Operative Techniken Oper Orthop Traumatol 2014 · 26:455–468 DOI 10.1007/s00064-014-0305-4 Received: 21 February 2014 Revised: 4 June 2014 Accepted: 4 June 2014 Published online: 29. September 2014 © Springer-Verlag Berlin Heidelberg 2014
Redaktion
M. Blauth, Innsbruck Zeichner
R. Himmelhan, Mannheim
Introductory remarks The incidence of postoperative periprosthetic fracture of the femur after primary implantation is reported to be less than 1%, and after revision surgery it is between 1.5 and 4.2% [18, 21, 23]. The Vancouver classification system has gained broad acceptance [6]. It reflects the localization of the fracture, the quality of the prosthesis fixation, and the quality of the bone itself. When the prosthesis is loose (Vancouver type B2 and B3 fractures), an exchange of the prosthesis is necessary [1, 5, 6, 9]. According to Bethea et al. [4], 75% of all postoperative periprosthetic fractures are related to loose implants; Duncan et al. [6] reported that 82% of type B fractures occurred in the presence of loose implants. During revision, the prosthesis can be replaced by a cemented or by a cementless stem implant [1, 5, 6, 9]. The disadvantage of a cemented stem is that cement can be forced into the fracture site and thus impede bony healing. Beals et al. [2] reported that 31% of revisions with cemented stems developed nonunions, 15% exhibited new fractures, and 15% developed permanent bone defects; by contrast, only 7% of patients with cementless implants suffered new fractures. Moreover, the quality of cementing is impaired by the fracture. Therefore most surgeons prefer revision with cementless implants. A variety of stems have been used as cementless implants for Vancouver type B2 and B3 periprosthetic fractures: (a)
B. Fink Klinik für Endoprothetik, Allgemeine und Rheumorthopädie, Orthopädische Klinik Markgröningen, Markgröningen
Revision arthroplasty in periprosthetic fractures of the proximal femur stems with proximal fixation, (b) nonmodular, fully porous, coated stems with distal fixation, (c) nonmodular, tapered, fluted stems with distal fixation, and (d) modular, tapered, fluted stems with distal fixation (. Tab. 1). The disadvantage of stems with proximal fixation in cases of periprosthetic fracture is that relative motion between the proximal fragment of the fracture and the prosthesis can interfere with bone growth onto the implant [17]. Moreover, when fixation of the cementless stem is proximal, the region of fixation is close to the fracture itself and thus the anchorage of the stem is reduced. In order to improve the proximal stability, this type of prosthesis is often combined with a strut graft. However, Incavo et al. [17] reported loose stems in over 50% of healed periprosthetic fractures, while Sledge et al. [27] observed similar problems in more than 25%. Cementless prostheses with distal fixation have the advantage that the point of fixation is located outside the fractured section; the fracture is bridged and fixed with cerclage wires or cables to the prosthesis. Thus the stability of the prosthesis is not influenced by the quality of the fracture fixation, and the fracture itself can heal without being exposed to torsional forces. In recent years, the modular revision stem has become more popular since it addresses two objectives of the revision surgery independently: Firstly, the distal stem component enables the solid fixation of the prosthesis in the isthmus of
the femur while bypassing the fracture, and secondly, the proximal section of the stem can be used to adjust the length and antetorsion of the stem. There are two implantation techniques with distally fixed revision stems. The first technique includes reduction and fixation of the fragments with clamps or cerclage wires before implantation of the stem. The second procedure begins with an extended trochanteric osteotomy down to the end of the fracture line and continues with a separation of the proximal fragment, the implantation of the stem in the distal fragment, and closes with an approximation of the proximal fragments around the stem with cerclages. The disadvantage of the first technique lies in the inability to monitor the actual fixation of the prosthesis stem, thus making it difficult to be sure that the fracture is bridged by the fixation zone. Therefore it is much more difficult to obtain reproducibly good results with this technique. Although Moran et al. [22] did not observe any complications in a small study of distal stem fixation with this method of implantation, Invaco et al. [17] reported one out of four cases of stem loosening while Park et al. [26] reported 7% loosening and 7% intraoperative fracture. The advantage of the second method of implantation with an extended trochanteric osteotomy lies mainly in the ability to monitor the zone of fixation and positioning of the new prosthesis at all times, so that the surgeon can be certain that the stem or its distal compo-
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Operative Techniken Tab. 1 Overview over the reported results of stem revision in Vancouver B2 and B3 periprosthetic fractures Author Incavo Sledge O’Shea Invaco Moran Ko Levine Park Mulay Fink
N (B2/ B3) 8/0 7/0 10/12 4/0 4/0 12/0 12/5 16/11 10/12 22/10
ETO
OP tech.
Study
No Yes Yes No No Yes Yes In 2 of 27 Yes Yes
1 1 2 1 1 2 2 1 2 2
Retrosp. Retrosp. Retrosp. Retrosp. Retrosp. Prosp. Retrosp. Retrosp. Prosp. Prosp.
Followup a 49 33 33.7 49 24 58.5 44.5 57.6 24 32.2
Union (%) 87.5 100 91 100 100 100 100 92.6 91 100
HHS 67.6 83 ≈75 78.3 87 ≈80 – 84.7 69 81.6
Subsidence (%) – 28.6 9.1 – – 16.6 17.6 7.4 77.3 0
Dislocation (%) 0 0 0 0 0 0 5.8 0 22.7 3.4
Fracture (%) 37.5 0 0 0 0 8.3 5.8 7.4 4.5 0
Infection (%) 0 0 4.5 0 0 8.3 5.8 3.7 4.5 0
Loosening (%) 25 0 0 25 0 0 0 7.4 0 0
ETO extended trochanteric osteotomy, Prosp. prospective, Retrosp. Retrospective, OP technique 1 reposition and reduction of the fragment before implantation of the stem, OP technique 2 implantation of the stem and then closure of the proximal fragments around the stem, Stem 1 with proximal fixation, Stem 2 nonmodular, distal fixation, fully porous-coated, Stem 3 nonmodular, distal fixation, conical, Stem 4 modular, distal fixation, conical, rough-blasted titaniumaIn months
nent is firmly anchored distal to the fracture, by means of a press fit, and can remove the loose stem and any residual cement fairly easily. In a prospective study of 32 periprosthetic fractures with a mean follow-up period of 32.2±10.4 months (24–60 months), we found with this second operative technique reproducible and very good results with respect to fixation of the prosthetic stem, and therefore subsidence, healing of the fracture, and clinical outcome [14]. The disadvantages of this technique are the extended trochanteric osteotomy with its extended approach and the fact that there are three fragments instead of the two that usually result from the fracture. However, neither our study nor previously published studies have reported any disadvantages of this surgical approach or a prolonged healing time (. Tab. 1). As mentioned by Berry [3], using this technique it is important not to strip the muscles of the fragments to preserve the blood supply of the bone. Reliable excellent fracture healing rates can be achieved, and due to callus formation improvement of deficient proximal femoral bone in Vancouver B3 fractures can be expected [3]. Therefore, we prefer extended trochanteric osteotomy via a posterolateral approach—independent of previous approaches used for prosthetic implantation—to leave the muscles on the bone and not to go through the vastus lateralis muscle. This paper describes this technique using the Revitan Curved™ (Zimmer GmbH, Winterthur, Switzerland) as
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an example of modular distal fixated revision stems.
Surgical principles and objective Removal of the loose stem after a periprosthetic fracture with minimal risk of additional fractures or perforations of the femoral shaft using a transfemoral approach according to Wagner. Preparation of a solid conical bed for the new, curved prosthetic stem distal to the fracture in the isthmus of the femur and its secure anchorage by cone-in-cone press-fit fixation taking leg length and antetorsion into account. Additional distal locking with an isthmic fixation zone of less than 3 cm. Fixation of the proximal fragments with cerclage wiring. Restoration of a pain-free limb allowing for immediate weight bearing.
Advantages F Minimal risk of additional intraoperative fractures or perforations of the femoral shaft during removal of the cement or implantation of the new stem. F Direct access to the medullary canal of the distal part of the femoral isthmus to ease cement removal and preparation of the bed of the new implant. F Good access to the acetabulum for changing the insert. F Relatively short surgical time, even for more difficult situations.
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F Controlled, step-by-step approach from removal of the loose stem and cement, secure fixation of the revision stem, to restoration of normal leg length and antetorsion. F Reliable healing of the osteotomy due to the intact vascularity of the bone flap, the extensive osteotomy, and the application of double cerclage at replantation in a modified technique according to Wagner and Wagner [28].
Disadvantages F Technically demanding approach. F Potentially more bleeding due to the additional osteotomy and in case of inadequate ligation of the perforating vessels. F Longer rehabilitation phase due to the extended surgical approach. Modular revision stem Revitan Curved is 10– 30% more expensive than the nonmodular straight Wagner SL Revision Stem, depending on stem length.
Indication F Periprosthetic fracture of the femur at the level of the prosthetic stem and a loose implant with or without bone defects (Vancouver types B2 and B3) [6].
Contraindications F Periprosthetic joint infection.
