Use of Locking Plate and Strut Onlay Allografts for Periprosthetic Fracture Around Well-Fixed Femoral Components

Background

The purpose of this study was to determine: validated clinical and radiographic outcomes of periprosthetic femoral fractures around stable hip implants treated with plate fixation and additional cortical strut onlay allografts without revision of the stem; radiographic signs of fracture healing; allograft-to-host bone union; resorption of cortical strut allograft; and frequency of complications.

Cortical strut allografts in salvage revision arthroplasty: Surgical technique and clinical outcomes

BackgroundThe aim of this study was to present our clinical outcomes and surgical technique in strut allografts preparation using staggered holes to enhance osteointegration and demineralised bone matrix (DBM) as an adjunct to cortical strut allografts in salvage revision arthroplasty patients.MethodsRetrospective consecutive series of patients who required strut allograft femoral reconstructions with minimum 2 years follow up between 2012 and 2018. Frozen washed irradiated, cortical struts were used and prepared adding 2 mm staggered drill holes along the length of the strut and applying DBM paste on the graft-host interface. Outcome measures included radiographic strut union, graft resorption, infection and complications.Results15 patients included; 3 males and 12 females with median age 72 years (range 60–93). All had significant bony defects (Paprosky III/IV in 12 cases including 3 cases of periprosthetic hip fractures and further 3 cases of periprosthetic knee fractures around revision hinged implants). At final follow up, median 3.8 years (range 2.7–7.2), 14/15 (93.3%) struts had united at a median 6 months (range 5–8), complete incorporation with cortical round-off was seen at median 12 months (range 8–48) in 12/15 (80%) struts, 2/15 (13.3%) show radiographic evidence of proximal minimal graft resorptions although the remainder of the strut had integrated and were asymptomatic. There were no cases of infection.ConclusionsUse of strut allografts helps to reconstruct bone defects, restore bone stock, and provide stable fixation for complex patterns of periprosthetic fractures around hip/knee implants and salvage revision cases with 93.3% union rate at median 6 months.     

Fixation of Vancouver B1 peri-prosthetic fractures by broad metal plates without the application of strut allografts

The use of allograft struts and cerclage wire, possibly augmented by plate fixation, for the treatment of Vancouver type-B1 peri-prosthetic fractures around a total hip replacement has been strongly advocated. We examined our results using plate fixation without allograft struts and compared them with the results of the use of struts alone or when combined with plate fixation. Of 20 consecutive patients with type-B1 fractures treated by open reduction and plate fixation, 19 were available for follow-up. The fractures healed in 18 patients with a mean time to weight-bearing of ten weeks (4 to 19). There were no cases of infection or malunion. Nonunion occurred in one patient and required a second plate fixation to achieve union. Safe, cost-effective treatment of Vancouver type-B1 fractures can be performed by plate fixation without the addition of cortical struts. This procedure may allow earlier weight-bearing than allograft strut fixation alone.     

Endosteal substitution with an allograft cortical strut in the treatment of a periprosthetic femur fracture: a case report

The use of allograft cortical struts in the treatment of periprosthetic fractures of the femur has been well described. Allograft struts are used to supplement cerclage wire fixation or may be placed outside the cortex opposite plate and screw fixation to improve screw fixation in osteoporotic bone. This generally requires extensive soft tissue stripping and may lead to delayed bony union. A technique is described wherein an allograft strut was inserted into the medullary canal through the fracture site and used as an endosteal substitution for osteoporotic cortical bone. This technique can improve screw fixation in osteoporotic bone while avoiding devascularization of the fractured femur.     

Periprosthetic fractures with extensive bone loss treated with onlay strut allografts

We reviewed a consecutive series of 19 patients with comminuted periprosthetic fractures, loosening of the femoral stem (Vancouver type B3) and significant loss of bone stock (Paprosky type III and IV). Sixteen porous-coated long stems and three Exeter stems, all with impaction grafting, were used. Large femoral onlay strut allografts were applied to maintain fracture reduction and improve stability. There was one early re-fracture at the tip of the femoral stem. Eighteen fractures healed without deformity and shortening. At the last follow-up at mean 3.7 (2.0-7.5) years, the mean Harris hip score was 76.4 (57.5-92.0). There was ingrowth of all strut grafts and significant augmentation of periprosthetic bone.     

