The Outcome of Fixing Distal Femur Periprosthetic Fracture around Total Knee Replacement using a Locking Plate Non-Contact Bridging (NCB)

@#Introduction: Surgical fixation of peri-prosthetic distal femur fractures around knee replacements poses a challenge, especially in frail patients, with variable outcomes reported in the literature. This study looks at the outcomes of a consecutive series of patients presenting with such fractures and treated by using a locking plate fixation. Materials and methods: A total of 21 consecutive patients who were admitted to our trauma unit over 31 months and underwent fixation with the Non-Contact Polyaxial Locking plate system were retrospectively identified and their acute treatment with follow-up outcomes were analysed. Results: The mean age was 81 years and 71% were in ASA grades 3 and 4. Fracture morphologies were classified as per the Su classification, yielding 8 (38%) classified as Su one, 4 (19%) as Su two, and 9 (43%) as Su type three. Postoperatively, 2 patients (9.5%) died due to hospital-acquired pneumonia, and another 2 patients (9.5%) developed wound infections necessitating further return to theatre. Additionally, 2 (9.5%) patients had distal femoral replacements due to non-union. Mean discharge time was 28 days with 12 patients (55% of patients) starting protected weight-bearing six weeks after surgery. Conclusion: The incidence of morbidity, mortality was significant and re-operation was required in patients treated as described, and these were partly attributed to the patient’s average age and the pre-existing comorbidities. Significant variations were noted in the time to discharge, rehabilitation, and time to achieve fracture union. However, the majority of fractures did eventually unite. Patients with comminuted fractures and insufficient bone stock are more likely to progress to non-union and end up requiring revision knee arthroplasty.

Outcomes of the Surgical Treatment of Periprosthetic Fractures Around the Knee with Locking Plates: A Single Centre Experience

@#Introduction: Surgical treatment options for periprosthetic fractures (PPF) include internal fixation with plate, intramedullary nailing and revision arthroplasty. We aimed at evaluating the surgical outcomes of patients who we had treated PPF with locking compression plates (LCP). Materials and methods: Twenty patients with PPF after primary total knee arthroplasty (TKA) between 2009 and 2016 were included in to the study. Knee Society Knee Scoring System (KSKSS) was used in the evaluation of radiologic and functional outcomes. There were periprosthetic supracondylar femoral fractures in 15 patients, and that of tibial fractures in 5 patients. For internal fixation, locking compression plate was preferred. Results: The mean age was 69 (range 61 to 78) years and the mean follow-up period was 72.25 (range 24 to 110) months. Union was achieved by 15.8 weeks in all the cases. Superficial infection and implant fracture were each seen in two patients. Revision operations were done to those patients with implant fracture. Mean KSKSS was 81.4 (75-87) and the mean functional score was 78.75 (75-85). Degenerative osteoarthritis patients were found to have higher age values than post-traumatic osteoarthritis patients (p = 0.001). When the union times were compared, it was found that the degenerative osteoarthritis patient group had a significantly shorter union than the post-traumatic osteoarthritis patient group (p = 0.036). Conclusion: Internal fixation with LCP is an effective treatment method in managing of PPF for patients with good bone stock. Rigid fixation should be done with the right surgical technique and an early movement must be initiated so that a good function can be achieved.

Analysis of the effect of surgical treatment of periprosthetic femoral fractures after hip replacement / 中国骨伤

