- Email: [email protected]
B3 Periprosthetic Fractures of the Femur
Accepted Manuscript Modified extended trochanteric osteotomy for the treatment of Vancouver B2/B3 periprosthetic fractures of the femur Andreas Ladurner, MD, Pia Zurmühle, MD, Vilijam Zdravkovic, MD, Karl Grob, MD PII:
S0883-5403(17)30199-7
DOI:
10.1016/j.arth.2017.02.079
Reference:
YARTH 55722
To appear in:
The Journal of Arthroplasty
Received Date: 17 November 2016 Revised Date:
13 February 2017
Accepted Date: 27 February 2017
Please cite this article as: Ladurner A, Zurmühle P, Zdravkovic V, Grob K, Modified extended trochanteric osteotomy for the treatment of Vancouver B2/B3 periprosthetic fractures of the femur, The Journal of Arthroplasty (2017), doi: 10.1016/j.arth.2017.02.079. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Titel Page
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Modified extended trochanteric osteotomy for the treatment of Vancouver B2/B3 periprosthetic fractures of the femur Andreas Ladurner, MD; Pia Zurmühle, MD; Vilijam Zdravkovic, MD; Karl Grob, MD
Corresponding author: Andreas Ladurner, MD Department of Orthopedics and Traumatology
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Department of Orthopedics and Traumatology, Kantonsspital St. Gallen, St. Gallen, Switzerland
Phone: 0041 (0)71 494 11 11
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Email: [email protected]
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Modified extended trochanteric osteotomy for the treatment of Vancouver B2/B3 periprosthetic fractures of the femur
Abstract
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Background: Femoral component revision is the treatment of choice for Vancouver type B2/3 periprosthetic femur fractures (PFF). The purpose of this study was to report the clinical
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outcome of revision total hip arthroplasty (THA) with the use of a modified extended
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trochanteric osteotomy (ETO) in PFF treatment.
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Methods: 43 cases between 2000 and 2014 were analyzed. Clinical and radiographic
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evaluation was performed with a mean follow up of 40 months. Patient survival following
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revision surgery, complications, radiographic outcomes as well as quality of life and hip
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function were assessed.
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Results: Merle d'Aubignè and Postel score averaged 15 and mean postoperative Harris hip
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score was 70. Radiographic evaluation revealed that the ETO and fractures healed in all but
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one patient within 9 months. Component stability and apparent osseointegration were not
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coincident with healing of the osteotomy and fracture sites proximal to the inserted stem. Six
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patients (15%) developed postoperative complications, these included: one non-union with
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progressive subsidence, two hip dislocations, two deep infections, and one breakage of the
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modular junction of the revision stem.
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Conclusion: The modified ETO with a lateral approach to the hip for the treatment of PFF is
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compatible with fracture healing, a low dislocation rate and good clinical results. However,
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component stability and apparent osseointegration are coincident with fracture healing only
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in the distal aspect of the inserted stem. Absence of proximal osseointegration might lead to
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poor osseous support resulting in inadequate fatigue strength at the junction of the dual
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modular revision stem.
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Keywords: Total hip arthroplasty (THA), periprosthetic femur fractures (PFF), extended
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trochanteric osteotomy (ETO), dual modular tapered stem
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Ethic: This study was approved by the local research ethics committee 1
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Funding: This research did not receive any specific grant from funding agencies in the public,
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commercial, or not-for-profit sectors
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Introduction
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The number of primary total hip arthroplasty is estimated to increase markedly during the
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coming decades [1,2]. Consequently, the number of revision of total hip arthroplasty will
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probably follow this development. Projection based on registry data indicate that the number
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of revision cases will double by the year 2026 [3]. Periprosthetic femoral fracture (PFF)
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occurring after THA implantation is one of the most common causes of revision surgery after
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aseptic loosening, osteolysis, pain and dislocation [4]. The reported incidence of PFF can be
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estimated up to 15% [5] and varies according to patient demographics, implants and
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technologies used, as well as the length of follow up [3,6,7]. PFF often occurs in elderly
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patients and predominantly results from low energy trauma with or without the presence of
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osteolytic changes around the femoral component. It has been shown that up to 82% of all
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postoperative PFF are associated with loose implants [8].
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Femoral component revision is the preferred method of treatment for Vancouver B2 and B3
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periprosthetic femur fractures, as the femoral component is loose [3,6,8–10]. The lack of
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metaphyseal support requires a revision stem that bypasses the defect. Options for
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treatment include cylindrical, non-modular cobalt-chromium stems, tapered, fluted modular
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titanium stems, long cemented stems, tumour prostheses and allograft composites. Modular
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stems allow the surgeon increased axial and rotational implant control together with more
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flexibility during the revision procedure to restore leg length and enhance implant stability.
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Revising femoral components after PFF can be technically demanding with several
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associated risks and complications. Reoperation rates of 23% and a postoperative
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complication rate of 18% have been reported [11]. In standard revision THA, exposure for
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implanting such femoral components can be simplified with the use of an extended
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trochanteric osteotomy (ETO) [10,12–14]. The outcomes of converting the periprosthetic
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femoral fracture into an ETO at the time of revision THA has proved successful in a small
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series of patients [13,15,16]. Including the fracture as a part of the ETO allows wide
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exposure and a direct access to the femoral diaphysis for implantation of the revision
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components. Recent literature demonstrates that the ETO has a relatively low rate of
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nonunion and is associated with fewer intraoperative femoral fractures or cortical
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perforations, as well as decreased surgical time [17–19]. However, with the traditional ETO
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technique that utilizes a posterior approach to the hip joint [20] and the release of the 2
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external rotators, a dislocation rate of up to 30% has been reported [3,4,14,15,21,22]. The
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purpose of this retrospective study was to report the clinical outcome of revision THA with the
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use of a modified ETO [10,14,19,23] for the treatment of Vancouver B2 and B3 periprosthetic
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fractures of the femur.
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Material and Methods
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We conducted a retrospective chart and radiographic review of 43 consecutive patients had
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undergone treatment for Vancouver B2 (N=40) and B3 (N=3) fractures with the use of a
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modified ETO at our institution between January 2000 and January 2014. Institutional review
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board approval was obtained. The study group consisted of 23 females and 20 males with a
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mean age at time of fracture treatment of 77.5 years (range 58 to 95 years). The right side
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was affected in 25/43 patients. All patients had a prior total hip arthroplasty performed either
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through an anterlateral or transgluteal approach. In 34 cases (79%) the femoral component
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had been uncemented and in 9 cases (21%) cemented fixation was used.
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The mean interval between THA and the PFF was 8.8 years (range 2 weeks to 29 years). 95
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% (41 patients) of the fractures occurred because of a fall from a level height or a twisting
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movement, and 5% (2 patients) were associated with high-energy mechanism of injury.
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Preoperatively, 33 patients were ambulatory with 22 maintaining an unassisted gait, 8 used
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canes, and 3 used a walker. 2 patients were wheelchair bound. However, pretraumatic
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mobility could not be assessed retrospectively in 8 patients.
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Clinical notes and radiographs were retrospectively evaluated for 40/43 patients. Three
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patients were lost to follow up. Patients were planned for clinical and radiographic follow up
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at eight weeks, six months, one year and two years after surgery (range 12 to 114 months
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post-surgery). Clinical assessment focussed on hip range of motion, walking ability
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(including the need for walking aids) and hip function. 29 out of the 40 patients underwent
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additional clinical and radiographic final follow up visit including a standardized questionnaire
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incorporating the Harris Hip score and Merle d’Aubigné and Postel pain and walking scores
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between March and September 2015. Eleven patients had died before final follow up
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evaluation of causes unrelated to revision THA surgery. In those cases, the patient’s general
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practitioner (GP) was interviewed about any further surgery on the index hip. According to
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the GP, no revision surgery was performed in the deceased patients. Kaplan-Meier
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calculations were performed and survivorship curves generated with aseptic loosening of the
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femoral components and revision surgery as end points.
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The following intra- and postoperative parameters were assessed from the chart review:
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Type and size of implant, mode of trochanter fixation, the number of cable wires used, the 3
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estimated blood loss, the need for intra- or postoperative blood transfusion, and
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complications. Concomitant procedures included revision of the acetabular component in one
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case due to malpositioning and a polyethylene liner exchange in one case.
