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Back to Journal »Orthopedic Research and Review» Volume 11
Interprosthetic femoral fractures: management challenges
Author Rozell JC, Delagrammaticas DE, Schwarzkopf R
Volume 2019 published on September 16, 2019: 11 pages 119-128
DOI https://doi.org/10.2147/ORR.S209647
Single anonymous peer review
Editor who approved for publication: Professor Clark Hung
Joshua C Rozell, 1 Dimitri E Delagrammaticas, 2 Ran Schwarzkopf1 1 Orthopedic Surgery, Langone Orthopedic Hospital, New York City, New York; 2Central Coast Orthopedics, San Luis Obispo, CA, USA Mailing address: Ran Schwarzkopf NYU Langone Orthopedic Hospital, 301 East 17th St, Suite 1402, New York, NY 10003, USA Phone 1 212 598 2783 Email [email protection] Abstract Fracture is a rare but serious complication after total hip and knee replacement. The classification system focuses not only on diagnosis, but also on treatment algorithms. The key to evaluating these fracture patients is to evaluate the location of the fracture, bone quality, and the presence of stalked implants. The gold standard for fracture fixation is to use double cortical and single cortical screws to lock the steel plate, supplemented by wires or cables as needed. For patients with damaged bone mass or insufficient bone area for fixation, allografts with struts or interprosthesis sleeves can be used for reinforcement. For fractures with severe bone loss, it may be necessary to switch to a large prosthesis or total femur replacement. Keywords: interprosthesis, total knee arthroplasty, total hip arthroplasty, revision, periprosthetic fracture
Hip and knee replacements are still one of the most common surgical procedures in the United States. As indications expand, the life expectancy of the aging population increases, and the demand for a more active and painless lifestyle increases, the usage rate is expected to increase . 1 As a result, patients with ipsilateral hip and knee prostheses are more likely to have an increased risk of complications around the prosthesis, especially interprosthetic femoral fractures (IFF), defined as ipsilateral hip and knee joints Fracture of the femur between the prostheses. Early reports on the treatment of these fractures made great reservations. The earliest report by Dave et al. described the use of Mennan plates, iliac crest bone grafts and 3 months to successfully treat a patient with an interprosthetic femoral shaft fracture around a handle total knee joint and total hip implant. patient. 2 However, a follow-up report by Kenny et al. showed poor results in the treatment of similar fractures. All 4 patients in the series failed initial treatment, and 2 of them required amputation above the knee or hip dislocation. 3 As a result of these early reports of advances in treatment strategies, namely the choice of implants and the understanding and classification of fracture types, the results of these complex injuries have been improved. The management and avoidance of treatment complications depend on the understanding of the patient, fracture type, intraoperative technique and joint replacement reconstruction plan. 4,5
More and more patients are living longer and undergoing joint replacement surgery, coupled with technological advancement and rapid recovery anesthesia programs, resulting in a sharp increase in the number of patients undergoing joint replacement surgery. 6-8 An estimated 620,000 of these patients have experienced THA and TKA. In addition, approximately 19,200 Americans have undergone ipsilateral hip and knee replacements. 9 As the quality of life improves, patients remain active, so more demands are placed on their implants. Therefore, the incidence of fractures around the prosthesis has also increased. Although still uncommon, the incidence of fractures around THA prosthesis is reported to be 0.1-5%, while the incidence of fractures around TKA prosthesis is 0.3-5.5%. 6,10-12
Dave et al. first described a subset of these fractures in 1995, called IFF. 2 Kenny et al. made an early estimate of the incidence of IFF, reporting an incidence rate of 1.25% in their series of more than 300 patients. 3 IFF is difficult to estimate, but recent reports estimate that the risk is about 5-7% of all periprosthetic fractures. 13 In some smaller series, Sah et al. reported 22 fractures over a 4-year period, while Platzer et al. reported 23 patients in 16 years. 14,15 Valle Cruz’s team reported 6 fractures in a cohort of 112 patients in 6 years. 16 Although these fractures are not common, they can have a major impact on the patient's prognosis. Recognizing and effectively managing these injuries is critical to maintaining the patient’s quality of life before injury.