Abstract · Zusammenfassung Oper Orthop Traumatol 2014 · 26:455–468 DOI 10.1007/s00064-014-0305-4 © Springer-Verlag Berlin Heidelberg 2014 B. Fink
Revision arthroplasty in periprosthetic fractures of the proximal femur Abstract Objective. Hip revision arthroplasty of a loose stem in the case of Vancouver type B2 and B3 periprosthetic fractures and cerclage wiring of the femoral shaft. Indications. Vancouver type B2 and B3 periprosthetic fractures of the proximal femur. Contraindications. Periprosthetic joint infection. Interprosthetic femoral fractures between the ends of hip and knee prosthetic stems that require total replacement of the femur. Surgical technique. Extended posterolateral approach to the tip of the fracture. Exposure along the septum intermusculare laterale with ligation of the perforating vessels below the fracture. Longitudinal osteotomy of the proximal fragment above the linea aspera using an oscillating saw under cooling. Ventral proximal osteotomy at the corner of the vasto-gluteal sling after short muscular incision using an osteotome chisel. Opening of the proximal fragment with lifting up of the bony flap like a transfemoral approach. Removal of the loosened prosthetic stem and
possibly the cement. Preparation of the distal fixation zone of the modular cementless revision stem in the isthmus of the femur distal of the fracture. Implantation of the distal component of the modular cementless revision stem. Use of additional distal interlocking screws in cases of destroyed isthmus with a fixation zone of less than 3 cm for the distal prosthetic component. Trial reposition after combination with the proximal trial component in situ. Assembly with the original proximal component in situ. Reposition with the original proximal component. Wound closure. Postoperative management. Thrombosis prophylaxis, physiotherapy, gait training with partial loading of the limb at 10 kg for a period of 6 weeks with hip flexion limited to 70°. Then, free range of movement and increased loading by 10 kg per week. Results. In all, 23 patients with periprosthetic fractures of Vancouver type B2 (15 patients) and type B3 (eight patients)—in 15 women and eight men in the age range of 70.7±12.2 (42–88) years—were followed up for at least
5 years. All fractures healed with a mean time of 14.4±5.3 weeks. No cases of subsidence of the stem were observed and, according to the classification of Engh et al. concerning the biological fixation of the stem, there was bony ingrowth fixation in 21 cases and two cases of stable fibrous fixation. One dislocation occurred and there were no cases of intraoperative fracture. The Harris Hip Score rose continually following the operations: from a 3-month postoperative score of 65.0±16.8 points, it rose to 86.9±16.2 points after 24 months and to 89.0±14.3 points after 5 years. According to the classification of Beals and Tower, all results were rated as excellent, i.e., the prefracture functional status was restored in all cases. Keywords Periprosthetic fracture · Revision arthroplasty · Proximal femur · Primary implantation · Implantation technique
Prothesenwechsel bei periprothetischen Frakturen des proximalen Femurs Zusammenfassung Operationsziel. Wechsel der gelockerten Schaftkomponente bei periprothetischer Fraktur vom Typ Vancouver B2 und B3 auf eine modulare, zementlose Revisionsprothese sowie Osteosynthese mit Cerclagen. Indikationen. Periprothetische Fraktur vom Typ Vancouver B2 und B3. Kontraindikationen. Periprothetischer Infekt. Interprothetische Fraktur zwischen gestielten Prothesen des proximalen und distalen Femurs, die einen totalen Femurersatz erfordert. Operationstechnik. Erweiterter posterolateraler Zugang bis unterhalb der Fraktur. Vorgehen im Septum intermusculare laterale unter Ligatur der Vasa perforantes bis distal der Fraktur. Längsosteotomie des proximalen Fragments oberhalb der Linea aspera mit oszillierender Säge unter Kühlung. Ventrale proximale Osteotomie am vastoglutealen Übergang mit Osteotomiemeißel nach kurzer Inzision der Muskulatur. Eröffnen des proximalen Fragments, wie bei einem transfemoralen Zugang, durch Hochklappen des Knochendeckels. Entfernen der gelock-
erten Schaftprothese und ggf. des Knochenzements. Präparieren des Fixationsbetts der modularen, zementlosen Revisionsprothese im Isthmus des Femur distal der Fraktur. Implantation der distalen Komponente des modularen, zementlosen Revisionsschaftes. Verwendung zusätzlicher Verriegelungsschrauben bei einer distalen Fixationszone unter 3 cm. Probereposition mit kombiniertem proximalem Probeteil. In-situ-Montage der originalen proximalen Prothesenkomponente. Reposition mit Original-Prothesenkopf. Weiterbehandlung. Thromboseprophylaxe, Physiotherapie, Gangschulung mit Teilbelastung von 10 bis 20 kg für die Dauer von 6 Wochen. Anschließend schrittweise Belastungssteigerung bis zur Vollbelastung 3 Monate postoperativ. Falls Teilbelastung nicht möglich (z. B. geriatrischer Patient): Belastung wie vom Patienten toleriert). Vermeidung von gleichzeitiger Flexion, Innenrotation und Adduktion für 3 Monate. Für 6 Wochen Limitierung der Flexion auf 70 Grad.
Ergebnisse. Alle 23 periprothetischen Frakturen (15 Vancouver B2 und 8 Vancouver B3) bei 15 Frauen und 8 Männern im Alter von 70,7±12,2 (42–88) Jahren mit einem Nachuntersuchungszeitraum von mindestens 5 Jahren waren nach durchschnittlich 14,4±5,3 Wochen geheilt. Der Prothesenschaft war bei keinem Patienten eingesunken. Einmal trat eine Luxation auf, eine intraoperative Fraktur in keinem Fall. Der HarrisHip-Score stieg postoperativ kontinuierlich an: von 65,0±16,8 Punkten nach 3 Monaten auf 86,9±16,2 Punkte 24 Monate postoperativ und 89,0±14,3 Punkte 5 Jahre postoperativ. Entsprechend der Klassifikation von Beals und Tower konnten alle Ergebnisse als exzellent eingestuft werden, da bei allen mindestens die gleiche Funktionalität wie vor dem Unfall erreicht wurde. Schlüsselwörter Periprothetische Fraktur · Prothesenwechsel · Proximaler Femur · Primäre Implantation · Implantationstechnikl
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Fig. 1 8 a Preoperative radiograph of a total hip arthroplasty implanted 9 years earlier with Vancouver type B2 periprosthetic fracture running through the anchorage zone of the stem after low-energy trauma. Measuring of the length of the proximal fragment on the lateral (H1) and medial side (H2). b Sketching the anchorage zone. c Choice of prosthetic components according to the templates. d Radiograph 6 days postoperatively after replacing the stem with a Revitan Curved after a transfemoral approach. e Radiograph 38 months postoperatively with osseous consolidation of the fractures. (From [14], courtesy of Lippincott Williams & Wilkins)
F Type B1 and C fractures with stable stems that can be treated with osteosynthesis. F Interprosthetic femoral shaft fractures in between the ends of hip and knee joint prostheses that can only be stabilized by total replacement of the femur.
Patient information F General surgical risks. F Joint dislocation. F Nerve lesions, specifically of the sciatic nerve. F Subsidence and/or loosening of the prosthesis F Fracture of the distal femur. F Insufficient healing of the bone flap with limping at the hip and/or greater trochanter pain. F Fracture of the bone flap and/or avulsion of the greater trochanter due to osteolysis with positive Trendelenburg’s sign and/or greater trochanter pain. F Prolonged postoperative rehabilitation with Trendelenburg’s sign up to 1 year. F Partial load bearing for 3 months.
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Preoperative work-up F Preoperative optimization of comorbidities. F 250 mg cefuroxime as a single shot perioperative antibiotic prophylaxis or 3×250 mg cefuroxime in 24 h for surgeries longer than 2 h. F Shaving of the leg immediately before the operation from the iliac crests to below the knee joint [16]. F At least AP radiographs of the femur at a film-focus distance of 115 cm, if possible in two views. Analyzing the x-rays to differentiate between B1 and B2 fractures. Radiolucent zones and fractures running through the anchorage zone of the old stems are indicative of B2 fractures. F Preoperative planning: On the AP film, the length of the bony flap, the fixation zone of the revision stem in the isthmus of the femur with endosteal contact of the stem on the medial and lateral side of the isthmus, and the expected distal and proximal implant components have to be determined. 1 Step 1: The length of the lateral end of the proximal fragment is measured from the tip of the greater trochanter (H1). This is the distal
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end of the transfemoral approach. The level of the medial end of the proximal fragment is measured in relation to the lateral end (H2). This is the medial distal end of the bony flap of the transfemoral approach (. Fig. 1a). 1 Step 2: Sketching in the anchoring zone of the distal component of the modular revision stem in the isthmus of the femur (. Fig. 1b). If the quality of the cortical bone is good, a fixation length of 30–50 mm is sufficient based of the cone-in-cone fixation principle with a conical stem implanted in a prepared conical fixation bed in the isthmus of the femur [8, 10, 12]. 1 Step 3: Selection of the prosthetic components based on the radiographic templates (. Fig. 1c). Selection of the distal components regarding length and diameter with templates. The aim is a solid pressfit fixation with the tip of the fluted stem in the isthmus of the femur of at least 3 cm to get a short as possible modular stem [8, 9, 10, 11, 12, 13]. In general, a thicker stem requiring a shorter fixation distance should be preferred rather than a thinner stem requiring a longer fix-
ation distance. The choice of the proximal component guarantees correct limb length. The center of rotation of the hip joint should be at the level of the tip of the greater trochanter. When the length of the proximal components cannot be estimated because of the fractured femur, planning on radiographs of the contralateral side can be helpful.
Surgical instruments and implants F Standard instruments for implantation. F Flexible intramedullary reamer with long guide wire. F Cerclage set, cerclage band set (e.g., Merete Medical GmbH, Alt-Lankwitz 102, 12247 Berlin, Germany, or Stemcup Medical Products AG, Aargauerstraße 180, 8048 Zurich, Switzerland) or cable system (e.g., Zimmer Germany GmbH, Maria-Merian-Straße 7, 24145 Kiel, Germany). F Modular uncemented revision prosthesis Revitan Curved (Zimmer Germany GmbH, Merzhauser Straße 112, 79100 Freiburg, Germany).
