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RESULTS OF TREATMENT OF PATIENTS WITH PERIPROSTHETIC FRACTURES OF THE FEMUR AFTER HIP
REPLACEMENT
Khominets V. V.
Head of the Department and Clinic of the Military Traumatology and Orthopedics of the Military Medical
Academy n.a. S.M. Kirov, Metlenko P.A.
Director of the Orthopedic Department of Clinic of the Military Traumatology and Orthopedics of the Military Medical Academy n.a. S.M. Kirov Bogdanov A.N.
Director of the Traumatology Department of Municipal Hospital No. 26
Kudyashev A.L.
Deputy Head of the Department and Clinic of the Military Traumatology and Orthopedics of the Military
Medical Academy n.a. S.M. Kirov Mirojevsky F.V.
Traumatologist-orthopadeist of the Clinic of the Military Traumatology and Orthopedics of the Military
Medical Academy n.a. S.M. Kirov Russia, Saint Petersburg
ABSTRACT
Purpose: the outcomes of 23 patients were analyzed in order to improve treatment outcomes of patients with periprosthetic fractures of the femur after hip replacement. Method: all patients were divided into 4 groups according to the Vancouver Classification of Periprosthetic Fractures of the Hip (Duncan C.P. et al, 1995). Based on the type of the fracture, stability of a femoral component and the quality of bone tissue, a strategy of surgical treatment of patients with periprosthetic fractures were suggested. Result: the functional results were estimated one year after the surgery using Harrison scale as well as X-ray control and CT where it was necessary. Conclusion: healing of fracture and good functional outcomes were achieved in 22 patients.
Keywords: periprosthetic fracture, total hip replacement, complications
Introduction:
Hip replacement is one of the most actively developing and successful approaches in the modern orthopedics. The rate of primary operative interventions and revisions has significantly increased in recent years [13, 16]. Therefore, a regular increase of the complications is observed, and periprosthetic fractures of the femur are known as one of these complications. This pathology is characterized by a high rate of unsatisfactory functional results, significant number of infectious complications and mortality [13, 16, 19].
The objective of this study is to analyze immediate treatment results in patients with periprosthetic fractures of femur after the total hip replacement, treated at the Clinic of the Military Traumatology and Orthopedics of the Kirov Military Medical Academy and its clinical site - the St. Petersburg SFHI Municipal Hospital No. 26.
Materials and methods.
Treatment results of 23 patients with peripros-thetic fractures of femur, which were treated at the
Clinic of the Military Traumatology and Orthopedics of the Military Medical Academy and the Traumatology Department of the St. Petersburg SFHI Municipal Hospital No. 26 in 2011-2016, were analyzed. Periprosthetic fractures were classified according to the Vancouver Classification (Duncan C.P. et al, 1995): type A - proximal fractures in the area of greater and lesser trochanters; type B - fractures around a femoral component (B1- fractures with stable endoprosthesis, B2 - fractures with unstable endoprosthesis and satisfactory condition of the bone tissue of proximal femur, B3 - comminuted fractures due to osteolysis and endoprosthesis instability; type C -fractures below femoral component with stable endoprosthesis) [5].
A-type periprosthetic fractures were diagnosed in 6 (26,1%) patients; B1 - in 8 (34.8%); B2 - in 4 (17.4%); B3 - in 2 (8.7%), C - in 3 (13.0%) patients. There were 13 men (56.5%) and 10 women (43.5%). The average age of the patients was 65±12 years (range, 42 - 88 years).
cementless fixation of the femoral component, tapered stem and polished cement femoral components.
In most cases cementless endoprostheses were primarily used - 19 (82.6%) cases, in 3 (13.0%) clinical cases - hybrid implants and in 1 (4.4%) - cement endoprosthesis. During the primary hip replacement a cement/cementless fixation of a tapered femoral component (Versys ET, Spotorno, CPT, Muller (Zimmer, the USA) was used for all patients. The distribution of the patients according to the femoral component type is shown in Table 2.
In patients with A-type periprosthetic fractures 2 cases (8.7%) were intraoperative fractures: an edge crack of the femur and the greater trochanter fracture were detected during the intramedullary channel treatment with files. Postoperative fractures of greater trochanter were detected in all cases.
Table 1.
