Periprosthetic Fractures of the Femur after Hip and Knee Replacement

Objective: To present the clinical and radiological results of treatment of periprosthetic fractures of the femur after hip and knee replacements. Subjects and Methods: Thirty-four patients (8 males and 26 females) with 34 fractures of the femur complicating hip and knee replacements are the subjects of this report. In 21 cases, the fracture affected the femur after hip replacement, and in 13 cases after knee replacement. Fractures around the hip replacement were classified according to Vancouver classification, and those around the knee replacement were classified according to Rorabeck. Location of fracture was defined as metaphyseal or diaphyseal. Arbitrary classification of fracture union was used. Fractures were considered to be either united or to have delayed union, after radiology. Conservative treatment and different methods of fixation were used. Clinical correlations between location of fracture and outcome were analyzed. Results: All 21 metaphyseal fractures after hip and knee replacements united. Eight diaphyseal fractures (6 after hip replacement and 2 after knee replacement) united. Five diaphyseal fractures after hip replacement had delayed union, and 4 fractures united after bone graft. In 1 case, fracture did not unite, the treatment was discontinued and the patient was lost to follow-up. Conclusion: Our data show that metaphyseal fractures, regardless of type of implant, Received: May 11, 2008 Revised: August 18, 2008 Wieslaw Pospula Al Razi Orthopedic Hospital PO Box 4235 Safat 13043 (Kuwait) Tel. +965 489 9096, Fax +965 482 2240, E-Mail [email protected] © 2009 S. Karger AG, Basel 1011–7571/09/0183–0198$26.00/0 Accessible online at: www.karger.com/mpp D ow nl oa de d by : 54 .7 0. 40 .1 1 11 /1 8/ 20 17 4 :3 8: 03 P M Periprosthetic Femoral Fracture Med Princ Pract 2009;18:198–203 199 but the results are frequently unsatisfactory and internal fixation is recommended in most cases. Fractures around loose implants need revision and fixation of the fracture according to local circumstances. Fixation methods include simple screws, cerclage wires, cable systems, ordinary plates alone or combined with strut graft and interlocking nails [10–16] . Recently developed locked plate systems are popular and very useful for periprosthetic fracture fixation [17, 18] . In this report, we present our experience with the treatment of periprosthetic fracture of the femur after hip and knee replacements. Subjects and Methods Between 1995 and 2007, there were 34 patients (8 males and 26 females) with periprosthetic femoral fractures around their implants treated in our hospital. The fracture involved hip replacement in 21 cases (average age 50 years, range 22–76) and knee replacement in 13 cases (average age 67 years, range 45–76). All hip and knee implants were cemented. Vancouver type A fracture was found in 10 cases and Vancouver type B1 in 8 cases; B2, B3 and C had 1 case of each type. The periprosthetic fracture around the total knee replacement were classified according to the Rorabeck classification. All these 13 fractures were type II, i.e. with displacement and stable implant. Treatment of femoral fractures in hip replacement Vancouver type A was conservative in 3 cases, simple screw fixation in 3 cases, cerclage wire in 3 cases and tension band in 3 cases. Vancouver B1, B2, B3 and C fractures were treated with Dall-Miles plates and cables in 2 cases, and low-contact dynamic compression plate and screws with or without cerclage wire ( fig. 1 ) or cable in 7 cases. Management of femoral fractures complicating total knee replacement included: conservative treatment in 2 cases, supracondylar femoral nail (Smith and Nephew; fig. 2 ) in 4 cases, condylar blade plate 95° in 2 cases, dynamic condylar screw in 2 cases, TomoFix locked plate in 1 case ( fig. 3 ) and standard DallMiles plate with cables in 2 cases ( fig. 4 ). Fixations of periprosthetic fractures after knee replacement were protected by a plaster of Paris cast for 3–4 weeks according to the stability of the fixation, and were followed by bracing and mobilization using continuous passive motion and an active exercise program. Clinical results in cases of periprosthetic fractures around a hip replacement were assessed in terms of pain, range of movement and walking ability according to the Merle d’Aubigne clinical score system [19] . In cases of fractures around total knee rea b a b c d Fig. 1. Fracture below the tip of well cemented stem of bipolar replacement. Long plate, screws and cerclage wire. a Initial X-ray. b Postoperative X-ray. Fig. 2. Periprosthetic fracture above the femoral component of the knee replacement. Fixation using supracondylar nails. Good clinical and radiological results. a Initial X-ray. b Intraoperative view. c Final X-ray (lateral). d Final X-ray (anteroposterior). C o lo r v er si o n av ai la b le o n lin e