Anesthesia and positioning F General or spinal anesthesia. F Preparation of a cell saver for autotransfusion (e.g., Haemonetics GmbH Germany, Wolfratshauser Straße 84, 81379 Munich, Germany). F Tranexan acid 1 g before the operation starts. F Lateral decubitus with anterior and posterior supports for the pelvis and trunk. F Affected leg draped fully mobile. The lower leg should be in a straight position to prevent tilting of the pelvis. F Image intensification of the affected leg should be tested preoperatively.
Surgical technique (. Fig. 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14)
Fig. 2 9 Lateral decubitus. Incision of 30– 40 cm starting posterolaterally and extending along the greater trochanter to the distal end of the fracture
Fig. 3 9 Dissection of the subcutaneous tissue and the fascia lata in the same direction. Blunt dissection of the gluteus maximum muscle in the direction of its fibers
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Fig. 4 8 The external rotators are cut close to their attachments and secured with stay sutures. Identification and preservation of the sciatic nerve (a). Extraction of the so-called neocapsule and the scar tissue to expose the joint (b)
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Fig. 5 9 Exposure of the femur anterior to the lateral lip of the linea aspera in the lateral intermuscular septum; the perforating vessels are ligated. The lateral hemicircumference of the femur is exposed at the tip of the proximal fragment
Fig. 6 8 a, b Osteotomy of the trochanteric region and distally into the proximal medial femur with a chisel starting anterior and proximal to the junction of the vastus lateralis and the gluteus medius with the leg in external rotation. Chisel is used to minimize the trauma to the muscles in that area
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Fig. 7 8 Posterior osteotomy anterior to the lateral lip of the linea aspera, preparation of the medial end of the distal fragment; anterior distal osteotomy of about 3 cm using an oscillating saw cooled with sterile Ringer’s solution with the leg in internal rotation
Fig. 9 8 The osteotomized lateral bone flap with the vastus lateralis attached is lifted from lateral to medial end. The prosthesis and bone cement are completely removed
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Fig. 8 8 Completion of the anterior osteotomy using a chisel that is passed from distal to proximal end underneath the vastus lateralis with the leg in external rotation. The attachment of the vastus lateralis muscle to the bone flap needs to be preserved. In cases of very oblique fractures with a short medial fragment from the calcar to the medial end of the proximal fragment, the osteotomy on the medial side can be completed by chiseling from proximal to distal end under the vastus lateralis starting at the border between the medial gluteal muscle and the vastus lateralis (see . Fig. 6)
Fig. 10 8 The complete removal of all cement or a sclerotic endofemoral projection (generally a pedestal at the tip of the prosthesis) is important; an osseous projection could deflect a reamer or rasp toward the opposite cortex and thus provoke perforation. Application of double cerclage with a single 1.5-mm cerclage wire adjacent distal to the fracture and bone flap to prevent the femoral isthmus from fissuring during reaming, rasping, or insertion of the original implant. The prophylactic cerclage will be left in place after the procedure to prevent fracture in the case of subsidence
Fig. 11 8 a Drilling through distal cement or a bone obstacle, first with a long 4.5-mm diameter drill, then a 6-mm and, finally, with an 8-mm diameter drill. In case of any doubt about the central, intramedullary position of the drill, drilling should be performed under image intensification. Remaining pieces of cement can now be removed with chisels and/or long thread cutters via a retrograde technique. Cylindrical preparation of the isthmus with medullary reamers that are inserted over an intramedullary guide wire. Its intramedullary position can be monitored with the image intensifier. Alternatively, the intramedullary guide wire can be advanced to the condylar region of the distal femur. Close attention should be paid for the rod not to perforate. Cylindrical reamers with ascending diameters and mounted on a flexible shaft are inserted over the intramedullary guide rod to ream the medullary canal in 0.5-mm to 1-mm increments. During this procedure attention must be focused on contact of the reamer with the cortex and the sound that is created by that procedure specifically in the isthmic part of the femur. If a cortical contact with high-pitched sound over a distance of 3–5 cm is achieved, medullary reaming should be discontinued. Preoperative planning is helpful with regard to the choice of reamer head. Additionally analyzing the reamer to detect reaming particles of the cortical bone may be helpful. As a rule of thumb the diameter of the last reamer is 4 mm (i.e., two rasp sizes) smaller than the calculated diameter of the implant stem. The assigned thickness of the distal component of the Revitan stem is determined at 11 cm above the tip of the conical stem by definition; at the distal end of the implant the diameter is 4 mm less. b Conical preparation of the distal prosthesis bed with special rasps. In accordance with preoperative planning, the length of the distal rasp components is selected with reference to the fracture to be bridged. Rasps of increasing diameters are used with the rasp impactor, starting with the diameter that is one size smaller than the last reamer. It is important that the antecurvation of the rasp corresponds to that of the femur. Once the appropriate rasp that should facilitate a good circular press-fit fixation in the isthmus has been selected, the length of the proximal rasp component is read off the scale of the rasp impactor at the level of the greater trochanter. The shortest (P 55) and longest proximal components (P 105) should be avoided so that there is room for variation when it comes to insertion of the definitive implant. In the case of the shortest proximal component, a trial reduction with the proximal rasp component can be made to be sure that reposition is possible. In the case of the longest proximal component, it should be checked whether the fixation zone is at the distal end of the rasp or if a thicker rasp would facilitate the use of a shorter stem combination with the fixation zone at the tip of the stem. Additional reaming of 1 mm with the flexible reamer may become necessary in this situation
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Fig. 12 8 Implantation of the modular revision stem. a The final distal component with the same size as the last rasp is advanced with light hammer blows on the stem impactor to achieve definitive distal press-fit anchorage. The intensity of the hammer blows should be adapted to the bone quality. Any obstacles in the proximal femur that would interfere with the progression of the prosthesis into the distal femur must be carefully avoided. The insertion depth of the implant is checked with the help of the markings on the stem impactor at the level of the greater trochanter. Reduction of the bony flap can be helpful for this measurement. b The proximal trial part is mounted on the definitive distal implant component with the corresponding nut that has been fixed onto the connecting bolt of the implant. The proximal trial part is supported on the shoulder of the distal implant component so that there is no contact with the conical connecting zone. Antetorsion can be adjusted to ±30° (marked on the prosthesis). It should be noted that there are left and right markings. After trial reduction the antetorsion and/or length of the proximal prosthesis component may be adapted. The proximal trial part can be changed for another size by loosening the nut. The antetorsion angle of the prosthesis can be readjusted as required. The tension in the proximal soft tissues and leg length can be assessed using trial heads of different lengths. As a rule of thumb, the center of the head should lie at the level of the trochanter tip. After exchanging the proximal trial part, trial reduction should be performed again. c In situ assembly with the selected proximal prosthesis component at the desired antetorsion angle. Detachment of the proximal trial part; the connecting taper is thoroughly cleaned with sterile Ringer’s solution and dried. The definitive proximal component, which corresponds to the size of the last proximal trial part, is positioned; simultaneously, antetorsion is adjusted as required. d The threaded rod of the stem tensioner is driven into the thread of the connecting taper; then, the handle of the stem tensioner is guided over the threaded rod and fastened with the nut. The two implant components are connected to each other using the torque wrench. During this procedure, the handle of the stem tensioner is used to neutralize the torque forces acting on the femur. Care must be taken that antetorsion is not affected. After tightening the components with the torque wrench, the nut of the stem tensioner is loosened by turning the torque wrench counterclockwise, and the stem tensioner is removed. e Seating of the conical nut onto the connecting taper with the aid of the setting instrument; tightening with the torque wrench. The torsional forces generated by the tightening procedure are neutralized using the handle for counter force
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Fig. 13 8 Additional distal locking. In case of a more distal fracture extension with a less than 3 cm fixation zone in the isthmus, interlocking screws are recommended to improve distal fixation. To make that happen, a distal component of at least 18 mm diameter and 200 or 260 mm length are necessary. Distal locking should always be regarded as an additional safety measure that cannot replace secure distal press-fit fixation and should therefore only be performed in exceptional situations. The targeting device is attached to the distal component already anchored in the femur before the required proximal component is inserted. a The targeting module, which corresponds to the length of the inserted distal component (L.200 mm or L.260 mm), is connected to the coupling arm and secured with a screw. This assembly is called the targeting device. b The connecting screw is screwed onto the connecting taper of the implant; the targeting device is advanced onto the distal implant component over the connecting screw. Its cams must latch precisely into the grooves of the implant component. c This assembly is secured to the connecting screw with a nut. d The tissue protection sleeve with inserted trocar is guided into the desired target drill hole. The skin is incised at the appropriate location; blunt dissection of the soft tissues to the bone with scissors or a clamp. The tissue protection sleeve with trocar is advanced to the bone. The trocar is removed. A drill hole is made in both cortices using a twist drill (4.0 mm diameter) that has been placed into the tissue protection sleeve. e Screw length is determined using the measuring device. Alternatively, screw length can be read off the drill directly. The drill tip should only project very slightly beyond the second cortex. f The previously determined locking screw (4.9 mm diameter) is inserted through the tissue protection sleeve with the screwdriver. Correct seating of the locking screw is monitored on the image intensifier. Removal of the interlocking screws is usually not necessary and leaving the screws helps to monitor stem fixation quality because breakage of the screws would indicate subsidence of the stem
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Fig. 14 8 Osteosynthesis of the proximal fragments. After implantation of the modular uncemented revision stem, osteosynthesis of the proximal fragments by fixing them around the stem usually with two or three double cerclage wires (1.5 mm). Alternatively, cerclage bands or cerclage cables can be used. We prefer using double cerclage wires because of high stability. In the case of a less than anatomic reduction of the proximal fragment, cancellous bone collected during reaming of the femoral canal can be put in the gap to support the healing of the gap. The gap will heal because of callus formation introduced by the fracture hematoma. After insertion of drains and suture of the vastus lateralis, the wound is closed in layers. The drains are connected to the cell saver and suction is applied for 6 h postoperatively with a reduced suction force of 10 cm of water head to prevent too much blood loss
Postoperative management F Radiologic documentation. F Drains are removed after 24–48 h. F Walking exercises with 10–15 kg partial weight bearing of the operated leg from the first postoperative day. Load increase depends on the quality of the bone, the patient’s age, and the quality of press-fit anchorage achieved intraoperatively. In general, partial loading of 10 kg continues for 6 weeks. The load limits are practiced on the weighing scale. Hip flexion is restricted to 70° for 6 weeks to reduce forces on the proximal osteosynthesis with cerclages. Next, after radiologic assessment of the femur in two planes, gradual increase in loading up to full weight bearing after 3 months. If partial weight bearing is not possible in old patients, weight bearing as tolerated is allowed. F Thrombosis prophylaxis until more than 30 kg bearing has been achieved.
