[ORT-L] Periprosthetic fracture


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[ORT-L] Periprosthetic fracture

alex at weborto
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Dec 16, 2008, 12:21 PM

Post #1 of 17 (13553 views)
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[ORT-L] Periprosthetic fracture	Can't Post

Dear All.

A male 59 y.o. referred to our unit >6 weeks after car accident. Initially managed on
traction. Cemented THR 5 years ago (DePuy Elite +).

How would you estimate the fracture - the stem looks stable, i.e.
Vancouver B1. Or B2?

Now the femur is deformed to varus and shortened, manual traction
already not enough to restore length/axis.

How would you manage the patient?

I think about custom-made retrograde nail which connects to the stem.
Never performed it to a cemented stem. Some site opening may be
necessary to remove at least pieces of broken cement mantle. Also
application of an ex-fix for longitudinal traction looks useful.
THX for your opinion.

--
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia

Attachments:

get_image.jpg (13.7 KB)

danschlatterer at yahoo
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Dec 16, 2008, 1:52 PM

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Re: [ORT-L] Periprosthetic fracture [In reply to]	Can't Post

hello,
the proximal portion of the stem looks stable. I would consider a long trochanteric plate (synthes) with cables and unicortical locking screws along stem and bicortical screws below. allograft strut probably not necessary. no cables around the fragments. or, a left supracondylar femur plate could be reversed and placed along greater trochanter and fixed to the bone as above. good case.
dan

Daniel R. Schlatterer, DO, MS
Vice Chairman,Orthopedic Surgery Residency Program
Associate Director, Orthopedic Trauma
Atlanta Medical Center
303 Parkway Dr. NE
Atlanta, GA 30312
404-265-1578

--- On Tue, 12/16/08, Alexander Chelnokov <alex@weborto.net> wrote:

From: Alexander Chelnokov <alex@weborto.net>
Subject: [ORT-L] Periprosthetic fracture
To: ORT-L@www2.aaos.org
Date: Tuesday, December 16, 2008, 3:21 PM

Dear All.

A male 59 y.o. referred to our unit >6 weeks after car accident. Initially
managed on
traction. Cemented THR 5 years ago (DePuy Elite +).

How would you estimate the fracture - the stem looks stable, i.e.
Vancouver B1. Or B2?

Now the femur is deformed to varus and shortened, manual traction
already not enough to restore length/axis.

How would you manage the patient?

I think about custom-made retrograde nail which connects to the stem.
Never performed it to a cemented stem. Some site opening may be
necessary to remove at least pieces of broken cement mantle. Also
application of an ex-fix for longitudinal traction looks useful.
THX for your opinion.

--
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia

huseyind at baskent-ank
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Dec 16, 2008, 11:48 PM

Post #3 of 17 (13550 views)
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Re: [ORT-L] Periprosthetic fracture [In reply to]	Can't Post

Dear Dr Chelnokov,

Although femoral stem seems stable, its cement mantle is completely
destroyed and devoid of bone medially and distally (where its most
necessary)
Fixation of the fracture with cable wire systems of course will heal the
fracture but reduction of the fracture can be demanding after 5 weeks and
loosening of this stem seems unavoidable.
My preference would be revision with a long porous coated femoral stem,
acetabular component looks stable but worn ( in 5 years?, patient must be an
active man) best is to revise it with a cementless cup.

Good luck

Huseyin Demirors MD
Associate Prof
Baskent University Ankara

----- Original Message -----
From: "Alexander Chelnokov" <alex@weborto.net>
To: <ORT-L@www2.aaos.org>
Sent: Tuesday, December 16, 2008 10:21 PM
Subject: [ORT-L] Periprosthetic fracture

Dear All.

A male 59 y.o. referred to our unit >6 weeks after car accident. Initially
managed on
traction. Cemented THR 5 years ago (DePuy Elite +).

How would you estimate the fracture - the stem looks stable, i.e.
Vancouver B1. Or B2?

