consequently all fractures healed within four months. The average knee range of motion was —10 to 93 degrees. Clinical results were evaluated according to Neer's criteria. All cases were ranked as unsatisfactory. In generally, walking ability tended to deteriorate because multiple fractures occurred ipsilatelly. One case developed secondary femoral fracture at the mid shaft postoperatively, because of jamming between the distal tip of the cement and proximal tip of the intramedullay nail.Use of retrograde supracondylar intramedullary nail is effective for this type of fracture, but we have to be careful about the length of the intramedullary nail before surgical planning. As rigid fixation is difficult for the osteoporotic bone, post operative treatment is also important.

Impaction allografting for femoral revision hip arthroplasty. Mid-term results after minimum five year follow-up in 46 cases.

Previously, only short-term follow-up results after femoral revision using impacted allograft and cemented stems the exchange technique have been published. We present the results of 46 femoral exchange revision procedures performed on 42 patients with five to nine years follow-up. At follow-up, five patients had died and two patients did not complete follow-up. Two patients were re-revised. One patient underwent re-revision due to early collapse of the impaction construct. In another patient, stem loosening due to acetabular revision occurred and a full re-revision of the impaction area was performed. One patient suffered late post-operative femoral fracture and three patients experienced hip dislocations. Ninety percent expressed satisfaction with the result. Harris Hip Score (HHS) improved from 36 to 82 (p < 0.001). Radiographically, one patient demonstrated stem subsidence of greater than 5mm. Eighty-six percent demonstrated signs of graft incorporation and only one patient demonstrated signs of loosening. Our results after a minimum of five years follow-up of patients surgically treated with the exchange femoral revision technique demonstrated good clinical and radiological results. With a re-revision rate of 4.3%, one case with subsidence exceeding 5 mm and one case with diaphyseal fracture, we did not observe the problems of subsidence and femoral fractures described in previous studies. (Hip International 2002; 4: 357-64).

Early complications after one hundred and forty-four consecutive hip revisions with impacted morselized allograft bone and cement.

The use of impacted morselized allograft bone and cement in hip revision arthroplasty has been popular, but studies that specifically address intraoperative and postoperative complications have been scarce. All complications that occurred during, and within the first year after, 144 consecutive hip revision arthroplasties (108 stems and 130 sockets) performed with impacted morselized allograft bone and cement were recorded. Clinical and radiographic follow-up evaluation was performed at three months and at one year after surgery for all patients except eight (seven who had died of causes unrelated to the hip surgery and one who had sustained a stroke). Of these eight patients, seven had a six-week and/or three-month follow-up evaluation. Thirty-nine femoral fractures occurred in thirty-seven hips; twenty-nine of the fractures occurred during surgery and ten, within five months after surgery. Of the intraoperative femoral fractures, twelve were proximal, nine were diaphyseal, and eight involved the greater trochanter. Of the postoperative femoral fractures, one was proximal and nine were diaphyseal. Other intraoperative complications were the creation of a femoral cortical window in seven hips and incidental perforation of the femoral cortex in fourteen. Multivariate analysis showed the risk factors for femoral fracture during or after revision to be concomitant disease, greater deficiency of the femoral bone stock, and an intraoperative femoral window or perforation. Other complications included dislocation of the femoral head in nine hips, deep infection in one hip, persistence of preoperative deep infection in one hip, and superficial wound infection requiring wound débridement in two hips. We found the complication rate to be high after hip revision arthroplasty performed with impacted morselized allograft bone and cement. The most serious complication was postoperative diaphyseal femoral fracture.

Impaction bone grafting for total hip revision.

We used impaction bone grafting for total hip revision on 26 hips in 25 patients. Average patient age was 68 (34-89) years, and average duration from last surgery was 9 years. In all cases morselized allograft bone was used for the graft, and the femoral component was a collarless, polished, tapered stem. Average duration of surgery was 2.4 h, intraoperative blood loss 600 cc, blood replacement 2.4 units, and acute-care hospital stay 5 days. Complications were varus placement of the stem in two patients and postoperative development of varus in one, one intraoperative and three postoperative femoral fractures, and one postoperative dislocation. Average subsidence was 0.6 cm. We believe that most, if not all, of these complications could have been prevented.