Errors, hazards, complications F Wound hematoma due to bleeding of the perforating vessels and/or from the bone: Secure ligature of the vessels and suction drainage of the wound for at least 6 h will reduce the risk of hematoma. Redon drains should then
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only be withdrawn on the third day. Postoperative lymph drainage supports hematoma resorption. If significant acute bleeding is evident, a revision should be done. F Clinical signs of infection: Surgical revision, thorough irrigation with antiseptic solution (e.g., Octenisept®, Schülke & Mayr GmbH, 22480 Norderstedt, Germany) and intravenous antibiosis [e.g., levofloxacin (Tavanic) and rifampicin (Eremfat or Rifa)], in addition to debridement and collection of at least five tissue specimens for bacteriologic investigation. Periprosthetic late infections of more than 3–4 weeks after implantation need septic one- or two-stage exchange of the whole prosthesis. F Lesions of the sciatic nerve—mostly caused by traction or pressure—are usually reversible. Early neurolysis is only recommended in case of persistent paralysis. F Fissure of the femoral isthmus during reaming, rasping, or insertion of the distal component: The prophylactic double cerclage below the bone flap prevents fractures. With a crack, the distal component should not be advanced any further! Additional double cerclage may be applied. F Inadequate anchorage of the modular revision stem due to a too slim com-
Operative Orthopädie und Traumatologie 5 · 2014
ponent or residual cement with subsidence of the stem or thigh pain: Subsidence of a few millimeters can be tolerated. If subsidence continues and complaints about “stem pain” as a sign of loosening, the stem has to be replaced by a thicker implant. F Intraoperative tendency to dislocation, especially with an unrevised cup with inadequate anteversion: adjustment of the proximal stem component to more antetorsion. With recurrent dislocations, surgical revision has to be performed. Both stem components are disconnected and reassembled with corrected antetorsion. An adequate soft tissue tension is achieved by using a longer head or by choosing a longer proximal component. Joint stability can be further improved by replacing the cup inlay with one with a higher rim, or by replacing the cup and improving its orientation. F Intraoperative fracture of the bone flap in poor-quality bone mostly in an area of thin bone when the bone flap is folded back: Fixation of the fragments with cerclage wires. F Postoperative avulsion of the greater trochanter due to tension of the gluteal muscles: No surgical treatment is required. Prolonged partial weight bearing is recommended.
Results In all, 23 patients with periprosthetic fractures of Vancouver type B2 (15 patients) and type B3 (eight patients, five of these with distal interlocking screws; . Fig. 15a, b, c) were followed up for at least 5 years (7.2±2.6 years). We did not encounter any iatrogenous intraoperative fracture. All fractures healed on average after 14.4±5.3 weeks. We observed no stem subsidence and bony ingrowth in 21 patients. Two patients showed signs of stable fibrous fixation according to the classification of Engh et al. [7] No breakage of the interlocking screws occurred. One patient sustained a dislocation. The Harris Hip Score [15] improved continuously from 65.0±16.8 points 3 months postoperatively to 86.9±16.2 points after 24 months and to 89.0±14.3 points after
Fig. 15 9 a Preoperative radiographs of a Vancouver type B3 periprosthetic fracture after failed doubleplate fixation. b Implantation of a Revitan Curved revision stem via a transfemoral approach with distal locking. c Bony healing 24 months postoperatively. (From [14], courtesy of Lippincott Williams & Wilkins)
5 years. According to the classification of Beals and Tower [2], all results were rated as excellent. A standardized surgical technique for the treatment of periprosthetic fractures of Vancouver types B2 and B3 with a modified transfemoral approach and a modular, tapered, fluted, cementless revision stem made of titanium yields reliable and satisfactory results with respect to fracture healing, stability of the stem, dislocation rate, intraoperative fracture, and clinical outcome.
Corresponding address Prof. Dr. B. Fink Klinik für Endoprothetik, Allgemeine und Rheumorthopädie, Orthopädische Klinik Markgröningen Kurt-Lindemann-Weg 10, 71706 Markgröningen Germany [email protected]
Compliance with ethical guidelines Conflict of interest. B. Fink is consultant for the company Zimmer. The accompanying manuscript does not include studies on humans or animals.
References 1. Adolphson P, Jonsson U, Kalen R (1987) Fractures of the ipsilateral femur after total hip arthroplasty. Arch Orthop Trauma Surg 106:353–357 2. Beals RK, Tower SS (1996) Periprosthetic fractures of the femur. An analysis of 93 fractures. Clin Orthop Relat Res 327:238–246 3. Berry DJ (2003) Treatment of Vancouver B3 periprosthetic femur fractures with a fluted tapered stem. Clin Orthop Relat Res 417:224–231 4. Bethea JS, DeAndrade JR, Fleming LL et al (1982) Proximal femoral fractures following total hip arthroplasty. Clin Orthop Relat Res 170:95–106 5. Cooke PH, Newman JH (1988) Fractures of the femur in relation to cemented hip prostheses. J Bone Joint Surg Br 70-B:386–389 6. Duncan DP, Masri BA (1995) Fractures of the femur after hip replacement. Instr Course Lect 44:293– 304 7. Engh CA, Glassman AH, Suthers KE (1990) The case of porous-coated hip implants: the femoral side. Clin Orthop Relat Res 261:63–81 8. Fink B, Fuerst M, Hahn M et al (2005) Fixationsprinzipien des zementlosen modularen Hüftrevisionsschaftes Revitan. Eine anatomische Studie. Unfallchirurg 108:1029–1037 9. Fink B, Fuerst M, Singer J (2005) Periprosthetic fractures of the femur associated with hip arthroplasty. Arch Orthop Trauma Surg 125:433–442 10. Fink B, Grossmann A, Schubring S et al (2007) A modified transfemoral approach using modular cementless revision stems. Clin Orthop Relat Res 462:105–114 11. Fink B, Grossmann A (2007) Modified transfemoral approach to revision arthroplasty with uncemented modular revision stems. Oper Orthop Traumatol 19:32–55 12. Fink B, Grossman A, Schubring S et al (2009) Shortterm results of hip revisions with a curved cementless modular stem in association with the surgical approach. Archiv Orthop Trauma Surg 128:65–73
13. Fink B, Grossmann A, Fuerst M (2010) Distal interlocking screws with a modular revision stem for revision total hip arthroplasty in severe bone defects. J Arthroplasty 25:759–765 14. Fink B, Grossmann A, Singer J (2012) Hip revision arthroplasty in periprosthetic fractures of Vancouver type B2 and B3. J Orthop Trauma 26:206–211 15. Harris WH (1969) Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by Mold arthroplasty. An end result study using a new method of result evaluation. J Bone Joint Surg Am 51:737–755 16. Heeg P (1991) Präoperative Rasur des Operationsgebietes. Operat Orthop Traumtol 3:218–219 17. Incavo SJ, Beard DM, Pupparo F et al (1998) Onestage revision of periprosthetic fractures around loose cemented total hip arthroplasty. Am J Orthop 27:35–41 18. Kavanagh BF (1992) Femoral fractures associated with total hip arthroplasty. Orthop Clin North Am 23:249–257 19. Ko PS, Lam JJ, Tio MK et al (2003) Distal fixation with Wagner revision stem in treating Vancouver type B2 periprosthetic femur fractures in geriatric patients. J Arthroplasty 13:446–452 20. Levine BR, Della Valle CJ, Lewis P et al (2008) Extended trochanteric osteotomy for the treatment of Vancouver B2/B3 periprosthetic fractures of the femur. J Arthroplasty 23:527–533 21. Lewallen DG, Berry DJ (1998) Periprosthetic fracture of the femur after total hip arthroplasty: treatment and results to date. Instr Course Lect 47:243– 249 22. Moran MC (1996) Treatment of periprosthetic fractures around total hip arthroplasty with an extensively coated femoral component. J Arthroplasty 11:981–988 23. Morrey BF, Kavanagh BF (1992) Complications with revision of the femoral component of total hip arthroplasty: comparison between cemented and uncemented techniques. J Arthroplasty 7:71–79
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24. Mulay S, Hassan T, Birtwistle S et al (2005) Management of types B2 and B3 femoral periprosthetic fractures by a tapered, fluted, and distally fixed stem. J Arthroplasty 20:751–756 25. O’Shea K, Quinlan JF, Kutty S et al (2005) The use of uncemented extensively porous-coated femoral components in the management of Vancouver B2 and B3 periprosthetic femoral fractures. J Bone Joint Surg Br 87-B:1617–1621 26. Park M-S, Lim Y-J, Chung W-C et al (2009) Management of periprosthetic femur fractures treated with distal fixation using a modular femoral stem using an anterolateral approach. J Arthroplasty 24:1270–1276 27. Sledge JB III, Abiri A (2002) An algorithm for the treatment of Vancouver Type B2 periprosthetic proximal femoral fractures. J Arthroplasty 17:887– 892 28. Wagner M, Wagner H (1999) Der transfemorale Zugang zur Revision von Hüftendoprothesen. Operat Orthop Traumtol 11:278–295
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Operative Orthopädie und Traumatologie 5 · 2014