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a standardized antero-posterior (AP) view of the pelvis as well as a lateral view of the
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affected hip and total femur. X-Rays taken immediately postsurgery and at each subsequent
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visit (8 weeks, 6 months, 1 year, 2 years and (in 29 Patients) at the time of final review) were
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analysed. Preoperative radiographs for all patients were evaluated and classified according
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to the Vancouver classification system [9,21]. The immediate postoperative radiographs
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served as a baseline, to which all other postoperative views were compared. All radiographic
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measurements were made by one orthopaedic surgeon who was not involved in the
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surgeries and focussed on implant stability and fracture union.
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Ingrowth of the femoral components over time was studied and assessed according to the
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classification of Engh et al. [24]. Fixed landmarks on the prosthesis (e.g. the modular
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junction) and the femur (e.g. tip of greater tuberosity, cerclage cables) were measured and
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subsidence was recorded if there was any change between these distances. Stems were
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classified as osseointegrated if there was increased density of bone adjacent the stem and if
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diverging radiolucent lines and prosthetic subsidence were absent.
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Clinical (no pain with weight bearing, palpation, or stressing of the site) and radiographic
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(bridging callus) evidence was used to determine the time of fracture healing.
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The overall outcome was graded using the system of Beals and Tower [25]. Excellent results
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included a stable arthroplasty and fracture union with minimal deformity or shortening.
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Fracture healing with moderate deformity/shortening and a stable subsidence of the femoral
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component classified the result as good. A loose component (regardless of pain status), non-
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union, sepsis, a new fracture or severe femoral deformity/shortening defined a poor result.
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Surgical Technique
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A cementless, tapered fluted dual modular titanium revision stem (Revitan® stem, Zimmer,
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Winterthur, Switzerland) was selected for all cases. This implant has a 2° taper and a
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reinforced junction to reduce the risk of stem breakage and is available with a straight or
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curved distal stem in combination with a spout or cylindrical proximal component. In our
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series, the curved stem in combination with a cylindrical proximal component was always
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used. Preoperative planning was performed in every case. Templates were used to estimate
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the diameter and length of the revision component required.
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A modified extended trochanteric osteotomy was used in all cases [10,14,19,23]. In a lateral
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decubitus position a lateral subvastus approach to the femur was performed (Fig 1a). The 4
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through the lateral intermuscular septum. The intermuscular septum was regarded as an
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anatomical limit for dorsal exposure. Therefore, the linea aspera was not exposed. No
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muscle fibres were stripped from the bone. Bone fragments were left attached to the
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surrounding tissue and care was taken to preserve the periosteum to the bone fragments
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[26]. The distal end of the fracture was then identified. A prophylactic cerclage cable was
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placed around the femur just distal to the extent of the fracture site to prevent propagation,
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as the canal was prepared for stem insertion later on. Depending on the integrity of the
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greater trochanter (fracture line, amount of osteolysis) the proximal osteotomy was either
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centred in the middle of the greater trochanter or at the junction between the dorsal and
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anterior two thirds of the greater trochanter. Care was taken, that any valuable trochanteric
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bone fragment remained in contact with the external rotators for final fixation. The posterior
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joint capsule was preserved. An extended osteotomy of the greater trochanter was made in a
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lateral to medial direction, centred over the anterior edge of the prosthetic stem,
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encompassing the anterior half of the circumference of the femoral canal. The osteotomy
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was performed with an oscillating saw and completed medially with an osteotome (Fig 1b).
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Whenever possible, the fracture line was included into the osteotomy. The length of the
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trochanteric osteotomy was planned to extend to the distal aspect of the fracture line. The
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osteotomized anterior trochanteric fragment together with the fractured bone fragments were
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reflected anteriorly along with the attached abductors and vastus lateralis, intermedius and
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tensor vastus intermedius. Anterior dislocation of the prosthetic hip was performed, the
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femoral component was extracted and debridement of the fracture fragments was performed
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removing intervening soft tissue or bone cement (Fig 1c). Whenever needed, revision of the
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acetabular component was performed. Obstruction of the femoral canal distal to the previous
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implanted stem was removed by use of a medullary cavity reamer. The femoral bone stock
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was further prepared using rasps of a progressively increasing size until distal circular
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surface fixation in the isthmus region of the femur was achieved. Trial femoral components
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were inserted prior to implantation of the definitive component. An implantation length in the
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intact distal femur twice the width of femoral diaphysis was necessary to obtain the definitive
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distal curved component. The modular portions were used to reproduce optimal implant
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length and antetorsion. Assembly of the cylindrical proximal component used was always
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done in situ after the curved stem was fully seated (Fig 1d). After reduction, the proximal
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fragments were draped around the implant and stabilized using 2mm Dall Miles cerclages
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(Fig 2). Reduction and osteosynthesis of the greater trochanter fragment was performed
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either with the use of a cerclage wire passed around the subtrochanteric bone fragments or
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through a transtrochanteric cannulated screw in combination with 1.5mm wires proximally
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osteolysis, the fragments were fixed by osteosutures only (Fig. 5).
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As recommended [27] the cerclage wires were always passed around the bone distal to the
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lesser trochanter. A bone graft from the greater trochanter (if available and left from the
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trochanteric preparation) was placed at the fracture site to assist healing of the osteotomy
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and fracture. Intraoperative radiographs were obtained optionally. The postoperative regimen
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consisted of partial weight bearing for 8 weeks (if possible) and progressive weight bearing
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thereafter.
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Results
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43 patients were treated for Vancouver B2 and B3 fractures with the use of a modified ETO
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at our institution between January 2000 and January 2014. Three were lost at follow up (one
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died four days after surgery due to causes unrelated to surgery and two patients were re-
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assessed at a different institution). Evaluation of 29 patients at the final follow up visit
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included a standardized questionnaire incorporating the Harris Hip score and Merle
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d’Aubigné and Postel pain and walking scores. Eleven patients had died before final follow
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up evaluation of causes unrelated to revision THA surgery.
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Overall mean length of follow up was 40 months (range 12 to 114 months), the mean follow
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up for the eleven patients that had died before final visit was 13.4 months (range 6 to 33
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months).
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203 Radiographic results
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Radiographic evidence of fracture healing was achieved in all but one patient. The mean
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time for ETO and fracture site healing in 39/40 patients was 9.1 months (Fig. 3).
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Osseointegration especially in the proximal part of the inserted stem was not coincident with
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healing of the osteotomy and fracture sites. The earliest osseointegration of the tapered
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fluted modular titanium revision stem occurred in the dorsal and lateral aspect of the femur in
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Gruen zone 3, 4, 5, 10, 11, 12, followed by zone 2, 1, 9, 13 and lastly in the area of Gruen
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zone 6, 7, 8 and 14 below the lesser trochanter (Fig. 6). No clear evidence or absence of
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osseointegration of the revision stem in the latter Gruen zones was noted in 19/40 cases
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(47.5%). The subtrochanteric ETO and fracture fragments were fixed with an average of 3
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cerclages. The average osteotomy length at time of revision was 135 mm (range 68 to 188
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mm). Depending on the bone quality of the greater trochanter the fixation of the ETO
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fragment occurred with osteosuture only (5/40), intraosseous cables in combination with
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cannulated screws (20/40) (Fig. 2) or subtrochanteric cable wire (15/40) (Fig. 3). Dislocation
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of the greater trochanter fragment of more than 1cm occurred in 3 patients. Heterotopic 6
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they were classified grade I in 1/6, grade II in 3/6, grade III in 1/6 and grade IV in 1/6
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patients. Subsidence of the Revitan stem was noted in 3/40 cases in the first six
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postoperative months. In one case each subsidence was 6mm and 8 mm, but they were
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found to stabilize without further change at the latest follow-up. In one case symptomatic
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subsidence of 32mm occurred. A stem revision was required due to concomitant failed
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fracture healing and aseptic loosening. In the remaining 37/40 cases no measurable
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subsidence occurred. 39/40 femoral components demonstrated evidence of osseointegration
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based on the criteria of Engh et al. [24].