Certain implant structural features add to the advantages of IFF or present management challenges. Regarding the distance between the prostheses, there is no clear consensus on how far apart the hip and knee stems should be to reduce the risk of fracture. Theoretically, the reduced distance may result in higher stress concentration in the femoral shaft, thereby increasing the risk of fracture at that location. A biomechanical study by Soenen et al. observed that a gap between stems <110 mm increases the risk of fracture; however, this study did not consider cortical thickness. 17 Another argument about the risk of IFF is the cortical and medullary diameter. In a series of 23 patients, Lipof et al. found that compared with intact femurs, the IFF group was more likely to have a significantly narrower femoral cortex in the isthmus, but a larger medullary canal, indicating the typical biomechanics seen in elderly patients The changes are the same as in 6, Valle Cruz et al. found a higher incidence of IFF in the distal region of the tip of the hip stem, which is related to the widening of the femoral canal and the narrowing of the femoral cortex. 16 Although increased diaphyseal stress is considered a higher risk for fractures compared to metaphyseal fractures, Mamczaks data confirms this view, showing a higher incidence of supracondylar IFF. 8
These changes in femoral structure make patients susceptible to periprosthetic and interprosthetic fractures, which are more generally related to overall bone health; therefore, the risk factors for patients with IFF are similar to the risk factors for periprosthetic fractures. These include inflammatory diseases such as women, advanced age, revision surgery, osteoporosis and rheumatoid arthritis. 18 Factors related to implants include compression stems as the risk of early fractures and the use of conventional polyethylene as the risk of advanced fractures for osteolytic lesions. 19, 20 Due to the use of highly cross-linked polyethylene (HXLPE) introduced in the late 1990s, osteolysis around total hip implants is far less common today. However, patients who underwent hip arthroplasty before using HXLPE have a higher risk of abrasion and osteolytic lesions, which leads to a decrease in the structural stability of the femur. Osteoporosis is also considered to be an independent risk factor for fractures. The modular mismatch between the bone-implant interface helps to create a stress shield in the already weakened bone, which may make the patient vulnerable to fractures in low-energy injury mechanisms. In addition, long-term use of bisphosphonates in these patients should be carefully considered, because the combination of inhibited bone turnover and repetitive stress may increase the risk of atypical fractures. 21 Platzer et al. reported that 73% of patients undergoing treatment for severe periprosthetic fractures of the distal femur had osteoporosis or rheumatoid arthritis. twenty two
The classification of intertrochanteric fractures has evolved from the Vancouver and Société Française de Chirurgie Orthopédique et Traumatologique classifications, which were originally used to describe peripheral femur and knee fractures, respectively, to the specific classification system for interprosthetic fractures described by Pires et al. (Figure 1) ).23-25 In this classification system, inter-prosthesis fractures are divided into three main types: Type I describes the fracture around the femoral prosthesis, Type II describes the fracture around the knee prosthesis without stalk, and Type III Describes the fracture around the femoral prosthesis. Knee prosthesis including extension rods. Type I and Type II fractures are further subdivided into A (stable femur and knee prosthesis), B (unstable femur but stable knee prosthesis), C (stable femur but unstable knee prosthesis) ) And D (unstable femoral and knee prostheses). For Type III fractures, this subgroup is different from Type I and Type II. Type IIIA represents a stable prosthesis with living bone between the prostheses, and Type IIIB describes a stable femoral and knee joint prosthesis with between the ends of the prosthesis. Inactive fragments or missing bones. Type IIIC describes unstable prostheses (hip, knee, or both), with living bone between the prostheses, type IIID represents unstable prostheses (hip, knee, or both) ), due to the lack of living bone between the ends of the prosthesis, the spacer segment is invalid. By providing descriptions of fracture locations, identification of existing arthroplasty prosthesis types, and descriptions of prosthesis stability, the classification system not only provides descriptive utility, but also aims to guide treatment strategies. For Type I and Type II fractures, treatment includes plate fixation with stable prostheses (subtype A) or transformation of unstable prostheses into longer and/or stalked prostheses, depending on the need for fracture fixation Add or not add auxiliary steel plate fixation (BC subtype). For type III fractures, stable implants with insufficient bone mass or unstable implants with insufficient bone mass can be treated with revision arthroplasty and/or plate fixation (with or without bone grafting). Depending on the quality of the bone and the availability of the original joint replacement prosthesis, the use of allogeneic stents for total femur replacement or femur augmentation can be considered, which is a tool available in this treatment algorithm (ID, IID, or BD type III). 25,26 Figure 1 The classification of interprosthetic femoral fractures described by Pires et al. Note: Data from Pires et al. 25,26
Figure 1 The classification of interprosthetic femoral fractures described by Pires et al. Note: Data comes from Pires et al. 25,26
IFF's surgical management posed significant surgical challenges. Dealing with these difficult fractures should rely on the preoperative patient's optimization of medical conditions, algorithms, and practical surgical methods, with the emphasis on compliance with the Arbeitsgemeinschaft für Osteosynthesefragen (AO) principle. Pre-operative surgical planning and any necessary implants, trays, and auxiliary grafts are critical to the success of the operating room. When positioning the patient for surgery, our preferred method is semi-lateral position, placed on a bean bag on a table that is completely light-transmissive. If you do not have a bean bag, you can use an inflatable rapid infusion set connected to a blood pressure cuff. The sleeve is placed under the patient's hip on the same side, and during various parts of the operation, the bag can be inflated or deflated to accommodate the radiographic view or surgical visualization. The surgical method may include a previous incision, but it is usually performed after the femur is exposed laterally to facilitate exposure, fracture reduction, and fixation. Special attention should be paid to limit periosteal dissection and soft tissue destruction during the dissection, as this may lead to a higher incidence of nonunion. For short lateral and large medial fracture fragments, an inert "S"-shaped incision is made from the lateral side, followed by lateral and medial femoral tracking to expose the knee joint distally. The patient’s previous medial parapatellar arthrotomy may be reopened to limit any patella devascularization with a parallel lateral parapatellar arthrotomy. This will provide expandable exposure to the medial and lateral sides of the distal femur, and if the varus stress test produces a lateral opening, it is easier to allow supplemental neutralization and fixation on the medial side of the femur after lateral plate fixation.
