Novel techniques advance periprosthetic fracture care
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Reported as the most frequently performed orthopedic procedures in the United States, research has projected an estimated increase in total hip and knee procedures of 176% and 139%, respectively, by 2040.
This increased volume of total joint arthroplasties combined with a population that is living longer and more active lives may result “in this perfect storm of having more periprosthetic fractures,” according to Samir Mehta, MD, chief of the orthopaedic trauma and fracture service at the University of Pennsylvania Health System.
Source: Miho J. Tanaka, MD, PhD
With an incidence of 0.2% to 3.5%, distal femoral periprosthetic fractures most commonly present as a low-energy fragility fracture, according to James C. Krieg, MD, chief of orthopaedic trauma and fracture care at the Rothman Orthopaedic Institute.
“You have to remember the milieu you are dealing with: people who are somewhat limited already in their activity,” Krieg told Healio | Orthopedics Today. “As we all get older, we get a little bit weaker and less able to accommodate an occasional stumble. The most common presentation that I see is somebody who simply stumbles and takes a ground level fall.”
Although not as common, Mehta said patients are also presenting with periprosthetic fractures due to higher levels of activity.
“We are finding that older patients are more active on their hip and knee replacements,” Mehta said. “Because they are engaging in higher energy activities, like skiing or pickleball, we are seeing events where patients are sustaining fractures due to those kinds of mechanisms in addition to what we consider low energy, like a ground level fall or a twisting injury in bed.”
He added the risk of periprosthetic fracture also depends on the prosthesis.
“Depending on how the prosthesis was put in, the kind of prosthesis being used [and] if the prosthesis has a stem or not also will factor into the kind of fracture that will occur and the risk of having a stress riser where the metal meets the native bone,” Mehta said.
Treatment options
Historically, the two main treatment options for distal femoral periprosthetic fractures used either intramedullary nailing or plating with screws, according to Mehta.
“[For the nailing approach], you make an incision by the knee, and you insert a metal intramedullary rod into the femur and stabilize the bone on the inside,” Mehta said. “The second way that we would consider fixing these is by putting a plate on the lateral side or outside part of the bone. In this case, you make an incision on the outside part of the leg and then you, preferably, percutaneously insert a plate and stabilize the femur that way.”
However, Mehta said earlier techniques were often flawed and led to fracture fixation failure and fracture nonunion.
To combat some of the shortcomings of the earlier distal femoral periprosthetic fracture treatment options, implant designers and surgeons have worked together to improve the tools and technologies available for both nailing and plating, according to Aaron Nauth, MD, MSc, FRCSC, associate professor of orthopedic surgery and chair of fracture care research at St. Michael’s Hospital, an affiliate of the University of Toronto.
“The technology that we have to fix these has evolved quite a bit over the last 20 years or so,” Nauth told Healio | Orthopedics Today. “Now we have advanced technology in terms of the type of plates that we can use. They are called locking plates, where the screws lock into the plates and that gives you much better fixation than we had in the past. The nail options have also advanced significantly in terms of how well they stabilize the bone and allow the patients to get up and weight-bear and move early.”
Dual fixation constructs
One technique that has gained popularity is use of a dual fixation construct, which includes the utilization of both a plate and a nail in concert with one another or with the use of two plates applied medially and laterally.
“More recently, there has been a trend with dual fixation constructs, meaning mixing technologies together to create a more stable and durable construct,” Mehta said. “In this case, what you are seeing a lot of is the concept of a nail-plate combination or a dual plate combination. You are inserting an intramedullary nail with a plate on the outside of the bone or applying plates both medially and laterally on the distal femur. This allows for good, stable fixation, preventing complications with collapse and nonunion that we have historically seen.”
According to Paul Tornetta III, MD, chair of the department of orthopedic surgery at Boston University Medical Center, surgeons who use plate fixation may be hesitant to allow patients with poor bone quality to immediately weight-bear due to implant failure, while surgeons who use nail fixation tend to allow patients to weight-bear right away. By combining the two, Tornetta said surgeons who are partial to plate fixation may help ease concerns of failure.
“If you are someone who likes to plate or believes that you need a plate for rotational control but there is not a lot of fixation, adding a nail to that will generally allow for more comfort on the surgeon’s level to weight-bear them right away,” Tornetta told Healio | Orthopedics Today.
Although the disadvantage of each implant is addressed with the dual construct, Krieg said a myriad of questions remain unanswered, including if the surgery can be performed in a timely manner and if there are any downsides with regard to bone biology with the use of dual fixation.
“The advantages are clear that we can get more stable constructs. We can push the envelope of early stability to allow for better early function,” Krieg said. “But it is a hard operation, and we need to find better ways to facilitate it and to trim down the amount of metal so that patients can accommodate it easier in their bodies.”
Distal femoral replacement
Another innovation in the care of distal femoral periprosthetic fractures is the concept of distal femoral replacement.
“[Distal femoral replacement] may be a technically easier solution in the right hands if the surgeon knows what they are doing, and it allows for immediate weight-bearing because you do not have to wait for any kind of bone healing,” Mehta said. “For [surgeons] who are tentative in terms of wanting to let people walk on these constructs, doing a distal femoral replacement may be a better option for a certain patient population. In some hands, removing the broken parts of the femur and replacing the entirety of the prosthesis is a faster procedure as well with less soft tissue trauma.”
However, the potential repercussions associated with a failed distal femoral replacement are sometimes too much to justify, according to Cory A. Collinge, MD, orthopedic trauma surgeon at Texas Health.
