Traumatic Periprosthetic Fracture Research Articles

Excellent Results of Large-Diameter Ceramic-On-Ceramic Bearings in Total Hip Arthroplasty at Minimum Ten-Year Follow-Up

BackgroundThis study reports the minimum 10 years results of total hip arthroplasty (THA) performed using a monoblock acetabular component with a large-diameter head ceramic-on-ceramic bearing. MethodsOf the 276 THAs included in this study, there were eleven deaths and 27 patients lost to follow up (11%) during the follow-up, leaving 237 (85%) hips available for review at a mean of 10.5 years (range, 10 to 12) postoperatively. Reoperations, implant revisions, adverse events, clinical outcomes, radiographic evaluation, and whole blood metal ion levels were assessed at the last follow-up. ResultsAfter a minimum of 10 years, implant survivorship was 98.7%. There were 3 revisions (1.3%): one for insufficient acetabular cup primary fixation, one traumatic periprosthetic acetabular fracture, and one probable deep chronic infection. No dislocation or ceramic implant fracture was observed. The mean University of California at Los Angeles activity score, Western Ontario and McMaster Universities Osteoarthritis Index score, and Forgotten Joint Score were 5.6 (2 to 10), 90.1 (9 to 100), and 79.2 (4 to 100), respectively. All patients (100%) were satisfied or very satisfied. Since implantation, 43% of patients reported hearing a squeaking noise from the prosthesis. But all patients who reported squeaking were satisfied with the surgery. The mean titanium level was 2.2 μg/L (1.1 to 5.6). No progressive radiolucent lines, osteolysis, or implant loosening signs were observed at the last radiographic evaluation. ConclusionsA large-diameter head ceramic-on-ceramic THA provides outstanding long-term (minimum 10 years) implant survivorship with unrestricted activity while avoiding implant impingement, liner fracture, and hip instability. Functional outcomes, satisfaction, and joint perception were excellent. Although the incidence of squeaking was high, it did not affect patient satisfaction or function. The systemic titanium levels were low, related to unavoidable passive corrosion of implant surfaces, and did not reveal any indirect signs of trunnionosis.

Mid- to long-term periprosthetic bone density changes after cementless short stem hip arthroplasty in elderly: A clinical and radiological analysis

IntroductionShort stem prostheses were originally designed for younger and more active patients. In recent years, they have been increasingly offered to older patients. This study evaluates the mid-to long-term survival of a short stem prosthesis and the changes in periprosthetic bone density following implantation of a cementless short hip stem in patients over 60 years of age. Methods118 patients aged over 60 received short stem prostheses. Clinical examination included Harris Hip Score (HHS) and Hip Disability and Osteoarthritis Outcome Score (HOOS). 93 patients were followed clinically for at least five years. 53 patients underwent dual-energy x-ray absorptiometry (DXA) and radiographic evaluation. Follow-up intervals were preoperative and postoperative (t0), at approximately six months (t1), at approximately two years (t2), and at approximately five years or later (t3). ResultsOver a mean 6.7-year observation period for all 118 patients, one stem revision occurred due to a traumatic periprosthetic stem fracture. The five-year survival rate for the endpoint survival of the Metha® stem in 95 at-risk patients is 99.2%. HHS improved significantly from t0 55.3 ± 11.5 (range 30–79) to t3 95.3 ± 8.6 (range 57–100) at a mean of 8.0 years (p < 0.001). HOOS improved significantly in each subscale (p < 0.001). Bone mineral density (BMD) was available for review in 53 patients after a mean of 7.1 years. BMD increased from t0 to t3 in region of interest (ROI) 3 (+0.4%) and ROI 6 (+2.9%) and decreased in ROI 1 (−10.3%), ROI 2 (−9.8%), ROI 4 (−5.3%), ROI 5 (−3.4%) and ROI 7 (−23.1%). ConclusionsThe evaluated short stem prosthesis shows a remarkably high survival rate in elderly patients, accompanied by excellent clinical results. Load transfer measurements show a metaphyseal-diaphyseal pattern with a trend towards increased diaphyseal transfer over the period observed.

What Is the Risk of Dislocation and Revision in Proximal Femoral Replacement with Dual-mobility Articulation After Two-stage Revision for Periprosthetic Hip Infection?