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228 Clinical results
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The mean postoperative Harris hip score was 70/100 points, and Merle d'Aubignè and Postel
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score averaged 15/18. Postoperative mean range of motion was 98.2° flexion (range 35° to
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120°) and -6° extension (range -10° to 0°). Mean in ternal and external rotation was 13.4°
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(range -10° to 40°) and 37.4° (range 15° to 75°) re
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34.4° (range 5° to 70°). At the latest available fo llow up, 6 patients exhibited a positive
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Trendelenburg sign. 21/40 patients (52.5%) walked fluently without assistance; 18/40
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patients were using a gait assisting device (11 required one or two canes and seven used
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walkers), and one patient was wheelchair bound due to general weakness. According to the
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Beals and Tower classification, there were 31/40 excellent, 5/40 good and 4/40 poor results.
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The mean intraoperative blood loss was 900ml. However, in 2/40 patients, the blood loss
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could not be reviewed retrospectively. 21/40 patients (53%) suffered from symptomatic
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anaemia requiring erythrocyte concentrate transfusion (ten patients required both intra- and
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postoperative transfusions, two patients had intraoperative blood cell transfusion, nine had
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postoperative transfusions). Mean transfusion rate in those 21 patients were 3 erythrocyte
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concentrates.
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Complications
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There were a total of 6/40 patients that developed postoperative complications (15 %). Five
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(12.5%) required further revision surgery. One patient (2.5%) developed non-union at the
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fracture site due to progressive subsidence up to 32mm. Two patients (5%) had dislocations,
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one requiring revision of the acetabular component while the other patient was treated
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conservatively after reposition. Two patients (5%) developed deep infections and of these the
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one with an acute infection was successfully treated with lavage and component exchange
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while the second patient with infection ten weeks postoperatively necessitated a full two-
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stage exchange arthroplasty. One patient (2.5%) sustained a fracture of the modular junction
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of the tapered and distally well fixed revision stem (Fig. 7). Despite at first glance not evident 7
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broken dual modular stem in the Gruen zones 6, 7 and 8. One direct surgery related
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complication was observed. Immediately postoperative, the patient was diagnosed with
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active bleeding from the descending branch of the lateral circumflex femoral artery, caused
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by intraoperative erosion while placing a cerclage wire. The problem was solved by
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angiographic coiling. Prolonged serous wound effusion of more than 14 days was noted in
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three cases. All of which resolved spontaneously without further intervention.
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Discussion
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Treatment of periprosthetic femoral fractures can be challenging, and high rates of
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complications, re-operations and early mortality are reported throughout the literature
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[8,11,29,30]. Clinical outcomes are often poor, and substantially burden the patients.
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Treatment goals consist of a stable joint, fracture healing and the return to pre-fracture
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function. Femoral component revision is the preferred method of treatment of Vancouver B2
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and B3 periprosthetic fractures.
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The extended trochanteric osteotomy (ETO) is known to be a useful technique for complex
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revision THA [13,14]. The two commonly used techniques are the standard ETO via a
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posterior approach or the modified ETO via a lateral approach. The traditional standard ETO
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technique as described by Younger et al [20] utilizes the posterior approach to the hip, with
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release of the external rotators, incision of the posterior joint capsule and posterior surgical
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dislocation. In the modified ETO technique, a lateral approach with osteotomy of the greater
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trochanter in its mid-portion is performed [10,14,19,23]. The modified ETO preserves the
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posterior capsule and external rotator attachments. The anterior joint capsule is incised and
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the dislocation and removal of the implant can be performed anteriorly without impairment to
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the posterior joint capsule and external rotators [10,19]. As the hip joint is advanced from
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distal through the extended trochanteric fragments violence to the abductor muscles e.g.
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gluteus medius and minimus muscles can be limited to the first three centimetres proximal to
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the tip of the greater trochanter (Fig. 1d), leaving the superior gluteal nerve untouched. It can
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be argued that performing an ETO in the setting of PFF will increase the number of fracture
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fragments. However, the fracture line can be included into the osteotomy if applicable. Our
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study results indicate that healing of the ETO can still be expected. Both techniques, the
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traditional and modified ETO provide wide exposure of the acetabulum, facilitate femoral
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component exposure and removal, aid in canal preparation and femoral reconstruction, and
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allow for correction of proximal femoral deformity [17,19]. An advantage of the ETO is that 8
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intermedius and tensor vastus intermedius can be preserved. The soft tissue attachment with
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its blood supply and large surface area of contact helps in healing the osteotomy.
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Only few authors have described the ETO in periprosthetic fractures. Levine et al. [13]
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reported his outcomes performed in 14 periprosthetic fractures. He used the standard ETO
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technique with posterior surgical dislocation. The ETO healed in all 14 hips within 13 weeks.
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Though there was a total of 5 (36%) postoperative complication in this series, none of the
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complications were related to the ETO. Drexler et al. [14] reported the use of a modified ETO
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in 34 patients with Vancouver B2/3 periprosthetic femur fractures treated with revision THA.
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They reported union in 33 out of 34 hips with survival rate of 88.2% after a mean follow-up of
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57 months.
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Despite excellent rates of fracture union, the most common complication after revision THA
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for a periprosthetic fracture is dislocation. Postoperative dislocation using the standard ETO
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has been reported to range from 7% to 30% [8,13]. In our series only two patients (5%)
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sustained a hip dislocation. While the modified ETO showed a lower dislocation rate, a
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higher incidence of trochanteric fracture and postoperative trochanteric dislocation may occur
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when compared to the standard ETO [19,31]. In the present study dislocation of the greater
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trochanter fragment of more than 1cm occurred in 3 patients (7.5%). Migration of the greater
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trochanter with the use of ETO has been reported by others [18].
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In 39/40 patients in the present series there was healing of both the femur fracture and the
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ETO. The above results are similar to others [13,14,16,19,30] where a union rate of 91% to
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100% with the use of ETO has been reported. Surgical techniques in the current study
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emphasised fracture healing, the preservation of the external rotator attachments, soft tissue
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handling and the avoidance of unnecessary exposure of the linea aspera, where the vessels
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enter the femur [26]. However, while osseointegration occurred rapidly in zone 3 to 5 and 10
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to 12 osseointegration was not evident radiologically in Gruen zone 6, 7, 8 and 14 at latest
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follow-up in 47.5% (Fig. 5). This area corresponds to the modular junction of the prosthetic
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stem and due to the lack of bony support, could be the reason for stem failure in this area as
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described in the literature [32]. Therefore, the shorter the proximal modular stem the higher
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the chance that the modular junction is situated in the zones where the osseointegration is
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absent. The lack of proximal bone restoration might be due to the fact that load transfer
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occurs through the tapered wedge portion of the distal stem and the proximal portion of the
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stem is bypassed and therefore does not stimulate bone ongrowth. Poor proximal osseous
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support causing inadequate fatigue strength in the prosthesis has been mentioned by others
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[33,34]. In one patient in the present study, the breakage of the dual modular stem occurred
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where no osseointegration was observed proximal to the junction (Fig. 7).
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ACCEPTED MANUSCRIPT Subsidence rates show a wide variance throughout the literature. Fink et al [35] reported no
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subsidence in a case series of 23 patients despite two patients who did not achieve bony
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ingrowth fixation. Others observed subsidence occurring in up to 50% of cases within 6
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months of surgery [5,6]. Bohm et al [36] suggested that the degree of subsidence correlated
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with the extent of preoperative femoral bone stock especially in the diaphysis, as well as with
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the quality of osseointegration and degree of osteoporosis. In the present study, early
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femoral component subsidence was noted in 3 cases (7.5%). One patient needed a second
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revision due to subsequent aseptic loosening. In two patients the subsidence was
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subsequently non-progressive and associated with femoral component osseointegration.
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All the patients in the present series were treated using a dual modular, tapered and distally
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fixed, non-cemented titanium alloy (TiAL6Nb7) revision stem (Revitan®, Zimmer GmbH,
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Winterthur, Switzerland). Modular fluted tapered stems have been used to treat Vancouver
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B2 and B3 fractures before [5,16,22,37].