As mentioned earlier, the classification of fractures helps clarify the fixation options for inter-prosthetic fractures, depending on the fracture pattern and location, the stability of the prosthesis, and the patient’s bone quality. For patients with sufficient bone, the structure may include locking plates, cables, intramedullary nails, or a combination of these. Currently, the locking plate is the implant of choice for the treatment of IFF (Figure 2A-D). 14,27-29 These implants provide stable fixation even in osteoporotic bones, help resist varus collapse when placed on the stretched side of the femur, and are usually applied to cover the periosteum tissue for protection The blood supply to the bones. 5 The main treatment goals are adequate fixation and restoration of length, alignment and rotation, early mobility and fracture healing. The locking plate should be applied along the length of the femur, spanning at least two cortical diameters of the previous implant stem. This helps to maximize the distribution of the force of the entire bone, protect the bone from further fractures, and reduce the overall stress concentration of the implant-bone interface. Many modern locking plates are titanium and have a modulus of elasticity similar to that of bone to limit the modulus mismatch. In addition, the function of cleverly placing the screw holes in the bone plate is to allow the screw to be inserted around the hip or knee joint and prevent the stamp effect in the bone, thereby reducing the risk of further fractures. Finally, in order to limit the stiffness of the structure and the possibility of nonunion, the screw density in the plate should be about 40-50% (Figure 3A-D). In areas that cannot be fixed with bicortical screws due to previous arthroplasty implants, cerclage cables or monocortical locking screws can be used to supplement the fixation (Figure 4). In addition, when there is a cross-shaped fixed TKA or a TKA with an open box structure, retrograde nails can be used. This is usually used for repairs or non-union settings between prostheses, where supplementary plates are also used because the nails cannot overlap the hip joint and cause stress concentration areas at the distal end of the hip prosthesis (Figure 5). A recent case series conducted by Hussain et al. reviewed 9 cases of IFF treated with retrograde nails and lateral locking plates. The fixation of the proximal end of the fracture includes an average of 3 bicortical screws and 1 monocortical screw, and at least 4 cortical fixations. They observed a 100% healing rate and immediate weight bearing. 30 Use intramedullary nails to play a role in biology and biomechanics. After the initial reduction with a steel plate, reaming the nail can make the cancellous bone impinge on the fracture site. In biomechanics, intramedullary nails impart longitudinal and rotational stability and enhance fixation stability. Figure 2 The preoperative X-rays (A, B) showed a long spiral oblique interprosthesis fracture with retrograde apex. The lateral femur locking plate is used for the internal fixation of the fracture (C, D), and the lag screw and positioning screw between the fracture pieces are added. Figure 3 The preoperative anterior and posterior (A) and lateral (B) films show that the plate osteosynthesis has a lateral locking plate and high screw density, so the structure is rigid and the fixation fails. The front and back (C, D) X-rays of the revision structure showed reduced screw density and structural rigidity between the fracture fragments, as well as proper prosthesis overlap. Figure 4 The anteroposterior X-ray of the proximal femur shows that the fracture around the prosthesis is fixed around the long cemented hip stem. Monocortical screws (marked with red boxes) and auxiliary cables are useful in this case because the amount of bone around the stem is limited and the cement cover is very hard. Figure 5 Anterior and posterior (A, B) and lateral (C) X-rays of fractures around the distal femoral prosthesis in patients with osteoporosis fixed with short retrograde nails and supplemented with long lateral locking plates. Lateral X-rays showed staggered screw holes to maximize the coverage of the nail and hip bone. (Photo courtesy: Derek J. Donegan, MD).