Dislocation is a major complication of revision THA after two-stage exchange for periprosthetic joint infection (PJI). The likelihood of dislocation can be particularly high if megaprosthetic proximal femoral replacement (PFR) has been performed during a second-stage reimplantation. Dual-mobility acetabular components are an established way of reducing the instability risk in revision THA; however, the likelihood of dislocation for dual-mobility reconstructions in the setting of a two-stage PFR has not been studied systematically, although patients with these reconstructions might be at an increased risk. (1) What is the risk of dislocation and revision for dislocation in patients who underwent PFR with a dual-mobility acetabular component as part of two-stage exchange for hip PJI? (2) What is the risk of all-cause implant revision and what other procedures were performed (apart from revision for a dislocation) in these patients? (3) What potential patient-related and procedure-related factors are associated with dislocation? This was a retrospective study from a single academic center including procedures performed between 2010 and 2017. During the study period, 220 patients underwent two-stage revision for chronic hip PJI. Two-stage revision was the approach of choice for chronic infections, and we did not perform single-stage revisions for this indication during the study period. Thirty-three percent (73 of 220) of patients underwent second-stage reconstruction with a single-design, modular, megaprosthetic PFR because of femoral bone loss, using a cemented stem. A cemented dual-mobility cup was the approach of choice for acetabular reconstruction in the presence of a PFR; however, 4% (three of 73) were reconstructed with a bipolar hemiarthroplasty to salvage an infected saddle prosthesis, leaving 70 patients with a dual-mobility acetabular component and a PFR (84% [59 of 70]) or total femoral replacement (16% [11 of 70]). We used two similar designs of an unconstrained cemented dual-mobility cup during the study period. The median (interquartile range) patient age was 73 years (63 to 79 years), and 60% (42 of 70) of patients were women. The mean follow-up period was 50 ± 25 months with a minimum follow-up of 24 months for patients who did not undergo revision surgery or died (during the study period, 10% [seven of 70] died before 2 years). We recorded patient-related and surgery-related details from the electronic patient records and investigated all revision procedures performed until December 2021. Patients who underwent closed reduction for dislocation were included. Radiographic measurements of cup positioning were performed using supine AP radiographs obtained within the first 2 weeks after surgery using an established digital method. We calculated the risk for revision and dislocation using a competing-risk analysis with death as a competing event, providing 95% confidence intervals. Differences in dislocation and revision risks were assessed with Fine and Gray models providing subhazard ratios. All p values were two sided and the p value for significance was set at 0.05. The risk of dislocation (using a competing-risks survivorship estimator) was 17% (95% CI 9% to 32%) at 5 years, and the risk of revision for dislocation was 12% (95% CI 5% to 24%) at 5 years among patients treated with dual-mobility acetabular components as part of a two-stage revision for PJI of the hip. The risk of all-cause implant revision (using a competing-risk estimator, except for dislocation) was 20% (95% CI 12% to 33%) after 5 years. Twenty-three percent (16 of 70) of patients underwent revision surgery for reinfection and 3% (two of 70) of patients underwent stem exchange for a traumatic periprosthetic fracture. No patients underwent revision for aseptic loosening. We found no differences in patient-related and procedure-related factors or acetabular component positioning for patients with dislocation with the numbers available; however, patients with total femoral replacements had a higher likelihood of dislocation (subhazard ratio 3.9 [95% CI 1.1 to 13.3]; p = 0.03) and revision for a dislocation (subhazard ratio 4.4 [95% CI 1 to 18.5]; p = 0.04) than those who received PFR. Although dual-mobility bearings might be an intuitive potential choice to reduce the dislocation risk in revision THA, there is a considerable dislocation risk for PFR after two-stage surgery for PJI, particularly in patients with total femoral replacements. Although the use of an additional constraint might appear tempting, published results vary tremendously, and future studies should compare the performance of tripolar constrained implants to that of unconstrained dual-mobility cups in patients with PFR to reduce the risk of instability. Level III, therapeutic study.

Dislocation rate, revisions and other complications of primary cemented hemiarthroplasty for displaced femoral neck fractures: a single-center cohort study of 743 unselected hips with a mean 2.7-year follow-up.