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Breakage of the modular junction as mentioned above can be a possible concern when using
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modular implants. Modularity probably increases the complication rate and might make the
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implants susceptible to corrosion, fretting or fatigue fracture at the modular junction [32–
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34,38]. Factors associated with increased risk of prosthetic fracture are high patient body
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weight or BMI, high patient activity level, small stem diameter, poor proximal osseous
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support, the use of extended trochanteric osteotomy (ETO), and varus orientation of the stem
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[32–34]. Richards et al. [39] reported 4 cases of stem breakage at the modular junction in a
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series of 109 patients after a mean follow up of 37 months. The author stated that all of the
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stem fractures occurred in older implant designs that are no longer in use, but that stem
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breakage was not observed with newer designs. Van Houwelingen et al. [37] showed similar
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results with five stem fractures in a series of 48 patients after a mean follow up of 84 months.
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Also this series analysed the original standard stem design that has now been modified.
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Overall implant survivorship was 90%. Norman et al. [32] reported two cases of a Revitan
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stem failure with breakage of the modular junction in two active male patients. In their
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analysis, undersizing of the stem diameter at the modular junction relative to the
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characteristics of the patients was stated as a possible cause. Nasr et al. [38] reported a
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single case of a fractured connection taper in a Revitan stem, highlighting that fractures can
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still occur with modern modular prostheses. The failure of the Revitan stem in the present
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study was initiated by a traumatic impact onto the hip due to fall from a bicycle which might
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have caused a fatigue crack of the modular junction. Therefore, while midterm survivorship of
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modular titanium stems are considered high, continued surveillance of stem junctional fatigue
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is required.
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The average Harris hip score in the present series was 70/100 points, and Merle d'Aubignè
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and Postel score averaged 15/18. Although this is a relatively low score and does not
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represent a return to a high level of function it is more likely related to the significant medical
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comorbidities, frail nature, and limited preoperative activity levels in these patients. Abdel et
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al. [22] reported a mean Harris hip score of 83, 4.5 years postoperatively in a series of 44
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patients. Several studies have also confirmed these low postoperative Harris hip scores
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ranging from 59 to 71 following treatment for periprosthetic femoral fractures [13,16,40–42].
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The main objectives when treating periprosthetic fractures are fracture union and reduced
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pain. Although unassisted ambulation is always a goal for these patients, in the present
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series only 18/40 patients (48%) walked fluently without assistance. 6/40 patients showed a
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positive Trendelenburg sign at final follow up. The relatively high rate of limping might be
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contributed to general weakness of a rather old patient cohort and may be due to multiple
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surgical interventions prior to PFF. Several studies have shown that typically 50% or more
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patients will require a postoperative assistive device and maintain a limited ambulatory status
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[3,14,39]. The presence of a positive Trendelenburg sign was not mentioned in previous
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papers.
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382 Complications
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Revision surgery was necessary in 12.5% of our patients (5 out of 40). The most common
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cause was infection (2 patients, 5%), with one necessitating a two-stage exchange, other
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causes were one subsidence, a recurrent dislocation, and a stem breakage. The latter two
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were associated with another trauma and not directly related to the previous surgery. The
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Swedish national hip registry shows a postoperative complication rate (requiring revision
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surgery) of 18% after PFF treatment [3]. Springer et al. [43] reviewed 116 patients (118 hips)
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after periprosthetic fracture treatment and reported a revision rate for loosening, non-union,
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recurrent dislocation, re-fracture or infection of 17% at the latest follow up of 5.4 years
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postoperative. Implants used were either cemented stems, proximally porous-coated or
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extensively porous-coated stems, allograft-prosthesis composite or tumour prosthesis. Abdel
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et al. [22] reported a series with comparable follow up time (mean 4.5 years) and number of
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cases (n=44). Treatment modality was similar to our series, using a modular fluted, tapered
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stems and (in many cases) an ETO. The reoperation rate in this series was 18% (7 out of
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44), mostly due to recurrent dislocation (5 out of 8 revisions).
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Conclusion 11
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In conclusion, the modified ETO with a lateral approach to the hip for the treatment of PFF is
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compatible with fracture healing, a low dislocation rate and good clinical results. However,
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component stability and apparent osseointegration are coincident with fracture healing in the
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distal aspect of the inserted stem only and not proximal. Absence of proximal
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osseointegration might lead to poor osseous support resulting in inadequate fatigue strength
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at the junction of the dual modular revision stem.
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Limitations of the present study include the retrospective design and relatively short time to
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follow up. Furthermore, patients’ preoperative medical condition may have some influence on
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the postoperative outcome.
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Figure Legend Page
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Fig. 1: Surgical technique: lateral subvastus approach to the femur (a), performing the osteotomy by use of an oszillating saw (b), opening the osteotomy and extraction of the prosthesis (c), assembly of the cylindrical proximal component in situ after the curved stem was fully seated (d)
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Fig. 2: Corresponding plain radiographs to the clinical case in Fig. 1. Preoperative (a), postoperative radiography (b)
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Fig. 3: PFF treatment in a 58 year old patient. PFF (a), postoperative radiography (b), result
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5 years postoperatively (c)
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Fig. 4: PFF treatment in a 78 year old patient. PFF (a), postoperative radiography, refixation of the greater trochanter by using intraosseous cables in combination with cannulated screws
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(b), fracture healing 6 months after surgery (c)
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Fig. 5: PFF with stem breakage after fall from level hight in a 76 year old patient. PFF (a), treatment with stem exchange, refixation of greater trochanter with sutures due to extensive
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bone loss (b), twelve years after stem exchange (c)
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Fig. 6a and 6b: radiographic osseointegration of the implant over time (ap view, axial view)
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Zone of primary osseointegration (Gruen zone 3,4,5,10,11,12) Zone of secondary osseointegration (Gruen zone 1,2,9, 13) Zone of tertiary (latest) osseointegration (Gruen zone 6,7,8,14)
a
b
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Fig. 7: Stem breakage after PFF treatment, solved by stem exchange. PFF (a), stem exchange via modified ETO (b), stem breakage at the modular junction 5 years after PFF treatment (c), treatment with stem exchange (d)
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S0883-5403(17)30199-7
DOI:
10.1016/j.arth.2017.02.079
Reference:
YARTH 55722
To appear in:
The Journal of Arthroplasty
Received Date: 17 November 2016 Revised Date:
13 February 2017
Accepted Date: 27 February 2017
Please cite this article as: Ladurner A, Zurmühle P, Zdravkovic V, Grob K, Modified extended trochanteric osteotomy for the treatment of Vancouver B2/B3 periprosthetic fractures of the femur, The Journal of Arthroplasty (2017), doi: 10.1016/j.arth.2017.02.079. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Titel Page
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Modified extended trochanteric osteotomy for the treatment of Vancouver B2/B3 periprosthetic fractures of the femur Andreas Ladurner, MD; Pia Zurmühle, MD; Vilijam Zdravkovic, MD; Karl Grob, MD
Corresponding author: Andreas Ladurner, MD Department of Orthopedics and Traumatology
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Kantonsspital St. Gallen Rorschacherstrasse 95
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9007 St. Gallen Switzerland
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Department of Orthopedics and Traumatology, Kantonsspital St. Gallen, St. Gallen, Switzerland
Phone: 0041 (0)71 494 11 11
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Fax: 0041 (0)71 494 28 69
Email: [email protected]
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Modified extended trochanteric osteotomy for the treatment of Vancouver B2/B3 periprosthetic fractures of the femur
Abstract
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Background: Femoral component revision is the treatment of choice for Vancouver type B2/3 periprosthetic femur fractures (PFF). The purpose of this study was to report the clinical
11
outcome of revision total hip arthroplasty (THA) with the use of a modified extended
12
trochanteric osteotomy (ETO) in PFF treatment.
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Methods: 43 cases between 2000 and 2014 were analyzed. Clinical and radiographic
15
evaluation was performed with a mean follow up of 40 months. Patient survival following
16
revision surgery, complications, radiographic outcomes as well as quality of life and hip
17
function were assessed.
