Clinical Review

Proximal Periprosthetic Femur Fractures: Strategies for Internal Fixation

Am J Orthop. 2016 May;45(4):213-218

As the number of patients living with total hip arthroplasty continues to rise, there will be an increase in periprosthetic fractures requiring surgical treatment. Treatment of periprosthetic femur fractures below a well-fixed hip arthroplasty stem presents a unique set of challenges. A review of the existing literature on surgical technique, including plate selection and configuration, proximal fixation options, and use of allograft, can serve to guide treatment of these challenging injuries. While not conclusive, the literature supports using soft tissue preserving techniques, bicortical proximal fixation, and fixation spanning the length of the femur.

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References

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The rate of total hip arthroplasty (THA) is rising and demand is expected to increase by 174% to 572,000 by 2030.¹ The rate of periprosthetic fracture around primary THA is frequently reported at around 1%,^2-4though a recent study of over 32,000 THAs quotes the 20-year probability of periprosthetic fracture at 3.5%.⁵ Revision THA is also increasing in frequency and associated rates of periprosthetic fracture range from 1.5% to 7.8% following revision THA,^3,4,6 with the probability of fracture at 20 years of 11%.⁷ Projection models predict that the number of periprosthetic fractures will rise by 4.6% per decade over the next 30 years.⁸

Broadly, treatment options include open reduction internal fixation (ORIF), revision THA, and combined approaches. The Vancouver classification, based on fracture location, stem stability, and bone loss, is often used to guide fracture treatment, with stable implants treated with ORIF and unstable implants requiring revision arthroplasty.

Fixation strategies for treatment of periprosthetic fracture around a well-fixed arthroplasty stem have evolved over time, and there continue to be a variety of available internal fixation options with no clear consensus on the optimal strategy.⁹ Rates of reoperation following ORIF of periprosthetic femur fracture are reported from 13% to 23%,^8,10-12 confirming that there remains room for improvement in management of these injuries.

Locking Plate Fixation

Early fixation strategies included allograft and cables alone as well as nonlocked plate and cerclage constructs. In response to the complication and reoperation rate for nonlocked plate constructs, reported at 33%,¹³ locking plates were introduced as a treatment option, allowing for both improved osseous vascularity and added screw options.¹⁴ When compared to the traditional nonlocked Ogden construct, locking plate constructs are more resistant to axial and torsional load.¹⁵ Clinically, the relative risk of nonunion after nonlocking plate fixation is reported at 11.9 times that of fixation with locking plate technology.¹⁶

Successful use of lateral locking plate fixation for treatment of this injury has been reported on in several clinical series.^17-20 Froberg and colleagues¹² evaluated 60 Vancouver B1 and C fractures treated by locking plate osteosynthesis and reported no nonunions, an improvement from previous constructs. However, 8 out of 60 patients with 2-year follow-up required reoperation—4 for infection, 3 for refracture, and 1 for stem loosening—making it clear that the locking plate alone was not a panacea.

With locking plate fixation a mainstay of modern treatment of periprosthetic femur fractures, many questions still remain.

Proximal Fixation

Even with the introduction of locked plates, treatment success after ORIF of Vancouver B1 fractures relies on adequate proximal fixation. Options for proximal fixation around the stem include cerclage wires or cables, unicortical locked screws, obliquely directed bicortical screws, and use of the locking attachment plate to insert bicortical locked screws. These strategies can be used in the presence of cemented or uncemented stems, with biomechanical evidence that screw fixation through the cement mantle does not cause failure.²¹

Several biomechanical studies address the stiffness and strength of varying proximal fixation strategies. While early fixation relied heavily on cables, the use of cables alone as proximal fixation has been linked to significantly higher rates of failure when compared to other constructs in a large clinical series.¹¹ Multiple biomechanical studies have shown that newer methods of proximal fixation provide more rigid constructs.^22,23

Unicortical locked screws appear to outperform cables biomechanically. The use of unicortical screws in lieu of or in addition to cables provides added resistance to lateral bending as well as torsion when compared to cables alone.²⁴ A second group found that unicortical locked screws alone were superior to combined fixation with cerclage wires and unicortical locked screws.²⁵

Added stability can be demonstrated by bicortical fixation strategies, which offer increased rigidity when compared to cables or unicortical screws.²² In vitro work has shown enhanced fixation stability with bicortical screw fixation using the locking attachment plate when compared to cerclage wires alone.^23,26Clinically, some authors have demonstrated success with the use of reversed distal femoral locking plates in order to enhance proximal locking options and allow for bicortical fixation around the stem.¹⁹As noted above, the data favor the opinion that clinical failure rates with cerclage wires alone are high, and biomechanically, bicortical fixation around the femoral stem appears to be superior to unicortical locked screw fixation or cerclage wires. If rigid proximal fixation is desired, an effort should be made to obtain bicortical fixation around the femoral stem.

Allograft

Allograft strut, either alone or in addition to plate osteosynthesis, has long been used in treatment of periprosthetic fractures. Proponents of this technique cite improved biomechanical stability¹⁷ and allograft incorporation resulting in restoration of bone stock.