Evidence of whether to use hemiarthroplasty (HA) or total hip arthroplasty for displaced femoral neck fractures (FNF) is still widely debated, especially when taking ambulatory status, age, and patient cognitive status into account. The current study aims to report the rates of dislocations, revisions and other complications for primary cemented HA in patients with displaced FNF. Single-center retrospective follow-up study of an unselected historic cohort. 743 consecutive hips (551W and 192M) at mean (SD) age of 83.6 (8.4) years received primary cemented HA for displaced FNF by posterolateral surgical approach between January 2012 and December 2019. Patient files and radiographs were evaluated for dislocations, revisions, and other complications until death or end of the follow-up period, and the educational level of the surgeon was noted. During a mean (SD) follow-up period of 2.7 (2.2) years, there were 6.1% (n = 45) dislocations, in which 82% (first dislocation) appeared within the first 30 postoperative days, and 51% (n = 23) of the dislocations requiring subsequent surgery. At the time of the last available follow-up, 57% (n = 421) of the patients were dead. A non-dislocation related revision was needed in 3.4% (n = 25) of the patients [in which infection accounted for 40% (n = 10) and traumatic periprosthetic fracture for 32% (n = 8)]. Thirty-day mortality was 9.2% and 1-year mortality 25.8%. There were no differences in patient's age, gender, or educational level of the surgeon between the dislocation and the no dislocation groups. Patients aged < 70years presented with a higher dislocation rate (p < 0.001) than the patients aged > 70years. Primary HA presents a safe and robust approach with acceptable complication rates in a genuine unselected cohort of displaced FNF, particularly for patients aged > 70.

Intermediate to long term results of stemless metaphyseal reverse shoulder arthroplasty: A five to nine year follow-up

BackgroundShoulder arthroplasty incidence is increasing as is the volume of revision surgeries. Revision surgery is easier if humeral bone stock is preserved with minimal bone defects and osteolysis. This has led to an increased focus on the development of various short stemmed and stemless implants which provides stable fixation whilst preserving humeral bone stock. PurposeTo review the medium to long term clinical and radiological outcomes, complications and survival rates of a stemless reverse shoulder prosthesis. Patients and methodPatients with a minimum follow-up of 60 months following a reverse stemless shoulder arthroplasty were deemed eligible. Clinical and radiological data on twenty-one patients operated between 2009 and 2014 were recorded prospectively. Survivorship and patient recorded symptoms with the end point of revision surgery were recorded. ResultsMean follow-up of 78 months (60–114 months). Mean range of active elevation was 136° (80–170°). Mean range of active abduction and active external rotation was 122° (70–170°) and 47° (10–75°) respectively. Mean Oxford score improved from 12 pre-operatively to 44 at final follow up (p < 0.0001). Mean Constant Murley Score improved from 18 to 72 (p < 0.0001). Mean ADLEIR score of 13 pre-operatively increased to 32 post-operatively (p < 0.0001). Notching was seen in 23.5% of cases and no radiolucent areas were observed around the glenoid component. There were two cases of post traumatic peri-prosthetic fractures that were managed conservatively and one case of deep-seated infection that required a washout. The survivorship at the most recent follow-up was 100%. ConclusionThe advantages of bone preservation with the stemless metaphyseal prosthesis combined with encouraging medium to long term clinical and radiological results are very promising, particularly with the improved post-operative patient satisfaction scores. This is the first study that reports the results with a minimum of 5 year follow-up and has the longest mean follow-up period. Clinical relevanceThe reverse stemless shoulder prosthesis is an effective and reliable option for elective shoulder arthroplasty.

Osteosynthesis and outcomes of traumatic periprosthetic femoral fractures after total hip arthroplasty