Locking compression plate fixation of Vancouver type-B1 periprosthetic femoral fractures

BACKGROUND: Fractures occurring at or near the distal tip of a hip prosthesis with a stable femoral stem (Vancouver type-B fractures) are associated with many complications because of the inherently unstable fracture pattern. Locking compression plates use screws that lock into the plate allowing multiple points of unicortical fixation. Such unicortical fixation may lower the risk of damage to the cement mantle or a stable femoral stem during the treatment of a periprosthetic femoral fracture. The purpose of this study was to analyze clinically and radiographically a group of patients with a Vancouver type-B1 periprosthetic femoral fracture treated with open reduction and internal fixation with use of a locking compression plate. METHODS: Fourteen consecutive patients (fourteen hips) with a Vancouver type-B1 periprosthetic femoral fracture were treated with a locking compression plate. There were five men and nine women with an average age of sixty-eight years at the time of fracture. All of the fractures occurred after a total hip arthroplasty performed with cement, and eleven of the arthroplasties were revisions. In addition to the plate, cortical strut allografts were used to stabilize five fractures. The patients were assessed clinically and radiographically. RESULTS: The average duration of follow-up was twenty months. Eight fractures healed uneventfully at an average of 5.4 months. Three treatment constructs failed with fracture of the plate within twelve months after surgery. An additional three constructs also failed because of plate pullout. All failures except one occurred in constructs in which a cortical strut allograft had not been utilized. CONCLUSIONS: On the basis of the high failure rate in this series of patients, locking compression plates do not appear to offer advantages over other types of plates in the treatment of type-B1 periprosthetic femoral fractures. Despite the potential to preserve the cement mantle, the locked screws did not appear to offer good pullout resistance in this fracture type. We believe that supplementation with strut allografts should be used routinely if this type of locking compression plate is selected to treat these fractures.     

Reinforcement of deficient femur with inlay strut grafts in revision hip arthroplasty: a small series

Failure of the femoral component due to severe loss of femoral bone is an important long-term complication of total hip arthroplasty. We treated four patients with a type IV femoral defect (Paprosky classification) because of aseptic and septic loosening. To enhance bone stock and create a stable prosthetic reconstruction we used femoral allografts as inlay strut grafts alone or combined with onlay strut grafts and impaction grafting. At a mean follow-up of 11 years all four patients presented good or excellent results with Harris Hip Score between 86 and 95 points. Radiologically, no migration of the stems were found and the struts showed signs of incorporation. Inlay strut grafts are a reliable method for bone reconstruction of deficient femoral bone stock in failed total hip replacement.     

Vancouver B1型股骨假体周围骨折的手术治疗

目的探讨Vancouver B1型股骨假体周围骨折的理想手术治疗方式。方法2000年3月至2008年1月,12例VancouverB1型股骨假体周围骨折患者行切开复位、内固定治疗。男2例,女10例;年龄62—85岁,平均72岁。内固定方式包括LISS锁定接骨板系统、加压接骨板系统,部分病例结合使用多道钢丝或钢缆捆扎固定,及异体柱状皮质骨和（或）DBM人工骨植骨。对术后骨折延迟愈合患者行自体骨髓灌注等治疗。结果患者均获得随访,随访时间12—96个月,平均32个月。除1例术后发生骨折移位失败外,骨折均愈合,愈合时间3～12个月,平均4．3个月。Harris评分：65—92分,平均79分。结论VancouverB1型股骨假体周围骨折发生率高,处理棘手。目前,LISS系统是治疗此类骨折最有效的方式之一,应尽量使用微创技术以减少骨折处的血供破坏,如需切开整复骨折,应常规植骨,必要时术后可于骨折处定期灌注自体骨髓以促进骨愈合。     

Supracondylar fractures of the femur above total knee arthroplasties with cortical allograft struts

Ten supracondylar fractures of the femur above a total knee arthroplasty were treated with open reduction and internal fixation using a metal plate and cortical allograft struts. Failure with nonunion of previous operative treatments was seen in 5 patients. The other 5 patients had either severe osteopenia or comminution of the fracture above the knee prosthesis. At an average of 38 months' follow-up, all the fractures healed with an average union time of 17.6 weeks. The postoperative knee alignment averaged 5.1 degrees valgus. Infection occurred in 1 patient, which resulted in a poor outcome. The remaining 9 patients were functioning well at the most recent follow-up examination. The use of cortical allograft struts combined with a compression plate provided satisfactory results for supracondylar fractures above knee prostheses with severe osteopenia or loss of bone stock after initial failure of internal fixation.     