OBJECTIVE@#To analyze and compare the clinical efficacy of different types of surgical treatment of periprosthetic femoral fracture(PFF) after hip arthroplasty (HA).@*METHODS@#From September 2010 to September 2016, 47 patients (47 hips) with periprosthetic fractures after total hip arthroplasty were retrospectively analyzed, including 13 males and 34 females. According to Vancouver classification, there were 2 patients with type AG, 17 patients with type B1, 19 patients with type B2, 7 patients with type B3 and 2 patients with type C. The age of patients ranged from 56 to 94 (71.5±8.3) years. After admission, nutritional risk screening (NRS2002) was used to assess the nutritionalstatus of the patients. Eighteen patients (38%) had malnutrition risk (NRS>3 points). After admission, the patients were given corresponding surgical treatment according to different types. Intraoperative blood loss was recorded. Harris score was used to evaluate the hip function. VAS pain score was performed on admission and after operation.@*RESULTS@#All the 47 patients were followed up for 19 to 62 (34±11) months. The Harris scores were (41.8±12.1) and (89.0±2.6) respectively before and 1 year after operation, and the difference was statistically significant (@*CONCLUSION@#The treatment of hip periprosthetic fracture patients should be based on the general situation of patients, imaging data, intraoperative correction classification, etc. to develop individualized treatment plan in line with patients. For patients with preoperative malnutrition risk, preoperative nutritional intervention may reduce intraoperative bleeding.

Treatment of Periprosthetic Femoral Fractures after Hip Arthroplasty

Although the incidence of postoperative periprosthetic femoral fractures after hip arthroplasty is expected to increase, these complex fractures are still challenging complications. To obtain optimal results for these fractures, thorough clinical and radiographic evaluation, precise classification, and understanding of modern management principles are mandatory. The Vancouver classification system is a simple, effective, and reproducible method for planning proper treatments of these injuries. The fractures associated with a stable femoral stem can be effectively treated with osteosynthesis, though periprosthetic femoral fractures associated with a loose stem require revision arthroplasty. We describe here the principles of proper treatment for the patients with periprosthetic femoral fractures as well as how to avoid complications.

Periprosthetic Fractures after Total Knee Arthroplasty: the Influence of Pre-Operative Mechanical Factors versus Intraoperative Factors

@#Introduction: Periprosthetic fractures are a devastating complication following total knee arthroplasty. Little is known about the effect of mechanical factors on the incidence of periprosthetic fractures. The aim of this study was to examine the correlation between pre-operative mechanical factors, like side of surgery, coronal alignment and pre-operative range of motion and intra-operative factors, and the incidence of a periprosthetic fracture, following primary total knee arthroplasty (TKA). Materials and Methods: Forty-two patients with periprosthetic fractures (PPF) after primary TKA were identified from our hospital arthroplasty registry. These patients were matched two-to-one for gender and age at primary knee arthroplasty to 84 patients without PPF. The incidence of periprosthetic fracture with regards to laterality, coronal alignment and pre-operative range of motion was analysed. Intra-operative factors like implant type, patellar resurfacing and notching were also analysed using logistic regression. Results: Coronal alignment, pre-operative range of motion and patella resurfacing were not significant predictors of periprosthetic fractures. Anterior femoral notching was found to be significantly higher in the fracture group with an odds ratio of 17. Left sided surgery was also significantly higher in the periprosthetic fracture group. Conclusion: Periprosthetic fractures are 17 times more likely to occur in a knee with anterior femoral notching. Preoperative factors like coronal alignment and poor preoperative range of motion do not seem to increase the risk of periprosthetic fractures after TKA.

Outcomes following Treatment of Geriatric Distal Femur Fractures with Analyzing Risk Factors for the Nonunion