Now the femur is deformed to varus and shortened, manual traction
already not enough to restore length/axis.

How would you manage the patient?

I think about custom-made retrograde nail which connects to the stem.
Never performed it to a cemented stem. Some site opening may be
necessary to remove at least pieces of broken cement mantle. Also
application of an ex-fix for longitudinal traction looks useful.
THX for your opinion.

--
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia
--

--

---
[This E-mail scanned for viruses by Declude Virus]

alex61 at gmail
New User

Dec 21, 2008, 11:18 AM

Post #4 of 17 (13530 views)
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Re: [ORT-L] Periprosthetic fracture [In reply to]	Can't Post

Dear colleagues

THX for the discussion. After few days of traction by ex-fix the
surgery was performed. An attempt of closed nailing was unsuccesful
because of fragment translation, which was blocked by cement
fragments. After removal of broken cement pieces reduction was reached
"automagically". Also some cement from lateral part was removed by
chisel to expose distal 40-50 mm of the stem to allow tight fit of the
nail. Further fixation by the nail was pretty easy and
straightforward. Images attached. The stem looked stable in its
proximal part both laterally and medially. Comments/critics are
welcome.

--
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia

Attachments:

get_image1.jpg (8.66 KB)

get_image2.jpg (12.0 KB)

get_image3.jpg (8.31 KB)

get_image4.jpg (6.96 KB)

jjbrooksmd at gmail
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Dec 21, 2008, 3:31 PM

Post #5 of 17 (13492 views)
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Re: [ORT-L] Periprosthetic fracture [In reply to]	Can't Post

I assume you preserved the medial fragment blood supply? If so, wow.
very very nice. I'd like to stand and applaud your avoidance of
strangulation cables around the medial fragment.

That's really a brilliant implant if the stem/nail interface is truly
rigid.

I just hope it's truly a B1.

Thanks very much for sharing that.

Jeff Brooks
Stamford, CT

On Dec 21, 2008, at 2:18 PM, Alexander Chelnokov wrote:

> Dear colleagues
>
> THX for the discussion. After few days of traction by ex-fix the
> surgery was performed. An attempt of closed nailing was unsuccesful
> because of fragment translation, which was blocked by cement
> fragments. After removal of broken cement pieces reduction was reached
> "automagically". Also some cement from lateral part was removed by
> chisel to expose distal 40-50 mm of the stem to allow tight fit of the
> nail. Further fixation by the nail was pretty easy and
> straightforward. Images attached. The stem looked stable in its
> proximal part both laterally and medially. Comments/critics are
> welcome.
>
> --
> Best regards,
> Alexander N. Chelnokov
> Ural Scientific Research Institute
> of Traumatology and Orthopaedics
> 7, Bankovsky str. Ekaterinburg 620014 Russia
> <get_image1.jpg><get_image2.jpg><get_image3.jpg><get_image4.jpg>

---
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jagdishmenon at yahoo
New User

Dec 21, 2008, 11:02 PM

Post #6 of 17 (13481 views)
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Re: [ORT-L] Periprosthetic fracture [In reply to]	Can't Post

WELL DONE , ALEXANDER
INGENIOUS
Regards
Jagdish Menon
Pondicherry
India
Â

--- On Mon, 22/12/08, Alexander Chelnokov <alex61@gmail.com> wrote:
From: Alexander Chelnokov <alex61@gmail.com>
Subject: Re: [ORT-L] Periprosthetic fracture
To: ORT-L@www2.aaos.org
Date: Monday, 22 December, 2008, 12:48 AM

Dear colleagues

THX for the discussion. After few days of traction by ex-fix the
surgery was performed. An attempt of closed nailing was unsuccesful
because of fragment translation, which was blocked by cement
fragments. After removal of broken cement pieces reduction was reached
"automagically". Also some cement from lateral part was removed by
chisel to expose distal 40-50 mm of the stem to allow tight fit of the
nail. Further fixation by the nail was pretty easy and
straightforward. Images attached. The stem looked stable in its
proximal part both laterally and medially. Comments/critics are
welcome.