Strut allografts for failed treatment of periprosthetic femoral fractures: Good outcome in 13 patients

Strut allografts are not recommended after a femoral shaft exposure, because they may endanger the femoral blood supply. Up till now, we have seen no clinical reports on this problem. We treated 13 consecutive patients with very large anteromedial and anterolateral femoral strut allografts to restabilize periprosthetic fractures which had become loose after a previous attempt at surgical fixation (Vancouver type B fractures with severe bone loss). In 8 cases, the stem was revised in conjunction with the use of strut allografts and in 5 cases, strut allografts alone were used. All refractures and nonunions healed without further treatment. At a mean follow-up of 3 (1.2-7) years, the mean Harris Hip Score was 78 (65-92). All strut grafts showed ingrowth with augmentation of periprosthetic bone on the radiographs. There were 3 complications, 1 nonprogressive subsidence of a revision stem (fibrous stable), 1 deep hematoma and 1 partial lesion of the sciatic nerve. In this series, strut grafts gave reliable healing with augmentation of the host bone stock despite previous femoral exposure, severe bone loss, adverse type of fracture, and persistent instability at the index operation.     

Strut allografts for failed treatment of periprosthetic femoral fractures: good outcome in 13 patients

Strut allografts are not recommended after a femoral shaft exposure, because they may endanger the femoral blood supply. Up till now, we have seen no clinical reports on this problem. We treated 13 consecutive patients with very large anteromedial and anterolateral femoral strut allografts to restabilize periprosthetic fractures which had become loose after a previous attempt at surgical fixation (Vancouver type B fractures with severe bone loss). In 8 cases, the stem was revised in conjunction with the use of strut allografts and in 5 cases, strut allografts alone were used. All refractures and nonunions healed without further treatment. At a mean follow-up of 3 (1.2-7) years, the mean Harris Hip Score was 78 (65-92). All strut grafts showed ingrowth with augmentation of periprosthetic bone on the radiographs. There were 3 complications, 1 nonprogressive subsidence of a revision stem (fibrous stable), 1 deep hematoma and 1 partial lesion of the sciatic nerve. In this series, strut grafts gave reliable healing with augmentation of the host bone stock despite previous femoral exposure, severe bone loss, adverse type of fracture, and persistent instability at the index operation.     

Cortical strut allografts for the treatment of femoral fractures and deficiencies in revision total hip arthroplasty

Thirty-three hips had revision total hip arthroplasty, using an average of three cortical strut allografts fixed to the femur with cables and followed-up for a mean of 4 years. The indications for strut allografts were ectatic femurs or segmental defects of the femoral diaphysis (22 hips), femoral fractures (10 hips), and severe proximal femoral osteolysis (1 hip). Twenty-one hips had an excellent or good clinical result, 6 had a fair clinical result, and 6 had a poor clinical result. Reoperation was done in six hips, but in only two hips was reoperation related to failure of the allograft. Nine of the 10 femoral fractures repaired with allograft struts healed by 3 to 6 months. Radiographs showed partial or complete bridging of the allograft to host bone with peripheral remodeling and minimal resorption in 30 of 33 hips. Strut allografts, fixed with multiple cables, are an important adjunct to femoral component revision for the restoration of deficient femoral bone stock and in the treatment of periprosthetic femur fractures.     

Revision total hip replacement using a cementless interlocking distal femoral stem with allograft-cemented composite and the application of intramedullary and onlay cortical strut allografts: two case reports