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Introductory remarks The incidence of postoperative periprosthetic fracture of the femur after primary implantation is reported to be less than 1%, and after revision surgery it is between 1.5 and 4.2% [18, 21, 23]. The Vancouver classification system has gained broad acceptance [6]. It reflects the localization of the fracture, the quality of the prosthesis fixation, and the quality of the bone itself. When the prosthesis is loose (Vancouver type B2 and B3 fractures), an exchange of the prosthesis is necessary [1, 5, 6, 9]. According to Bethea et al. [4], 75% of all postoperative periprosthetic fractures are related to loose implants; Duncan et al. [6] reported that 82% of type B fractures occurred in the presence of loose implants. During revision, the prosthesis can be replaced by a cemented or by a cementless stem implant [1, 5, 6, 9]. The disadvantage of a cemented stem is that cement can be forced into the fracture site and thus impede bony healing. Beals et al. [2] reported that 31% of revisions with cemented stems developed nonunions, 15% exhibited new fractures, and 15% developed permanent bone defects; by contrast, only 7% of patients with cementless implants suffered new fractures. Moreover, the quality of cementing is impaired by the fracture. Therefore most surgeons prefer revision with cementless implants. A variety of stems have been used as cementless implants for Vancouver type B2 and B3 periprosthetic fractures: (a)
B. Fink Klinik für Endoprothetik, Allgemeine und Rheumorthopädie, Orthopädische Klinik Markgröningen, Markgröningen
Revision arthroplasty in periprosthetic fractures of the proximal femur stems with proximal fixation, (b) nonmodular, fully porous, coated stems with distal fixation, (c) nonmodular, tapered, fluted stems with distal fixation, and (d) modular, tapered, fluted stems with distal fixation (. Tab. 1). The disadvantage of stems with proximal fixation in cases of periprosthetic fracture is that relative motion between the proximal fragment of the fracture and the prosthesis can interfere with bone growth onto the implant [17]. Moreover, when fixation of the cementless stem is proximal, the region of fixation is close to the fracture itself and thus the anchorage of the stem is reduced. In order to improve the proximal stability, this type of prosthesis is often combined with a strut graft. However, Incavo et al. [17] reported loose stems in over 50% of healed periprosthetic fractures, while Sledge et al. [27] observed similar problems in more than 25%. Cementless prostheses with distal fixation have the advantage that the point of fixation is located outside the fractured section; the fracture is bridged and fixed with cerclage wires or cables to the prosthesis. Thus the stability of the prosthesis is not influenced by the quality of the fracture fixation, and the fracture itself can heal without being exposed to torsional forces. In recent years, the modular revision stem has become more popular since it addresses two objectives of the revision surgery independently: Firstly, the distal stem component enables the solid fixation of the prosthesis in the isthmus of
the femur while bypassing the fracture, and secondly, the proximal section of the stem can be used to adjust the length and antetorsion of the stem. There are two implantation techniques with distally fixed revision stems. The first technique includes reduction and fixation of the fragments with clamps or cerclage wires before implantation of the stem. The second procedure begins with an extended trochanteric osteotomy down to the end of the fracture line and continues with a separation of the proximal fragment, the implantation of the stem in the distal fragment, and closes with an approximation of the proximal fragments around the stem with cerclages. The disadvantage of the first technique lies in the inability to monitor the actual fixation of the prosthesis stem, thus making it difficult to be sure that the fracture is bridged by the fixation zone. Therefore it is much more difficult to obtain reproducibly good results with this technique. Although Moran et al. [22] did not observe any complications in a small study of distal stem fixation with this method of implantation, Invaco et al. [17] reported one out of four cases of stem loosening while Park et al. [26] reported 7% loosening and 7% intraoperative fracture. The advantage of the second method of implantation with an extended trochanteric osteotomy lies mainly in the ability to monitor the zone of fixation and positioning of the new prosthesis at all times, so that the surgeon can be certain that the stem or its distal compo-
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Operative Techniken Tab. 1 Overview over the reported results of stem revision in Vancouver B2 and B3 periprosthetic fractures Author Incavo Sledge O’Shea Invaco Moran Ko Levine Park Mulay Fink
N (B2/ B3) 8/0 7/0 10/12 4/0 4/0 12/0 12/5 16/11 10/12 22/10
ETO
OP tech.
Study
No Yes Yes No No Yes Yes In 2 of 27 Yes Yes
1 1 2 1 1 2 2 1 2 2
Retrosp. Retrosp. Retrosp. Retrosp. Retrosp. Prosp. Retrosp. Retrosp. Prosp. Prosp.
Followup a 49 33 33.7 49 24 58.5 44.5 57.6 24 32.2
Union (%) 87.5 100 91 100 100 100 100 92.6 91 100
HHS 67.6 83 ≈75 78.3 87 ≈80 – 84.7 69 81.6
Subsidence (%) – 28.6 9.1 – – 16.6 17.6 7.4 77.3 0
Dislocation (%) 0 0 0 0 0 0 5.8 0 22.7 3.4
Fracture (%) 37.5 0 0 0 0 8.3 5.8 7.4 4.5 0
Infection (%) 0 0 4.5 0 0 8.3 5.8 3.7 4.5 0
Loosening (%) 25 0 0 25 0 0 0 7.4 0 0
ETO extended trochanteric osteotomy, Prosp. prospective, Retrosp. Retrospective, OP technique 1 reposition and reduction of the fragment before implantation of the stem, OP technique 2 implantation of the stem and then closure of the proximal fragments around the stem, Stem 1 with proximal fixation, Stem 2 nonmodular, distal fixation, fully porous-coated, Stem 3 nonmodular, distal fixation, conical, Stem 4 modular, distal fixation, conical, rough-blasted titaniumaIn months
nent is firmly anchored distal to the fracture, by means of a press fit, and can remove the loose stem and any residual cement fairly easily. In a prospective study of 32 periprosthetic fractures with a mean follow-up period of 32.2±10.4 months (24–60 months), we found with this second operative technique reproducible and very good results with respect to fixation of the prosthetic stem, and therefore subsidence, healing of the fracture, and clinical outcome [14]. The disadvantages of this technique are the extended trochanteric osteotomy with its extended approach and the fact that there are three fragments instead of the two that usually result from the fracture. However, neither our study nor previously published studies have reported any disadvantages of this surgical approach or a prolonged healing time (. Tab. 1). As mentioned by Berry [3], using this technique it is important not to strip the muscles of the fragments to preserve the blood supply of the bone. Reliable excellent fracture healing rates can be achieved, and due to callus formation improvement of deficient proximal femoral bone in Vancouver B3 fractures can be expected [3]. Therefore, we prefer extended trochanteric osteotomy via a posterolateral approach—independent of previous approaches used for prosthetic implantation—to leave the muscles on the bone and not to go through the vastus lateralis muscle. This paper describes this technique using the Revitan Curved™ (Zimmer GmbH, Winterthur, Switzerland) as
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an example of modular distal fixated revision stems.
Surgical principles and objective Removal of the loose stem after a periprosthetic fracture with minimal risk of additional fractures or perforations of the femoral shaft using a transfemoral approach according to Wagner. Preparation of a solid conical bed for the new, curved prosthetic stem distal to the fracture in the isthmus of the femur and its secure anchorage by cone-in-cone press-fit fixation taking leg length and antetorsion into account. Additional distal locking with an isthmic fixation zone of less than 3 cm. Fixation of the proximal fragments with cerclage wiring. Restoration of a pain-free limb allowing for immediate weight bearing.
Advantages F Minimal risk of additional intraoperative fractures or perforations of the femoral shaft during removal of the cement or implantation of the new stem. F Direct access to the medullary canal of the distal part of the femoral isthmus to ease cement removal and preparation of the bed of the new implant. F Good access to the acetabulum for changing the insert. F Relatively short surgical time, even for more difficult situations.
Operative Orthopädie und Traumatologie 5 · 2014
F Controlled, step-by-step approach from removal of the loose stem and cement, secure fixation of the revision stem, to restoration of normal leg length and antetorsion. F Reliable healing of the osteotomy due to the intact vascularity of the bone flap, the extensive osteotomy, and the application of double cerclage at replantation in a modified technique according to Wagner and Wagner [28].
Disadvantages F Technically demanding approach. F Potentially more bleeding due to the additional osteotomy and in case of inadequate ligation of the perforating vessels. F Longer rehabilitation phase due to the extended surgical approach. Modular revision stem Revitan Curved is 10– 30% more expensive than the nonmodular straight Wagner SL Revision Stem, depending on stem length.
Indication F Periprosthetic fracture of the femur at the level of the prosthetic stem and a loose implant with or without bone defects (Vancouver types B2 and B3) [6].
Contraindications F Periprosthetic joint infection.