--
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia

huseyind at baskent-ank
New User

Dec 22, 2008, 12:15 AM

Post #7 of 17 (13479 views)
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Re: [ORT-L] Periprosthetic fracture [In reply to]	Can't Post

Excellent technique and surgery,

I would like to ask one little question, you said 'tight fit of the nail' to the femoral stem, since all the rotational stability of the system (distal fragment with nail and locking screws) comes from that point, is it reliable?.

Best regards,
Huseyin Demirors MD

----- Original Message -----
From: "Alexander Chelnokov" <alex61@gmail.com>
To: <ORT-L@www2.aaos.org>
Sent: Sunday, December 21, 2008 9:18 PM
Subject: Re: [ORT-L] Periprosthetic fracture

> Dear colleagues
>
> THX for the discussion. After few days of traction by ex-fix the
> surgery was performed. An attempt of closed nailing was unsuccesful
> because of fragment translation, which was blocked by cement
> fragments. After removal of broken cement pieces reduction was reached
> "automagically". Also some cement from lateral part was removed by
> chisel to expose distal 40-50 mm of the stem to allow tight fit of the
> nail. Further fixation by the nail was pretty easy and
> straightforward. Images attached. The stem looked stable in its
> proximal part both laterally and medially. Comments/critics are
> welcome.
>
> --
> Best regards,
> Alexander N. Chelnokov
> Ural Scientific Research Institute
> of Traumatology and Orthopaedics
> 7, Bankovsky str. Ekaterinburg 620014 Russia
>
> --
>
>
--

wdburman at frontiernet
New User

Dec 22, 2008, 5:00 AM

Post #8 of 17 (13476 views)
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Re: [ORT-L] Periprosthetic fracture [In reply to]	Can't Post

Hello Alex,

Thank you for an interesting case presentation.

At 11:38 PM -0600 12/21/08, Kanlic, Enes wrote:
>>> is it any series published-presented doing it this - whose way?)

Besides your reference from Prof. R. Schnettler published in CORR 2007
http://www.ncbi.nlm.nih.gov/pubmed/17632420
Also see: On-line 2008 dissertation "The Bridging
Nail" by Rutger Zuurmond, from Groningen,
Netherlands
http://dissertations.ub.rug.nl/faculties/medicine/2008/r.g.zuurmond/
(also published in Injury 2007)
http://www.ncbi.nlm.nih.gov/pubmed/17306269

Bill

Bill Burman, MD
HWB Foundation
http://www.hwbf.org

At 12:18 AM +0500 12/22/08, Alexander Chelnokov wrote:
>Dear colleagues
>
>THX for the discussion. After few days of traction by ex-fix the
>surgery was performed. An attempt of closed nailing was unsuccesful
>because of fragment translation, which was blocked by cement
>fragments. After removal of broken cement pieces reduction was reached
>"automagically". Also some cement from lateral part was removed by
>chisel to expose distal 40-50 mm of the stem to allow tight fit of the
>nail. Further fixation by the nail was pretty easy and
>straightforward. Images attached. The stem looked stable in its
>proximal part both laterally and medially. Comments/critics are
>welcome.
>
>--
>Best regards,
> Alexander N. Chelnokov
>Ural Scientific Research Institute
>of Traumatology and Orthopaedics
>7, Bankovsky str. Ekaterinburg 620014 Russia
>
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---
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tfinlayson at comcast
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Dec 22, 2008, 10:21 AM

Post #9 of 17 (13476 views)
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Re: [ORT-L] Periprosthetic fracture [In reply to]	Can't Post

Looks nice. I'm glad to see that the diameter of the nail used in this case has allowed him to keep some cortical bone in the diaphysis.