It is often difficult to perform repeated revision total hip replacement (re-THR) after prosthesis loosening stemming from infection, mechanical loosening, and osteolysis. Reasons for this include the size of the bone defect and poor quality of the remaining bone. We have previously performed revision surgery using a cementless interlocking distal femoral stem with segmental cortical allograft-cemented composite for reconstruction in the presence of circumferential bone loss of the proximal femur according to Gustilo classification type IV [1]. However, in the case where the distal femur had a stovepipe canal due to osteoporosis, osteolysis, and infection, it was difficult to achieve stable fixation to the distal femoral cortical bone using a cementless interlocking distal femoral stem. Therefore, a cortical strut allograft is inserted into the femoral bone canal on the medial side, followed by the insertion of an interlocking stem. A further cortical strut allograft is inserted on the lateral side of the distal femur. In addition, the distal onlay allograft should pass over the allograft–host bone junction. The two allografts are finally secured with interlocking screws. The bone allografting to augment femoral bone deficiency was performed using mainly cadaveric bone allografts obtained from our bone bank [2, 3]. In this report, we describe two cases of re-THR involving the use of intramedullary and onlay cortical strut allografts with a cementless interlocking distal femoral long stem to achieve favorable fixation stability. The two patients were asked if the data from the case could be submitted for publication, and both gave their consent     

全髋关节置换术后股骨假体周围Vancouver B型骨折治疗的随访研究

目的 探讨全髋关节置换术后股骨假体周围Vancouver B型骨折治疗方法的选择,总结同种异体皮质骨板移植重建股骨假体周围骨折的临床效果.方法 22例全髋关节置换术后股骨假体周围骨折患者,男7例,女15例;年龄平均65岁(53～75岁).Vancouver分类B1型5例,B2型4例,B3型13例.B1型骨折采用异体皮质骨板移植加钢丝环扎治疗;B2型骨折选择加长股骨柄翻修;B3型骨折选择骨水泥柄翻修,加同种异体皮质骨板移植和钢丝环扎同定.所有患者均获得随访,随访时间平均67个月(37～95个月).采用Harris髋关节功能评分、X线片、外周血T淋巴细胞亚群、抗体免疫复合物检测 和核素骨显像对治疗结果进行评价.结果 22例患者骨折全部愈合,21例患者能自由行走,1例需要助 行器帮助.末次随访Harris评分平均89分(79～93分).患者未发生免疫排斥反应;术后3个月,骨折愈合,术后12个月,移植骨板与宿主骨骨性愈合,股骨皮质厚度增加3～5mm;核素骨显像骨板移植区放射性核素分布较对侧浓集.3例患者移植骨板出现部分吸收现象.术后2年.骨板与宿主骨融合,移植骨板吸收停止.结论 针对股骨假体周围骨折不同类型分别采取不同方法治疗能够取得较好疗效,同种异体皮质骨板移植在维持骨折稳定性、促进骨折愈合、增加局部骨量和改善骨强度方面有较好疗效.     

钢板加异体骨板治疗股骨干钢板内固定术后骨不连

目的探讨钢板加异体骨板治疗股骨干钢板内固定术后骨不连的临床疗效。方法对19例股骨干骨折钢板内固定术后骨不连患者采用钢板加对侧异体骨板夹心法手术治疗,术后1年采用Merchan标准评定膝关节功能。结果患者切口均一期愈合,无脂肪栓塞、感染、排异等反应。19例均获得随访,时间14~44个月。患者术后均达到骨性愈合,时间为4~9个月。无内固定失败、畸形愈合和不愈合等发生。术后1年膝关节功能按Merchan标准评定:优11例,良6例,可2例。结论钢板加对侧异体骨板是治疗股骨干骨折钢板内固定术后骨不连的有效方法。     

Superior outcome of strut allograft-augmented plate fixation for the treatment of periprosthetic fractures around a stable femoral stem

Purpose

This study was designed to compare the outcome of two surgical approaches for treating femoral periprosthetic fractures around a stable femoral stem. The hypothesis was that plate fixation alone might be associated with a higher complication rate due to insufficient mechanical stability. We also considered that the addition of a strut allograft would contribute to fracture healing by means of osteoconduction.

Methods

We retrospectively assessed the outcome of 21 patients who sustained periprosthetic fractures around a total hip replacement system (Vancouver type B1 and type C fractures) and who were treated in our department (January 2006 and August 2011) either by plate fixation alone or by plate fixation and a strut allograft. The mean postoperative follow-up was 23 months (range 9–69 months). Eleven patients were treated by plate fixation alone (Plate Group), and 10 patients were treated by plate fixation and a deep frozen cortical strut allograft (AG Group). Functional outcome was rated by the Harris Hip scoring system. Postoperative radiographs were assessed for evidence of fracture union. Surgical failure was defined as any complication requiring surgical revision.