PurposeThe aim of this retrospective study was to investigate the treatment of traumatic periprosthetic femoral fractures with open reduction and internal fixation. The outcomes with the use of the surgical techniques were also reported.MethodsBetween September 2017 and September 2019, 25 patients with traumatic periprosthetic femoral fractures were managed by open reduction and internal fixation in Ain Shams University Hospital, Egypt. The fixation methods were selected based on the surgeon’s preference. Outcomes were assessed using the Harris Hip Score, visual analogue score (VAS) for pain, and EuroQol 5 Dimensions – 5 Level (EQ5D-5L) prior to and after surgery. Patients were regularly followed up for one year. A P value < 0.05 was considered to be statistically significant.ResultsThe mean age at surgery was 77 years (range, 51 to 95 years), 64% (n = 16) were females. According to the Vancouver classification, there were 1 type AG, 15 type B1, and 9 type C fractures. Postoperative complications included wound site infection (n = 2) and non-union (n = 1). The mean pre-trauma Harris Hip Score was 77.44 ± 8.63 (range, 65 to 90), and the mean Harris Hip Score collected at the final follow-up was 72.47 ± 8.85 (range, 60 to 86) (P < 0.05). The mean pre-trauma VAS was 2.20 ± 1.21 (range, 0 to 4), and the mean VAS recorded at the final follow-up was 3.00 ± 1.41 (range, 0 to 5) (P < 0.05). According to the EQ5D-DL assessed at the final follow-up, no patient felt that their daily life and activities became more problematic.ConclusionThis study provided added validation of the current management of periprosthetic femoral fractures after total hip arthroplasty. Using the proper fixation and implant can achieve a reliable fixation and good functional recovery.Level of evidenceIVa

Strategies of management of traumatic periprosthetic acetabular fractures around a pre-existing total hip arthroplasty

Introductionand aim: Traumatic peri-prosthetic fractures are relatively rare fractures that pose a significant surgical challenge. They have a fracture pattern that is different from its iatrogenic counterpart. This study aimed at reviewing the modalities of treatment of such injuries, proposing a treatment algorithm and reporting the outcomes of these injuries. Patients and methodsWe propose an algorithm for management of traumatic peri-prosthetic acetabular fractures which depends on fracture displacement, implant stability and associated bone loss.Twelve patients with traumatic peri-prosthetic acetabular fractures were treated between January 2012 and December 2018. All patients were treated surgically. Patients were allowed immediate weight bearing as pain allowed. Assessment was carried out using the Oxford Hip Score (OHS) and the Merle D’aubigné score (MDP). ResultsMean patient age 71 (range: 59–80). 8 patients underwent implant removal, fracture fixation and re-implantation of revision acetabular cup (displaced fracture, unstable implant, adequate bone stock). Three patients required acetabular reconstruction (inadequate bone stock). One patient underwent revision acetabular component. One patient suffered from recurrent dislocation that required surgical intervention. Mean follow up was 27 Months (range 12–48). Mean OHS was 36 (range 10–47). Mean MDP was 12 (range 9–18) with 80% excellent and good results. ConclusionSurgical management of peri-prosthetic acetabular fractures can produce good to excellent results provided adequate assessment and surgical planning have been carried out. Fracture displacement, implant stability and bone stock should be carefully assessed.

Reconstruction survival of segmental megaendoprostheses: a retrospective analysis of 28 patients treated for intercalary bone defects after musculoskeletal tumor resections

IntroductionIntercalary endoprosthetic reconstructions have been reserved for patients with a limited life expectancy due to reports of high rates of early mechanical and reconstruction failure.Materials and methodsIn this study, we retrospectively analyzed 28 patients who underwent intercalary endoprosthetic reconstruction of the femur (n = 17) or tibia (n = 11) regarding reconstruction survival and causes of complications and reconstruction failure.ResultsA total of 56 stems were implanted in this collective, 67.9% of which were implanted using cementation. Eight different stem designs were implanted. The mean patient age at the time of operation was 42.3 years. The mean bone defect needing reconstruction measured 18.5 cm. Resection margins were clear in 96.4% of patients. Of twenty-six complications, five were not implant-associated. We observed infection in 10.7% (n = 3) and traumatic periprosthetic fracture in 3.6% (n = 1) of cases. The most frequent complication was aseptic stem loosening (ASL) (53.8%; n = 14) occurring in eight patients (28.6%). The metaphyseal and meta-diaphyseal regions of femur and tibia were most susceptible to ASL with a rate of 39.1% and 31.3% respectively. No ASLs occurred in epiphyseal or diaphyseal location. Overall reconstruction survival was 43.9% and 64.3% including patients who died of disease with their implant intact. Overall limb survival was 72.7%.ConclusionsProper planning of segmental reconstructions including stem design with regard to unique anatomical and biomechanical properties is mandatory to address the high rates of ASL in metaphyseal and metadiaphyseal stem sites. With continued efforts of improving stem design in these implantation sites and decreasing rates of mechanical failure, indications for segmental megaendoprostheses may also extend to younger patients with the localized disease for their advantages of early weight bearing and a lack of donor-site morbidity.

