Interprosthetic femoral fractures treated with locking plate

Purpose

Interprosthetic fractures are challenging to manage. Although treatment of femoral fractures around a single implant has been described, there is little literature for treatment of interprosthetic femoral fractures. This study analyses the management and outcomes of 15 patients with interprosthetic femoral fractures treated with locking plates.

Methods

A retrospective chart review was conducted of 17 patients with interprosthetic femur fracture treated with locking plates from 2002 to 2013. Patient demographics and comorbidities were collected. Preoperatively, patients were classified with the Vancouver or Su classification system. Intraoperative use of bone graft and/or cerclage cables was also examined. Clinical and radiographic outcomes were evaluated for union, time to full weight bearing, return to preinjury level of activity, and pain assessed with visual analog scale (VAS).

Results

There were 15 patients with interprosthetic fractures meeting criteria for this study. Average patient age was 80.53 (range, 61–92) years. Bone grafting was used in 23.5 % (four of 17) and cerclage cables in 29.4 % (five of 17). Patients achieved complete union and return to full weight bearing an average of 4.02 (range, two to six) months later. Average VAS pain score was 1.00 (range, zero to six). All patients returned to their preoperative ambulatory status.

Conclusion

Locking plates could achieve satisfactory results for interprosthetic fractures. Considering an individual’s fracture type, bone quality and protheses to determine the appropriate plate length and optional use of cerclage and/or bone graft was essential. In this limited sample size, interprosthetic fractures occurred at similar rates at the supracondylar region and diaphysis.     

Pedicled vascularized fibular graft with Ilizarov external fixator for reconstructing a large bone defect of the tibia after tumor resection

Background

Large bony defects in the middle or distal third of the tibia resulting from surgical resection of malignant bone tumors present a difficult reconstructive challenge. Various methods of reconstruction are available, such as allografts, vascularized fibular graft (either free or pedicled), or endoprothesis replacement for distal defects.

Materials and methods

Twelve patients—eight males and four females with mean age of 18 years at operation (range 14–25 years)—with malignant bone tumors of the tibial shaft were selected as candidates for wide resection of the tumor and reconstruction of the bony defect by ipsilateral vascularized fibular graft based on the peroneal vessels. Preoperative staging studies, including plain radiography, local MRI, isotopic bone scan, and chest CT, were done for every patient before biopsy. Ilizarov external fixation was then applied in all cases. The average length of the bony gap bridged was 14.5 cm (13–16.5 cm) and the mean length of the harvested graft was 16.3 cm (15–18 cm). The average operation time was 7.5 h (5.5–9.5 h).

Results

The mean follow-up period was 38 months (range 32–52 months). Bony union at the proximal and distal ends of the fibula occurred in nine patients (75 %) and at a mean time of 5.5 months (range 4.5–8 months). Graft hypertrophy occurred in all patients. The mean percentage of hypertrophy was 95 % (range 80–160 %). The mean MSTS functional score was 84 % (range 80–92 %). A leg length discrepancy of 2 cm was reported in two patients and was managed using a shoe lift.

Conclusion

Reconstruction of bony defects of the middle or distal tibia after bone tumor resection using pedicled vascularized fibula is a useful limb salvage procedure. The procedure can be performed relatively quickly and inexpensively and has a low rate of late complications. It leads to a good outcome regarding the union, hypertrophy, and function.     

Effectiveness of exchange nailing and augmentation plating for femoral shaft nonunion after nailing

Purpose

We assessed indications and outcomes of exchange nailing and augmentation plating for femoral shaft nonunion following femoral nail failure.

Methods

We retrospectively reviewed the records of 21 consecutive patients with femoral shaft nonunion treated with femoral nailing from August 2008 to June 2013. Nonunion cases with infection were excluded from this study. The study population consisted of nine men and 12 women, with an average age of 40 (range 21–61) years. All patients received internal fixation using exchange nailing and an augment plate coupled with decortication and bone graft.

Results

All patients in our study obtained osseous union with a mean time of six (range four to12) months. Mean operation time was three hours (range two to five hours), and mean blood loss was 800 ml (range 500–950 ml). There were no postoperative complications. At the last follow-up, all patients could flex their knees > 110°.

Conclusions

Exchange nailing and augment plating coupled with decortication and bone graft is an effective treatment option for femoral shaft nonunion and has more indications and higher union rate than the popular exchange nailing treatment.     