PURPOSE: Many international journals have published studies on the results of distal femoral fractures in elderly people, but only a few studies have been conducted on the Korean population. The aim of this study was to determine the factors that are associated with the outcomes and prognosis of fixation of distal femur fractures using the minimally invasive plate osteosynthesis (MIPO) technique in elderly patients (age≥60) and to determine the risk factors related witht he occurrence of nonunion. MATERIALS AND METHODS: This study is a retrospective study. From January 2008 to June 2018, distal femur fracture (AO/OTA 33) patients who underwent surgical treatment (MIPO) were analyzed. A total of 52 patients were included in the study after removing 121 patients that met with the exclusion criteria. Medical records, including surgical records, were reviewed to evaluate the patients' underlying disease, bone mineral density, the number of days delayed from surgery, complications and mortality. In addition, follow-up radiographs were used to determine bone union, delayed union and nonunion. RESULTS: The average time to achieve bone union was 19.95 weeks, the rate of nonunion was 20.0% (10/50) and the overall mortality was 3.8% (2/52). There were no significant differences in the clinical and radiological results of those patients with or without periprosthetic fracture. On the univariate analysis, which compared the union group vs. the nonunion group, no factors were identified as significant risk factors for nonunion. On the multiple logistic regression analysis, medical history of cancer was identified as a significant risk factor for nonunion (p=0.045). CONCLUSION: The rate of nonunion is high in the Korean population of elderly people suffering from distal femur fracture, but the mortality rate appears to be low. A medical history of cancer is a significant risk factor for nonunion. Further prospective studies are required to determine other associated factors.

Treatment of Periprosthetic Femoral Fractures Following Hip Arthroplasty / 대한고관절학회지

PURPOSE: This study was performed to assess potential improvements in clinical outcomes when applying recent advanced hip arthroplasty surgical techniques and understand the potential relationship between bone mineral density (BMD) and surgical outcomes. MATERIALS AND METHODS: Among 37 cases of periprosthetic femoral fractures after hip arthroplasty treated between March 2014 and September 2016, all included a follow-up of at least one year and were included in this study. Outcomes were evaluated using the Beals and Tower's criteria. BMD was examined in 27 of 37 cases and the relationship between osteoporosis and treatment outcomes was analyzed. Advanced hip arthroplasty surgical approaches varied depending on the fracture type: i) open reduction with wiring for Vancouver A, ii) open reduction with double plate fixation for Vancouver B1, iii) revision THA with long stem for Vancouver B1-Nonunion, B2 and B3, and iv) open reduction with double plate fixation for Vancouver C. RESULTS: When assessed using the Beals and Tower's criteria, 33 out of 37 (89.2%) patients were excellent and 4 (10.8%) were poor. These outcomes were an improvement compared with series I (81.8%). When analyzed according to the Vancouver classification, patients with type A (n=8), type B1 (n=16), and type B2 (n=2) were all excellent, the patients with type B3 were excellent (n=1) and poor (n=1), and the patients with type C were excellent (n=6) and poor (n=3). The mean BMD was −2.6 (T-score) in 27 of 37 cases and −4.4 in 4 cases with poor prognosis. Osteoporosis was statistically correlated to those classified as poor by Beals and Tower. CONCLUSION: The results of the analysis suggest that applying new surgical hip arthroplasty treatment approaches leads to improved outcomes compared with the author's previous study. When treating periprosthetic femoral fractures following total hip arthroplasty, an appropriate internal fixation method should be selected, at least in part based on the Vancouver classification. In addition, osteoporosis may be a major prognostic factor for the outcomes of surgical treatment.

Impact of time to surgery from injury on postoperative infection and deep vein thrombosis in periprosthetic knee fractures / 中华创伤杂志(英文版)

PURPOSE@#Periprosthetic fracture (PPF) is a serious complication that occurs in 0.3%-2.5% of all total knee arthroplasties used to treat end-stage arthritis. To our knowledge, there are no studies in the literature that evaluate the association between time to surgery after PPF and early postoperative infections or deep vein thrombosis (DVT). This study tests our hypothesis that delayed time to surgery increases rates of postoperative infection and DVT after PPF surgery.@*METHODS@#Our study cohort included patients undergoing PPF surgery in the American College of Surgeons National Surgical Quality Improvement Program database (2006-2015). The patients were dichotomized based on time to surgery: group 1 with time ≤2 days and group 2 with time >2 days. A 2-by-2 contingency table and Fisher's exact test were used to evaluate the association between complications and time to surgery groups, and multivariate logistic regression was used to adjust for demographics and known risk factors.@*RESULTS@#A total of 263 patients (80% females) with a mean age of 73.9 ± 12.0 years were identified receiving PPF surgery, among which 216 patients were in group 1 and 47 patients in group 2. Complications in group 1 included 3 (1.4%) superficial infections (SI), 1 (0.5%) organ space infection (OSI), 1 (0.5%) wound dehiscence (WD), and 4 (1.9%) deep vein thrombosis (DVT); while complications in group 2 included 1 (2.1%) SI, 1 (2.1%) OSI, 1 (2.1%) DVT, and no WD. No significant difference was detected in postoperative complications between the two groups. However, patients in group 2 were more likely (p = 0.0013) to receive blood transfusions (57.5%) than those in group 1 (32.4%).@*CONCLUSION@#Our study indicates patients with delayed time to surgery have higher chance to receive blood transfusions, but no significant difference in postoperative complications (SI, OSI, WD, or DVT) between the two groups.