Abstract · Zusammenfassung Oper Orthop Traumatol 2014 · 26:455–468 DOI 10.1007/s00064-014-0305-4 © Springer-Verlag Berlin Heidelberg 2014 B. Fink
Revision arthroplasty in periprosthetic fractures of the proximal femur Abstract Objective. Hip revision arthroplasty of a loose stem in the case of Vancouver type B2 and B3 periprosthetic fractures and cerclage wiring of the femoral shaft. Indications. Vancouver type B2 and B3 periprosthetic fractures of the proximal femur. Contraindications. Periprosthetic joint infection. Interprosthetic femoral fractures between the ends of hip and knee prosthetic stems that require total replacement of the femur. Surgical technique. Extended posterolateral approach to the tip of the fracture. Exposure along the septum intermusculare laterale with ligation of the perforating vessels below the fracture. Longitudinal osteotomy of the proximal fragment above the linea aspera using an oscillating saw under cooling. Ventral proximal osteotomy at the corner of the vasto-gluteal sling after short muscular incision using an osteotome chisel. Opening of the proximal fragment with lifting up of the bony flap like a transfemoral approach. Removal of the loosened prosthetic stem and
possibly the cement. Preparation of the distal fixation zone of the modular cementless revision stem in the isthmus of the femur distal of the fracture. Implantation of the distal component of the modular cementless revision stem. Use of additional distal interlocking screws in cases of destroyed isthmus with a fixation zone of less than 3 cm for the distal prosthetic component. Trial reposition after combination with the proximal trial component in situ. Assembly with the original proximal component in situ. Reposition with the original proximal component. Wound closure. Postoperative management. Thrombosis prophylaxis, physiotherapy, gait training with partial loading of the limb at 10 kg for a period of 6 weeks with hip flexion limited to 70°. Then, free range of movement and increased loading by 10 kg per week. Results. In all, 23 patients with periprosthetic fractures of Vancouver type B2 (15 patients) and type B3 (eight patients)—in 15 women and eight men in the age range of 70.7±12.2 (42–88) years—were followed up for at least
5 years. All fractures healed with a mean time of 14.4±5.3 weeks. No cases of subsidence of the stem were observed and, according to the classification of Engh et al. concerning the biological fixation of the stem, there was bony ingrowth fixation in 21 cases and two cases of stable fibrous fixation. One dislocation occurred and there were no cases of intraoperative fracture. The Harris Hip Score rose continually following the operations: from a 3-month postoperative score of 65.0±16.8 points, it rose to 86.9±16.2 points after 24 months and to 89.0±14.3 points after 5 years. According to the classification of Beals and Tower, all results were rated as excellent, i.e., the prefracture functional status was restored in all cases. Keywords Periprosthetic fracture · Revision arthroplasty · Proximal femur · Primary implantation · Implantation technique
Prothesenwechsel bei periprothetischen Frakturen des proximalen Femurs Zusammenfassung Operationsziel. Wechsel der gelockerten Schaftkomponente bei periprothetischer Fraktur vom Typ Vancouver B2 und B3 auf eine modulare, zementlose Revisionsprothese sowie Osteosynthese mit Cerclagen. Indikationen. Periprothetische Fraktur vom Typ Vancouver B2 und B3. Kontraindikationen. Periprothetischer Infekt. Interprothetische Fraktur zwischen gestielten Prothesen des proximalen und distalen Femurs, die einen totalen Femurersatz erfordert. Operationstechnik. Erweiterter posterolateraler Zugang bis unterhalb der Fraktur. Vorgehen im Septum intermusculare laterale unter Ligatur der Vasa perforantes bis distal der Fraktur. Längsosteotomie des proximalen Fragments oberhalb der Linea aspera mit oszillierender Säge unter Kühlung. Ventrale proximale Osteotomie am vastoglutealen Übergang mit Osteotomiemeißel nach kurzer Inzision der Muskulatur. Eröffnen des proximalen Fragments, wie bei einem transfemoralen Zugang, durch Hochklappen des Knochendeckels. Entfernen der gelock-
erten Schaftprothese und ggf. des Knochenzements. Präparieren des Fixationsbetts der modularen, zementlosen Revisionsprothese im Isthmus des Femur distal der Fraktur. Implantation der distalen Komponente des modularen, zementlosen Revisionsschaftes. Verwendung zusätzlicher Verriegelungsschrauben bei einer distalen Fixationszone unter 3 cm. Probereposition mit kombiniertem proximalem Probeteil. In-situ-Montage der originalen proximalen Prothesenkomponente. Reposition mit Original-Prothesenkopf. Weiterbehandlung. Thromboseprophylaxe, Physiotherapie, Gangschulung mit Teilbelastung von 10 bis 20 kg für die Dauer von 6 Wochen. Anschließend schrittweise Belastungssteigerung bis zur Vollbelastung 3 Monate postoperativ. Falls Teilbelastung nicht möglich (z. B. geriatrischer Patient): Belastung wie vom Patienten toleriert). Vermeidung von gleichzeitiger Flexion, Innenrotation und Adduktion für 3 Monate. Für 6 Wochen Limitierung der Flexion auf 70 Grad.
Ergebnisse. Alle 23 periprothetischen Frakturen (15 Vancouver B2 und 8 Vancouver B3) bei 15 Frauen und 8 Männern im Alter von 70,7±12,2 (42–88) Jahren mit einem Nachuntersuchungszeitraum von mindestens 5 Jahren waren nach durchschnittlich 14,4±5,3 Wochen geheilt. Der Prothesenschaft war bei keinem Patienten eingesunken. Einmal trat eine Luxation auf, eine intraoperative Fraktur in keinem Fall. Der HarrisHip-Score stieg postoperativ kontinuierlich an: von 65,0±16,8 Punkten nach 3 Monaten auf 86,9±16,2 Punkte 24 Monate postoperativ und 89,0±14,3 Punkte 5 Jahre postoperativ. Entsprechend der Klassifikation von Beals und Tower konnten alle Ergebnisse als exzellent eingestuft werden, da bei allen mindestens die gleiche Funktionalität wie vor dem Unfall erreicht wurde. Schlüsselwörter Periprothetische Fraktur · Prothesenwechsel · Proximaler Femur · Primäre Implantation · Implantationstechnikl
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Fig. 1 8 a Preoperative radiograph of a total hip arthroplasty implanted 9 years earlier with Vancouver type B2 periprosthetic fracture running through the anchorage zone of the stem after low-energy trauma. Measuring of the length of the proximal fragment on the lateral (H1) and medial side (H2). b Sketching the anchorage zone. c Choice of prosthetic components according to the templates. d Radiograph 6 days postoperatively after replacing the stem with a Revitan Curved after a transfemoral approach. e Radiograph 38 months postoperatively with osseous consolidation of the fractures. (From [14], courtesy of Lippincott Williams & Wilkins)
F Type B1 and C fractures with stable stems that can be treated with osteosynthesis. F Interprosthetic femoral shaft fractures in between the ends of hip and knee joint prostheses that can only be stabilized by total replacement of the femur.
Patient information F General surgical risks. F Joint dislocation. F Nerve lesions, specifically of the sciatic nerve. F Subsidence and/or loosening of the prosthesis F Fracture of the distal femur. F Insufficient healing of the bone flap with limping at the hip and/or greater trochanter pain. F Fracture of the bone flap and/or avulsion of the greater trochanter due to osteolysis with positive Trendelenburg’s sign and/or greater trochanter pain. F Prolonged postoperative rehabilitation with Trendelenburg’s sign up to 1 year. F Partial load bearing for 3 months.
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Preoperative work-up F Preoperative optimization of comorbidities. F 250 mg cefuroxime as a single shot perioperative antibiotic prophylaxis or 3×250 mg cefuroxime in 24 h for surgeries longer than 2 h. F Shaving of the leg immediately before the operation from the iliac crests to below the knee joint [16]. F At least AP radiographs of the femur at a film-focus distance of 115 cm, if possible in two views. Analyzing the x-rays to differentiate between B1 and B2 fractures. Radiolucent zones and fractures running through the anchorage zone of the old stems are indicative of B2 fractures. F Preoperative planning: On the AP film, the length of the bony flap, the fixation zone of the revision stem in the isthmus of the femur with endosteal contact of the stem on the medial and lateral side of the isthmus, and the expected distal and proximal implant components have to be determined. 1 Step 1: The length of the lateral end of the proximal fragment is measured from the tip of the greater trochanter (H1). This is the distal
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end of the transfemoral approach. The level of the medial end of the proximal fragment is measured in relation to the lateral end (H2). This is the medial distal end of the bony flap of the transfemoral approach (. Fig. 1a). 1 Step 2: Sketching in the anchoring zone of the distal component of the modular revision stem in the isthmus of the femur (. Fig. 1b). If the quality of the cortical bone is good, a fixation length of 30–50 mm is sufficient based of the cone-in-cone fixation principle with a conical stem implanted in a prepared conical fixation bed in the isthmus of the femur [8, 10, 12]. 1 Step 3: Selection of the prosthetic components based on the radiographic templates (. Fig. 1c). Selection of the distal components regarding length and diameter with templates. The aim is a solid pressfit fixation with the tip of the fluted stem in the isthmus of the femur of at least 3 cm to get a short as possible modular stem [8, 9, 10, 11, 12, 13]. In general, a thicker stem requiring a shorter fixation distance should be preferred rather than a thinner stem requiring a longer fix-
ation distance. The choice of the proximal component guarantees correct limb length. The center of rotation of the hip joint should be at the level of the tip of the greater trochanter. When the length of the proximal components cannot be estimated because of the fractured femur, planning on radiographs of the contralateral side can be helpful.
Surgical instruments and implants F Standard instruments for implantation. F Flexible intramedullary reamer with long guide wire. F Cerclage set, cerclage band set (e.g., Merete Medical GmbH, Alt-Lankwitz 102, 12247 Berlin, Germany, or Stemcup Medical Products AG, Aargauerstraße 180, 8048 Zurich, Switzerland) or cable system (e.g., Zimmer Germany GmbH, Maria-Merian-Straße 7, 24145 Kiel, Germany). F Modular uncemented revision prosthesis Revitan Curved (Zimmer Germany GmbH, Merzhauser Straße 112, 79100 Freiburg, Germany).
Anesthesia and positioning F General or spinal anesthesia. F Preparation of a cell saver for autotransfusion (e.g., Haemonetics GmbH Germany, Wolfratshauser Straße 84, 81379 Munich, Germany). F Tranexan acid 1 g before the operation starts. F Lateral decubitus with anterior and posterior supports for the pelvis and trunk. F Affected leg draped fully mobile. The lower leg should be in a straight position to prevent tilting of the pelvis. F Image intensification of the affected leg should be tested preoperatively.