Kniegelenknahe Osteotomietechniken

Background

Bone geometry following osteotomy around the knee suggests that biplanar rather than uniplanar open wedge techniques simultaneously create smaller wedge volumes and larger bone surface areas. However, precise data on the bone surface area and wedge volume resulting from both open and closed wedge high tibial osteotomy (HTO) and distal femoral osteotomy (DFO) techniques remain unknown.

Objectives

It was hypothesized that biplanar rather than uniplanar osteotomy techniques better reflect the ideal geometrical requirements for bone healing, representing a large cancellous bone surface combined with a small wedge volume.

Methods

Tibial and femoral artificial bones were assigned to four different groups of valgisation and varisation osteotomy consisting of open wedge and closed wedge techniques in a uniplanar and biplanar fashion. Bone surface areas of all osteotomy planes were quantified. Wedge volumes were determined using a prism-based algorithm and applying standardized wedge heights of 5 mm, 10 mm and 15 mm.

Results

Both femoral and tibial biplanar osteotomy techniques created larger contact areas and smaller wedge volumes compared to the uniplanar open wedge techniques.

Conclusion

Although this idealized geometrical view of bony geometry excludes all biological factors that might influence bone healing, the current data suggest a general rule for the standard osteotomy techniques applied and all surgical modifications: reducing the amount of slow gap healing and simultaneously increasing the area of faster contact healing may be beneficial for osteotomy healing. Thus, biplanar rather than uniplanar osteotomy should be performed for osteotomy around the knee.     

A Preliminary Comparison Suggests Poor Performance of Carbon Fiber Reinforced Versus Titanium Plates in Distal Femoral Osteotomy

Background

Carbon fiber-reinforced (CFR) polymer implants have theoretical advantages over titanium plates.

Questions/Purposes

The aim of the present study was to assess our early outcomes with CFR plates in lateral opening-wedge distal femoral osteotomy to correct valgus lower limb malalignment. We asked the following: (1) Did the CFR polymer implant change time to union when compared with the titanium implant? (2) Did the incidence of displacement of medial cortical fractures differ between the implants? (3) Did the incidence of complications differ between the two techniques, and did other factors, such as bone graft material used, affect healing?

Methods

A retrospective review of 16 limbs treated with an opening-wedge distal femoral osteotomy for genu valgum using either titanium (n = 10) or CFR plates (n = 6) was performed. Patient and clinical covariates as well as the primary outcome of time to union and secondary outcome of fracture displacement were collected and analyzed.

Results

Those treated with CFR plates had longer times to union than did those in the titanium-treated group (median, 121.5 vs 81.5 days, respectively). The incidence of fracture displacement was higher in the CFR plate-treated group (CFR, n = 5/6; titanium, n = 1/10). Although the CFR plate-treated group had a 33% nonunion incidence while the titanium group had no nonunions, the study lacked the power to show significance. Bone graft material used did not affect outcome. Complication rates were higher in the CFR plate-treated patients.

Conclusion

The CFR plate was associated with a longer time to unite and higher fracture displacement rate than the titanium plate. As this is a retrospective case series, further research is required to confirm these results and clarify best practices in plating of distal femoral osteotomy for deformity correction.

     

Revision total knee arthroplasty: experience with tantalum cones in severe bone loss

Background

Tantalum-made cones have been developed to compensate for large bone defect involving metaphyseal segment or major portion of the condyle or plateau during knee revision prosthetic surgery.

Materials and methods

We present our experience with femoral and tibial tantalum cones in 11 knees (12 cones overall were used, 6 on femur and 6 on tibia) with 2B or 3 Engh defect type during knee revision arthroplasty. Both cemented and cementless cones were used. Patients were submitted to a specific study protocol in order to exclude a new or persistent infection. Only one intra-operative complication not related to the implantation of the trabecular metal cone was observed.

Results

Neither early nor late post-operative re-infection was reported in our series at a mean follow-up of 39.8 months. Radiological analysis showed no cases of aseptic loosening or migration of the components. The only post-operative complication was delayed union of the tibial tuberosity in a patient who required osteotomy for surgical exposure. All patients improved both clinically and functionally.

Conclusions

The results of this study support the use of femoral and tibial porous tantalum metaphyseal cones as a viable option for revision knee arthroplasty with large amount of bone defects in both tibia and femur. We think that the main advantages of tantalum cones compared to structural bone graft lie in faster full weight-bearing recovery and in the cones' potential long-term maintenance of mechanical support. By our results, we can eventually exclude any concern regarding a possible direct correlation of the trabecular metal cones with re-infection.     

