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.
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 gelockerten 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 Harris-Hip-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.
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Conflict of interest. B. Fink is consultant for the company Zimmer. The accompanying manuscript does not include studies on humans or animals.
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Fink, B. Revision arthroplasty in periprosthetic fractures of the proximal femur. Oper Orthop Traumatol 26, 455–468 (2014). https://doi.org/10.1007/s00064-014-0305-4
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DOI: https://doi.org/10.1007/s00064-014-0305-4
Keywords
- Periprosthetic fracture
- Revision arthroplasty
- Proximal femur
- Primary implantation
- Implantation technique