Results

The 21 patients included 17 females and 4 males. The average age was 79 years (range, 73–88) for the Plate Group and 82 years (range, 53–94) for the AG Group, and the average time to fracture union was 12 weeks (range, 2.5–6 months) and 12.95 weeks (range, 1.5–3) respectively. The overall failure rate was significantly higher in the Plate Group: 5 of them required revision surgery compared to none in the AG Group (p = 0.014).

Conclusion

The results of this analysis indicate that a strut allograft augmentation approach to Vancouver type B1 and type C periprosthetic fractures results in a better outcome than plate fixation alone by apparently adding mechanical stability and enhancing the biological healing process.     

Structural bone grafting for femoral reconstruction

Structural grafting for femoral reconstruction has been used in femoral revision surgery in connection with partial bone loss. In patients in whom the proximal femur is compromised significantly circumferentially, or is entirely absent, segmental proximal femoral allografts are indicated. Onlay cortical allografts have been used to supplement bone stock when the intact femur has advanced noncircumferential deficiencies attributable to osteoporosis, osteolysis, or other causes. The procedure using proximal femoral allografts was performed in 262 patients from 1983 to 1997. Satisfactory results were obtained in 85% of the patients. More than 1000 cortical onlay bone plate allografts were performed from 1984 to 1997. Detailed information was obtained on 251 patients who underwent surgery from 1984 to 1990. These constructs reliably united with the host bone and increased bone mass long-term.     

Cortical onlay strut allograft with cerclage wiring of periprosthetic fractures of the humerus without stem loosening: technique and preliminary results

The goal of this study was to describe an internal fixation technique for periprosthetic humeral fractures using a cortical onlay strut allograft stabilized with cerclage wires and to evaluate the preliminary results of this approach. An anterolateral approach was used to direct access the fracture and to protect the radial nerve. The fracture was reduced with two forceps, under visual control. The fracture was surrounded by two hemicylinder tibial allografts, placed around the humerus with no prior reaming to create a “sarcophagus” system. The allograft was as long as possible for optimal mechanical stability, without creating impingement with the glenoid and the elbow. Final fixation of the allograft was obtained with two cerclage wires. The arm was immobilized in a simple sling. Passive then active rehabilitation was begun after 1 month. Six women, mean age 74.3 ± 10.9 years old, were included in the study between 2013 and 2015 with a mean follow-up of 10 ± 2 months. Bone union was obtained in all patients after 6 months of follow-up with no recurrent fractures.     

全髋关节置换术后股骨假体周围骨折的治疗

目的：分析全髋关节置换术后股骨假体周围骨折的病因和治疗结果．探讨其治疗方法。方法：回顾性研究自1998年12月-2003年3月治疗并随访观察的11例全髋关节置换术后股骨假体周围骨折患者，男8例，女3例，平均年龄为56岁(43-75岁)，采用Vancouver分型，A型2例，B2型7例．B3型1例，C型1例。采用非手术治疗5例；手术治疗6例，其中1例为非手术治疗后骨折畸形愈合行翻修术。采用长柄假体翻修联合异体皮质骨板固定5例．其中使用非骨水泥型远端固定假体4例．使用骨水泥型假体1例。采用切开复位内固定治疗1例。结果：所有病例均获随访，平均随访25．6个月(7～50个月)。9例骨折愈合，平均愈合时间4个月(3-6个月)，2例骨折未愈合。均为非手术治疗病例，手术治疗6例骨折均愈合。至目前为止，7例假体稳定，1例翻修术后出现连续的影像学透亮线．3例假体松动，假体稳定的患者功能好于假体松动者．假体稳定患者的Harris评分平均91分。所有异体皮质骨板在1年内均与宿主骨整台．没有异体皮质骨板骨折发生。结论：假体稳定的A型骨折可以采用非手术治疗。对于B1型和C型骨折，如无手术禁忌证，应行切开复位内固定术。对于假体松动的骨折患者，使用长柄远端固定非骨水混型假体联合异体皮质骨板是最佳的治疗方法。     

Role of locking plates in treatment of difficult ununited fractures: a clinical study

Objective:To present our experience in treatment of difficult ununited long bone fractures with locking plate.Methods:Retrospective evaluation of locking plate fixation in 10 difficult nonunions of lon...