Patients Distribution According to the Fracture Type and Sex
Fracture Type Patients No. Sex Distribution
Male Female
A 6 3 3
B1 8 5 3
B2 4 2 2
B3 2 2 -
C 3 1 2
TOTAL 23 13 10
Functional results were evaluated according to the Harris Hip Score. Postoperative X-ray control, and, if necessary, computerized tomography (5 patients) were performed for all patients.
Results.
In 3 (13.0%) cases the femur fractures were intraoperative, in 20 (87.0%) patients - occurred in the postoperative period. The periprosthetic fractures of femur occurred in 2 weeks to 11 years after the primary hip replacement. The distribution of patients according to the fracture type and sex is shown in Table 1.
In most cases a trauma being a result of fall in everyday life was defined as the main cause of fracture in the postoperative period. Predisposing factors are osteoporosis, osteolysis of the proximal femur,
Table 2.
Patients Distribution According to the Type of Primary Femoral Component.
Femoral Component Type Patients No.
Versys ET 15
Spotorno 4
Muller 1
CPT 3
Total 23
No fractures of the lesser trochanter or osteolysis were detected. In 3 cases (13.0%) periprosthetic fractures were stable, so it was possible to treat it traditionally (immobilization with the hip bandage). In 2 cases (8.7%) for unstable fracture of the greater trochanter and in 1 case (4.4%) for the crack of the cortical part of femur an osteosynthesis with a tensionband wiring was performed.
In B1 periprosthetic fractures (8 cases) - an open reduction of the bone fragments, its fixation with cerclage wires and internal osteosynthesis with the plate were applied. As for these fractures, a special attention was paid to a thorough examination of radiographs and evaluation of the femoral component stability. It is often difficult to differentiate between B1 and B2 fractures, therefore resulting in development of the femoral component instability and unsatisfactory functional outcomes.
For the treatment of patients with B2 fractures (4 cases) a replacement of instable femoral component with a Wagner cementless revision component, fixation with a plate with angle stability screws and cer-
clages were applied. Cemented femoral components were not used for these fractures, because bone cement in most cases leads to interposition of fracture line that deteriorates and significantly obstructs bone fragments reduction. No bone allografts were used in all cases.
For B3 fractures (2 cases) - Wagner long-stem cementless revision component of distal fixation and osteosynthesis with NCB (Zimmer) special plate designed for periprosthetic fractures with angle stability, enabling a polyaxial passage of screws, cerclage wires and cables, were applied.
The distinction feature in treatment of B2/B3 fractures was a reduction of femur fragments with the cerclage wire seams performed after the removal of instable stem of the endoprosthesis. After that, a bone fixation with a plate (serving as a splint supporting the bone), enabling to perform a fitting of the revision femoral component. Finally, the screws were inserted or additional wire cables were used in order to provide the stability of the osteosynthesis.
Clinical case No. 1.
A 58-year-old man was treated at Clinic of MTO of MMA from 07.08.2014 till 27.08.2014. Diagnosis: Closed periprosthetic comminuted fracture of the right femur with fragments disposition. Surgery: cemented total hip replacement of the right hip joint (2005), hybrid total hip replacement of the left hip joint (2012), IHD, exertional angina (III Grade), atherosclerosis of aorta and coronary arteries, atherosclerotic and post-infarction (MI as of 19.06.09) cardiosclerosis. Balloon angioplasty and stenting of the anterior interventricular branch in 2009. Idiopathic hypertensia (III grade), CHF (IIA), II Grade. Grade IV Cardiac Complications (very high). Duodenum ulcer, remission. Sequelae due to craniotomy (1993) associated with the angioreticulema of the right cerebellar hemisphere (repeated craniotomy in 1993): bilateralpyramidal/cerebellar symptoms. B3 fracture according to the Vancouver Classification for fractures. Surgery performed: revision of the instable cement femoral component with the replacement with the cementless distal fixation component (Wagner), open reduction and internal fixation with the periprosthetic NCB (Zimmer, the USA), screws, cables, and cerclage wires (Fig.1). In patients with the periprosthetic fractures of C type closed reduction and internal minimal-invasive plate osteosynthesis were performed (Fig. 2).
Fracture union was achieved in 22 (95.6%) patients. The control imaging was not performed only for one patient, he was asked by phone if he walked with a full bearing load against the limb being operated or needed a walking stick for long walks. The average term for a fracture union was 14.3±5.2 weeks. There were no cases of surface/deep infection or dislocations.