18 19
Results: Merle d'Aubignè and Postel score averaged 15 and mean postoperative Harris hip
20
score was 70. Radiographic evaluation revealed that the ETO and fractures healed in all but
21
one patient within 9 months. Component stability and apparent osseointegration were not
22
coincident with healing of the osteotomy and fracture sites proximal to the inserted stem. Six
23
patients (15%) developed postoperative complications, these included: one non-union with
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progressive subsidence, two hip dislocations, two deep infections, and one breakage of the
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modular junction of the revision stem.
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Conclusion: The modified ETO with a lateral approach to the hip for the treatment of PFF is
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compatible with fracture healing, a low dislocation rate and good clinical results. However,
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component stability and apparent osseointegration are coincident with fracture healing only
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in the distal aspect of the inserted stem. Absence of proximal osseointegration might lead to
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poor osseous support resulting in inadequate fatigue strength at the junction of the dual
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modular revision stem.
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Keywords: Total hip arthroplasty (THA), periprosthetic femur fractures (PFF), extended
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trochanteric osteotomy (ETO), dual modular tapered stem
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Ethic: This study was approved by the local research ethics committee 1
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Funding: This research did not receive any specific grant from funding agencies in the public,
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commercial, or not-for-profit sectors
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Introduction
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The number of primary total hip arthroplasty is estimated to increase markedly during the
45
coming decades [1,2]. Consequently, the number of revision of total hip arthroplasty will
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probably follow this development. Projection based on registry data indicate that the number
47
of revision cases will double by the year 2026 [3]. Periprosthetic femoral fracture (PFF)
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occurring after THA implantation is one of the most common causes of revision surgery after
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aseptic loosening, osteolysis, pain and dislocation [4]. The reported incidence of PFF can be
50
estimated up to 15% [5] and varies according to patient demographics, implants and
51
technologies used, as well as the length of follow up [3,6,7]. PFF often occurs in elderly
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patients and predominantly results from low energy trauma with or without the presence of
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osteolytic changes around the femoral component. It has been shown that up to 82% of all
54
postoperative PFF are associated with loose implants [8].
55
Femoral component revision is the preferred method of treatment for Vancouver B2 and B3
56
periprosthetic femur fractures, as the femoral component is loose [3,6,8–10]. The lack of
57
metaphyseal support requires a revision stem that bypasses the defect. Options for
58
treatment include cylindrical, non-modular cobalt-chromium stems, tapered, fluted modular
59
titanium stems, long cemented stems, tumour prostheses and allograft composites. Modular
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stems allow the surgeon increased axial and rotational implant control together with more
61
flexibility during the revision procedure to restore leg length and enhance implant stability.
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Revising femoral components after PFF can be technically demanding with several
63
associated risks and complications. Reoperation rates of 23% and a postoperative
64
complication rate of 18% have been reported [11]. In standard revision THA, exposure for
65
implanting such femoral components can be simplified with the use of an extended
66
trochanteric osteotomy (ETO) [10,12–14]. The outcomes of converting the periprosthetic
67
femoral fracture into an ETO at the time of revision THA has proved successful in a small
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series of patients [13,15,16]. Including the fracture as a part of the ETO allows wide
69
exposure and a direct access to the femoral diaphysis for implantation of the revision
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components. Recent literature demonstrates that the ETO has a relatively low rate of
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nonunion and is associated with fewer intraoperative femoral fractures or cortical
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perforations, as well as decreased surgical time [17–19]. However, with the traditional ETO
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technique that utilizes a posterior approach to the hip joint [20] and the release of the 2
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external rotators, a dislocation rate of up to 30% has been reported [3,4,14,15,21,22]. The
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purpose of this retrospective study was to report the clinical outcome of revision THA with the
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use of a modified ETO [10,14,19,23] for the treatment of Vancouver B2 and B3 periprosthetic
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fractures of the femur.
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Material and Methods
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We conducted a retrospective chart and radiographic review of 43 consecutive patients had
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undergone treatment for Vancouver B2 (N=40) and B3 (N=3) fractures with the use of a
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modified ETO at our institution between January 2000 and January 2014. Institutional review
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board approval was obtained. The study group consisted of 23 females and 20 males with a
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mean age at time of fracture treatment of 77.5 years (range 58 to 95 years). The right side
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was affected in 25/43 patients. All patients had a prior total hip arthroplasty performed either
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through an anterlateral or transgluteal approach. In 34 cases (79%) the femoral component
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had been uncemented and in 9 cases (21%) cemented fixation was used.
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The mean interval between THA and the PFF was 8.8 years (range 2 weeks to 29 years). 95
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% (41 patients) of the fractures occurred because of a fall from a level height or a twisting
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movement, and 5% (2 patients) were associated with high-energy mechanism of injury.
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Preoperatively, 33 patients were ambulatory with 22 maintaining an unassisted gait, 8 used
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canes, and 3 used a walker. 2 patients were wheelchair bound. However, pretraumatic
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mobility could not be assessed retrospectively in 8 patients.
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Clinical notes and radiographs were retrospectively evaluated for 40/43 patients. Three
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patients were lost to follow up. Patients were planned for clinical and radiographic follow up
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at eight weeks, six months, one year and two years after surgery (range 12 to 114 months
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post-surgery). Clinical assessment focussed on hip range of motion, walking ability
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(including the need for walking aids) and hip function. 29 out of the 40 patients underwent
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additional clinical and radiographic final follow up visit including a standardized questionnaire
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incorporating the Harris Hip score and Merle d’Aubigné and Postel pain and walking scores
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between March and September 2015. Eleven patients had died before final follow up
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evaluation of causes unrelated to revision THA surgery. In those cases, the patient’s general
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practitioner (GP) was interviewed about any further surgery on the index hip. According to
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the GP, no revision surgery was performed in the deceased patients. Kaplan-Meier
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calculations were performed and survivorship curves generated with aseptic loosening of the
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femoral components and revision surgery as end points.
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The following intra- and postoperative parameters were assessed from the chart review:
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Type and size of implant, mode of trochanter fixation, the number of cable wires used, the 3
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estimated blood loss, the need for intra- or postoperative blood transfusion, and
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complications. Concomitant procedures included revision of the acetabular component in one
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case due to malpositioning and a polyethylene liner exchange in one case.
113 For radiological evaluation, all patients underwent pre-operative X-ray examination including
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a standardized antero-posterior (AP) view of the pelvis as well as a lateral view of the
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affected hip and total femur. X-Rays taken immediately postsurgery and at each subsequent
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visit (8 weeks, 6 months, 1 year, 2 years and (in 29 Patients) at the time of final review) were
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analysed. Preoperative radiographs for all patients were evaluated and classified according
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to the Vancouver classification system [9,21]. The immediate postoperative radiographs
120
served as a baseline, to which all other postoperative views were compared. All radiographic
121
measurements were made by one orthopaedic surgeon who was not involved in the
122
surgeries and focussed on implant stability and fracture union.
123
Ingrowth of the femoral components over time was studied and assessed according to the
124
classification of Engh et al. [24]. Fixed landmarks on the prosthesis (e.g. the modular
125
junction) and the femur (e.g. tip of greater tuberosity, cerclage cables) were measured and
126
subsidence was recorded if there was any change between these distances. Stems were
127
classified as osseointegrated if there was increased density of bone adjacent the stem and if
128
diverging radiolucent lines and prosthetic subsidence were absent.
129
Clinical (no pain with weight bearing, palpation, or stressing of the site) and radiographic
130
(bridging callus) evidence was used to determine the time of fracture healing.
131
The overall outcome was graded using the system of Beals and Tower [25]. Excellent results
132
included a stable arthroplasty and fracture union with minimal deformity or shortening.
133
Fracture healing with moderate deformity/shortening and a stable subsidence of the femoral
134
component classified the result as good. A loose component (regardless of pain status), non-
135
union, sepsis, a new fracture or severe femoral deformity/shortening defined a poor result.
