Combined Surgical and Medical Treatment for Vancouver B1 and C Periprosthetic Femoral Fractures: A Proposal of a Therapeutic Algorithm While Retaining the Original Stable Stem

Introduction There is lack of consensus regarding best operative fixation strategy for periprosthetic femoral fractures (PFFs) around a stable stem. Evidence exists that some patterns of fracture around a stable stem are better treated with revision surgery than with standard fixation. Anyway, a more aggressive surgical procedure together with medical treatment could allow for stem retention, and reduced risk of nonunion/hardware failure, even in these cases. Significance This paper is placed in a broader context of lack of studies on the matter, and its aim is to shed some light on the management of PFFs around a stable stem, when peculiar mechanical and biological aspects are present. Results Based on our casuistry in the treatment of nonunions after PFF successfully treated with original stem retention, and on review of Literature about risk factors for fixation failure, an algorithm is proposed that can guide in choosing the ideal surgical technique even for first-time PFFs with a stable stem, without resorting to revision. Mechanical (major and minor) and biological (local and systemic) factors that may influence fracture healing, leading to nonunion and hardware failure, and subsequent need for re-operation, are considered. The proposed surgical technique consists of rigid fixation with absolute stability (using a plate and structural allograft) plus local biological support (structural allograft and autologous bone marrow concentrate over a platelet-rich plasma-based scaffold) at fracture site. Systemic anabolic treatment (Teriparatide) is also administered in the post-operative period. Conclusion Mechanical factors are not the only issues to be considered when choosing the surgical approach to PFFs over a stable stem. Systemic and local biological conditions should be taken into account, as well. A therapeutic algorithm is proposed, given the prosthetic stem to be stable, considering mechanical and biological criteria.

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Combined Surgical And Medical Treatment For Periprosthetic Femoral Fractures Over A Stable Stem (Vancouver Type B1 And C): A Proposal Of A Therapeutic Algorithm To Reduce The Risk Of Nonunion.

10.21203/rs.3.rs-38837/v1 ◽

2020 ◽

Author(s):

Nicola Mondanelli ◽

Giovanni Battista Colasanti ◽

Carlo Cataldi ◽

Fabio Moreschini ◽

Vanna Bottai ◽

...

Keyword(s):

Locking Plate ◽

Platelet Rich Plasma ◽

Femoral Fractures ◽

Autologous Bone Marrow ◽

Fracture Site ◽

Histological Evaluation ◽

Rigid Fixation ◽

Structural Allograft ◽

Periprosthetic Femoral Fractures ◽

Therapeutic Algorithm

Abstract Background: There is lack of consensus regarding best operative fixation strategy for periprosthetic femoral fractures (PFFs) around a stable stem. Based on our experience in the treatment of nonunions after PFFs and other challenging cases and on Literature, we propose an algorithm that can guide in choosing the ideal surgical technique even for first-time PFFs with a stable stem.Methods: We retrospectively reviewed data on patients who failed to heal after a surgically treated Vancouver type B1 or C PFF. All patients were treated with locking plate, double structural allograft and autologous bone marrow concentrate (BMC) over a platelet-rich plasma (PRP)-based membrane at fracture site. All patients were also pharmacologically treated with Teriparatide in the postoperative period. We studied patients with radiograms, histological evaluation of the nonunion area, and phosphocalcic metabolism. Patients were assessed subjectively, clinically and radiographically until healing and then annually.Results: All nonunions healed over a six months period, and functional recovery appeared to be good. Retrospective evaluation of the proposed algorithm showed that none of the patients met biological or mechanical criteria such as to make valid the treatment with locking plate alone.Conclusion: Mechanical factors are not the only issues that should be taken into account when choosing the surgical approach to PFFs over a stable stem. Systemic and local biological conditions are factors that should drive to a rigid fixation with absolute stability (using a plate and structural allograft) plus local biological support (structural allograft and autologous BMC in a PRP-based scaffold) and systemic anabolic treatment (Teriparatide) in the first instance. A therapeutic algorithm is proposed, given the prosthetic stem to be stable, taking into account mechanical and biological criteria.

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Preoperative Planning and Surgical Technique in the Management of Periprosthetic Femoral Fractures Using a Tapered Modular Fluted Prosthesis With Distal Fixation

Operative Techniques in Orthopaedics ◽

10.1053/j.oto.2009.05.006 ◽

2009 ◽

Vol 19 (3) ◽

pp. 137-142 ◽

Cited By ~ 4

Author(s):

José A. Rodriguez ◽

Amrit Goyal ◽

Raman R. Thakur ◽

Ajit J. Deshmukh ◽

Amar S. Ranawat ◽

...

Keyword(s):

Surgical Technique ◽

Preoperative Planning ◽

Femoral Fractures ◽

Periprosthetic Femoral Fractures ◽

Distal Fixation

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Finite element analysis of double‐plate fixation using reversed locking compression‐distal femoral plates for Vancouver B1 periprosthetic femoral fractures

BMC Musculoskeletal Disorders ◽

10.1186/s12891-021-04152-5 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Daisuke Takahashi ◽

Yoshihiro Noyama ◽

Tsuyoshi Asano ◽

Tomohiro Shimizu ◽

Tohru Irie ◽

...