Serum albumin enhances bone healing in a nonunion femoral defect model in rats: a computer tomography micromorphometry study

Purpose

Blood-derived proliferative factors such as platelet rich plasma or activated plasma are promising adjuvants for bone grafts. Our earlier studies showed that serum albumin itself can markedly enhance the proliferation of stem cells on bone allograft and postulated that albumin coating alone may improve bone graft integration in vivo.

Methods

Two femoral defect models were performed in adult male Wistar rats. In the critical size model a six millimetre gap was created in the midshaft of the femur and fixed with plate and screws, while a nonunion model was established by the interposition of a spacer in the osteotomy for four weeks which resulted in compromised healing and nonunion. Albumin coated and uncoated grafts were placed into the defects. Bone healing and morphometry were evaluated by μCT and histology four weeks after implantation of the grafts.

Results

In the critical size model none of the bone grafts were able to bridge the defect, and graft resorption was the typical outcome. In the nonunion model regular uncoated grafts had a low union rate (two out of six), which increased markedly when albumin coating was applied (six out of eight). Trabecular thickness and pattern factor improved significantly in the albumin coated group versus uncoated or empty controls.

Conclusions

Our results showed that serum albumin coating of bone grafts can enhance the remodelling and efficacy of treatment in a nonunion model.     

Induced membrane technique for the treatment of congenital pseudarthrosis of the tibia: preliminary results of five cases

Purpose

The purpose of this study was to evaluate the two-stage surgical technique combining induced membrane, spongy autograft and intramedullary fixation for the treatment of congenital pseudarthrosis of the tibia (CPT).

Methods

Three boys and two girls were treated by this technique between 2003 and 2008. All patients had type IV CPT in Crawford’s classification. Four of them had a limited dystrophic form, whereas one case presented an extensive tibia bone dystrophy. The average age of patients at the time of surgery was 23 months (range 10–30 months), with an average follow-up of 5.8 years (range 2.4–8.1 years).

Results

Satisfactory tibial bony union was achieved in all cases at the last follow-up. Bone healing was obtained in the four limited forms after an average term of 4 months. One patient suffered from a non-displaced fracture that healed by casting in a usual period of time. The patient with an extensive dystrophic bone had to undergo a secondary inter-tibiofibular bone graft to finally achieve bone union.

Conclusions

The preliminary results show that this technique is successful in CPT. It may be used even in young children and offers a good alternative to other treatments available, avoiding external fixation and the technical difficulties of microvascular surgery.     

Comparisons of tunnel-graft angle and tunnel length and position between transtibial and transportal techniques in anterior cruciate ligament reconstruction

Purpose

Our aim was to evaluate tunnel-graft angle, tunnel length and position and change in graft length between transtibial (30 patients) and anteromedial (30 patients) portal techniques using 3D knee models after anterior cruciate ligament (ACL) reconstruction.

Methods

The 3D angle between femoral or tibial tunnels and graft at 0° and 90° flexion were compared between groups. We measured tunnel lengths and positions and evaluated the change in graft length from 0° to 90° flexion.

Results

The 3D angle at the femoral tunnel with graft showed a significant difference between groups at 0° flexion (p?=?0.01) but not at 90° flexion (p?=?0.12). The 3D angle of the tibial tunnel showed no significant differences between groups. Femoral tunnel length in the transtibial group was significantly longer than in the transportal group (40.7 vs 34.7 mm,), but tibial tunnel length was not. The relative height of the lateral femoral condyle was significantly lower in the transportal than the transtibial group (24.1 % vs 34.4 %). No significant differences were found between groups in terms of tibial tunnel position. The change in graft length also showed no significant difference between groups.

Conclusion

Even though the transportal technique in ACL reconstruction can place the femoral tunnel in a better anatomical position than the transtibial technique, it has risks of a short femoral tunnel and acute angle at the femoral tunnel. Moreover, there was also no difference in the change of the graft length between groups.     

Three to seven year follow-up of a tapered modular femoral prosthesis in revision total hip arthroplasty

Purpose

Modular femoral prostheses can provide independent distal fixation and intraoperative flexibility and are being used increasingly, especially in patients with proximal femoral bone defects. This retrospective clinical study evaluated whether modular prostheses were effective and reliable implants for femoral revision.