Femoral Periprosthetic Fractures after Total Knee Arthroplasty: New Surgically Oriented Classification with a Review of Current Treatments

PURPOSE: As the number of total knee arthroplasties (TKAs) increases, the incidence of femoral periprosthetic fractures after TKA is also increasing. This review aimed to suggest a new surgically oriented classification system for femoral periprosthetic fractures. METHODS: We investigated the classifications, and current treatment trends for femoral periprosthetic fractures after TKA by means of a thorough review of the relevant literature. RESULTS: Numerous studies reported good results of surgical treatment with modern fixatives including locking compression plates and retrograde intramedullary nails. However, few classifications of femoral periprosthetic fractures reflect the recent developments in surgical treatment. CONCLUSIONS: We recommend that surgical management be considered the first-line treatment for femoral periprosthetic fractures after TKA. Our new classification will help in deciding the surgical treatment option for femoral periprosthetic fractures after TKA.

Clinical effect of cemented long stem prosthesis and memory alloy embracing fixator in the treatment of type B2 periprosthetic fractures / 中国综合临床

Objective To study the clinical effect of cemented long stem prosthesis and memory alloy embracing fixator in the treatment of type B2 periprosthetic fractures.Methods Fom April 2014 to April 2016,102 cases of peripheral B2 periprosthetic fractures patients were selected and randomly divided into bone cement long stem prosthesis revision surgery(group A) and revision of cemented long stem prosthesis combined with memory alloy embracing fixator(group B),each group with 51 cases.Clinical efficacy was evaluated according to Beals and Tower criteria,used Harris score to evaluate the hip the joint function,used the Visual Analogue Scale(VAS) score to evaluate the pain,after follow-up of 40 months,the clinical curative effect of 2 groups of patients,fracture healing time,complications and Harris score and VAS score were observed.Results The excellent rate of B group was significantly higher than that of A group,with statistical significance(90.2% vs.72.5%,χ2=5.239,P<0.05).Fracture healing time of group B was shorter than that of group A,with statistically significant ((10.2±2.5) weeks vs.(21.3±8.9) weeks,t=8.575,P<0.05).Harris the score of group B was higher than the group A,with statistically significant((89.9±13.5) points vs.(71.2±18.9) points,t=5.750,P<0.05).VAS score of group B was significantly lower than the group A,with statistically significant((1.23±0.25) points vs.(5.98±1.08) points,t=30.600,P<0.05).There were no complications such as infection,nonunion,loss of reduction and loosening of internal fixation in the 2 groups.Conclusion Revision of cemented long stem prosthesis combined with memory alloy embracing fixator is an ideal methods for the treatment of type B2 periprosthetic femoral fractures,which provides a good initial stability for fracture healing.