Figure 2 The preoperative X-rays (A, B) showed a long spiral oblique interprosthesis fracture with retrograde apex. The lateral femur locking plate is used for the internal fixation of the fracture (C, D), and the lag screw and positioning screw between the fracture pieces are added.
Figure 3 The preoperative anterior and posterior (A) and lateral (B) films show that the plate osteosynthesis has a lateral locking plate and high screw density, so the structure is rigid and the fixation fails. The front and back (C, D) X-rays of the revision structure showed reduced screw density and structural rigidity between the fracture fragments, as well as proper prosthesis overlap.
Figure 4 The anteroposterior X-ray of the proximal femur shows that the fracture around the prosthesis is fixed around the long cemented hip stem. Monocortical screws (marked with red boxes) and auxiliary cables are useful in this case because the amount of bone around the stem is limited and the cement cover is very hard.
Figure 5 Anterior and posterior (A, B) and lateral (C) X-rays of fractures around the distal femoral prosthesis in patients with osteoporosis fixed with short retrograde nails and supplemented with long lateral locking plates. Lateral X-rays showed staggered screw holes to maximize the coverage of the nail and hip bone. (Photo courtesy: Derek J. Donegan, MD).
Due to the relatively low incidence of IFF, clinical literature mainly appears in the form of case reports and case series. However, recently, Bonnevialle et al. conducted a retrospective multicenter study of 51 patients with an average age of 82.5 years who developed IFF between 2009 and 2015. With an average follow-up of 27 months, there were 6 cases of mechanical complications and 2 cases of surgical complications. Site infection and 2 cases of loosening illustrate the pathological nature of this injury. The overall mortality rate at the final review was 31% (9 deaths in the first 6 months), and the median survival time was 3.45 years. 13
In a smaller series, Hoffman et al. reviewed 27 IFFs retrospectively over a period of 7 years, most of which were women. They reported an 89% healing rate of the long-side titanium plate. They advocated the use of submuscular plate technology to avoid soft tissue peeling and adequate fixation of the proximal end around the hip stem. 9 A patient did have a hardware failure and needed further treatment with double steel plates. This can be used as an additional option for fixation in situations where the amount of bone before or after the stem is limited. If possible, a smaller plate can be placed on the anterior surface of the femur to improve biomechanical stability. The angle of the screw is at an angle to the inside or outside of the femoral stem. Sah et al. evaluated 22 IFF patients treated with a locking condyle plate using minimally invasive techniques. All fractures healed within 14 weeks. 14 Similarly, Platzer et al. retrospectively evaluated 23 IFFs treated with locking plates and auxiliary cerclage cables. By 6 months, 82% of patients were cured by radiography. The reason for these four failures was poor reset and fixation techniques. 15 In addition, although treatment algorithms have not yet been universally adopted, adherence to the previously described fixation and surgical principles can maximize the chances of healing and obtain satisfactory results in these difficult fracture patterns.
Special consideration should be given to cases where insufficient bone mass limits standard fixation or arthroplasty reconstruction methods. The aforementioned initial management needs to assess the stability of the implant, which will determine the ability to retain or need to modify the existing prosthesis. For stable implants, fixation methods may include steel plates with or without auxiliary bone grafts or cortical strut reinforcement; long transverse locking plates are still the preferred implant for osteoporosis or damaged bone. 9,14,15,28,29,31–33 When knee prostheses allow the introduction of intramedullary devices, dual fixation methods including intramedullary nails and plate fixation as described above may be an option in the initial treatment. 30 In the case of unstable knee prosthesis without a handle component, it may be necessary to modify the handle component with or without supplementary metaphyseal fixation (Figure 6). For unstable hip prostheses, the treatment is first Including modification of a longer distal joint prosthesis. After the revision of joint replacement components, the fracture should be fixed with steel plates as needed and bone augmentation should be supplemented as needed. The interprosthesis sleeve helps to bypass the lack of diaphyseal bone between the stalked prostheses. 34 The enhancement of cortical struts in the case of interprosthetic fractures has not been clearly described; however, the experience of treatment of single-joint periprosthetic fractures can be extrapolated and applied to treat interprosthetic fractures with insufficient bone mass or nonunion. In these cases, cortical struts can be used to restore the non-circumferential loss of cortical bone, bypass stress rise, and further provide biological stability at the allograft-host bone interface. 31-33 Auxiliary autograft or allogeneic bone graft can further provide osteoinduction and bone conduction support to promote fracture healing. 35 In some cases, revision and reconstruction options are limited due to a large amount of bone loss around the loose femur or knee joint prosthesis, or both prostheses are loose and reconstruction of both is not feasible, revision may require full femur Prosthesis. 3,5,14,25 Similarly, in the case of multiple fracture fixation failures or persistent fracture nonunion, repairing a giant prosthesis may provide the ultimate treatment. 3,5 Figure 6 Anterior and posterior (A) and lateral (B) radiographs. Stalked revision total knee arthroplasty after a fracture around the prosthesis around the loose total knee joint prosthesis. The fixation is supplemented by a long horizontal locking plate and several adapter plates to maximize the purchase of screws around the stem. Abundant callus was observed at the junction of stems, indicating a strong healing response.
