Validation of a new classification system for interprosthetic femoral fractures

Interprosthetic femoral fracture (IFF) incidence is gradually increasing as the population is progressively ageing. However, treatment remains challenging due to several contributing factors, such as poor bone quality, patient comorbidities, small interprosthetic fragment, and prostheses instability. An effective and specific classification system is essential to optimize treatment management, therefore diminishing complication rates. This study aims to validate a previously described classification system for interprosthetic femoral fractures.     

Clinical outcome of interprosthetic femoral fractures treated with polyaxial locking plates

IntroductionTotal hip arthroplasty (THA) and total knee arthroplasty (TKA) are common procedures in the increasing older population. According to the AAOS, approximately 19,200 Americans are actually living with ipsilateral prosthetic hip and knee leading to 240 interprosthetic fractures annually. Few reviews and case reports give an idea of the obvious problem to achieve consolidation in interprosthetic fractures. Preconfigured plates have been shown to be superior compared with other treatments in patients with stable components. Utilization of internal fixators for interprosthetic fractures might be advantageous.The purpose of this study was to evaluate interprosthetic femoral fractures with polyaxial locking plate treatment in regard to surgical procedure, complications, and clinical outcome.MethodsBetween 2005 and 2012, 143 patients underwent surgical treatment for periprosthetic femur fractures. Thirty-two fractures were identified as interprosthetic fractures. Five patients were excluded. Fractures were classified according to OTA/AO system, Vancouver, Rorabeck, Soenen and Pires. Trauma fellowship trained orthopaedic surgeons performed the surgeries using a NCB-construct (Zimmer Inc., Warshaw, IN). Plate choice was determined according to radiographic classification. Submuscular plate insertion was performed if possible. Complications were recorded concerning infection, union, fixation failure, and revision surgery.ResultsTwenty-seven patients were identified. There were 92.6% females. Follow-up by regular outpatient clinic visits was 24 months. Surface replacements were found in 18 TKA. Nine patients had a stemmed femur component of their TKA. 89% healed after the index procedure. Three patients developed a nonunion with 1 construct leading to hardware failure. Previous revision THA or Pires/modified Vancouver classification did not influence nonunion formation, but all patients with nonunion formation were classified as AO/OTA type B (p = 0.001). These fractures were treated with longer plates (p = 0.015), but with similar working length (p = 0.400). Plate design, additional cerclages, or submuscular insertion did not influence nonunion formation.ConclusionInterprosthetic fracture treatment remains challenging. NCB-locked plating can achieve satisfactory results. Additional soft tissue damage can be prevented by submuscular plate insertion. Treatment of type B fractures resulted in significantly greater nonunion rate. Therefore, consideration of the individual fracture type is essential to determine plate length, plate type, and additional bone grafting or BMP supplementation.     

Stress fractures of the femoral neck following total knee arthroplasty

The author reviews the literature concerning stress fractures of the femoral neck following total knee arthroplasty and presents two additional cases. These fractures are rare and are frequently missed initially. Awareness of the condition may help to make early diagnosis.     

Outcome of proximal femoral fractures caused by cycling in the young and mid-aged

Background

Cycling is gaining more popularity both as a sport, on and off-road and also as a means of commute. Cycling accidents harbour significant injury risks including fractures. Proximal femoral fractures are uncommonly associated with cycling in the young adult population. The purpose of this study is to describe this unique pattern of injury as well as the outcome of proximal femoral fractures caused by cycling in the young to mid age population.

Methods

Study design: retrospective cohort study. 23 fractures in 22 patients were available for analysis. 11 were femoral neck fractures, with six displaced ones, and the rest trochanteric fractures. 21 patients were male patients, and the average age was 42 (range 27–60). All patients but two were operated within 24 h from admission. Radiographic analysis included reduction quality, fracture classification and arthritic changes. Clinical outcome was measured using SF-12 and Oxford hip scores.

Results

All fractures healed. Two patients with displaced femoral neck fractures developed avascular necrosis requiring arthroplasty. One patient developed an AVN 2 years after a stable trochanteric fracture but did not require an arthroplasty as of yet. Eight patients required hardware removal due to symptoms. 77% of patients had resumed cycling at the pre-injury level. Mean SF-12 score was 47.1 ± 11.7 for the physical component and 53.7 ± 6.3 for the mental component. Mean oxford hip score as was 40.1 ± 12.2. Radiographic analysis revealed good to acceptable reduction quality. Fracture type, age, cycling type and reduction were not significantly associated with outcome.

Conclusion

Proximal femoral fractures caused by cycling in young to mid-aged adults are an emerging pattern of injury. Overall favourable result can be expected in the majority of cases, with displaced femoral neck fractures having a risk for AVN. Further delineation of the exact cause for this phenomenon is required with possible intervention for injury prevention.     

