Dynamic compression plate fixation for post-operative fractures around the tip of a hip prosthesis

Injury, Int. J. Care Injured (2005) 36, 417—423

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Dynamic compression plate fixation for post-operative fractures around the tip of a hip prosthesis S.G. Haidar*, M.I. Goodwin Poole General Hospital, Poole, Dorset, UK Accepted 12 July 2004

KEYWORDS Periprosthetic; Fracture; Hip; Dynamic compression plate

Summary Post-operative fractures around the tip of the femoral component of a hip prosthesis are inherently unstable and have been reported to be associated with high nonunion rate if treated conservatively. A group of 27 of these fractures were treated with dynamic compression plates between 1994 and 2000. The fractures followed primary total hip arthroplasty in 10 cases, revision surgery in five cases and hemiarthroplasty in 12 cases. According to the Vancouver classification, there were 18 type B1, six type B2 and three type B3 fractures. The average age was 82 years. The average follow up was 35.7 months (range 12—72 months). Complications included one nonunion (B3) and three fixation failures (one B2 and two B3). Also, two cases became infected, one of these was managed conservatively, the other needed removal of plate and prosthesis. Twenty patients regained their pre-injury mobility. Dynamic compression plate fixation is sufficient for type B1 and some selected cases of type B2 fractures that occur around the tip of a hip prosthesis. # 2004 Elsevier Ltd. All rights reserved.

Introduction The number of post-operative periprosthetic femoral fractures has increased due to the increased elderly population and consequent increase in the number of patients undergoing either hemi or total hip arthroplasty.2,14 These * Corresponding author. Present address: 187 Court Oak Road, Harborne, Birmingham B17 9AD, UK. Tel.: +44 121 4266871; fax: +44 121 5075483; mobile: +44 7815200491. E-mail address: [email protected] (S.G. Haidar).

fractures are the second commonest cause of revision hip arthroplasty after implant loosening.14 Although, it is difficult to assess the true incidence of these fractures, they are estimated to occur at a rate of 1.1% post-primary total hip arthroplasty and 4.0% post-revision arthroplasty.2,23 The incidence following hemiarthroplasty is not known.23 Periprosthetic fractures do not form a homogenous group of fractures and therefore cannot be treated by a single approach. As more literature is emerging a better understanding of the diversity of

0020–1383/$ — see front matter # 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2004.07.032

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these fractures is being recognised; hence different approaches specific for each fracture type are being established. The purpose of this study was to assess the outcome of post-operative femoral shaft fractures around the tip of a hip prosthesis that were managed primarily and solely with a dynamic compression plate fixation.

Materials and methods Thirty-two patients with post-operative periprosthetic femoral fractures around the tip of a hip prosthesis were treated with dynamic compression plates between March 1994 and December 2000. Three patients who died within 2 months of surgery were excluded and two patients were lost to follow up. Twenty-seven patients were followed up; their results were retrospectively assessed through their clinical and radiological notes. There were 15 females and 12 males. The average age was 82 years (range 51—98 years). The fracture involved the right side in 12 cases and left side in 15 cases. Twelve fractures occurred post-Austin Moore hemiarthroplasty. Fifteen fractures occurred post-cemented total hip arthroplasty; 10 of which were primary and the other five were revisions. Minor trauma at home due to a slip or a fall was the cause of the periprosthetic fracture in all cases. According to the Vancouver Classification,4 18 fractures were type B1, six were type B2 and three were type B3. With regards to type B2 fractures, the loosening was confined to three or less zones according to Gruen et al.8 Slight varus position (less than 78) was found in four cases: two Austin Moore cases (cases 8 and 13) and two total hip arthroplasties (case 6 with type B1 and normal length stem and case 22 with type B2 and long stem). The Tower and Beals21 and Mont and Maar19 classifications were also used (Table 1). All fractures were treated with laterally positioned dynamic compression plates. No stem was revised. Lag screws were used when possible. Proximal fixation was obtained by passing screws through two cortices either anterior or posterior to the prosthesis; in cemented cases, screws were passed through the cement mantle. At least eight cortices were secured on both sides of the fracture as recommended by Cooke and Newman6 and Serocki et al.18 Additional support was obtained by using cerclage wires in 10 cases. Two cerclage wires were used in eight cases. Three and four cerclage wires were each used in one case. Bone graft harvested from the iliac crest was used in two cases (one B2 and one B3). The post-operative regimen consisted of early nonweight bearing mobilisation if it was possible, otherwise toe-touch was

S.G. Haidar, M.I. Goodwin

allowed. The average follow up was 36 months (range 12—72 months).