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Surgical Technique
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A cementless, tapered fluted dual modular titanium revision stem (Revitan® stem, Zimmer,
139
Winterthur, Switzerland) was selected for all cases. This implant has a 2° taper and a
140
reinforced junction to reduce the risk of stem breakage and is available with a straight or
141
curved distal stem in combination with a spout or cylindrical proximal component. In our
142
series, the curved stem in combination with a cylindrical proximal component was always
143
used. Preoperative planning was performed in every case. Templates were used to estimate
144
the diameter and length of the revision component required.
145
A modified extended trochanteric osteotomy was used in all cases [10,14,19,23]. In a lateral
146
decubitus position a lateral subvastus approach to the femur was performed (Fig 1a). The 4
ACCEPTED MANUSCRIPT lateral intermuscular septum perforating vessels were ligated two centimetres above the exit
148
through the lateral intermuscular septum. The intermuscular septum was regarded as an
149
anatomical limit for dorsal exposure. Therefore, the linea aspera was not exposed. No
150
muscle fibres were stripped from the bone. Bone fragments were left attached to the
151
surrounding tissue and care was taken to preserve the periosteum to the bone fragments
152
[26]. The distal end of the fracture was then identified. A prophylactic cerclage cable was
153
placed around the femur just distal to the extent of the fracture site to prevent propagation,
154
as the canal was prepared for stem insertion later on. Depending on the integrity of the
155
greater trochanter (fracture line, amount of osteolysis) the proximal osteotomy was either
156
centred in the middle of the greater trochanter or at the junction between the dorsal and
157
anterior two thirds of the greater trochanter. Care was taken, that any valuable trochanteric
158
bone fragment remained in contact with the external rotators for final fixation. The posterior
159
joint capsule was preserved. An extended osteotomy of the greater trochanter was made in a
160
lateral to medial direction, centred over the anterior edge of the prosthetic stem,
161
encompassing the anterior half of the circumference of the femoral canal. The osteotomy
162
was performed with an oscillating saw and completed medially with an osteotome (Fig 1b).
163
Whenever possible, the fracture line was included into the osteotomy. The length of the
164
trochanteric osteotomy was planned to extend to the distal aspect of the fracture line. The
165
osteotomized anterior trochanteric fragment together with the fractured bone fragments were
166
reflected anteriorly along with the attached abductors and vastus lateralis, intermedius and
167
tensor vastus intermedius. Anterior dislocation of the prosthetic hip was performed, the
168
femoral component was extracted and debridement of the fracture fragments was performed
169
removing intervening soft tissue or bone cement (Fig 1c). Whenever needed, revision of the
170
acetabular component was performed. Obstruction of the femoral canal distal to the previous
171
implanted stem was removed by use of a medullary cavity reamer. The femoral bone stock
172
was further prepared using rasps of a progressively increasing size until distal circular
173
surface fixation in the isthmus region of the femur was achieved. Trial femoral components
174
were inserted prior to implantation of the definitive component. An implantation length in the
175
intact distal femur twice the width of femoral diaphysis was necessary to obtain the definitive
176
distal curved component. The modular portions were used to reproduce optimal implant
177
length and antetorsion. Assembly of the cylindrical proximal component used was always
178
done in situ after the curved stem was fully seated (Fig 1d). After reduction, the proximal
179
fragments were draped around the implant and stabilized using 2mm Dall Miles cerclages
180
(Fig 2). Reduction and osteosynthesis of the greater trochanter fragment was performed
181
either with the use of a cerclage wire passed around the subtrochanteric bone fragments or
182
through a transtrochanteric cannulated screw in combination with 1.5mm wires proximally
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ACCEPTED MANUSCRIPT (Fig. 2, 3, 4). Where the trochanteric bone fragments were too weak due to pre-existing
184
osteolysis, the fragments were fixed by osteosutures only (Fig. 5).
185
As recommended [27] the cerclage wires were always passed around the bone distal to the
186
lesser trochanter. A bone graft from the greater trochanter (if available and left from the
187
trochanteric preparation) was placed at the fracture site to assist healing of the osteotomy
188
and fracture. Intraoperative radiographs were obtained optionally. The postoperative regimen
189
consisted of partial weight bearing for 8 weeks (if possible) and progressive weight bearing
190
thereafter.
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191
Results
193
43 patients were treated for Vancouver B2 and B3 fractures with the use of a modified ETO
194
at our institution between January 2000 and January 2014. Three were lost at follow up (one
195
died four days after surgery due to causes unrelated to surgery and two patients were re-
196
assessed at a different institution). Evaluation of 29 patients at the final follow up visit
197
included a standardized questionnaire incorporating the Harris Hip score and Merle
198
d’Aubigné and Postel pain and walking scores. Eleven patients had died before final follow
199
up evaluation of causes unrelated to revision THA surgery.
200
Overall mean length of follow up was 40 months (range 12 to 114 months), the mean follow
201
up for the eleven patients that had died before final visit was 13.4 months (range 6 to 33
202
months).
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203 Radiographic results
205
Radiographic evidence of fracture healing was achieved in all but one patient. The mean
206
time for ETO and fracture site healing in 39/40 patients was 9.1 months (Fig. 3).
207
Osseointegration especially in the proximal part of the inserted stem was not coincident with
208
healing of the osteotomy and fracture sites. The earliest osseointegration of the tapered
209
fluted modular titanium revision stem occurred in the dorsal and lateral aspect of the femur in
210
Gruen zone 3, 4, 5, 10, 11, 12, followed by zone 2, 1, 9, 13 and lastly in the area of Gruen
211
zone 6, 7, 8 and 14 below the lesser trochanter (Fig. 6). No clear evidence or absence of
212
osseointegration of the revision stem in the latter Gruen zones was noted in 19/40 cases
213
(47.5%). The subtrochanteric ETO and fracture fragments were fixed with an average of 3
214
cerclages. The average osteotomy length at time of revision was 135 mm (range 68 to 188
215
mm). Depending on the bone quality of the greater trochanter the fixation of the ETO
216
fragment occurred with osteosuture only (5/40), intraosseous cables in combination with
217
cannulated screws (20/40) (Fig. 2) or subtrochanteric cable wire (15/40) (Fig. 3). Dislocation
218
of the greater trochanter fragment of more than 1cm occurred in 3 patients. Heterotopic 6
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ACCEPTED MANUSCRIPT ossifications were diagnosed in 6/40 patients and according to the Brooker classification [28],
220
they were classified grade I in 1/6, grade II in 3/6, grade III in 1/6 and grade IV in 1/6
221
patients. Subsidence of the Revitan stem was noted in 3/40 cases in the first six
222
postoperative months. In one case each subsidence was 6mm and 8 mm, but they were
223
found to stabilize without further change at the latest follow-up. In one case symptomatic
224
subsidence of 32mm occurred. A stem revision was required due to concomitant failed
225
fracture healing and aseptic loosening. In the remaining 37/40 cases no measurable
226
subsidence occurred. 39/40 femoral components demonstrated evidence of osseointegration
227
based on the criteria of Engh et al. [24].
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228 Clinical results
230
The mean postoperative Harris hip score was 70/100 points, and Merle d'Aubignè and Postel
231
score averaged 15/18. Postoperative mean range of motion was 98.2° flexion (range 35° to
232
120°) and -6° extension (range -10° to 0°). Mean in ternal and external rotation was 13.4°
233
(range -10° to 40°) and 37.4° (range 15° to 75°) re
234
34.4° (range 5° to 70°). At the latest available fo llow up, 6 patients exhibited a positive
235
Trendelenburg sign. 21/40 patients (52.5%) walked fluently without assistance; 18/40
236
patients were using a gait assisting device (11 required one or two canes and seven used
237
walkers), and one patient was wheelchair bound due to general weakness. According to the
238
Beals and Tower classification, there were 31/40 excellent, 5/40 good and 4/40 poor results.
239
The mean intraoperative blood loss was 900ml. However, in 2/40 patients, the blood loss
240
could not be reviewed retrospectively. 21/40 patients (53%) suffered from symptomatic
241
anaemia requiring erythrocyte concentrate transfusion (ten patients required both intra- and
242
postoperative transfusions, two patients had intraoperative blood cell transfusion, nine had
243
postoperative transfusions). Mean transfusion rate in those 21 patients were 3 erythrocyte
244
concentrates.