Bilateral femoral neck stress fractures following total knee arthroplasty: a case report and review of literature

Stress fracture of the femoral neck following total knee arthroplasty (TKA) is an uncommon complication with only 20 cases having been described in English literature so far. Stress fractures of femoral neck occurring simultaneously on both sides following a bilateral total knee replacement is an exceptional occurrence, which to the best of our knowledge, has not been described previously. We describe a patient suffering from osteoarthritis of both knees, who was treated with bilateral total knee arthroplasty simultaneously. He developed spontaneous fractures of femoral neck on both sides 9 months following the total knee replacement in the absence of any known risk factors for stress fractures. He was treated with bipolar hemi replacement arthroplasty for displaced fracture on one side and closed reduction/internal fixation on the undisplaced side. A high index of suspicion is needed to diagnose this unusual complication of total knee arthroplasty before the fracture displaces necessitating a prosthetic replacement.     

股骨干骨折合并同侧髋臼骨折与髋关节后脱位的治疗体会

股骨干骨折是较常见的骨折，而合并同侧髋臼骨折与髋关节后脱位的发病率较低，易出现漏诊或延迟诊断。2000年1月-2005年12月，我院共收治此类患者8例，报道如下。     

一期人工全髋关节置换治疗股骨头粉碎性骨折

目的探讨一期人工全髋关节置换治疗股骨头粉碎性骨折的疗效。方法对11例股骨头粉碎性骨折患者行人工全髋关节置换术。结果11例均获随访,时间3～41（28±4.5）个月。6例基本达到骨折前的状况,5例生活基本自理。根据Harris评分标准：优（93±2.6分）6例,良（86±2.2分）5例。结论一期人工全髋关节置换治疗股骨头粉碎性骨折患者疗效满意,可减少并发症,改善生活质量。     

Dual mobility cup reduces dislocation and re-operation when used to treat displaced femoral neck fractures

Purpose

Total hip arthroplasty (THA) as primary treatment for displaced femoral neck fractures is controversial as THA is associated with higher rates of dislocation but lower rates of re-operation compared to hemiarthroplasty (HA). A dual mobility cup (DMC) design is associated with lower dislocation and re-operation rates in elective surgery. Is this also the case when used to treat displaced femoral neck fractures? The aim of this study is to compare rates of dislocation and re-operation of any kind following treatment for displaced femoral neck fractures with either bipolar HA or THA with DMC.

Methods

Two consecutive groups of patients treated for displaced femoral neck fractures at the Regional Hospital in Viborg in Denmark were included. In 2007–2008 171 patients (mean age 84.1 years) were treated with bipolar HA. In 2009–2010 175 patients (mean age 75.2 years) were treated with THA with DMC. Data regarding rates of dislocation and re-operation were obtained by retrospective review of medical records.

Results

We found a statistically significant difference regarding rates of dislocation and re-operation of any kind in favour of THA with DMC. Dislocation occurred in 25/171 patients [95 % confidence interval (CI) 9.3–19.9 %] treated with bipolar HA and 8/175 patients (95 % CI 1.5–7.7 %) treated with THA with DMC (p = 0.002). Re-operations were required in 32/171 patients (95 % CI 12.9–24.6 %) treated with bipolar HA and 16/175 patients (95 % CI 4.8–13.4 %) treated with THA with DMC (p = 0.01).

Conclusions

Our findings indicate that THA with DMC is superior to bipolar HA following treatment for displaced femoral neck fractures in regard to rates of dislocation and re-operation.     

Management of periprosthetic distal femur fractures using distal femoral arthroplasty and fixation - Comparative study of outcomes and costs

PurposeOur study compares the outcome and cost of distal femoral arthroplasty to that of Fixation (Plating/Retrograde Nailing) in the management of distal femur peri-prosthetic fractures.MethodsWe reviewed our database for patients admitted with peri-prosthetic distal femoral fractures between 2005 and 2013 (n = 61). The patients were stratified into 2 groups based on management method. The Distal Femoral Arthroplasty group (Group A) had 21 patients and the Fixation group (Group B) had 40 patients. Outcome & cost were compared. Minimum follow-up was 3 years.ResultsThe mean length of stay in group A was 9 days whereas in group B was 32 days. All patients were fully weight bearing by day 3 in group A, compared to a mean of 11 weeks in group B. Mean OKS was 28 and KSS score was 70 in group A compared to 27 and 68 in group B. In group A, there were 2 deaths, 1 superficial infection, and 1 DVT. In group B, there were 6 deaths, 1 failure of fixation, 6 mal-unions, 1 non-union and 2 infections. Overall, the distal femoral arthroplasty procedure costs approximately £9600 and the fixation group costs were on average of £9800.ConclusionDistal femoral arthroplasty appears to provide good clinical results, with comparable overall costs to fixation.     

