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Implant choice, early mobilization remain important for periprosthetic lower limb fractures
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ISTANBUL — Surgeons should seek to mobilize patients with lower limb periprosthetic fractures as soon as possible and choose an appropriate implant based on fracture severity, according to a presenter at the EFORT Congress.
“Periprosthetic fractures are a problem which is growing due to the fact that we have many [older] patients with prostheses,” George Macheras, MD, PhD, from KAT General Hospital in Athens, Greece, said. “The problem is, the bone quality is not so good all the time. The injury is severe so you have to stabilize as soon as possible and you have to give the opportunity to walk again if it is possible in the first 24 to 48 hours.”
George Macheras
Macheras said surgeons should first grade the severity of the fracture using the Vancouver Classification. He noted that choosing an implant with good stability and a quality surface for bone growth is essential. In general, surgeons should seek to restore anatomical alignment, maintain bone stock for possible revision, create a stable prosthesis, mobilize the patient early and ensure fracture union. Additionally, surgeons should exclude infection in case of loosening.
For B2 fractures, Macheras recommended a revision long stem prosthesis with cables, plates or struts aiding additional rotational stability. He noted that if done correctly, the implant loosening rate is about 12%, with some published papers reporting as high as 20%. B3 fractures are a challenge because the patient has poor bone quality that requires a long stem revision hip arthroplasty in addition to an allograft-prosthetic composite revision. Macheras said revision hip arthroplasty cemented long stems are generally porous, while long uncemented stem choices range from tapered, proximally coated, extensively porous coated and locking as well as allograft composites.
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Tapered stems provide fixation through bypassing the proximal femur and gaining fixation in the distal femoral shaft while avoiding stress concentration at the implant tip. However, Macheras noted reports of subsidence after placing the stem. Locking stems involve placing 2 or more distal fixation screws and removing them 6 to 9 months postoperatively after the fracture has healed. These stems can provide opportunities for early weight-bearing, but distal anchorage for secondary osteointegration is difficult, Macheras said.
Proximally coated stems do not have sufficient distal stability, while extensively coated porous stems have a high success rate, with scratch fit providing additional stability, Macheras said. He noted that a necessary part of a successful extensively coated porous stem procedure is 5 cm of diaphyseal fixation. Additionally, allograft composites can be useful for B3 fractures with severe comminution and lack of bone stock, he added. Impaction grafting where severe osteolysis is present has the potential for long-term fixation, but Macheras said that the procedure is technically challenging and subsidence may occur after implant placement.
Regardless of treatment method, an agreeable surgical team is one of the most important factors for success, Macheras said.
"It is very important to have teamwork in order to be able to give patients the best outcome, mobilize them and send them home," he said.
Reference:
Macheras G. Revision arthroplasty with long stems in periprosthetic fractures. Presented at: 14th EFORT Congress. 5-8 June, 2013; Istanbul.
Disclosure: Macheras has no relevant financial disclosures.