Method

This case series consisted of 58 patients who underwent hip revision with a tapered modular femoral prosthesis at our institution between 2004 and 2008. Mean patient age at surgery was 64 years (range 18–86 years). Femoral bone defects before revision surgery were evaluated using the Paprosky classification. All patients were followed for a minimum of 3 years (mean 4.3 years, range 3–7 years) with clinical and radiographic evaluation. Re-revisions and complications were also recorded.

Results

Two stems required re-revision, one each for recurrent deep infection and periprosthetic fracture. At last follow-up, the Harris Hip Score and Visual Analog Pain Scores had improved significantly, the median radiographic stem migration was 1.6 mm, leg length discrepancy was corrected in 64 % of the patients and osseointegration occurred in 90 %. Complications included intraoperative fracture in 10 (17 %) patients and hip dislocation in 2 (3 %).

Conclusion

Modular femoral components can improve hip function, provide distal fixation, equalize leg length, and result in fewer complications when used to revise failed femoral components.     

Hybrid grafting of post-traumatic bone defects using β-tricalcium phosphate and demineralized bone matrix

Objectives

Management of post-traumatic bone defects continues to be a substantial clinical challenge in orthopaedic trauma. This retrospective study evaluates the results of primary hybrid grafting of residual bone defects or voids, in displaced and comminuted long-bone fractures treated by plate fixation, using β-tricalcium phosphate and demineralized bone matrix.

Materials and Methods

Fifty-four patients having 62 fractures were included. Their mean age was 40.7 ± 10.7 years; femoral and tibial fractures were the commonest (70.9 %) in this study. Eight fractures (12.9 %) were open injuries; 13 fractures had critical-sized defects that averaged 3.4 ± 0.9 cm. Cortical bone defects occurred in 51 cases, and cancellous bone voids in eleven. Eleven patients (20 %) were polytraumatized. Tobramycin powder was added to the graft in all open fractures. The functional outcome was evaluated according to a modified Karlström and Olerud criteria.

Results

All fractures (100 %) had solid union without any implant failure. There was a significant delayed union (P < 0.001) in all critical-sized defects. The mean healing time showed a highly significant difference (P < 0.001) between closed and open fractures. The functional outcome was excellent in 28 fractures, good in 21 fractures, fair in nine fractures and poor in four fractures.

Conclusions

We believe that the ideal bone graft substitute for all situations does not exist; however, this hybrid grafting is a very good alternative to autogenous grafts especially in polytraumatized patients and when massive bone grafting is needed to reconstruct more than one bone in absence of segmental defects.     

Role of muscle pedicle bone graft as an adjunct to open reduction and internal fixation in the management of neglected and ununited femoral neck fracture in young adults: a prospective study of 17 cases

Aim

To evaluate the role of quadratus femoris muscle pedicle bone grafting along with open reduction and internal fixation in the treatment of neglected and ununited femoral neck fractures in young adults.

Materials and methods

Young adults within the age group of 15–45 years with ununited, old neglected fractures of femoral neck were included in the study. All patients underwent quadratus femoris muscle pedicle bone grafting along with open reduction and internal fixation. The post-operative complications and functional recovery was assessed using Charnley’s modification of Merle D’Aubigne and Postel hip scoring.

Results

A total of 17 patients were included in the study. The average time of union following the procedure was found to be approximately 8 months. There were two cases of delayed union and no cases of avascular necrosis. Ten patients (58.8 %) had excellent or very good post-operative functional results and 6 patients (35.3 %) had good or satisfactory results.

Conclusion

Muscle pedicle bone grafting is a useful adjunct to open reduction and internal fixation for ununited femoral neck fractures. It achieves good final functional results comparable with other methods, but requires greater expertise.     

Total hip arthroplasty with step-cut subtrochanteric femoral shortening osteotomy in high riding hip dislocated patients with previous femoral osteotomy

Background

To evaluate the long-term clinical and radiological outcomes of cementless total hip arthroplasty (THA) in high riding hip dislocated patients with previous proximal femoral osteotomy.

Lesser trochanteric osteotomy in total hip arthroplasty for treating CROWE type IV developmental dysplasia of hip

Purpose

The study was designed to evaluate the efficacy and safety of lesser trochanteric osteotomy for femoral shortening in total hip arthroplasty in treatment of 28 cases of CROWE IV developmental dysplasia of the hip (DDH).

Methods

Patients underwent progressive femoral shortening at the level of lesser trochanteric to make reduction possible into the anatomical acetabulum in all hips. The results were collected and evaluated clinically and radiographically.