Exchange impaction allografting for femoral revision hip arthroplasty: Results in 87 cases after 3.6 years' follow-up

A total of 87 femoral exchange revision procedures were performed in 80 patients. Mean follow-up time was 3.6 years. Patients were followed prospectively. At follow-up, 5 patients had died, and 74 (93 %) completed follow-up. Results were evaluated on the basis of incidence of rerevisions and other complications, patient satisfaction, and preoperative and postoperative Harris hip score. Radiographic evaluation included preoperative femoral bone status evaluated according to Endo-Klinik and Mallory, incidence of subsidence, bone–graft incorporation, and signs of loosening. Three patients were rerevised, 2 patients suffered postoperative femoral fractures, 5 patients had hip dislocations, and 1 patient suffered deep infection. Of patients, 90% expressed satisfaction with the result. Harris hip score improved from 39 to 82 (P <.001). Radiographically, only 2 patients showed subsidence of >5 mm. Of patients, 88% showed signs of graft incorporation, and only 1 patient showed signs of loosening. Intermediate follow-up evaluation of the exchange femoral revision technique showed good clinical and radiographic results. With a rerevision rate of 3.5% and incidence of >5 mm subsidence of 2.5%, we did not observe the problems of subsidence and femoral fractures that previous studies have described.

ガンマネイル法による骨接合術後に大腿骨骨折を合併した症例の検討

The postoperative results of the gamma nail for trochanteric and subtrochanteric fractures were studied in 74 cases from January 1999 to August 2000. Postoperative complications observed were postoperative femoral fractures in 5 cases, stable fractures in 3 cases, and unstable fractures in the remaining case. In stable fractures, the nail sometimes obstructs reduction, causing the postoperative fractures. To avoid fractures, it is nessesarry to study the appropriate surgical techniques and select the devices carefully.

Percutaneous treatment of peritrochanteric fractures using the Gamma nail.

The goal of the current study was to analyze patients treated with the Gamma nail, and to describe techniques that prevent commonly reported complications. One hundred patients with closed peritrochanteric femur fractures were treated by one surgeon using the Gamma nail. Ninety patients met the minimum 6 month followup requirement. Eighty-eight of the 90 fractures (98%) healed after the index procedure. There were nine (10%) complications (nine patients) with four patients (4%) requiring surgical intervention. One patient required total hip arthroplasty because of nonunion, and one patient required cerclage wiring of a postoperative femoral fracture. The third patient had an infection develop which resolved after debridement and a course of antibiotics. The fourth patient complained of thigh pain, which resulted in hardware removal. In the five remaining patients with complications, one patient had multi-infarct dementia and the family refused additional treatment, two patients with intraoperative femur fractures did not require treatment and two patients with thigh pain did not require additional treatment. Surgical time averaged 53 minutes and blood loss averaged 104 cc. Percutaneous fixation using the Gamma nail is effective in treating patients with peritrochanteric fractures. Surgical time and blood loss were minimized, early weightbearing was initiated, and previously reported complications were decreased.

A comparison of collared and collarless femoral components in primary cemented total hip arthroplasty: A randomized clinical trial

Between July 1986 and November 1989, 437 consecutive primary cemented total hip arthroplasties were performed using a straight-stemmed titanium alloy femoral component. Collared and collarless versions of this identical stem were randomly chosen by computer allowing a comparison between 213 collared stems (198 patients) and 224 collarless stems (209 patients). Diagnosis, sex, weight, and average age (72.8 years, collared; 72.0 years, collarless) were similar. Follow-up averaged 76 months (collared) and 72 months (collarless) with 49 patients followed for at least 10 years. Calcar-collar contact was noted in 205 hips (96%) on the initial postoperative radiograph. Early complications, including dislocations (5% each group), were similar. Late complications included 3 deep infections (2 collared, 1 collarless) and 2 postoperative femur fractures (1 each). Hip scores at the most recent follow-up averaged 91.2 and 90.1 in the collared and collarless groups. No or slight pain was noted in 93% of collared and 91.5% of collarless hips. Although no radiographic differences were noted in distal cortical hypertrophy, stem subsidence, and osteolysis, collarless hips lost significantly more medial femoral neck cortical bone (average 0.90 mm vs 0.63 mm). A higher incidence of radiolucent lines in femoral zone VI (20.7% vs 9.4%) was also noted in collarless hips.

Postoperative Periprosthetic Femoral Fracture Associated with Loosening of the Femoral Prosthesis

Postoperative Periprosthetic Femoral Fracture Associated with Loosening of the Femoral Prosthesis

人工股関節置換術に伴う大腿骨骨折の治療経験

人工股関節置換術に伴う大腿骨骨折の治療経験

Controlled Perforation

Removal of cement from the femoral canal during total hip revision arthroplasty continues to be very challenging. The technique is described using multiple 9-mm perforations placed at least 5 cm apart on the anterior surface of the femoral shaft. The tip of the revision stem should be at least 5 cm distal to the most distal perforation. From January 1984 to December 1986, 219 cases of revision total hip arthroplasties were performed using this technique; the incidence of ipsilateral postoperative femoral fractures was nine out of 219. Eight of these fractures were at the tip or distal to the femoral prosthesis and were associated with trauma. One fracture occurred through a perforation site and had an associated fracture of the femoral component. This method appears to be a reliable and safe method of cement removal from the femoral canal.