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Lecturer: Nailing periprosthetic distal femur fractures is effective, challenging
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BELFAST, NORTHERN IRELAND — Nonoperative treatment, open reduction and internal fixation, and revision arthroplasty are the main options available to trauma surgeons when they treat periprosthetic distal femur fractures. However, Anthony S. Rhorer, MD, said he prefers nailing these fractures whenever possible.
“Periprosthetic fractures are an increasing problem. There are a lot of different ways to treat them. If the implants are stable, I would say fix it. If they are loose, revise it and fix the fracture,” Rhorer said during the Adrian Henry Lecture at the British Orthopaedic Association Annual Congress.
Nailing has its issues, however, and the associated surgical technique requires extra care, he noted.
“When in doubt, scan and plan,” said Rhorer, of Scottsdale, Ariz., U.S.A.
According to Rhorer, a radiolucent table, co-linear reduction clamp, radiolucent triangle and bone hook are helpful in addressing these fractures. He places the hook under the anterior flange of the knee prosthesis, which helps flex that part of the component when he reduces the fracture.
Rhorer noted that having an ideal starting point for retrograde nailing a periprosthetic distal femur fracture may not be possible, particularly when the patient has a total knee prosthesis in situ. In those cases, the design of the implant dictates the starting point for nailing, he said.
Locking plates are another option for fixing a periprosthetic distal femur fracture. However, the risk of failed locked plates is high in patients with this type of fracture, particularly when the plate is proximal to the knee prosthesis. Therefore, Rhorer recommended using hybrid fixation to mitigate problems in that setting.
“Your other option is revision arthroplasty, which obviously you are going to do with somebody with a loose prosthetic, no distal bone. But beware, this may require revision of the tibial side and may require a hinge prosthesis. It may seem like a good idea, but it may go south quick,” Rhorer said. – by Susan M. Rapp
Reference:
Rohrer AS. Navigating fixation of difficult femur fractures. Presented at: British Orthopaedic Association Annual Congress; Sept. 13-16, 2016; Belfast, Northern Ireland.
Disclosure: Rhorer reports he is a consultant to ITS-implant, Smith & Nephew, Globus Medical and Innovision.