Periprosthetic fractures of the acetabulum: revision endoprosthetics

Periprosthetic acetabular fractures are an increasing severe complication in revision arthroplasty. A differentiation is made between periprosthetic acetabular fractures (acute/traumatic fractures) and insufficiency fractures (chronic fractures). This article introduces anovel treatment algorithm that provides assistance in therapeutic decision making for implant selection and the anchoring philosophy based on diagnostic decision criteria and the relevant load-bearing osseous structures, taking the defect situation into account. The article provides an overview of original and review articles. The essential criteria for decisions in treatment planning are based on the stability of the primary cup, the load-bearing ability of the main anatomical structures and the resulting defect situation. For insufficiency fractures the reason for the revision and therefore the exclusion of periprosthetic joint infections (PJI) must additionally be considered. In the case of proven PJI a two-stage or multistage prosthesis exchange must be carried out. Based on the extent of apparent bony defects and pelvic discontinuity, the spectrum of treatment options ranges up to implantation of individual patient custom-made acetabular components. This overview introduces anew treatment algorithm that provides assistance in decision making for traumatic periprosthetic acetabular fractures and insufficiency fractures. It also provides decision criteria for selection of implants and the surgical approach. Due to the complexity of revision arthroplasty often requiring specialized expertise in trauma and orthopedic surgery and experienced revision surgeons, the operative treatment of periprosthetic acetabular fractures should only be carried out in specialized orthopedic and trauma surgery centers with appropriate experience.

Traumatic periprosthetic fractures in patients with total hip replacement

The incidence of periprosthetic hip fractures is increasing due to the increase in endoprosthetic hip replacements. These fractures require astaged and individual treatment concept with the aim of mobilization of the patient as early as possible. The special challenge in the diagnostics is to identify pre-existing signs of loosening of the prosthesis. When the prosthesis is still firmly fixed femoral fractures can be treated with angular stable osteosynthesis. Loosened stems usually have to be revised, mostly in combination with osteosynthesis. Fractures around the acetabulum with a fixed cup can be treated nonoperatively or with osteosynthesis, while loosened cups have to be revised. In revision surgery the stabilization of the dorsal column is crucial for a successful outcome.

Frail Patients Benefit From Less Invasive Procedures.

Purpose:A traumatic periprosthetic fracture (PPF) is a long-term complication of total hip arthroplasty. Treatment options include revision, open reposition and internal fixation (ORIF), and minimally invasive techniques (MITs). To select the optimal surgical procedure, the level of frailty has to be considered, especially in patients with geriatric trauma. The aim of this study is to determine whether a frail patient has a better outcome postoperatively after less invasive treatment.Methods and materials:Sixty-three patients with an PPF were analyzed in this retrospective study. The level of frailty was obtained by the complex fracture frailty index (CFFI). The CFFI combines comorbidities, laboratory tests, physical abilities, social factors, and cognitive functions. Primary outcomes in this study include mortality, minor complications, and 3 major complications (deceased, reoperation or immobility after 1 year).Results:Thirty frail patients had lower survival rates (P = .014) and significantly more major complications with a relative risk of 3.7 (P = .02). In the entire group of 63 patients, there were no significant differences detected in the outcome measures; however, when specified in a subgroup of 30 frail patients according to our CFFI, significant differences were found. Patients treated with MIT had significantly less major and minor complications compared to ORIF and revision. Furthermore, patients treated with ORIF experienced significantly less minor complications than with revision surgery (P = .015).Discussion and conclusion:This study shows that frail patients can be adequately detected using our frailty score CFFI and have a lower survival rate, regardless the type of surgery. Another finding is that for frail patients, more invasive surgery has a negative influence on the outcome of the treatment. Therefore, it is of great importance to assess and use the patient’s level of frailty to determine the surgical procedure for a PPF.