Fracturas periprotésicas de fémur en artroplastia total de rodilla: experiencia con técnica mínimamente invasiva / Peri-prosthetic femoral fractures in total knee arthroplasty: experience using minimally invasive plate osteosynthesis

ANTECEDENTES: La fractura periprótesica de fémur en artroplastia total de rodilla supone uno de los mayores retos quirúrgicos. La tasa de complicaciones generales supera el 30% tanto con tratamiento conservador como con el quirúrgico. Parece que la técnica de osteosíntesis con placas bloqueadas de manera mínimamente invasiva ofrece buenos resultados para el tratamiento de las fracturas en las que no existe movilización del componente femoral. MÉTODOS: Se estudian retrospectivamente, desde enero de 2005 hasta diciembre del 2011, 32 pacientes, evaluando el tiempo de consolidación, el rango de movilidad, la deambulación y el alineamiento final mediante la realización de telemetrías en carga. El seguimiento medio fue de 56,5 meses (25-144). RESULTADOS: Se siguieron 32 pacientes (31 mujeres; un hombre) de los cuales el rango medio de edad fue de 77 años (70-89). Tres pacientes fallecieron (9%) y 4 pacientes (12%) se perdieron en la evolución final. La tasa media de consolidación fue de 16,5 semanas (8-24); no se produjeron infecciones, presentaron 3 seudoartrosis y solo se produjo un alineamiento en excesivo valgo (15°). El balance articular fue similar al previo a la fractura. La deambulación final fue igual a la previa en 24 de los 25 casos. CONCLUSIONES: Es una técnica adecuada para conseguir la consolidación en este tipo de fracturas y restablecer tanto la movilidad previa como un alineamiento correcto de la extremidad.

BACKGROUND: Peri-prosthetic fracture of the distal femur above total knee arthroplasty presents a challenging surgical problem for orthopaedic surgeons, as complication rates for both surgical and non-surgical treatment have been reported to be as high as 30%. The minimally invasive plate osteosynthesis (MIPO) technique seems to have better results than other techniques in this type of fracture when there is no loosening of the femoral implant. METHODS: A total of 32 patients with this fracture were treated from January 2005 to December 2011. A retrospective review was conducted on the weeks of consolidation, range of motion, final alignment, and the ability to walk. The mean follow up was 56.5 months (25-144). RESULTS: A total of 32 (31 female, 1 male) patients, with a mean age 77 (70-89) years old were treated, of whom 3 (9%) died and 4 were lost to follow-up. The mean time of consolidation was 16.5 weeks (8-24). There were no infections, although there were 3 non-unions and 1 malalignment (15° of valgus). We were able to restore the range of motion in every patient as it was before the fracture, as well as the ability to walk outdoors in 24 patients. CONCLUSION: The MIPO technique is a great technique in order to achieve a good range of motion and alignment of these fractures.

Tratamiento de las fracturas periprotesicas de cadera de tipos B2 y B3 con tallos no cementados de fijacion distal / Treatment of type B2 and B3 periprosthetic hip fractures with distal fixation cementless stem

Introducción: La fractura periprotésica es la tercera causa más frecuente de revisión de cadera por detrás del aflojamiento aséptico y la infección. Aquellas que se presentan asociadas a un tallo flojo (B2) o a un déficit de capital óseo (B3) deben ser tratadas con la revisión femoral. Materiales y Métodos: Se estudiaron retrospectivamente 38 pacientes con fracturas periprotésicas de fémur de tipos B2 y B3 tratadas con tallos no cementados de fijación distal sin injerto óseo ni placas de osteosíntesis. El tiempo de seguimiento promedio fue de 2.5 años (rango 1.5-10). Resultados: El puntaje promedio en el Harris Hip Score fue 69 (rango 57-91). En todos los casos, se logró la consolidación ósea. La supervivencia libre de revisión fue del 94,8%. Las complicaciones fueron: un (2,6%) hundimiento del tallo >5 mm, una (2,6%) luxación, dos (5,2%) infecciones y un (2,6%) hematoma de la herida. Conclusión: La técnica de revisión con tallos no cementados de fijación distal sin el aporte de injerto óseo ha demostrado ser un método eficaz para tratar las fracturas periprotésicas de cadera de tipos B2 y B3.