Surgical technique (. Fig. 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14)
Fig. 2 9 Lateral decubitus. Incision of 30– 40 cm starting posterolaterally and extending along the greater trochanter to the distal end of the fracture
Fig. 3 9 Dissection of the subcutaneous tissue and the fascia lata in the same direction. Blunt dissection of the gluteus maximum muscle in the direction of its fibers
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Fig. 4 8 The external rotators are cut close to their attachments and secured with stay sutures. Identification and preservation of the sciatic nerve (a). Extraction of the so-called neocapsule and the scar tissue to expose the joint (b)
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Fig. 5 9 Exposure of the femur anterior to the lateral lip of the linea aspera in the lateral intermuscular septum; the perforating vessels are ligated. The lateral hemicircumference of the femur is exposed at the tip of the proximal fragment
Fig. 6 8 a, b Osteotomy of the trochanteric region and distally into the proximal medial femur with a chisel starting anterior and proximal to the junction of the vastus lateralis and the gluteus medius with the leg in external rotation. Chisel is used to minimize the trauma to the muscles in that area
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Fig. 7 8 Posterior osteotomy anterior to the lateral lip of the linea aspera, preparation of the medial end of the distal fragment; anterior distal osteotomy of about 3 cm using an oscillating saw cooled with sterile Ringer’s solution with the leg in internal rotation
Fig. 9 8 The osteotomized lateral bone flap with the vastus lateralis attached is lifted from lateral to medial end. The prosthesis and bone cement are completely removed
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Fig. 8 8 Completion of the anterior osteotomy using a chisel that is passed from distal to proximal end underneath the vastus lateralis with the leg in external rotation. The attachment of the vastus lateralis muscle to the bone flap needs to be preserved. In cases of very oblique fractures with a short medial fragment from the calcar to the medial end of the proximal fragment, the osteotomy on the medial side can be completed by chiseling from proximal to distal end under the vastus lateralis starting at the border between the medial gluteal muscle and the vastus lateralis (see . Fig. 6)
Fig. 10 8 The complete removal of all cement or a sclerotic endofemoral projection (generally a pedestal at the tip of the prosthesis) is important; an osseous projection could deflect a reamer or rasp toward the opposite cortex and thus provoke perforation. Application of double cerclage with a single 1.5-mm cerclage wire adjacent distal to the fracture and bone flap to prevent the femoral isthmus from fissuring during reaming, rasping, or insertion of the original implant. The prophylactic cerclage will be left in place after the procedure to prevent fracture in the case of subsidence
Fig. 11 8 a Drilling through distal cement or a bone obstacle, first with a long 4.5-mm diameter drill, then a 6-mm and, finally, with an 8-mm diameter drill. In case of any doubt about the central, intramedullary position of the drill, drilling should be performed under image intensification. Remaining pieces of cement can now be removed with chisels and/or long thread cutters via a retrograde technique. Cylindrical preparation of the isthmus with medullary reamers that are inserted over an intramedullary guide wire. Its intramedullary position can be monitored with the image intensifier. Alternatively, the intramedullary guide wire can be advanced to the condylar region of the distal femur. Close attention should be paid for the rod not to perforate. Cylindrical reamers with ascending diameters and mounted on a flexible shaft are inserted over the intramedullary guide rod to ream the medullary canal in 0.5-mm to 1-mm increments. During this procedure attention must be focused on contact of the reamer with the cortex and the sound that is created by that procedure specifically in the isthmic part of the femur. If a cortical contact with high-pitched sound over a distance of 3–5 cm is achieved, medullary reaming should be discontinued. Preoperative planning is helpful with regard to the choice of reamer head. Additionally analyzing the reamer to detect reaming particles of the cortical bone may be helpful. As a rule of thumb the diameter of the last reamer is 4 mm (i.e., two rasp sizes) smaller than the calculated diameter of the implant stem. The assigned thickness of the distal component of the Revitan stem is determined at 11 cm above the tip of the conical stem by definition; at the distal end of the implant the diameter is 4 mm less. b Conical preparation of the distal prosthesis bed with special rasps. In accordance with preoperative planning, the length of the distal rasp components is selected with reference to the fracture to be bridged. Rasps of increasing diameters are used with the rasp impactor, starting with the diameter that is one size smaller than the last reamer. It is important that the antecurvation of the rasp corresponds to that of the femur. Once the appropriate rasp that should facilitate a good circular press-fit fixation in the isthmus has been selected, the length of the proximal rasp component is read off the scale of the rasp impactor at the level of the greater trochanter. The shortest (P 55) and longest proximal components (P 105) should be avoided so that there is room for variation when it comes to insertion of the definitive implant. In the case of the shortest proximal component, a trial reduction with the proximal rasp component can be made to be sure that reposition is possible. In the case of the longest proximal component, it should be checked whether the fixation zone is at the distal end of the rasp or if a thicker rasp would facilitate the use of a shorter stem combination with the fixation zone at the tip of the stem. Additional reaming of 1 mm with the flexible reamer may become necessary in this situation
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Fig. 12 8 Implantation of the modular revision stem. a The final distal component with the same size as the last rasp is advanced with light hammer blows on the stem impactor to achieve definitive distal press-fit anchorage. The intensity of the hammer blows should be adapted to the bone quality. Any obstacles in the proximal femur that would interfere with the progression of the prosthesis into the distal femur must be carefully avoided. The insertion depth of the implant is checked with the help of the markings on the stem impactor at the level of the greater trochanter. Reduction of the bony flap can be helpful for this measurement. b The proximal trial part is mounted on the definitive distal implant component with the corresponding nut that has been fixed onto the connecting bolt of the implant. The proximal trial part is supported on the shoulder of the distal implant component so that there is no contact with the conical connecting zone. Antetorsion can be adjusted to ±30° (marked on the prosthesis). It should be noted that there are left and right markings. After trial reduction the antetorsion and/or length of the proximal prosthesis component may be adapted. The proximal trial part can be changed for another size by loosening the nut. The antetorsion angle of the prosthesis can be readjusted as required. The tension in the proximal soft tissues and leg length can be assessed using trial heads of different lengths. As a rule of thumb, the center of the head should lie at the level of the trochanter tip. After exchanging the proximal trial part, trial reduction should be performed again. c In situ assembly with the selected proximal prosthesis component at the desired antetorsion angle. Detachment of the proximal trial part; the connecting taper is thoroughly cleaned with sterile Ringer’s solution and dried. The definitive proximal component, which corresponds to the size of the last proximal trial part, is positioned; simultaneously, antetorsion is adjusted as required. d The threaded rod of the stem tensioner is driven into the thread of the connecting taper; then, the handle of the stem tensioner is guided over the threaded rod and fastened with the nut. The two implant components are connected to each other using the torque wrench. During this procedure, the handle of the stem tensioner is used to neutralize the torque forces acting on the femur. Care must be taken that antetorsion is not affected. After tightening the components with the torque wrench, the nut of the stem tensioner is loosened by turning the torque wrench counterclockwise, and the stem tensioner is removed. e Seating of the conical nut onto the connecting taper with the aid of the setting instrument; tightening with the torque wrench. The torsional forces generated by the tightening procedure are neutralized using the handle for counter force
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Fig. 13 8 Additional distal locking. In case of a more distal fracture extension with a less than 3 cm fixation zone in the isthmus, interlocking screws are recommended to improve distal fixation. To make that happen, a distal component of at least 18 mm diameter and 200 or 260 mm length are necessary. Distal locking should always be regarded as an additional safety measure that cannot replace secure distal press-fit fixation and should therefore only be performed in exceptional situations. The targeting device is attached to the distal component already anchored in the femur before the required proximal component is inserted. a The targeting module, which corresponds to the length of the inserted distal component (L.200 mm or L.260 mm), is connected to the coupling arm and secured with a screw. This assembly is called the targeting device. b The connecting screw is screwed onto the connecting taper of the implant; the targeting device is advanced onto the distal implant component over the connecting screw. Its cams must latch precisely into the grooves of the implant component. c This assembly is secured to the connecting screw with a nut. d The tissue protection sleeve with inserted trocar is guided into the desired target drill hole. The skin is incised at the appropriate location; blunt dissection of the soft tissues to the bone with scissors or a clamp. The tissue protection sleeve with trocar is advanced to the bone. The trocar is removed. A drill hole is made in both cortices using a twist drill (4.0 mm diameter) that has been placed into the tissue protection sleeve. e Screw length is determined using the measuring device. Alternatively, screw length can be read off the drill directly. The drill tip should only project very slightly beyond the second cortex. f The previously determined locking screw (4.9 mm diameter) is inserted through the tissue protection sleeve with the screwdriver. Correct seating of the locking screw is monitored on the image intensifier. Removal of the interlocking screws is usually not necessary and leaving the screws helps to monitor stem fixation quality because breakage of the screws would indicate subsidence of the stem
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Fig. 14 8 Osteosynthesis of the proximal fragments. After implantation of the modular uncemented revision stem, osteosynthesis of the proximal fragments by fixing them around the stem usually with two or three double cerclage wires (1.5 mm). Alternatively, cerclage bands or cerclage cables can be used. We prefer using double cerclage wires because of high stability. In the case of a less than anatomic reduction of the proximal fragment, cancellous bone collected during reaming of the femoral canal can be put in the gap to support the healing of the gap. The gap will heal because of callus formation introduced by the fracture hematoma. After insertion of drains and suture of the vastus lateralis, the wound is closed in layers. The drains are connected to the cell saver and suction is applied for 6 h postoperatively with a reduced suction force of 10 cm of water head to prevent too much blood loss
Postoperative management F Radiologic documentation. F Drains are removed after 24–48 h. F Walking exercises with 10–15 kg partial weight bearing of the operated leg from the first postoperative day. Load increase depends on the quality of the bone, the patient’s age, and the quality of press-fit anchorage achieved intraoperatively. In general, partial loading of 10 kg continues for 6 weeks. The load limits are practiced on the weighing scale. Hip flexion is restricted to 70° for 6 weeks to reduce forces on the proximal osteosynthesis with cerclages. Next, after radiologic assessment of the femur in two planes, gradual increase in loading up to full weight bearing after 3 months. If partial weight bearing is not possible in old patients, weight bearing as tolerated is allowed. F Thrombosis prophylaxis until more than 30 kg bearing has been achieved.