Fig. 1. Radiographs and CT-images ofpatient P. with the B3 periprosthetic fracture offemur: a) X-ray imaging on admission; b) X-ray imaging after the surgery; c) X-ray imaging within 4 months after the surgery (settling of the femoral component is no more than 4 mm); d) X-ray imaging within 7 months after the surgery (no settling of the femoral component was detected); e) control CT-imaging within 7 months after the surgery (union of the
femur fracture, stable femoral component).
Fig. 2. Imaging ofpatient M. with a C-type periprosthetic fracture of the femur: a) X-ray imaging upon admission; b) X-ray imaging after the surgery; c) X-ray imaging within 3 months after the surgery.
Primary survival rate of the endoprosthesis was 95.6%. In 1 case (4.4%) stem instability was detected within 10 months after the femur union of the periprosthetic fracture. This case was interpreted as an incorrect classification of the periprosthetic fracture (B2 type was interpreted as B1 type), therefore resulting in incorrect choice of surgical approach - an internal plate osteosynthesis was applied, and no revision or replacement of the femoral component was performed.
In all patients the results of an interview based on the Harris Hip Score, which was held 3 months after the surgery, were 64.9±16.7 scores. After 1 year 16 (69.9%) patients were interviewed using the same method, and the result was 86.5±15.9 scores.
Clinical case No. 2.
A 79- year-old woman was admitted at Clinic of the MTO of the MMA on 27.07.2014. Diagnosis: Closed periprosthetic comminuted fracture of the right femur with fragments disposition. Surgery: cemented total hip replacement of the right hip joint (2003). IHD, exertional angina (III Grade), atherosclerosis of aorta and coronary arteries, idiopathic hypertensia (II grade). B1 fracture according to the Vancouver Classification for fractures. Surgery performed: open re-
duction and internal fixation with a plate of an angle stability, screws and cerclage wires. Within 3 months after the surgery the patient could walk using crutches with a partial loading of an operated limb, there were no signs of femoral component instability. Within ten months after the surgery the patient started to complain on severe pain in the right hip, significantly reducing the quality of life and self-service. Control X-ray imaging and CT imaging were obtained. The fracture union of femur and signs of femoral component instability were detected. Femoral component was replaced with a Wagner's long-stem component (Fig.
3).
In 2 (8.7%) cases (1 man and 1 woman) the results were evaluated at 7 and 10 months, respectively. After the control X-ray imaging and CT investigation a femur union and "Good" result according to Harris Hip Score (83 scores) were reported in one of the patient. In the second patient (clinical case No. 2) an aseptic instability of the endoprosthesis femoral component was detected during the radiography, and the functional outcomes were evaluated as "Poor" (67 scores).
Applied strategy of periprosthetic fracture treatment in analyzed cohort of patients is shown in Table 3.
Fig. 3. Imaging ofpatient N. with a B2 periprosthetic fracture of the femur: a) X-ray imaging on admission; b) X-ray imaging after the surgery; c) X-ray imaging within 3 months after the surgery; d) X-ray imaging within 10 months after the surgery (the signs of the femoral component instability - indicated with an arrow); e) Imaging
after the revision of femoral component.
Table 3.
Current Strategy of Periprosthetic Fracture Treatment in Analyzed Cohort of Patients.
Periprosthetic fractures of femur
Stability of the femoral component
Stable Unstable
Type A Type B1/C Type B2 Type B3
Traditional or operative therapy (fixation with screws and cerclage wires) Operative therapy: internal plate osteosynthesis (predominantly of an angle stability), with screws, cerclage wires and cables. Operative therapy: internal plate osteosyn-thesis (predominantly of an angle stability), with screws, cerclage wires and cables + revision using cementless femoral components (incl. long stems of a distal fixation) Operative therapy: internal plate osteosynthesis (predominantly of an angle stability), with screws, cerclage wires and cables + revision using cementless femoral components (incl. long stems of a distal fixation) + application of bone auto-grafts (for the defects of proximal femur)
Discussion.