Introduction: Periprosthetic hip fracture is the third most common cause of hip revision, behind aseptic loosening and infection. Fractures presenting in combination with a loose stem (B2) or poor bone stock (B3) should be revised. Methods: We retrospectively evaluated 38 patients with type B2 and B3 periprosthetic hip fractures that had been treated with distal fixation cementless stem without bone graft or a plate. Follow-up averaged 2.5 years (range 1.5-10). Results: The mean postoperative Harris Hip Score was 69 points (range 57-91). Fracture consolidation was achieved in all patients. Implant survival at last follow-up was 94.8%. Complications were: one (2.6%) stem subsidence, one (2.6%) dislocation, two (5.2%) infections and one (2.6%) hematoma. Conclusion: Hip revision in the set of type B2 and B3 periprosthetic fracture with distal fixation cementless stem without bone graft is an effective technique.

Application of 3D printing technology in reconstruction of an complex periprosthetic femoral fracture of tumor knee joint / 吉林大学学报(医学版)

Objective:To perform the preoperative design and operative simulation for periprosthetic femoral fractures (PFF)in one patient with complex tumor knee replacement under assistance of three-dimensional (3D) printing technology,and to explore a more accurate and feasible way to restore the normal anatomy and function of this kind of patients.Methods:The female patient aged 32 years old diagnosed with PFF after an complex tumor knee replacement was selected.The CT images of the patient’s bilateral legs were collected and reconstructed.The bilateral femurs were virtually sliced and the important parameters at each location of both sides were recorded respectively.Novel femoral stem and nail paths were specially designed on the basis of original prosthesis according to these parameters. Then vitual assemble was made with the residual femur. The prosthetic femoral stem components and navigator were customized based on the 3D simulation results when no more errors were found.The residual femoral resin model,customized components and navigator were printed with an SLA 3D printer.The bone cement was taken out and newly designed femoral stem was implanted successfully according to the steps designed preoperatively.The preconcerted allograft bone plates were applied for patch of the bone defect.The pathological results,X-ray and functional scores were included in the observation indexes. Results: With the help of successfully preoperative computer matching,successfully printed bone model-prosthesis assemble and re-customized navigator,the operation was successfully performed.The postoperative alignment shown in the X-ray image was good.The patient was able to normally walk and squat one month after operation with a crutch.MSTS93 score was improved from 0 before operation to 14 only one month after operation.Conclusion:As for PFF of complex tumor knee joint,preoperative design and simulation with 3D printing technology may provide a more accurately and effectively operative outcome than traditional methods.

Periprosthetic Fracture after Hook Plate Fixation in Neer Type II Distal Clavicle Fracture: A Report of 3 Cases

Hook plate fixation is a treatment method for the displaced distal clavicle fracture with favorable results regarding bone union and shoulder function, however possible complications include impingement syndromes, subacrormial erosions, acromial fractures, and periprosthetic fractures. In this report, we observed 3 cases of periprosthetic fracture after hook plate fixation. All cases of periprosthetic fractures were initiated at the medial end screw holes. The causes of these periprosthetic fractures appeared to be the off centered fixation of medial end screws near the anterior or posterior cortex which were specific during operations with hook plates with more than 6 holes and the increased stress on the medial end screw by over-reduced or inferiorly reduced position of the distal end of the clavicle by the hook plate.

Periprosthetic Fractures Following Total Knee Arthroplasty

Periprosthetic fractures after total knee arthroplasty may occur in any part of the femur, tibia and patella, and the most common pattern involves the supracondylar area of the distal femur. Supracondylar periprosthetic fractures frequently occur above a well-fixed prosthesis, and risk factors include anterior femoral cortical notching and use of the rotational constrained implant. Periprosthetic tibial fractures are frequently associated with loose components and malalignment or malposition of implants. Fractures of the patella are much less common and associated with rheumatoid arthritis, use of steroid, osteonecrosis and malalignment of implants. Most patients with periprosthetic fractures around the knee are the elderly with poor bone quality. There are many difficulties and increased risk of nonunion after treatment because reduction and internal fixation is interfered with by preexisting prosthesis and bone cement. Additionally, previous soft tissue injury is another disadvantageous condition for bone healing. Many authors reported good clinical outcomes after non-operative treatment of undisplaced or minimally displaced periprosthetic fractures; however, open reduction or revision arthroplasty was required in displaced fractures or fractures with unstable prosthesis. Periprosthetic fractures around the knee should be prevented by appropriate technique during total knee arthroplasty. Nevertheless, if a periprosthetic fracture occurs, an appropriate treatment method should be selected considering the stability of the prosthesis, displacement of fracture and bone quality.