Surgical Techniques of Using Direct Anterior Approach and Bridging Plate Fixation of Periprosthetic Fracture of an Arthrodesed Hip: A Case Report: 通過直接前路及橋狀鋼板固定手術治療伴有髖關節融合的近端股骨人工假體周圍骨折:一病例報告

We present a case of a 65-year-old woman with traumatic periprosthetic fracture of left proximal femur with ipsilateral arthrodesed hip and cobra plate in-situ. It imposes challenges on achievement of stable fixation for fracture management and preservation of blood supply for fracture healing. Minimally invasive plate osteosynthesis through direct anterior approach was executed with intraoperative templating. Anterior bridging plating using pre-bent reverse distal femoral locking compression plate (less invasive stabilisation system) was performed successfully. The patient had a fracture union in 10 months and returned to the previous mobility status. This technique can achieve stable fixation and preservation of blood supply for fracture healing through minimal invasive technique.

Traumatic Periprosthetic Acetabular Fracture Treated with One-Stage Exchange and Bone Reconstruction Using a Synthetic Bone Graft Substitute.

A case of a traumatic periprosthetic acetabular fracture in an elderly patient, which was treated by one-stage hip exchange with implantation of an antiprotrusio cage and reconstruction of the acetabular bone loss with an injectable calcium sulphate/hydroxyapatite bone graft substitute, is reported. The paste-like bone graft substitute was injected through the holes of the antiprotrusio cage. After a setting time of 15 minutes, a low-profile cup was cemented onto the cage using polymethylmethacrylate and a new stem was inserted. The patient was encouraged to ambulate three days postoperatively weight-bearing as tolerated. At the one-year follow-up visit the patient was ambulatory and full weight-bearing without any walking aids. The follow-up radiographs demonstrated stable position and articulation of the revision hip arthroplasty with no signs of loosening of the antiprotrusio cage. However, the most interesting finding was that the bone graft substitute had remodelled to a great extent into bone. This calcium sulphate/hydroxyapatite composite shows high osteoconductive potential and can be used to regenerate bone stock in revision arthroplasty.

34-week follow-up of suture anchor fixation for a traumatic patellar fracture overlying a total knee arthroplasty

Traumatic patellar fractures following total knee arthroplasty (TKA), in the absence of patella resurfacing, are uncommon but debilitating injuries. Open reduction and internal fixation is associated with significant complications, thus conservative management is often preferred. We report the first known publication of the fixation of a comminuted periprosthetic patellar fracture using suture anchors, with good results at 34-week postoperative follow-up. The suture anchor technique offers an alternative option in the management of traumatic periprosthetic fractures of the unresurfaced patella, where tension band and cerclage wiring are not possible due to fracture comminution and poor bone quality.

Reverse shoulder arthroplasty with a short metaphyseal humeral stem

Reverse shoulder prostheses have been gaining popularity in recent years. A short metaphyseal stem design will allow bone stock preservation and minimize stem related complications. We examined the clinical and radiographic short-term outcome of a short metaphyseal stem reverse shoulder arthroplasty. Thirty-one patients, with a mean follow-up of 36 months (24-52), were evaluated clinically with the Constant-Murley score, patient satisfaction and pain relief scores. The fixation of the glenoid and humeral components, subsidence and notching were evaluated on radiographs. The indications were cuff tear arthropathy (22), fracture sequelae (five) and rheumatoid arthritis (four). The average Constant score improved from 12.7 (range two to 31) pre-operatively to 56.2 (range 17-86) postoperatively. It rose from 13.5 to 58.3 in patients with Cuff arthropathy, from 15.8 to 62.0 in revision arthroplasty, from 10.2 to 47.4 in those with fracture sequelae, and from 11.5 to 55.3 in patients with rheumatoid arthritis. The overall mean patient satisfaction score improved from 2.4/10 to 8.5/10 and mean pain score improved from 0.8/15 to 12.5/15. We found an overall improvement in active forward flexion from 46.8 to 128.5° and from 41.6 to 116.5° in abduction. No humeral loosening or subsidence was observed. Two cases of grade 1-2 glenoid notching were reported. Overall there were three intra-operative fractures that did not affect the operation and healed without affecting the good results. There were five late traumatic periprosthetic fractures, only one of them required a revision surgery to a stemmed implant and the rest healed without surgery. There were two early dislocations that had to be revised. The clinical and radiographic evaluation of a bone preserving metaphyseal humeral component in reverse shoulder arthroplasty is promising, with good clinical results, no signs of loosening or subsidence.