Errors, hazards, complications F Wound hematoma due to bleeding of the perforating vessels and/or from the bone: Secure ligature of the vessels and suction drainage of the wound for at least 6 h will reduce the risk of hematoma. Redon drains should then
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only be withdrawn on the third day. Postoperative lymph drainage supports hematoma resorption. If significant acute bleeding is evident, a revision should be done. F Clinical signs of infection: Surgical revision, thorough irrigation with antiseptic solution (e.g., Octenisept®, Schülke & Mayr GmbH, 22480 Norderstedt, Germany) and intravenous antibiosis [e.g., levofloxacin (Tavanic) and rifampicin (Eremfat or Rifa)], in addition to debridement and collection of at least five tissue specimens for bacteriologic investigation. Periprosthetic late infections of more than 3–4 weeks after implantation need septic one- or two-stage exchange of the whole prosthesis. F Lesions of the sciatic nerve—mostly caused by traction or pressure—are usually reversible. Early neurolysis is only recommended in case of persistent paralysis. F Fissure of the femoral isthmus during reaming, rasping, or insertion of the distal component: The prophylactic double cerclage below the bone flap prevents fractures. With a crack, the distal component should not be advanced any further! Additional double cerclage may be applied. F Inadequate anchorage of the modular revision stem due to a too slim com-
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ponent or residual cement with subsidence of the stem or thigh pain: Subsidence of a few millimeters can be tolerated. If subsidence continues and complaints about “stem pain” as a sign of loosening, the stem has to be replaced by a thicker implant. F Intraoperative tendency to dislocation, especially with an unrevised cup with inadequate anteversion: adjustment of the proximal stem component to more antetorsion. With recurrent dislocations, surgical revision has to be performed. Both stem components are disconnected and reassembled with corrected antetorsion. An adequate soft tissue tension is achieved by using a longer head or by choosing a longer proximal component. Joint stability can be further improved by replacing the cup inlay with one with a higher rim, or by replacing the cup and improving its orientation. F Intraoperative fracture of the bone flap in poor-quality bone mostly in an area of thin bone when the bone flap is folded back: Fixation of the fragments with cerclage wires. F Postoperative avulsion of the greater trochanter due to tension of the gluteal muscles: No surgical treatment is required. Prolonged partial weight bearing is recommended.
Results In all, 23 patients with periprosthetic fractures of Vancouver type B2 (15 patients) and type B3 (eight patients, five of these with distal interlocking screws; . Fig. 15a, b, c) were followed up for at least 5 years (7.2±2.6 years). We did not encounter any iatrogenous intraoperative fracture. All fractures healed on average after 14.4±5.3 weeks. We observed no stem subsidence and bony ingrowth in 21 patients. Two patients showed signs of stable fibrous fixation according to the classification of Engh et al. [7] No breakage of the interlocking screws occurred. One patient sustained a dislocation. The Harris Hip Score [15] improved continuously from 65.0±16.8 points 3 months postoperatively to 86.9±16.2 points after 24 months and to 89.0±14.3 points after
Fig. 15 9 a Preoperative radiographs of a Vancouver type B3 periprosthetic fracture after failed doubleplate fixation. b Implantation of a Revitan Curved revision stem via a transfemoral approach with distal locking. c Bony healing 24 months postoperatively. (From [14], courtesy of Lippincott Williams & Wilkins)
5 years. According to the classification of Beals and Tower [2], all results were rated as excellent. A standardized surgical technique for the treatment of periprosthetic fractures of Vancouver types B2 and B3 with a modified transfemoral approach and a modular, tapered, fluted, cementless revision stem made of titanium yields reliable and satisfactory results with respect to fracture healing, stability of the stem, dislocation rate, intraoperative fracture, and clinical outcome.
Corresponding address Prof. Dr. B. Fink Klinik für Endoprothetik, Allgemeine und Rheumorthopädie, Orthopädische Klinik Markgröningen Kurt-Lindemann-Weg 10, 71706 Markgröningen Germany [email protected]
Compliance with ethical guidelines Conflict of interest. B. Fink is consultant for the company Zimmer. The accompanying manuscript does not include studies on humans or animals.
References 1. Adolphson P, Jonsson U, Kalen R (1987) Fractures of the ipsilateral femur after total hip arthroplasty. Arch Orthop Trauma Surg 106:353–357 2. Beals RK, Tower SS (1996) Periprosthetic fractures of the femur. An analysis of 93 fractures. Clin Orthop Relat Res 327:238–246 3. Berry DJ (2003) Treatment of Vancouver B3 periprosthetic femur fractures with a fluted tapered stem. Clin Orthop Relat Res 417:224–231 4. Bethea JS, DeAndrade JR, Fleming LL et al (1982) Proximal femoral fractures following total hip arthroplasty. Clin Orthop Relat Res 170:95–106 5. Cooke PH, Newman JH (1988) Fractures of the femur in relation to cemented hip prostheses. J Bone Joint Surg Br 70-B:386–389 6. Duncan DP, Masri BA (1995) Fractures of the femur after hip replacement. Instr Course Lect 44:293– 304 7. Engh CA, Glassman AH, Suthers KE (1990) The case of porous-coated hip implants: the femoral side. Clin Orthop Relat Res 261:63–81 8. Fink B, Fuerst M, Hahn M et al (2005) Fixationsprinzipien des zementlosen modularen Hüftrevisionsschaftes Revitan. Eine anatomische Studie. Unfallchirurg 108:1029–1037 9. Fink B, Fuerst M, Singer J (2005) Periprosthetic fractures of the femur associated with hip arthroplasty. Arch Orthop Trauma Surg 125:433–442 10. Fink B, Grossmann A, Schubring S et al (2007) A modified transfemoral approach using modular cementless revision stems. Clin Orthop Relat Res 462:105–114 11. Fink B, Grossmann A (2007) Modified transfemoral approach to revision arthroplasty with uncemented modular revision stems. Oper Orthop Traumatol 19:32–55 12. Fink B, Grossman A, Schubring S et al (2009) Shortterm results of hip revisions with a curved cementless modular stem in association with the surgical approach. Archiv Orthop Trauma Surg 128:65–73
13. Fink B, Grossmann A, Fuerst M (2010) Distal interlocking screws with a modular revision stem for revision total hip arthroplasty in severe bone defects. J Arthroplasty 25:759–765 14. Fink B, Grossmann A, Singer J (2012) Hip revision arthroplasty in periprosthetic fractures of Vancouver type B2 and B3. J Orthop Trauma 26:206–211 15. Harris WH (1969) Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by Mold arthroplasty. An end result study using a new method of result evaluation. J Bone Joint Surg Am 51:737–755 16. Heeg P (1991) Präoperative Rasur des Operationsgebietes. Operat Orthop Traumtol 3:218–219 17. Incavo SJ, Beard DM, Pupparo F et al (1998) Onestage revision of periprosthetic fractures around loose cemented total hip arthroplasty. Am J Orthop 27:35–41 18. Kavanagh BF (1992) Femoral fractures associated with total hip arthroplasty. Orthop Clin North Am 23:249–257 19. Ko PS, Lam JJ, Tio MK et al (2003) Distal fixation with Wagner revision stem in treating Vancouver type B2 periprosthetic femur fractures in geriatric patients. J Arthroplasty 13:446–452 20. Levine BR, Della Valle CJ, Lewis P et al (2008) Extended trochanteric osteotomy for the treatment of Vancouver B2/B3 periprosthetic fractures of the femur. J Arthroplasty 23:527–533 21. Lewallen DG, Berry DJ (1998) Periprosthetic fracture of the femur after total hip arthroplasty: treatment and results to date. Instr Course Lect 47:243– 249 22. Moran MC (1996) Treatment of periprosthetic fractures around total hip arthroplasty with an extensively coated femoral component. J Arthroplasty 11:981–988 23. Morrey BF, Kavanagh BF (1992) Complications with revision of the femoral component of total hip arthroplasty: comparison between cemented and uncemented techniques. J Arthroplasty 7:71–79
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24. Mulay S, Hassan T, Birtwistle S et al (2005) Management of types B2 and B3 femoral periprosthetic fractures by a tapered, fluted, and distally fixed stem. J Arthroplasty 20:751–756 25. O’Shea K, Quinlan JF, Kutty S et al (2005) The use of uncemented extensively porous-coated femoral components in the management of Vancouver B2 and B3 periprosthetic femoral fractures. J Bone Joint Surg Br 87-B:1617–1621 26. Park M-S, Lim Y-J, Chung W-C et al (2009) Management of periprosthetic femur fractures treated with distal fixation using a modular femoral stem using an anterolateral approach. J Arthroplasty 24:1270–1276 27. Sledge JB III, Abiri A (2002) An algorithm for the treatment of Vancouver Type B2 periprosthetic proximal femoral fractures. J Arthroplasty 17:887– 892 28. Wagner M, Wagner H (1999) Der transfemorale Zugang zur Revision von Hüftendoprothesen. Operat Orthop Traumtol 11:278–295
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