Treatment of Periprosthetic Femoral Fractures Following Total Knee Arthroplasty

PURPOSE: The purpose of this study is to compare the treatment results of fracture fixations by using two minimal invasive techniques for patients with periprosthetic femoral fractures following total knee arthroplasty. MATERIALS AND METHODS: We reviewed 36 patients (5 males, 31 females) of periprosthetic femoral fractures whom were treated surgically between January 2005 and January 2011. Mean patient age was 68.9 years (range, 43 to 81 years) old and the follow-up period averaged 41 months (range, 18 to 72 months). Nineteen patients were treated with minimal invasive locking plate fixations (group I) and 17 patients with retrograde intramedullary nailing (group II). Clinical and radiological outcomes in each group were comparatively analyzed. RESULTS: Successful bone unions occurred in all patients and the mean time to bone union was 3.7 months in group I and 4.2 months in group II. There were no statistical differences between the two groups according to mean operative time and mean intraoperative blood loss. There were also no statistical differences between two groups according to clinical outcomes but the valgus deformity was apparent in group II and radiological outcomes revealed significant differences between the two groups. CONCLUSION: For the treatment of periprosthetic femoral fractures after total knee arthroplasty, two minimal invasive techniques have shown good clinical results. However, the minimal invasive plate fixation showed better results in the radiological alignments.

Treatment Results of a Periprosthetic Femoral Fracture Case Series: Treatment Method for Vancouver Type B2 Fractures Can Be Customized

BACKGROUND: Currently, an algorithmic approach for deciding treatment options according to the Vancouver classification is widely used for treatment of periprosthetic femoral fractures after hip arthroplasty. However, this treatment algorithm based on the Vancouver classification lacks consideration of patient physiology and surgeon's experience (judgment), which are also important for deciding treatment options. The purpose of this study was to assess the treatment results and discuss the treatment options using a case series. METHODS: Eighteen consecutive cases with periprosthetic femoral fractures after total hip arthroplasty and hemiarthroplasty were retrospectively reviewed. A locking compression plate system was used for osteosynthesis during the study period. The fracture type was determined by the Vancouver classification. The treatment algorithm based on the Vancouver classification was generally applied, but was modified in some cases according to the surgeon's judgment. The reasons for modification of the treatment algorithm were investigated. Mobility status, ambulatory status, and social status were assessed before the fracture and at the latest follow-up. Radiological results including bony union and stem stability were also evaluated. RESULTS: Thirteen cases were treated by osteosynthesis, two by revision arthroplasty and three by conservative treatment. Four cases of type B2 fractures with a loose stem, in which revision arthroplasty is recommended according to the Vancouver classification, were treated by other options. Of these, three were treated by osteosynthesis and one was treated conservatively. The reasons why the three cases were treated by osteosynthesis were technical difficulty associated with performance of revision arthroplasty owing to severe central migration of an Austin-Moore implant in one case and subsequent severe hip contracture and low activity in two cases. The reasons for the conservative treatment in the remaining case were low activity, low-grade pain, previous wiring around the fracture and light weight. All patients obtained primary bony union and almost fully regained their prior activities. CONCLUSIONS: We suggest reaching a decision regarding treatment methods of periprosthetic femoral fractures by following the algorithmic approach of the Vancouver classification in addition to the assessment of each patient's hip joint pathology, physical status and activity, especially for type B2 fractures. The customized treatments demonstrated favorable overall results.