Periprosthetic fractures in the resurfaced hip—A case report and review of the literature

Traumatic periprosthetic fractures adjacent a hip resurfacing prosthesis are rare. When proximal fractures are encountered the obvious surgical solution is to revise to a large head stemmed femoral component. A previously well functioning implant may however be retained as various non-operative and operative treatment options exist. This paper reports the case history of a traumatic periprosthetic fracture successfully treated with cannulated screw fixation and reviews the current literature.

Reverse oblique intertrochanteric femoral fractures treated with the intramedullary hip screw (IMHS)

Recent studies have recommended the use of cephalo-medullary devices for the treatment of reverse oblique intertrochanteric femoral fractures (Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen, OTA/AO 31-A3). Both the proximal femoral nail (PFN) and the gamma nail (GN) have shown good outcome results but the results of treatment with the intramedullary hip screw (IMHS) have not been reported in the literature. Our aim was to review the outcomes of these unstable fractures treated with the IMHS implant at our institute. Between 1999 and 2008, 6724 consecutive hip fractures were treated at our institute. There were 115 reverse oblique intertrochanteric fractures and 63 of these were treated with the IMHS. We retrospectively reviewed clinical and radiological records for these fractures treated with the IMHS. Follow-up duration ranged from 1 to 6 years. Amongst the 63 patients treated with the IMHS, 57 (90.5%) fractures were reduced satisfactorily with one poorly positioned hip screw and one breach of the anterior femoral cortex. The mean operative time was 115 min, 22 patients required a blood transfusion and 20 had postoperative medical complications. The major orthopaedic complications included two cases of malrotation, three nonunions and one traumatic periprosthetic fracture with a total failure rate of 7.9%. There were four cases of distal locking bolts breaking or backing out. The 30-day mortality was 6.5%. The clinical and radiological outcomes achieved with the IMHS compare favourably to the results achieved with other cephalo-medullary devices. We consider the long IMHS a good implant for the treatment of these unstable fractures.

Proximale knöcherne Integration des zementfreien Vektor-Titanschafts in der Hüftendoprothetik. Mittel- und langfristige Ergebnisse

The objective of this study is to establish the medium-term and long-term clinical and radiological results with the cementless Vektor-Titan stem. Special consideration has been given to evaluate the extent to which the implant design achieves proximal stress transfer, thus avoiding stress shielding in the proximal femur. From October 10, 1996, to May 18, 2000, 432 Vektor-Titan stems were implanted in 348 patients in the Wichernhaus Orthopaedic Clinic at Rummelsberg Hospital. The results were evaluated clinically and radiologically within the scope of a retrospective cohort study. The Vektor stem is a titanium straight stem designed for cementless fixation. It has a high proximal volume in the form of a three-dimensional taper with longitudinal ribs. This design achieves strong primary fixation in the proximal metaphysis. The survival probability of the stem was 99.08 % after a mean time of 7.5 years after surgery. One implant had to be replaced due to a traumatic periprosthetic fracture. Another had to be replaced after 9 months due to septic loosening, and a third after 14 months due to a suspected low-grade infection which, however, was not confirmed intraoperatively. The fourth stem required replacement after 75 months, again due to a periprosthetic fracture. Based on the Merle d'Aubigné score , surgery led to very good clinical results in 254 cases (58.8 %) and to good improvement in 130 cases (30.1 %). In 33 cases (7.6 %) there was a moderate improvement in the score, and in 15 cases (3.5 %) there was no improvement. Bone structure was radiologically normal in 421 cases (97.5 % of all cases). No signs of atrophy were found in the proximal femur and the trochanters. On the contrary, there was evidence of an even denser bone structure at the level of the osteotomy and the lateral implant fixation within the greater trochanter. There the trabeculae were visibly aligned towards the surface of the implant, indicative of direct biological fixation at the bone-implant interface. These findings remained unchanged over long observation periods. There were no changes along the diaphyseal stem. Medium-term and long-term results with the cementless Vektor-Titan stem show a low rate of implant loosening with stable metaphyseal fixation and preservation of bone structure in the proximal femur and the absence of changes along the diaphyseal stem.