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Complications
247
There were a total of 6/40 patients that developed postoperative complications (15 %). Five
248
(12.5%) required further revision surgery. One patient (2.5%) developed non-union at the
249
fracture site due to progressive subsidence up to 32mm. Two patients (5%) had dislocations,
250
one requiring revision of the acetabular component while the other patient was treated
251
conservatively after reposition. Two patients (5%) developed deep infections and of these the
252
one with an acute infection was successfully treated with lavage and component exchange
253
while the second patient with infection ten weeks postoperatively necessitated a full two-
254
stage exchange arthroplasty. One patient (2.5%) sustained a fracture of the modular junction
255
of the tapered and distally well fixed revision stem (Fig. 7). Despite at first glance not evident 7
ACCEPTED MANUSCRIPT radiologically, no in-growth of bone was seen intraoperatively in the proximal aspect of the
257
broken dual modular stem in the Gruen zones 6, 7 and 8. One direct surgery related
258
complication was observed. Immediately postoperative, the patient was diagnosed with
259
active bleeding from the descending branch of the lateral circumflex femoral artery, caused
260
by intraoperative erosion while placing a cerclage wire. The problem was solved by
261
angiographic coiling. Prolonged serous wound effusion of more than 14 days was noted in
262
three cases. All of which resolved spontaneously without further intervention.
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263 264
Discussion
266
Treatment of periprosthetic femoral fractures can be challenging, and high rates of
267
complications, re-operations and early mortality are reported throughout the literature
268
[8,11,29,30]. Clinical outcomes are often poor, and substantially burden the patients.
269
Treatment goals consist of a stable joint, fracture healing and the return to pre-fracture
270
function. Femoral component revision is the preferred method of treatment of Vancouver B2
271
and B3 periprosthetic fractures.
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The extended trochanteric osteotomy (ETO) is known to be a useful technique for complex
274
revision THA [13,14]. The two commonly used techniques are the standard ETO via a
275
posterior approach or the modified ETO via a lateral approach. The traditional standard ETO
276
technique as described by Younger et al [20] utilizes the posterior approach to the hip, with
277
release of the external rotators, incision of the posterior joint capsule and posterior surgical
278
dislocation. In the modified ETO technique, a lateral approach with osteotomy of the greater
279
trochanter in its mid-portion is performed [10,14,19,23]. The modified ETO preserves the
280
posterior capsule and external rotator attachments. The anterior joint capsule is incised and
281
the dislocation and removal of the implant can be performed anteriorly without impairment to
282
the posterior joint capsule and external rotators [10,19]. As the hip joint is advanced from
283
distal through the extended trochanteric fragments violence to the abductor muscles e.g.
284
gluteus medius and minimus muscles can be limited to the first three centimetres proximal to
285
the tip of the greater trochanter (Fig. 1d), leaving the superior gluteal nerve untouched. It can
286
be argued that performing an ETO in the setting of PFF will increase the number of fracture
287
fragments. However, the fracture line can be included into the osteotomy if applicable. Our
288
study results indicate that healing of the ETO can still be expected. Both techniques, the
289
traditional and modified ETO provide wide exposure of the acetabulum, facilitate femoral
290
component exposure and removal, aid in canal preparation and femoral reconstruction, and
291
allow for correction of proximal femoral deformity [17,19]. An advantage of the ETO is that 8
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ACCEPTED MANUSCRIPT the insertion of the gluteus medius and minimus along with the origin of the vastus lateralis,
293
intermedius and tensor vastus intermedius can be preserved. The soft tissue attachment with
294
its blood supply and large surface area of contact helps in healing the osteotomy.
295
Only few authors have described the ETO in periprosthetic fractures. Levine et al. [13]
296
reported his outcomes performed in 14 periprosthetic fractures. He used the standard ETO
297
technique with posterior surgical dislocation. The ETO healed in all 14 hips within 13 weeks.
298
Though there was a total of 5 (36%) postoperative complication in this series, none of the
299
complications were related to the ETO. Drexler et al. [14] reported the use of a modified ETO
300
in 34 patients with Vancouver B2/3 periprosthetic femur fractures treated with revision THA.
301
They reported union in 33 out of 34 hips with survival rate of 88.2% after a mean follow-up of
302
57 months.
303
Despite excellent rates of fracture union, the most common complication after revision THA
304
for a periprosthetic fracture is dislocation. Postoperative dislocation using the standard ETO
305
has been reported to range from 7% to 30% [8,13]. In our series only two patients (5%)
306
sustained a hip dislocation. While the modified ETO showed a lower dislocation rate, a
307
higher incidence of trochanteric fracture and postoperative trochanteric dislocation may occur
308
when compared to the standard ETO [19,31]. In the present study dislocation of the greater
309
trochanter fragment of more than 1cm occurred in 3 patients (7.5%). Migration of the greater
310
trochanter with the use of ETO has been reported by others [18].
311
In 39/40 patients in the present series there was healing of both the femur fracture and the
312
ETO. The above results are similar to others [13,14,16,19,30] where a union rate of 91% to
313
100% with the use of ETO has been reported. Surgical techniques in the current study
314
emphasised fracture healing, the preservation of the external rotator attachments, soft tissue
315
handling and the avoidance of unnecessary exposure of the linea aspera, where the vessels
316
enter the femur [26]. However, while osseointegration occurred rapidly in zone 3 to 5 and 10
317
to 12 osseointegration was not evident radiologically in Gruen zone 6, 7, 8 and 14 at latest
318
follow-up in 47.5% (Fig. 5). This area corresponds to the modular junction of the prosthetic
319
stem and due to the lack of bony support, could be the reason for stem failure in this area as
320
described in the literature [32]. Therefore, the shorter the proximal modular stem the higher
321
the chance that the modular junction is situated in the zones where the osseointegration is
322
absent. The lack of proximal bone restoration might be due to the fact that load transfer
323
occurs through the tapered wedge portion of the distal stem and the proximal portion of the
324
stem is bypassed and therefore does not stimulate bone ongrowth. Poor proximal osseous
325
support causing inadequate fatigue strength in the prosthesis has been mentioned by others
326
[33,34]. In one patient in the present study, the breakage of the dual modular stem occurred
327
where no osseointegration was observed proximal to the junction (Fig. 7).
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9
ACCEPTED MANUSCRIPT Subsidence rates show a wide variance throughout the literature. Fink et al [35] reported no
329
subsidence in a case series of 23 patients despite two patients who did not achieve bony
330
ingrowth fixation. Others observed subsidence occurring in up to 50% of cases within 6
331
months of surgery [5,6]. Bohm et al [36] suggested that the degree of subsidence correlated
332
with the extent of preoperative femoral bone stock especially in the diaphysis, as well as with
333
the quality of osseointegration and degree of osteoporosis. In the present study, early
334
femoral component subsidence was noted in 3 cases (7.5%). One patient needed a second
335
revision due to subsequent aseptic loosening. In two patients the subsidence was
336
subsequently non-progressive and associated with femoral component osseointegration.
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337
All the patients in the present series were treated using a dual modular, tapered and distally
339
fixed, non-cemented titanium alloy (TiAL6Nb7) revision stem (Revitan®, Zimmer GmbH,
340
Winterthur, Switzerland). Modular fluted tapered stems have been used to treat Vancouver
341
B2 and B3 fractures before [5,16,22,37].
342
Breakage of the modular junction as mentioned above can be a possible concern when using
343
modular implants. Modularity probably increases the complication rate and might make the
344
implants susceptible to corrosion, fretting or fatigue fracture at the modular junction [32–
345
34,38]. Factors associated with increased risk of prosthetic fracture are high patient body
346
weight or BMI, high patient activity level, small stem diameter, poor proximal osseous
347
support, the use of extended trochanteric osteotomy (ETO), and varus orientation of the stem
348
[32–34]. Richards et al. [39] reported 4 cases of stem breakage at the modular junction in a
349
series of 109 patients after a mean follow up of 37 months. The author stated that all of the
350
stem fractures occurred in older implant designs that are no longer in use, but that stem
351
breakage was not observed with newer designs. Van Houwelingen et al. [37] showed similar
352
results with five stem fractures in a series of 48 patients after a mean follow up of 84 months.