Figure 6 Anterior and posterior (A) and lateral (B) radiographs of a stalked revision total knee arthroplasty after a periprosthesis fracture around a loose total knee joint prosthesis. The fixation is supplemented by a long horizontal locking plate and several adapter plates to maximize the purchase of screws around the stem. Abundant callus was observed at the junction of stems, indicating a strong healing response.
Our preferred algorithm combines treatments based on Pires et al. classification and adheres to strict surgical principles to maximize bone healing and limb alignment recovery (Figure 7). For IFF with stabilized hip and knee implants, the fixation includes a long, transverse femoral locking plate that spans at least two cortical diameters of the two implants. If the total knee prosthesis does not have a stem, the flared mouth of the locking plate extends to the condyle area, and multiple locking screws are gathered around the implant as much as possible. In the case of bone cement implants, a diamond tip drill can be used to pierce the bone cement cover to allow more screw fixation. The plate should be applied with minimal damage to the periosteum and soft tissue, and extend proximally beyond the hip stem, and fix with unicortical and bicortical locking screws as appropriate. The circling cable can be applied by embossing on the steel plate to supplement the fixation. When the femoral hip joint or knee joint components are loose and the fracture is far away from the implant, the joint replacement is modified to a diaphyseal femoral implant or a stalked knee prosthesis, supplemented by plate osteosynthesis. If the fracture closely surrounds one implant that is determined to be loose, such that the fracture is away from the other implant and no fractured diaphysis extends, the correction component is used to bypass the fracture to correct the single component. However, in general, the auxiliary steel plate should be used freely to disperse the contact force of the entire femur and limit the stress rise, especially in the bone area where the high modulus does not match. If both implants become loose, further evaluation of bone quality will determine a wider range of treatment options. If the bone quality is sufficient, the two components can be modified and the interprosthesis sleeve can be placed as the internal strut. Cortical strut grafts can supplement additional biological and structural fixation and are secured in place with cerclage cables. If the bone mass is insufficient, the patient may get the greatest benefit and more convenient surgery, and switch to total femur replacement. Figure 7 The author's preferred management strategy for interprosthetic femoral fracture fixation based on fracture location, implant stability, and bone mass.
Figure 7 The author's preferred management strategy for interprosthetic femoral fracture fixation based on fracture location, implant stability, and bone mass.
After fixing the fracture between the prostheses, allowing the bone to heal and maintaining a stable structure is the most important. Therefore, patients usually use a walking aid to keep their toes in contact with a weight bearing (10%) during the first 6 weeks after surgery. A multimodal pain management strategy using acetaminophen, small and judicious use of opioids, and various gabapentanes. The effect of non-steroidal anti-inflammatory drugs on fracture healing is still controversial, but three doses of ketorolac are usually injected intramuscularly or intravenously immediately after surgery. Physiotherapy starts on the day of surgery or the first day after surgery, focusing on range of motion, strength and gait training. At the 6th week, follow-up X-rays were obtained to assess the degree of healing. At that time, the patient may progress to partial weight bearing and transition to full weight bearing in the next 2-4 months.
Femoral fracture between prostheses is a thorny clinical problem, facing more and more ipsilateral total hip and knee replacement patients, its incidence is getting higher and higher. When treating patients with IFF, careful consideration of the patient’s preoperative medical condition, implant type and stability, and surrounding bone mass will help guide treatment options. Standard fixation options include locking plates and screws, supplementary cerclage cables, and possible bone grafting. In the case of an unstable or loose implant, techniques include intramedullary nails, interprosthetic sleeves, revision arthroplasty components, and graft materials. Finally, total femoral replacements or large prostheses are usually only used for patients with limited bone mass and loose implants.
Dr. Ran Schwarzkopf provides consulting services to Smith & Nephew, holds stock options in Intelijoint, and participates in Smith & Nephew's Gaussian surgical research. The authors report no other conflicts of interest in this work.
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