49: Fixation of Periprosthetic Femoral Fractures Using Locked Plates Combined with Minimally Invasive Insertion

PROCEDURE 49 Fixation of Periprosthetic Femoral Fractures Using Locked Plates Combined with Minimally Invasive Insertion



G. Yves Laflamme



image



PITFALLS



• Many fractures classified as Vancouver type B1 (well-fixed stem) are in reality type B2 fractures with a loose stem that were not recognized (Lindahl et al., 2006).

• A periprosthetic fracture associated with bone loss usually requires structural allograft to span the defect.


Indications



image Periprosthetic fractures of the femur associated with well-fixed total hip arthroplasty
• Vancouver type B1 fractures around the tip of the femoral stem

• Vancouver type C fractures distal to the tip of the stem (Brady et al., 2000)



Controversies



• With a cemented femoral stem, violation of the cement mantle with unicortical locking screws may induce crack propagation that could lead to loosening of the femoral stem (Fulkerson et al., 2006)


Examination/Imaging



image Preoperative assessment should include range of motion of the hip and knee, soft tissue (scars) evaluation, neurovascular status, and leg lengths.

image Adequate radiographs are needed to identify the extent of the fracture, stability of the prosthesis, and the quality of the bone.
• The standard radiographs include a low anteroposterior (AP) pelvis radiograph, a frog-leg or cross-table lateral of the affected hip, and AP and lateral views of the entire femur, including the knee.

• Figure 1 shows AP pelvis (Fig. 1A) and AP (Fig. 1B) and lateral (Fig. 1C) femur radiographs of a periprosthetic fracture in a 102-year-old female patient with a well-fixed Moore’s prosthesis.

image If acetabular osteolysis is seen or suspected, then Judet films should be obtained, with a computed tomography scan to assess the extent of bony deficiency.

image Preoperative templating is necessary to determine plate length, plate contouring, and approximate screw lengths.

image

FIGURE 1




Treatment Options



• The vast majority of displaced fractures are treated operatively except for the high-risk patient. Nonoperative treatment may be appropriate for stable and nondisplaced fractures. As the proximal fragment has always been a problem, many types of fixation devices have been used. Two strut allografts or a combination of one strut and one plate have proven to be the strongest constructs tested (Wilson et al., 2005).

• The Dall-Miles plates and cable system alone is insufficient for the treatment of periprosthetic femoral fractures (Tsiridis et al., 2003).


Surgical Anatomy



image The lateral approach is a quick and easy approach that involves splitting of the vastus lateralis muscle.
• There is no internervous plane or intermuscular plane.

• The quadriceps receives its nerve supply (femoral nerve) high in the thigh, so splitting the muscle distally does not denervate it (Fig. 2).

image Numerous perforating branches of the profunda femoris artery traverse the vastus lateralis muscle and can be damaged during the approach.

image At the level of the knee, the lateral superior genicular artery is at risk and may need to be coagulated (Fig. 3A and 3B).

image

FIGURE 2


image

FIGURE 3




PEARLS



• Fluoroscopic visualization of the entire femur in both AP and lateral views must be verified prior to patient draping.



PITFALLS



• Care must be taken during rotational alignment of the limb because the bump will cause the hip to be in an externally rotated position. An inflatable/deflatable bump can solve this problem (see Fig. 4B).

image

FIGURE 4



Positioning



image The patient is placed in a supine position on a radiolucent table (Fig. 4A).
• A small bump or a beanbag should be used under the ipsilateral hip (Fig. 4B).

• The entire leg and lateral hip region should be prepped and draped to allow proximal extension of the surgical exposure.

image Gross metaphyseal alignment is obtained using manual traction or skeletal traction.

image A fluoroscopy C-arm is positioned on the contralateral side, and the monitor is placed on the same side near the foot of the table.



Controversies



• The patient can be placed in the lateral decubitus position, affected side up, on a radiolucent table, especially if the stability of the implant is uncertain. Extension of the incision proximally allows access to the hip joint to test or revise the implants.


Portals/Exposures



image The surgeon begins with the small, distal, longitudinal incision (5 cm) over the lateral femoral condyle of the knee (distal window) (Fig. 5A).
• For distal extension, it may be necessary to incise the anterior fibers of the iliotibial tract and then carry down through the capsule and synovium.

• Care must be taken to identify the superior lateral genicular artery and to avoid damage to the lateral meniscus (Fig. 5B).

image A second incision (5 cm) at the tip of the plate is a straight lateral proximal thigh incision (proximal window) (Fig. 6A).
• The dissection is carried down to the iliotibial fascia, which is then incised parallel to its fibers.
image

FIGURE 5

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Jun 7, 2016 | Posted by in ORTHOPEDIC | Comments Off on 49: Fixation of Periprosthetic Femoral Fractures Using Locked Plates Combined with Minimally Invasive Insertion

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