Keyword(s):

Finite Element Analysis ◽

Finite Element ◽

Plate Fixation ◽

Weight Bearing ◽

Femoral Fractures ◽

Full Weight Bearing ◽

Loading Test ◽

Lateral Plate ◽

Element Analysis ◽

Periprosthetic Femoral Fractures

Abstract Background Internal fixation is recommended for treating Vancouver B1 periprosthetic femoral fractures. Although several fixation procedures have been developed with high fixation stability and union rates, long-term weight-bearing constructs are still lacking. Therefore, the aim of the present study was to evaluate the stability of a double-plate procedure using reversed contralateral locking compression-distal femoral plates for fixation of Vancouver B1 periprosthetic femoral fractures under full weight-bearing. Methods Single- and double-plate fixation procedures for locking compression-distal femoral plates were analysed under an axial load of 1,500 N by finite element analysis and biomechanical loading tests. A vertical loading test was performed to the prosthetic head, and the displacements and strains were calculated based on load-displacement and load-strain curves generated by the static compression tests. Results The finite element analysis revealed that double-plate fixation significantly reduced stress concentration at the lateral plate place on the fracture site. Under full weight-bearing, the maximum von Mises stress in the lateral plate was 268 MPa. On the other hand, the maximum stress in the single-plating method occurred at the defect level of the femur with a maximum stress value of 1,303 MPa. The principal strains of single- and double-plate fixation were 0.63 % and 0.058 %, respectively. Consistently, in the axial loading test, the strain values at a 1,500 N loading of the single- and double-plate fixation methods were 1,274.60 ± 11.53 and 317.33 ± 8.03 (× 10− 6), respectively. Conclusions The present study suggests that dual-plate fixation with reversed locking compression-distal femoral plates may be an excellent treatment procedure for patients with Vancouver B1 fractures, allowing for full weight-bearing in the early postoperative period.

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Preliminary Examination of an Appropriate Price Calculation Method and Medical Treatment Costs for Foreign Visitors in Japan

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18115837 ◽

2021 ◽

Vol 18 (11) ◽

pp. 5837

Author(s):

Tomoyuki Takura ◽

Keyword(s):

Medical Treatment ◽

Price Level ◽

Femoral Fractures ◽

Japanese Patients ◽

Insurance Companies ◽

Public Healthcare ◽

Preliminary Examination ◽

Two Stages ◽

External Injury ◽

Japanese Tourists

This study proposes a method for calculating the appropriate medical treatment price level for foreign visitors (FVs) in Japan. Hospital management costs and foreign prices were analyzed from a market principles perspective to determine the medical treatment price. The study involved two stages: a preliminary survey and an extended survey, supplemented by an international survey. Relatively frequent diseases were selected, and the costs incurred by hospitals for the treatment of FVs were analyzed though data from three hospitals, covering 24 outpatients and 4 inpatients. Payments made by three insurance companies for overseas medical institution services for Japanese tourists with pharyngitis were analyzed. This study shows that the appropriate medical treatment prices for FVs, considering profits, were 1.22–4.26 times higher compared with prices under Japan’s public health insurance plans. Furthermore, these prices were 1.31–4.26 times higher for outpatients with pharyngitis and external injury and 1.22–3.66 times higher for inpatients with appendicitis and femoral fractures. The price of pharyngitis treatment in 12 countries was USD 20.32–158.75 per patient for Japanese tourists, whereas FVs paid 60.24 dollars (1.13 times higher than Japan’s public healthcare price) in Japan. This study shows it was appropriate to set the ideal price level for FVs higher than that for Japanese patients.

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Early Surgery Does Not Improve Outcomes for Patients with Periprosthetic Femoral Fractures—Results from the Registry for Geriatric Trauma of the German Trauma Society

Medicina ◽

10.3390/medicina57060517 ◽

2021 ◽

Vol 57 (6) ◽

pp. 517

Author(s):

Christopher Bliemel ◽

Katherine Rascher ◽

Tom Knauf ◽

Juliana Hack ◽

Daphne Eschbach ◽

...

Keyword(s):

Surgical Treatment ◽

Mortality Rate ◽

Femoral Fractures ◽

Geriatric Trauma ◽

Outcome Parameters ◽

Periprosthetic Femoral Fractures ◽

Trauma Society ◽

Eq5d Index ◽

Early Surgical Treatment

Background and Objectives: Appropriate timing of surgery for periprosthetic femoral fractures (PFFs) in geriatric patients remains unclear. Data from a large international geriatric trauma register were analyzed to examine the outcome of patients with PFF with respect to the timing of surgical stabilization. Materials and Methods: The Registry for Geriatric Trauma of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie (DGU)) (ATR-DGU) was analyzed. Patients treated surgically for PFF were included in this analysis. As outcome parameters, in-house mortality rate and mortality at the 120-day follow-up as well as mobility, the EQ5D index score and reoperation rate were analyzed in relation to early (<48 h) or delayed (≥48 h) surgical stabilization. Results: A total of 1178 datasets met the inclusion criteria; 665 fractures were treated with osteosynthesis (56.4%), and 513 fractures were treated by implant change (43.5%). In contrast to the osteosynthesis group, the group with implant changes underwent delayed surgical treatment more often. Multivariate logistic regression analysis of mortality rate (p = 0.310), walking ability (p = 0.239) and EQ5D index after seven days (p = 0.812) revealed no significant differences between early (<48 h) and delayed (≥48 h) surgical stabilization. These items remained insignificant at the follow-up as well. However, the odds of requiring a reoperation within 120 days were significantly higher for delayed surgical treatment (OR: 1.86; p = 0.003). Conclusions: Early surgical treatment did not lead to decreased mortality rates in the acute phase or in the midterm. Except for the rate of reoperation, all other outcome parameters remained unaffected. Nevertheless, for most patients, early surgical treatment should be the goal, so as to achieve early mobilization and avoid secondary nonsurgical complications. If early stabilization is not possible, it can be assumed that orthogeriatric co-management will help protect these patients from further harm.

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