“To remove large masses of bone does create some problems if that procedure was to fail,” Collinge told Healio | Orthopedics Today. “Let us say a distal femur replacement goes into somebody and it becomes infected, or the fixation fails and becomes loose for whatever reason, there are not many good reconstructive procedures after that to salvage the situation. A fair number of those people end up with an above knee amputation. So, for most people, we look at that treatment alternative as the end of the line and only recommend if a reasonable repair is not possible.”
Postoperative pearls
The treatment of a distal femoral periprosthetic fracture does not end when the surgery is complete. Deliberate postoperative and rehabilitation processes are an integral component of successful periprosthetic fracture care, according to Collinge.
“The goal is to get patients mobile as soon as possible and get them out of bed so they do not get the complications of bed rest,” Collinge said. “After that, we want the joint moving quickly, so that it does not get stiff and affect their gait or their mobility in general. We want most of these people to be weight-bearing as tolerated if at all possible.”
Patient education is also an important element in the postoperative stages, according to Nauth.
“Educating the patients about the significance of the injury, what is going to be required in terms of their rehabilitation and then setting up the expectations for how long it is going to take them to get better and what they need to do to get there are all important components of the education piece,” Nauth said.
To help patients stay motivated in their rehabilitation, Tornetta said the cardiac and pulmonary function of the patient should be at the maximum and patients should remain hydrated. He also said the patient’s family and friends should be involved in “pushing the patient to have a positive attitude about getting back to function.”
“Older patients, as a general rule, tend to be a little bit less proactive,” Tornetta said. “They are a little bit more trusting of the medical system and what people tell them. You have to be aggressive about telling them to get back up ... because if the goal is to get back to their preoperative function, that has to start early on.”
Next steps
Collinge said there are several avenues that research on distal femoral periprosthetic fracture care may venture into, such as making the bone “more resistant to screw loosening or implant failure.”
“In the shorter term, we will continue to watch repair systems evolve to maximize linking plates or plates and nails to increase strength, as well as creating more flexibility for surgeons with modularity of the systems where plates can be mixed and matched to customize the implant for your patient,” Collinge said.
He continued, “Maybe as time moves along, we will be better at protecting the femur, so that if you treat a fracture distally, you would go ahead and prophylactically protect the proximal femur with a plate or a nail or some device that would prevent future fractures. And maybe we will have a scenario where we lock up the entire femur and make it indestructible for the rest of that patient’s life.”
Although biologics may play a role in faster healing of distal femoral periprosthetic fractures in older patients, Tornetta said it “has a lot of promise that we are not yet seeing.”
“There are advantages coming in biologics, whether they be local or systemic, and we hope to see that fast,” Tornetta said. “The faster we can get people to heal, the better. We are always optimistic about the advances in biologics.”
Krieg said the goal for patients will be to reduce recovery times in combination with a lower risk profile, “so that they can get back on their feet more predictably a bit quicker.”
Advice
Tornetta said a focal point when working with an aging patient population is to have a cohesive team.
“It is critical to have a strong alliance between the medical team — the orthopedic team and the anesthesia team — to make sure that all of the medical comorbidities are managed appropriately [and] the patient is optimized for their treatment,” Tornetta said. “We want to avoid the complications of recumbency, but, at the same time, we want to make the surgery, which can be fast or it can take a while if it becomes complicated, as safe as possible for the patient.”
According to Tornetta, perioperative management of the patient is critical, with renal, pulmonary and cardiac function all making a difference in outcomes.
“It is a team approach to these patients that is a little bit more extensive than a 30-year-old who has an isolated distal femur from a car accident,” he said.
Mehta said it is critical to have surgeons who treat distal femoral periprosthetic fractures frequently, whether they are arthroplasty surgeons, trauma surgeons or traumaplasty surgeons comfortable with performing both orthopedic trauma and arthroplasty, as surgeons who understand both the trauma and arthroplasty sides of periprosthetic fracture care will be important as the specialty continues to evolve.
“The techniques in hip and knee replacement have advanced over the years, as have the techniques in orthopedic trauma and fracture surgery. We get into our silos sometimes and do not realize what the other side is doing,” Mehta said. “Having surgeons who are comfortable or understand the nuances on both ends of the equation would help and is ideal in the management of these patients who have [periprosthetic] implant fractures.”
- References:
- Bostrom N, et al. J Orthop. 2024;doi:10.1016/j.jor.2024.02.039.
- Canton G, et al. Acta Biomed. 2017;doi:10.23750/abm.v88i2-S.6522.
- Jassim SS, et al. Injury. 2014;doi:10.1016/j.injury.2013.10.032.
- Lunenfeld B, et al. Best Pract Res Clin Obstet Gynaecol. 2013;doi:10.1016/j.bpobgyn.2013.02.005.
- Marino DV, et al. Periprosthetic Distal Femur Fracture. 2023 Aug 7. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan. PMID:32119326.
- Shichman I, et al. JBJS Open Access. 2023;doi:10.2106/JBJS.OA.22.00112.
- For more information:
- Cory A. Collinge, MD, of Texas Health, can be reached at ccollinge@msn.com.
- James C. Krieg, MD, of the Rothman Institute, can be reached at james.krieg@rothmanortho.com.
- Samir Mehta, MD, of the University of Pennsylvania Health System, can be reached at samir.mehta@pennmedicine.upenn.edu.
- Aaron Nauth, MD, MSc, FRCSC, of the University of Toronto, can be reached at aaron.nauth@unityhealth.to.
- Paul Tornetta III, MD, of Boston University Medical Center, can be reached at ptornetta@gmail.com.
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