Periprosthetic fractures of the femur associated with hip arthroplasty

The nature of the treatment of periprosthetic fractures depends on the localisation, the stability of the prosthesis and the condition of the bone. The Vancouver fracture classification has proved to be of value in determining specific modes of treatment. The current review analyses the different therapeutic options resulting in a concept of fracture-specific treatment. In this report we propose an extended version of this classification in which periprosthetic fractures associated with endoprostheses anchored in the epiphysis or metaphysis, as well as interprosthetic fractures, are taken into consideration.     

股骨转子周围骨折并股骨中上段骨折的手术治疗

[目的]探讨应用股骨近端髓内钉配合有限切开复位钛捆绑带内固定治疗股骨转子周围骨折并股骨中上段骨折的手术方法和疗效。[方法]对2002年1月～2006年10月收治的21例股骨转子周围骨折并股骨中上段骨折的病人，均采用股骨近端髓内钉固定或配合行有限切开复位钛捆绑带内固定技术治疗。[结果]21例病人全部获得9个月～5年的随访，平均13个月，所有病例均达临床骨性愈合，未出现内固定物折断、松动、脱出等情况。患肢髋膝关节功能均恢复良好。[结论]根据病人的年龄和骨折的类型，采用股骨近端髓内钉或配合行有限切开复位钛捆绑带内固定技术是一种良好的内固定方式，具有创伤小、操作简便易行、固定牢固可靠、利于骨折愈合等优点，良好的保留了患肢的功能。技术的主要关键是在微创的前提下达到解剖复位。     

人工膝关节置换治疗膝关节骨性关节炎的股骨髁上骨折

股骨髁上骨折合并膝关节骨性关节炎采用常规切开复位内固定术后患者容易出现膝关节僵直,需再次行人工全膝关节置换术。2008年2月-2010年6月,我院应用特殊人工膝关节置换治疗2例膝关节骨性关节炎的股骨髁上骨折患者,疗效较好,报道如下。     

股骨近端防旋髓内钉固定治疗股骨转子间骨折的失效原因分析

目的:探讨股骨近端防旋髓内钉（PFNA）固定治疗股骨转子间骨折失效的原因及危险因素。方法:回顾性分析2013年3月至2018年3月期间天津市第五中心医院骨科采用PFNA固定治疗的568例股骨转子间骨折患者资料。男348例,女220例;年龄为44~93岁,平均74.6岁。根据骨折稳定性将患者分为两组：稳定组424例,骨折...     

骨水泥型人工股骨头置换治疗高龄股骨颈骨折

目的探讨骨水泥型人工股骨头置换治疗高龄股骨颈骨折的近期疗效。方法对30例高龄股骨颈骨折患者采用骨水泥型人工股骨头置换治疗。根据Harris评分法评估临床效果。结果 30例均获得随访12~24个月。患者髋关节功能均恢复良好,未发现感染、髋内翻、假体松动下沉、关节脱位者。髋关节功能根据Harris评分,优17例,良9例,中4例,优良率86.67%。结论应用骨水泥型人工股骨头置换治疗高龄股骨颈骨折患者手术风险小、费用低、并发症少,术后可早期下床活动,提高了生活质量,疗效可靠。     

One-year outcome for elderly patients with displaced intracapsular fractures of the femoral neck managed non-operatively

The outcome of patients with a displaced intracapsular femoral neck fracture treated non-operatively was assessed at 1 year and compared with patients managed operatively over the same time period. Data were collected prospectively for 102 consecutive patients. 80 patients underwent hemiarthroplasty and 22 were managed non-operatively. Patients were managed non-operatively if they were felt to have an unacceptably high risk of death within the perioperative period despite medical optimisation. Non-operative management entailed active early mobilisation without bed rest or traction.Patients managed non-operatively had a greater 30-day mortality compared with operatively managed patients. Deaths were due to pre-existing medical conditions or events, which had occurred at the time of hip fracture. No patient in the non-operative treatment group developed pneumonia, pressure sores or thrombo-embolic events. Patients treated non-operatively, who survived 30 days after fracture, had a mortality rate over the following year comparable with those who had undergone surgery.At 1 year, all non-operatively managed patients were able to transfer without pain and 6 of the 11 surviving patients were able to mobilise with walking aids. At 1 year, the majority of surviving non-operatively managed patients were living in their own homes.Surgical intervention is the treatment of choice for the majority of elderly patients with a displaced intracapsular femoral neck fracture. However, in patients with life-threatening medical co-morbidity, non-operative treatment with early mobilisation can yield acceptable results.     