Results Full details are summarised in Table 1. Clinical and radiological union was evident in 23 fractures (85%) (Fig. 1). The average time to radiological union was 4.2 months (range 3—6 months). Fixation failed in two cases, one type B2 and one type B3 at 6 months and 1 week, respectively. In the first case (Fig. 2), the patient had a fall and sustained a refracture; he underwent a cemented revision arthroplasty; the final result during follow up was unsatisfactory with persistent nonunion. In the second case (Figs. 3—5), the patient died a week after the re-fracture, no further operations were performed. There was one plate fracture (type B3) 6 months after fixation, the patient underwent a

Figure 1 Case 6, 5 years after application of dynamic compression plate, there is no sign of stem loosening.

Details of the 27 patients

No.

Age

Sex

Side

Primary

Mobility

V

B&T

M&M

BG

Cerclage

Union (months)

Complications

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

81 72 89 86 94 72 90 83 92 89 89 76 74 91 73 83 91 78 74 51 85 87 92 67 76 86 98

M M F F F F M F F M M F M M M F F M M M M F F F F F F

L R L L L R R R L L R R L L R R R L L L L R R L L R L

THR THR AM THR AM THR AM AM AM AM AM AM AM THR THR AM THR AM Rev (1) THR Rev (1) Rev (1) AM THR Rev (2) Rev (1) THR

1 stick No aid Zimmer Zimmer Whe/chai No aid Zimmer 2 sticks 1 stick 1 stick No aid No aid 1 stick 2 sticks No aid 1 stick No aid Zimmer No aid No aid Zimmer Zimmer 2 sticks No aid Zimmer No aid Zimmer

B1 B1 B1 B1 B1 B1 B1 B1 B1 B1 B1 B1 B1 B1 B1 B1 B1 B1 B2 B2 B2 B2 B2 B2 B3 B3 B3

3A 3B 3B 3A 3B 3A 3A 3B 3B 3A 3A 3A 3A 3A 3A 3A 3A 3A 3A 3C 3C 3C 3B 3B 3A 3A 3A

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

N N N N N N N N N N N N N N N N N N Y (ic) N N N N N Y (ic) N N

4 2 N N 3 N N 2 N 2 N N N N N N N N 2 3 2 N 2 N N N 2

3.5 3 5 4.5 6 3 5 4.5 5 4 4 3.5 3.5 4 4 4.5 5 3.5 — 3 4.5 4.5 5 3.5 — — —

3 cm short, hip pain

Second op

BG

Chest infection, DVT

Wound infection

Hip pain

Fixation failure

Rev

Deep infection DVT

Girdle stone

2 cm short Plate fracture Nonunion Fixation failure

Rev Rev

Y (fh)

Y (fh) Y (fh)

Follow up 72 24 14 58 36 61 23 12 39 25 34 27 41 30 29 31 12 52 36 48 42 40 32 48 27 35 —

Dynamic compression plate fixation for post-operative fractures

Table 1

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Figure 2

Case 19 (type B2 fracture) fixation failure. This patient had a fall at home 6 months post-surgery.

Figure 3

Case 27, type B3 fracture.

Dynamic compression plate fixation for post-operative fractures

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Figure 5 Case 27, fixation failure (re-fracture) 1 week post-surgery.

Discussion Figure 4 plate.

Case 27, fixation with dynamic compression

cemented revision arthroplasty, and the result was poor. There was one case (type B3) of nonunion; the quality of bone was poor in this case and the fracture was not well reduced. This patient underwent cemented revision arthroplasty with bone graft; the result was very poor with partial absorption of the femur. There were two cases of infection (one type B1 and one B2). The first case was managed conservatively, whereas the second had removal of plate and prosthesis (Girdlestone’s procedure). Twenty patients regained their pre-injury mobility (Table 1). One patient had significant limping due to a Girdlestone’s procedure and two patients complained of hip pain (one had 3 cm shortening). The mobility of these three patients deteriorated moderately after fracture healing. During the follow-up period, none of the healed fractures were revised and no progressive loosening was encountered in hip arthroplasty cases.