--
Terry I. Finlayson, MD
Alpine Orthopaedic Specialists
2310 North 400 East
Suite A
North Logan, UT 84341
(435) 787-2000 Office
(435) 787-1913 Fax
tfinlayson@alpineortho.com

-------------- Original message --------------
From: "Alexander Chelnokov" <alex61@gmail.com>

> Dear colleagues
>
> THX for the discussion. After few days of traction by ex-fix the
> surgery was performed. An attempt of closed nailing was unsuccesful
> because of fragment translation, which was blocked by cement
> fragments. After removal of broken cement pieces reduction was reached
> "automagically". Also some cement from lateral part was removed by
> chisel to expose distal 40-50 mm of the stem to allow tight fit of the
> nail. Further fixation by the nail was pretty easy and
> straightforward. Images attached. The stem looked stable in its
> proximal part both laterally and medially. Comments/critics are
> welcome.
>
> --
> Best regards,
> Alexander N. Chelnokov
> Ural Scientific Research Institute
> of Traumatology and Orthopaedics
> 7, Bankovsky str. Ekaterinburg 620014 Russia

Attachments:

get_image1.jpg (8.66 KB)

get_image2.jpg (12.0 KB)

get_image3.jpg (8.31 KB)

get_image4.jpg (6.96 KB)

tfinlayson at comcast
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Dec 22, 2008, 10:21 AM

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Re: [ORT-L] Periprosthetic fracture [In reply to]	Can't Post

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get_image1.jpg (8.66 KB)

get_image2.jpg (12.0 KB)

get_image3.jpg (8.31 KB)

get_image4.jpg (6.96 KB)

alex61 at gmail
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Dec 22, 2008, 10:38 AM

Post #11 of 17 (13476 views)
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Re: [ORT-L] Periprosthetic fracture [In reply to]	Can't Post

Hello

2008/12/22 Jeff Brooks <jjbrooksmd@gmail.com>:
> I assume you preserved the medial fragment blood supply?

Certainly.

> I just hope it's truly a B1.

Maybe in case of succesful nailing/stem lengthening any B2 and even
maybe B3 fractures are converted to B1?

--
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia
---
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alex61 at gmail
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Dec 22, 2008, 10:43 AM

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Dear Bill

2008/12/22 Bill Burman <wdburman@frontiernet.net>:
> Also see: On-line 2008 dissertation "The Bridging Nail" by Rutger Zuurmond,
> from Groningen, Netherlands
> http://dissertations.ub.rug.nl/faculties/medicine/2008/r.g.zuurmond/
> (also published in Injury 2007)

THX for the references which are more than relevant!
Well, the publications are quite latest so the topic is really hot.

--
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia
---
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alex61 at gmail
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Dec 22, 2008, 10:51 AM

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Hello

2008/12/22 Hüseyin Demirörs <huseyind@baskent-ank.edu.tr>:
> you said 'tight fit of the nail' to
> the femoral stem, since all the rotational stability of the system (distal
> fragment with nail and locking screws) comes from that point, is it
> reliable?.

Well, the nail was hammered to the stem until it was jammed. Of course
we should test the nail-stem interface in lab but practically it is
strong enough. And applied rotation would dislocate the hip first
rather than disimpact the nail.

--
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia
---
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jjbrooksmd at gmail
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Dec 22, 2008, 11:02 AM

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Re: [ORT-L] Periprosthetic fracture [In reply to]	Can't Post

maybe you're right, alex. lengthening the stem with your nail does get
it a press fit distally, but quality thereof depends on nail/stem
interface rigidity, right? surely the rigidity of your nail/stem
interface does not match that of a long single-piece revision stem.
but, i wonder if it is sufficient to do the job if this is truly a B2?

the failures in the study **(Lindahl et.al. JBJS Br, 2006) of the
swedish registry showed a suggestion of increased risk of failure when
fixing Fxs below loose stems (when one recognizes most of the B1
failures in the study were unrecognized B2's), but maybe this patient
will behave differently?

please update us on this case in a year. very intriguing!