Treatment of resistant nonunion of supracondylar fractures femur by megaprosthesis

Resistant nonunion of distal femoral fractures in the elderly is a great challenge to treat because it is often associated with multiple problems like poor bone quality, arthritis, disuse osteopenia, joint contractures, and implant failure. We treated ten patients with megaprosthesis and report the outcome. Ten elderly patients of resistant nonunion of distal femoral fractures with arthritis knee were treated with megaprosthesis. The median patient age was 74 years (68-85 years). All these patients had undergone at least two prior operative procedures and were operated by us, 24-33 months following the first index surgery. Modular Resection System was used in all the patients. Eight patients were available for follow-up. Median follow-up period was 4 years. Two patients required extended local wound care for wound skin necrosis. One patient sustained traumatic periprosthetic subtrochanteric fracture following a subsequent trauma. No thromboembolic complications were seen. All knees showed satisfactory alignment and range of motion. Postoperative, median knee society pain score, and knee society function score were 84 (80-88) and 88 (84-92) at last follow-up. Megaprosthesis can be offered as a one-stage salvage procedure for difficult nonunion in distal femoral fractures associated with bone loss, osteoporosis, and secondary knee arthritis.

Failed internal fixation due to osteonecrosis following traumatic periprosthetic fracture after hip resurfacing arthroplasty

A 55-year-old man had undergone a Birmingham Hip Resurfacing (Cup 56, Head 50; BHR; Smith and Nephew TLC, London, UK) for primary osteoarthritis. The index procedure and postoperative healing were uneventful and radiographs showed well-fixed femoral and acetabular components. 18 weeks after surgery, the patient was involved in a motorcycle accident and fell on the operated hip. An undislocated vertical fracture of the femoral neck was treated surgically to preserve the prosthesis. As the centrally located implant stem might cause difficulty with the placing of typical implants (e.g. screw-plate device or a cephalomedullary nail), 3 parallel cannulated cancellous screws in a triangular configuration (Figure 1A) were used for fixation of the fracture. Care was taken to avoid contact between the implanted stainless steel screws and both the stem and lateral walls of the femoral component. The patient was operated on 14 h after the injury. Figure 1. A. Traumatic periprosthetic femoral neck fracture 18 weeks after the index procedure treated with cannulated cancellous screws. B. Collapse of the femoral neck (short arrow) led to marked dislocation of both the proximal femoral remnant and all 3 screws ... 11 weeks later, the patient presented with hip pain. Radiographs showed 15-mm descent of the femoral component and a dislocation of all 3 screws (Figure 1B). The arthroplasty was converted to a femoral stemmed total hip replacement with extra-large femoral head (cement-free BiCONTACT System, Aesculap AG, Tuttlingen, Germany) (Figure 1C) and retention of the well-fixed acetabular component. Follow-up at 8 months was uneventful. Retrieved femoral remnant tissue with the in situ femoral component and several bone tissue fragments from the neck obtained at revision surgery were immediately fixed in buffered formalin for further analysis. The specimen was cut with the femoral component in situ, by a diamond-coated band saw, into 4 quadrants and analyzed macroscopically and by contact radiography (Faxitron X-Ray LLC, Wheeling, IL). Both the medial and lateral sections of the central slice were completely embedded in plastic after cement dissolution with acetone and removal of the prosthesis. The specimens were processed undecalcified and embedded in methylmethacrylate. From each undecalcified processed plastic block, one 5-μm section was cut with a heavy-duty microtome. The sections were stained by the toluidine blue staining method. Macroscopically (Figure 2A), a well-fixed femoral component with minimal cement mantle and focal superficial cement penetration was found. Contact radiography of the specimen revealed no reaction to the intraosseously located screw (Figure 2B). Figure 2. A. Well-fixed femoral component, narrow superficial zone of cement penetration, and irregular fracture line were apparent macroscopically on the cut plane. B. Absence of vital reaction to the screw was evident by contact radiography several weeks after ... Microscopically, foreign body granulomas and loose fibrosis were apparent at the bone-cement interface (Figure 2C). The remaining bone tissue showed a loss of stainable osteocytes and disorganized intertrabecular bone marrow. More distally, many dead, irregular bone fragments—so-called “bone chips” (Doorn et al. 1996)—without resorptive reaction were found in the vicinity of both the intraosseous screw and the fracture line (Figure 2D). In contrast with the former, multifocal fracture of bone trabeculae associated with the formation of microcallus (Figure 2E) and broad areas of mineralized callus (Figure 2F) were present in the bone fragments removed from the rest of the femoral neck at the revision surgery. We found no fibrocartilaginous tissue, characteristic of pseudoarthrosis.