353
Also this series analysed the original standard stem design that has now been modified.
354
Overall implant survivorship was 90%. Norman et al. [32] reported two cases of a Revitan
355
stem failure with breakage of the modular junction in two active male patients. In their
356
analysis, undersizing of the stem diameter at the modular junction relative to the
357
characteristics of the patients was stated as a possible cause. Nasr et al. [38] reported a
358
single case of a fractured connection taper in a Revitan stem, highlighting that fractures can
359
still occur with modern modular prostheses. The failure of the Revitan stem in the present
360
study was initiated by a traumatic impact onto the hip due to fall from a bicycle which might
361
have caused a fatigue crack of the modular junction. Therefore, while midterm survivorship of
362
modular titanium stems are considered high, continued surveillance of stem junctional fatigue
363
is required.
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364 10
ACCEPTED MANUSCRIPT Clinical results
366
The average Harris hip score in the present series was 70/100 points, and Merle d'Aubignè
367
and Postel score averaged 15/18. Although this is a relatively low score and does not
368
represent a return to a high level of function it is more likely related to the significant medical
369
comorbidities, frail nature, and limited preoperative activity levels in these patients. Abdel et
370
al. [22] reported a mean Harris hip score of 83, 4.5 years postoperatively in a series of 44
371
patients. Several studies have also confirmed these low postoperative Harris hip scores
372
ranging from 59 to 71 following treatment for periprosthetic femoral fractures [13,16,40–42].
373
The main objectives when treating periprosthetic fractures are fracture union and reduced
374
pain. Although unassisted ambulation is always a goal for these patients, in the present
375
series only 18/40 patients (48%) walked fluently without assistance. 6/40 patients showed a
376
positive Trendelenburg sign at final follow up. The relatively high rate of limping might be
377
contributed to general weakness of a rather old patient cohort and may be due to multiple
378
surgical interventions prior to PFF. Several studies have shown that typically 50% or more
379
patients will require a postoperative assistive device and maintain a limited ambulatory status
380
[3,14,39]. The presence of a positive Trendelenburg sign was not mentioned in previous
381
papers.
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382 Complications
384
Revision surgery was necessary in 12.5% of our patients (5 out of 40). The most common
385
cause was infection (2 patients, 5%), with one necessitating a two-stage exchange, other
386
causes were one subsidence, a recurrent dislocation, and a stem breakage. The latter two
387
were associated with another trauma and not directly related to the previous surgery. The
388
Swedish national hip registry shows a postoperative complication rate (requiring revision
389
surgery) of 18% after PFF treatment [3]. Springer et al. [43] reviewed 116 patients (118 hips)
390
after periprosthetic fracture treatment and reported a revision rate for loosening, non-union,
391
recurrent dislocation, re-fracture or infection of 17% at the latest follow up of 5.4 years
392
postoperative. Implants used were either cemented stems, proximally porous-coated or
393
extensively porous-coated stems, allograft-prosthesis composite or tumour prosthesis. Abdel
394
et al. [22] reported a series with comparable follow up time (mean 4.5 years) and number of
395
cases (n=44). Treatment modality was similar to our series, using a modular fluted, tapered
396
stems and (in many cases) an ETO. The reoperation rate in this series was 18% (7 out of
397
44), mostly due to recurrent dislocation (5 out of 8 revisions).
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400
Conclusion 11
ACCEPTED MANUSCRIPT 401
In conclusion, the modified ETO with a lateral approach to the hip for the treatment of PFF is
402
compatible with fracture healing, a low dislocation rate and good clinical results. However,
403
component stability and apparent osseointegration are coincident with fracture healing in the
404
distal aspect of the inserted stem only and not proximal. Absence of proximal
405
osseointegration might lead to poor osseous support resulting in inadequate fatigue strength
406
at the junction of the dual modular revision stem.
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Limitations of the present study include the retrospective design and relatively short time to
409
follow up. Furthermore, patients’ preoperative medical condition may have some influence on
410
the postoperative outcome.
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Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89:780–5. doi:10.2106/JBJS.F.00222. Lindahl H. Epidemiology of periprosthetic femur fracture around a total hip arthroplasty. Injury 2007;38:651–4. doi:10.1016/j.injury.2007.02.048. Malchau H, Herberts P, Eisler T, Garellick G, Söderman P. The Swedish Total Hip Replacement Register. J Bone Joint Surg Am 2002;84–A Suppl:2–20. Ohly NE, Whitehouse MR, Duncan CP. Periprosthetic femoral fractures in total hip arthroplasty. Hip Int 2014;24:556–67. doi:10.5301/hipint.5000155. Munro JT, Garbuz DS, Masri BA, Duncan CP. Tapered fluted titanium stems in the management of Vancouver B2 and B3 periprosthetic femoral fractures. Clin Orthop Relat Res 2014;472:590–8. doi:10.1007/s11999-013-3087-3. Hernandez-Vaquero D, Fernandez-Lombardia J, de Los Rios JL, Perez-Coto I, Iglesias-Fernandez S. Treatment of periprosthetic femoral fractures with modular stems. Int Orthop 2015;39:1933–8. doi:10.1007/s00264-015-2958-5. Lindahl H. Epidemiology of periprosthetic femur fracture around a total hip arthroplasty. Injury 2007;38:651–4. doi:10.1016/j.injury.2007.02.048. Lindahl H, Malchau H, Odén A, Garellick G. Risk factors for failure after treatment of a periprosthetic fracture of the femur. J Bone Joint Surg Br 2006;88:26–30. doi:10.1302/0301-620X.88B1.17029. Brady OH, Garbuz DS, Masri BA, Duncan CP. The reliability and validity of the Vancouver classification of femoral fractures after hip replacement. J Arthroplasty 2000;15:59–62. Grob K. Revisionsprothetik am Hüftgelenk. Die Rolle der erweiterten Trochanterosteotomie. Lead Opin Zeitschrift Für Orthopäden, Rheumatol Und Unfallchirurgen 2008;1:60–3. Lindahl H, Malchau H, Herberts P, Garellick G. Periprosthetic femoral fractures classification and demographics of 1049 periprosthetic femoral fractures from the Swedish National Hip Arthroplasty Register. J Arthroplasty 2005;20:857–65. doi:10.1016/j.arth.2005.02.001. Sambandam SN, Duraisamy G, Chandrasekharan J, Mounasamy V. Extended trochanteric osteotomy: current concepts review. Eur J Orthop Surg Traumatol 2016;26:231–45. doi:10.1007/s00590-016-1749-z. 12
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[18]
[19] [20]
[21] [22]
[23]
[24] [25] [26]
[27]
[28]
[29]
[30]
[31]
[32]
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[16]
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Fig. 1: Surgical technique: lateral subvastus approach to the femur (a), performing the osteotomy by use of an oszillating saw (b), opening the osteotomy and extraction of the prosthesis (c), assembly of the cylindrical proximal component in situ after the curved stem was fully seated (d)
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Fig. 2: Corresponding plain radiographs to the clinical case in Fig. 1. Preoperative (a), postoperative radiography (b)
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Fig. 3: PFF treatment in a 58 year old patient. PFF (a), postoperative radiography (b), result
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5 years postoperatively (c)
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Fig. 4: PFF treatment in a 78 year old patient. PFF (a), postoperative radiography, refixation of the greater trochanter by using intraosseous cables in combination with cannulated screws
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(b), fracture healing 6 months after surgery (c)
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Fig. 5: PFF with stem breakage after fall from level hight in a 76 year old patient. PFF (a), treatment with stem exchange, refixation of greater trochanter with sutures due to extensive
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Fig. 6a and 6b: radiographic osseointegration of the implant over time (ap view, axial view)
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Zone of primary osseointegration (Gruen zone 3,4,5,10,11,12) Zone of secondary osseointegration (Gruen zone 1,2,9, 13) Zone of tertiary (latest) osseointegration (Gruen zone 6,7,8,14)
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Fig. 7: Stem breakage after PFF treatment, solved by stem exchange. PFF (a), stem exchange via modified ETO (b), stem breakage at the modular junction 5 years after PFF treatment (c), treatment with stem exchange (d)
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