Risk Factors of Periprosthetic Fracture after Total Knee Arthroplasty

PURPOSE: To evaluate the incidence rate and risk factors for periprosthetic fracture after total knee replacement (TKR). MATERIALS AND METHODS: We carried out a retrospective case-control study of 596 patients (951 knees) who underwent TKR between 1999 and 2006 and who were followed up over 36 months. We classified patients into group I (study group) and group II (control group). We subdivided risk factors as pre-operative, intra-operative, and post-operative factors. Age, osteoporosis, revision arthroplasty, CVA, and alcohol dependence were categorized as pre-operative factors; anterior femoral notching and prosthetic types (mobile, fixed, and load-bearing) were considered intra-operative factors; and post-operative activity level was classified as a post-operative factor. We obtained information from the patients' charts, X-ray film, and telephone interviews. RESULTS: The overall incidence rate was 2.25%; 3 patients were male, and 18 were female (14.28% and 85.72%, respectively). Old age (p<0.01, odds ratio=1.14), osteoporosis (p=0.01, odds ratio=4.74), revision arthroplasty (p=0.01, odds ratio=7.46), CVA (p=0.02, odds ratio=8.55), and alcohol dependence (p=0.03, odds ratio=44.54) were statistically significant among the pre-operative factors. Among the intra-operative factors, anterior femoral notching (p<0.01, odds ratio=11.74) was significant, and continued heavy labor (p<0.01, odds ratio=8.14) was significant among the post-operative factors. CONCLUSION: We concluded that old age, osteoporosis, revision arthroplasty, comorbidity related with falling down, anterior femoral notching, and continued heavy labor were associated with periprosthetic fracture after TKR.

Operative Treatment of Periprosthetic Unstable Femoral Fractures of Vancouver Type B1 and C with Variable Plates / 대한고관절학회지

PURPOSE: The purpose of this study is to evaluate the outcome after operative treatment with plate fixation in Vancouver B1 and C periprosthetic unstable femoral fractures. MATERIALS AND METHODS: We conducted a retrospective assessment of 15 patients who had under gone treatment for a periprosthetic unstable femoral fracture around primary hip arthroplasty between April 1997 and July 2010. The mean age of patients was 69 years(53 to 82 years) at the time of surgery and the mean duration of follow-up was 29.2 months (six to 110 months). According to Vancouver classification, 10 patients were type B1 and five were type C. According to the time of operation, open reduction and internal fixation was performed using four different plates. Bone graft was applied in all patients, regardless of the type of plate. The present review describes the clinical and radiographic results. RESULTS: All patients were able to ambulate without assistance of crutches or walkers. Of the 15 patients, the fracture site was united in all patients. Postoperative dislocation of the ipsilateral hip was observed in one patient; however, there was no occurrence of further complications, such as infections, nerve injuries, or loosening of the femoral stems. CONCLUSION: In Vancouver type B1 and C fractures, without any loosening of the femoral stems, open reduction with plate fixation using our operative methods provided a satisfactory result.

Antibiotic-impregnated Cement Plate for the Treatment of Infected Periprosthetic Femoral Fracture after Cementless Total Hip Arthroplasty: A Case Report / 대한고관절학회지

A 62-year-old man with an infected periprosthetic femoral fracture, which occurred after a cementless total hip arthroplasty (THA) procedure, was treated utilizing an antibiotic-impregnated cement plate for internal fixation. Open reduction and internal fixation using a cable plate were initially attempted in his case, but a deep infection with methicillin-resistant staphylococcus epidermidis at the fracture site occurred 2 months after the initial cable plate procedure. Using an antibiotic-impregnated cement plate for internal fixation, one month later, the fracture had stabilized. Successful fusion occurred at 12 months after deploying the antibiotic-impregnated cement plate. This technique was useful in this complicated case because it facilitated the goals of eradicating infection, alleviating pain, and improving function.