Results

The mean follow-up period was 55.3 months. The average postoperative leg length discrepancy was eight millimetres for unilateral THA patients. A modified Merle d’Aubigné scale was improved from 9.3 preoperatively to 15.9 postoperatively. Sciatic nerve palsy was confirmed in two hips which resolved completely in six months. The Trendelenburg sign was positive in two hips at the final follow-up. No revision surgery was required by the final follow-up.

Conclusion

Lesser trochanteric osteotomy proved to be safe and effective in femoral shortening for treatment of CROWE IV DDH without the problem of nonunion at the site of osteotomy.     

Risk factors and complications in hip reconstruction for nonambulatory patients with cerebral palsy

Background

Hip dysplasia is prevalent in nonambulatory children with cerebral palsy, and may contribute to a decreased quality of life (Lonstein in J Pediatr Orthop 6:521–526, 1). Reconstructive procedures such as a femoral varus derotation osteotomy with or without a pelvic osteotomy are commonly employed with the goal of achieving and maintaining well reduced hips.

Purposes

The goals of this study are both to characterize the complications of reconstructive procedures and to identify risk factors that may contribute to these complications.

Patients and methods

A retrospective analysis was conducted among 61 nonambulatory children (93 hips) with cerebral palsy who underwent a femoral varus derotation osteotomy, with or without an open reduction and/or pelvic osteotomy, from 1992 through 2008 at our institution. The average patient age was 8.1 years (2.6–14.7) and the mean follow-up time was 5.9 years (2.1–15.9).

Results

The cumulative complication rate per patient including failures to cure was 47.6 %. Spica casting was found to be a risk factor for all complications (P = 0.023); whereas patients younger than 6 years old (P = 0.013) and children with a tracheostomy (P = 0.004) were found to be risk factors for resubluxation following surgery.

Conclusions

Although reported complication rates of hip reconstructive procedures performed upon children with cerebral palsy have varied considerably, those with more severe disease have experienced more complications. We report our tertiary referral center’s complication rate and our institutional experiences with risk factors for complications and failures to cure.

Level of evidence

IV, Retrospective case series.     

Double locking plate fixation for femoral shaft nonunion

Introduction

Nonunions after operative fixation of the femur, although infrequent, remain a challenge for orthopedic surgeons. The aim of this study was to assess the effectiveness of double locking plate fixation in the treatment for femoral shaft nonunions.

Materials and methods

From 2009 to 2013, 21 patients with femoral nonunions (mean age 46.9 years, range 25–81) were treated and evaluated utilizing double locking plate fixation. Patients were followed for at least 6 months postoperatively or until they achieved complete union to investigate bone healing and functional outcomes in femoral shaft nonunions treated with double locking plate and autogenous cancellous bone graft.

Results

The main outcomes evaluated were the presence of bony union, time to achieve union, and SF-36 score. All 21 femoral nonunions healed (100 % union rate). The average time to bony union was 5.3 months (range, 4–7). The mean follow-up duration time was 24.8 months (range, 6–60). Average scores of the physical function and bodily pain components of the SF-36 were 96 (range, 90–99) and 94.2 (range, 92–99), respectively. No significant complications were noted postoperatively.

Conclusion

Because of the high union rates and lack of significant complications in our series, double locking plate fixation can serve as an effective method of addressing femoral shaft nonunions. No significant complications were found postoperatively.

     

Locked plating for femoral fractures in polio patients

Background

Femoral fractures in polio survivors present unique challenges; the bone is often small, deformed, osteoporotic and hypovascularized. Locked compression plating aided in achieving a better construct stability of osteoporotic fractures.

Methods

A total of 13 unilateral femoral fractures in adult polio patients were fixed with locked compression plating in a prospective study. Mean age was 49.8 years (range 34–62). In 6 cases, the small size of the bone matched only narrow plates, and in 6 cases the plate was contoured to fit the cortex. Average follow-up period was 18.4 months (range 12–24).

Results

Radiological evidence of union was apparent in 12 cases after 12–20 weeks (mean 16.3). One case was considered ununited after 28 weeks and progressed to union with bone grafting after another 12 weeks. At the end of the follow-up period, 12 patients returned to their prefracture Vignos disability scale, only the case that experienced nonunion showed functional deterioration.

Conclusion

The locked compression plate withstood fixing femoral fractures in polio patients, addressing the challenges of a smaller, osteoporotic, less vascularized and sometimes deformed femur.