Fractures around the tip of a hip prosthesis are associated with a high rate of complications,6—13 especially a poor union rate if treated conservatively.1,3,6,10,11 Johansson et al.10 reported unsatisfactory results in all their patients (seven patients) after conservative management. In general, adult femoral shaft fractures are usually treated surgically and intramedullary fixation has superseded plating in recent decades. Nevertheless, in periprosthetic fractures, extramedullary fixation is advantageous in two situations. Firstly, when the prosthesis is stable hence a revision into a longer stemmed implant is not needed. Secondly, when a prolonged revision surgery is contraindicated (too elderly, infirm or low mobility patients). The occupation of the medullary canal by the prosthesis provoked the development of many devices aiming at avoiding this canal such as Parham bands, Partridge bands, Ogden plate, Dahl plate, Mennen clamp plate and cable and plate systems (for example Dall—Miles plate). However, all these devices had inconsistent and disappointing results.5,9,15—18,22—24 These devices are considered as internal bone sutures rather than fixation devices.5

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S.G. Haidar, M.I. Goodwin

Dennis et al.7 biomechanically evaluated five extramedullary fixation techniques that are used for periprosthetic femoral shaft fractures: a plate with cables, a plate with proximal cables and distal bicortical screws, two allograft cortical struts with cables, a plate with proximal unicortical screws and distal bicortical screws or a plate with proximal unicortical screws and cables and distal bicortical screws. The last two were significantly more stable in axial compression, lateral bending and torsional loading. In our series, bicortical fixation was secured both proximally and distally; the good results that were obtained in type B1 and type B2 fractures (100% and 83% union rate, respectively) correlate with the conclusion of Dennis et al. and confirm the importance of the bicortical fixation proximally. Most of recently published reports advocate revision surgery with a long stem for type B2 fractures12,20,23–—this being the recent policy in our unit. However, in our six cases of type B2 fractures, three patients already had long stems and two patients were too elderly and frail to tolerate a major surgery (aged 85 and 92 years). In fact, the only failed case of type B2, in our series, achieved clinical and radiological union, but sustained a serious fall and refractured at 6 months follow up. With regards to type B3 fractures, there was 100% failure rate; this was probably due to the poor quality of bone in these fractures. Type B3 fractures are most often found in revision cases; this explains the fact that most of our complications were encountered in revision cases as illustrated in Figs. 6 and 7. In accordance with previous reports,6,18 the violation of the cement mantle proximally by screws did not lead to premature femoral component loosening in arthroplasty cases during radiological follow-up. Also all four cases of slightly varus positioned stems healed with no complications (Fig. 1); nevertheless there were no cases of severe varus position, as these were not considered suitable for plating. Although plating does not form an optimal biomechanical fixation for adult femoral shaft frac-

Figure 7 tion.

Complications according to previous opera-

tures, it seems to be adequate for low-demand patients, such as this group with periprosthetic fractures and an average age of 82 years, to allow early mobilisation. In addition, plating has the advantage of availability of both equipment and skills in any trauma unit. Selection of the right case with good quality bone (type B1 or B2 fractures) and applying a plate of sufficient length are preconditions for success. Bone graft is not necessary. Several recently published papers advocate the use of cortical onlay allograft struts in combination with either plating or revision or both of them.5,12,20 This technique is not necessary for type B1 and type B2 fractures. Bone graft, cortical onlay allograft strut, proximal femoral allograft or prosthetic proximal femoral replacement should be used for type B3 fractures as needed to replace the poor quality bone in these cases.12,20 The use of a plate with proximal and distal screws fixation for these fractures was previously reported by Cooke and Newman,6 Serocki et al.18 and Siegmeth et al.19 (seven, five and five cases, respectively). Interpretation of the outcome of these studies is difficult due to the small number of patients, including different types of fractures, lacking of appropriate classification and employing multiple interventions. In our study, we avoided these shortfalls; therefore, interpretation of our results is unequivocal. In conclusion, we recommend dynamic compression plate with bicortical proximal and distal fixation for type B1 fractures around the tip of a hip prosthesis. We also recommend this fixation for type B2 fractures when revision surgery is not/contra indicated, we do not recommend it as a sole management for type B3 fractures.

References

Figure 6

Complications according to fracture type.

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