Treatment of ipsilateral hip and femoral shaft fractures with reconstructive intramedullary interlocking nail

Objective: To evaluate the results of reconstructive intramedullary interlocking nail in the treatment of ipsllateral hip and femoral shaft fractures. Methods: From August 1997 to November 2001, 13 patients were treated with the reconstructive intramedullary interlocking nail. Nine patients were associated with ipsllateral femoral neck fractures, three with ipsilateral intertrochanteric fractures, and one with subtrochanteric fracture. Results: The follow-up time was from 6 to 38 months with an average of 14 months. All the femoral shaft and hip fractures healed up well. There was no nonunion of the femoral neck, and only one varns malunion. No patient had avascular necrosis of the femoral head. The average healing time for femoral neck fracture was 4.6 months and for shaft fracture 5.8 months. The joint movement and other functions were fairly resumed. Conclusions: The reconstructive intramedullary interlocking nail, with less trauma, refiable fixation, and high rate of fracture healing, is an ideal method of choice in the treatment of ipsilateral hip and femoral shaft fractures.     

人工股骨头置换治疗老年不稳定股骨转子间骨折

目的探讨人工股骨头置换治疗老年股骨转子间骨折的临床疗效。方法采用人工股骨头置换术治疗老年不稳定股骨转子间骨折患者28例。结果28例均获得随防,时间12～24（16±4）个月。患者均在术后6周下地负重行走。髋关节功能接近伤前水平,生活基本能够自理。髋关节功能按Harris评分：术前为84～97（90±4）分;术后为82～95（89±3）分。结论人工股骨头置换治疗老年不稳定股骨转子间骨折可早期下床锻炼,减少并发症,提高患者的生活质量。     

Equivalent mortality and complication rates following periprosthetic distal femur fractures managed with either lateral locked plating or a distal femoral replacement

IntroductionManagement of distal femur fractures above total knee arthroplasty (TKA) remains challenging. Two common surgical options are locked lateral plating (LLP) and distal femoral arthroplasty (DFR). Unfortunately, approximately 30–50% of patients may die within one year of injury, require further surgery, or not regain prior mobility performance. We compared 87 LLP to 53 DFR patients – to our knowledge the largest comparative study – focusing on 90- and 365-day mortality, mobility maintenance, and further surgery.MethodsWe performed a retrospective review of patients at least 55 years old who sustained femur fractures near a primary TKA (essentially OTA-33 or Su types 1, 2, or 3) from 2000 to 2015 assigning cohort based on treatment: LLP or DFR. We excluded patients having prior care for the injury, whose surgery was not for fracture (e.g. loosening), or having other surgical intervention (e.g. intramedullary nail).ResultsResults Cohorts were similar based on body mass index and age adjusted Charlson Comorbidity Index (aaCCI). LLP was more common than DFR for fractures above and at the level of the implant, but similar for fractures within the implant for patients with aaCCI ≥ 5. LLP and DFR had similar mortality at 90 days (9% vs 4%) and 365 days (22% vs 10%), need for additional surgery (9% vs 3%), and survivors maintaining ambulation (77% vs 81%). Patients whose surgery occurred 3 or more days after presentation had similar mortality risk to those whose surgery was before 3 days. The mean age of one year survivors was 77 whereas for patients who died it was 85. Neither surgical choice nor aaCCI was associated with increased risk in time to surgery.ConclusionsFracture location, remaining bone stock, and patient’s prior mobility and current comorbidities must guide treatment. Our study suggests that 90- and 365-day mortality, final mobility, and re-operation rate are not statistically different with LLP vs DFR management.     

骨水泥型人工髋关节置换术治疗老年不稳定股骨粗隆间骨折

目的探讨骨水泥型人工髋关节置换术治疗老年不稳定股骨粗隆间骨折的手术技术和疗效。方法采用骨水泥型柄行人工髋关节置换术治疗29例老年不稳定股骨粗隆间骨折,其中行全髋关节置换术6例,标准双极人工股骨头置换术23例。结果本组手术时间51～90min,平均78min;术中出血量300—600ml,平均410ml;其中19例术中输血,输血量200～800ml,平均320ml。随访期间死亡1例,其余28例术后随访5～30个月,平均18．6个月。术后1d患者可拄双拐下床活动。术后1个半月,24例患肢功能明显改善,行走能力基本恢复到伤前水平。未出现髋臼磨损及股骨假体松动、下沉等并发症。出现脑梗死1例,下肢深静脉血栓2例,异位骨化2例。髋关节功能按Harris评分标准评定：优6例,良18例,可4例,差1例。结论骨水泥型人工髋关节置换术治疗老年不稳定股骨粗隆间骨折有良好的近期疗效。