According to different authors the rate of intraoperative periprosthetic fractures varies from 0.1% to 27.8%, and during the postoperative period - from 0.07% to 18% [1, 2, 8, 15]. Predisposing factors that lead to their occurrence are osteoporosis, osteopenia and bone structure changes (for instance, due to rheumatoid arthritis or Paget's disease), as well as intraoperative surgery errors (defects and split of the femur due to improper channel preparation with files). Besides, risk factors include using of cementless femoral components, stem instability, revision hip replacement and advanced age of patient [14, 15, 18]. According to several studies, the rate of periprosthetic fractures may increase by 12% in patients, who have undergone a primary hip replacement, which is associated with the femoral head fracture due to significant decrease of bone density [12]. There are some publications describing dependence between the rate of periprosthetic fractures and femoral component design. Evidencing from the Nordic Arthroplasty Register periprosthetic fractures more frequently occur when using polished cemented femoral components of Exeter and CPT types [4, 17].
Conservative treatment and osteosynthesis by the external fixation devices have not been so widely spread for management of such patients in routine clinical practice. The most popular approaches are open reduction and internal fixation with plates. Ex-tramedullar fixators for periprosthetic fractures were developing from «Mennen Plate» devices to modern plates with angular stable screws, enabling their tangential polyaxial passage combined with a use of cerclage wires and cables. In many cases for treatment of periprosthetic fractures of femur and femoral component revision the intramedullary osteosynthesis with long-stem revision system [3, 9, 11] is performed.
In order to achieve successful treatment outcomes in such patients a surgical hospital should be equipped with modern implants, including revision components of hip implants, as well as high-technology equipment and trained medical personnel. Moreover, despite the significant costs of treatment of these patients, the complication rate is still high enough and can reach up to 25.4 % [6, 7, 10].
Conclusions
Periprosthetic fracture of femur is a serious complication of hip replacement, demanding a specialized approach to the choice of treatment strategy for the patients of this category depending on fracture type, femoral component stability and bone tissue condition.
The stability of the femoral component should be accurately evaluated, especially during the differential exclusion of the B1/B2 periprosthetic fractures, wherein a CT-investigation being one of the essential diagnostic tool.
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ГИПОГЛИКЕМИЧЕСКОЕ, ГИПОЛИПИДЕМИЧЕСКОЕ И АНТИОКСИДАНТНОЕ ДЕЙСТВИЕ РАСТИТЕЛЬНОГО СРЕДСТВА «ГЛЮКОВИТ» ПРИ АЛЛОКСАНОВОМ ДИАБЕТЕ У КРЫС
Лемза С.В.
Институт общей и экспериментальной биологии СО РАН, г. Улан-Удэ,
к.б.н., старший научный сотрудник Линхоева Е.Г. Эндокринологический центр, г. Улан-Удэ,
к.м.н, врач Торопова А.А.
Институт общей и экспериментальной биологии СО РАН, г. Улан-Удэ,
к.б.н., научный сотрудник Петров Е.В.
Институт общей и экспериментальной биологии СО РАН г. Улан-Удэ,
к.фарм.н., научный сотрудник
HYPOGLYCEMIC, HYPOLIPIDEMIC AND ANTIOXIDANT EFFECTS OF PLANT REMEDY "GLYUCOVIT" IN RAT ALLOXAN-INDUCED DIABETES
Lemza S.V.
Institute of General and Experimental Biology, SB RAS, Ulan-Ude, PhD,
senior researcher Linkhoeva E. G.
Endocrinological Center, Ulan-Ude, PhD, physician
Toropova A.A.
Institute of General and Experimental Biology, SB RAS, Ulan-Ude, PhD,
scientific researcher Petrov E. V.
Institute of General and Experimental Biology, SB RAS, Ulan-Ude, PhD,
scientific researcher
АННОТАЦИЯ
Цель настоящего исследования оценить роль многокомпонентного фитоэкстракта «Глюковит» при экспериментальном аллоксановом диабете у крыс. Оценивалось влияние «Глюковита» при внутрижелу-дочном введении (300мг/кг веса) на уровень глюкозы в крови, гликогена в печени, активность антиокси-дантных ферментов, липидный профиль, содержание АТФ, пировиноградной и молочной кислоты, а также активность пируваткиназы в гомогенате печени у здоровых и диабетических крыс. Установлено, что после введения «Глюковита» диабетическим крысам измененный уровень глюкозы в крови, гликогена и липидного профиля имел тенденцию к сближению с нормальными значениями. Существенно сниженные активности антиоксидантных ферментов таких как каталаза, супероксиддисмутаза и глутатион-редуктаза у диабетических крыс повышались на фоне введения испытуемого фитоэкстракта. Также су-
