Re-fractures after periprosthetic femoral fracture: A difficult to treat growing evidence.

INTRODUCTION: Periprosthetic fractures are increasing. The treatment is mostly surgical, but it has a high complication rate. Re-fracture and non-union with implant failure are the more frequent complications. Those complications are difficult to treat and can lead to severe disability. The purpose of this study is to determine the clinical results of periprosthetic femoral re-fracture treatment. MATERIALS AND METHODS: Twenty patients were treated for femoral re-fractures (17 women, 3 men). The mean age and follow-up are 75.7 years (46-95) and 6.15 years (0.4-15) respectively. The diagnosis of new periprosthetic fracture according to Vancouver classification were: 3 type A, 5 type B1, 1 type B2, 2 B3, 8 type C; 1 Lewis-Rorabeck type II. Patients were followed-up clinically, with a Harris Hip Score, and radiologically at 2, 4, 6, 12 months, and then annually. RESULTS: All patients healed except for two cases in which an infection occurred. Two cases, treated with plate osteosynthesis, had a malunion in varus. Six patients died for unrelated reasons after fracture healing. One patient was excluded because of a follow-up shorter than 12 months. In 16 cases (84%) a Trendelenburg gait or the use of aids for walking has been necessary. At final follow-up the mean HHS was 65 (range 45-82). Fractures treatment differed depending on the type of the fracture, prosthesis stability and bone loss. Tension band wiring, long plate fixation, revision with a long stem with cables or a sandwich technique (two plates or one plate plus one strut graft) have been performed according to fracture type. CONCLUSIONS: Re-fractures and non-union with implant failure are common after periprosthetic fracture treatment. Infection and malunion are the main complications of their treatment. Residual limping with the necessity of aids even after fracture healing is often present. The choice of a correct surgical strategy is essential to minimize the risk of new complications and ensure the highest possibility to heal. The most important factor is to achieve a good stability, a reasonable vital environment and don't leave new areas of lower resistance uncovered. Poor functional outcome has to be expected especially in refracture after a revision surgery.

Bilateral femoral shaft fractures complicated by fat and pulmonary embolism: a case report.

A 25-year-old man was admitted to our hospital because of pulmonary embolism and suspected fat embolism after sustaining bilateral femoral shaft fracture. A left arm weakness, tachycardia and sudden hemoglobin drop delayed his definitive fixation with intramedullary nailing. His clinical course was further complicated by bleeding from the pin sites of the external fixators which had initially been used to temporarily stabilize his femoral fractures (clotting disturbances). A lower leg Doppler ultrasound and a new pelvic-chest CT angiography excluded any remaining thrombus, meanwhile the embolus had broken in smaller pieces, more distally. His unfractionated heparin was revised to a Low Molecular Weight Heparin at prophylactic dose. After a 10 day period and when his condition had been improved bilateral reamed nailing was performed. Although bilateral closed femoral shaft fractures should be stabilized early, fat embolism syndrome (FES) and thromboembolic events (TEV) should always be kept in mind in these patients.

Management of the Schatzker VI fractures with lateral locked screw plating.

Complex proximal tibial plateau fractures need surgical treatment to achieve good clinical results. The treatment of this kind of fractures is often complicated either by the patient's compromised general conditions, or by soft tissue damage. The locking plate combines the technical advantages of an angular stable plate with those of the modern biological plating technique. From December 2002 to December 2008 we treated 18 patients with complex fractures of the tibial plateau (Schatzker VI). All patients were treated with a fixed angle locking plate, 15 with the LISS (Less Invasive Stabilisation System) and 3 with ZPLT (Zimmer Periarticular Locking Plate system). Average time for full weight bearing was 16.2 weeks. In 3 cases we removed the fixation devices after healing because the patients didn't tolerate the fixation devices. Two patients developed superficial infections that we treated with antibiotic therapy. In 2 cases the LISS plate broke because of pseudarthrosis at the diaphyseal level. To conclude, analysing the results we obtained, we consider that the LISS system is an extremely effective fixation device for the treatment of such difficult and complicated fractures as high energy tibial plateau fractures certainly are. Indirect reduction of the fracture, obtained either with an external fixator, or with traction, must precede the use of the fixation device. The failures, such as post-op malalignment or loss of reduction, are due to a wrong evaluation of the fracture morphology. In fact, comminuted fractures, dislocation and rotation of the medial tibial plateau cannot be stabilised just with lateral angular stable plates, but fixation of the medial tibial plateau must be performed first.

Minimal-invasive posterior approach in the treatment of the posterior wall fractures of the acetabulum.

We examined patients affected by a posterior wall fracture of the acetabulum treated with a minimally invasive posterior approach (from 12 to 18 cm). During 2004-2006 19 patients were treated by this approach. 4 patients had a combined surgery by the ileo-inguinal approach. Fracture fixation was performed using reconstruction plates and screws. All the patients were studied with typical X-rays projection for pelvis and iliac oblique view and obturator oblique view (Judet view) and CT scan with 3D reconstruction. After 3 months a CT scan was performed on about 30% of our patients, which demonstrated the perfect healing of the fractures. The most important advantages we observed using this approach were a lesser split of the gluteus maximus and no risk of damage for the superior gluteal nerve. In the early post-operative rehabilitation we examined the trophism of the gluteus maximus, which was found to be better than in patients treated with the typical Kocher-Langenbeck approach. The only absolute contraindication for this technique is in obese patients. The post-operative complications include one case of heterotypic ossification of the gluteus minimus and one case of peroneal-nerve palsy with the spontaneous and complete recovery within 6 months. According to our experience this kind of approach could be used for posterior wall fracture of the pelvis and it can be extended to transverse fractures. In the post-operative period the greatest advantage is the lesser muscle damage and therefore a most effective rehabilitation.