** http://www.jbjs.org.uk/cgi/content/abstract/88-B/1/26

Jeff

On Mon, Dec 22, 2008 at 1:43 PM, Alexander Chelnokov <alex61@gmail.com> wrote:
> Dear Bill
>
> 2008/12/22 Bill Burman <wdburman@frontiernet.net>:
>> Also see: On-line 2008 dissertation "The Bridging Nail" by Rutger Zuurmond,
>> from Groningen, Netherlands
>> http://dissertations.ub.rug.nl/faculties/medicine/2008/r.g.zuurmond/
>> (also published in Injury 2007)
>
> THX for the references which are more than relevant!
> Well, the publications are quite latest so the topic is really hot.
>
> --
> Best regards,
> Alexander N. Chelnokov
> Ural Scientific Research Institute
> of Traumatology and Orthopaedics
> 7, Bankovsky str. Ekaterinburg 620014 Russia
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>

--
Jeffrey J. Brooks, MD
Orthopaedic Surgery & Sports Medicine Center
1290 Summer Street, #4400
Stamford, CT 06905
---
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alex61 at gmail
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Dec 22, 2008, 11:46 AM

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Re: [ORT-L] Periprosthetic fracture [In reply to]	Can't Post

Dear Jeff

2008/12/23 Jeff Brooks <jjbrooksmd@gmail.com>:
> it a press fit distally, but quality thereof depends on nail/stem
> interface rigidity, right?

Yes.

> surely the rigidity of your nail/stem
> interface does not match that of a long single-piece revision stem.

Despite single-piece or fused or threaded construct could be more
rigid, rigidity of this nail/stem interface is definitely enough for
weight-bearing and other physiological loads at least until the femur
is united.

> but, i wonder if it is sufficient to do the job if this is truly a B2?

And even in case of B3 revision with a long stem is a common approach.
Here we have quite similar construct.

> the failures in the study **(Lindahl et.al. JBJS Br, 2006) of the
> swedish registry showed a suggestion of increased risk of failure when
> fixing Fxs below loose stems (when one recognizes most of the B1
> failures in the study were unrecognized B2's), but maybe this patient
> will behave differently?

Well, the authors absolutely reasonable stated that "Plate fixation
was inadequate in these cases". They didn't analyze the discussed
method of fixation. I expect this patient will behave differently
because locked nails behave better than plates in shaft fractures.

--
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia
---
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tfinlayson at comcast
New User

Dec 22, 2008, 12:37 PM

Post #16 of 17 (13476 views)
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Re: [ORT-L] Periprosthetic fracture [In reply to]	Can't Post

When "hammering" the nail onto the stem how do you know when to stop? I would certainly worry about loosening the stem by "hammering on it in a retrograde direction. On the other hand, if it's not a secure enough interference fit you have instability of the inerface.

--
Terry I. Finlayson, MD
Alpine Orthopaedic Specialists
2310 North 400 East
Suite A
North Logan, UT 84341
(435) 787-2000 Office
(435) 787-1913 Fax
tfinlayson@alpineortho.com

-------------- Original message --------------
From: "Alexander Chelnokov" <alex61@gmail.com>

> Hello
>
> 2008/12/22 Hüseyin Demirörs :
> > you said 'tight fit of the nail' to
> > the femoral stem, since all the rotational stability of the system (distal
> > fragment with nail and locking screws) comes from that point, is it
> > reliable?.
>
> Well, the nail was hammered to the stem until it was jammed. Of course
> we should test the nail-stem interface in lab but practically it is
> strong enough. And applied rotation would dislocate the hip first
> rather than disimpact the nail.
>
>
> --
> Best regards,
> Alexander N. Chelnokov
> Ural Scientific Research Institute
> of Traumatology and Orthopaedics
> 7, Bankovsky str. Ekaterinburg 620014 Russia
> ---
> [This E-mail scanned for viruses by Declude Virus]
>

tfinlayson at comcast
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Dec 22, 2008, 12:37 PM

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