Fracturas Periimplantes, No Protesicas 2018
Fracturas Periimplantes, No Protesicas 2018
Fracturas Periimplantes, No Protesicas 2018
https://doi.org/10.1007/s00402-018-2905-1
TRAUMA SURGERY
Abstract
Introduction Non-prosthetic peri-implant fractures (NPPIFs) are an under-reported entity. Management is challenging
because of alterations in anatomy, the presence of orthopaedic implants and phenomena such as stress shielding, disuse
osteopenia and fracture remodeling. The aims of this paper were to review patterns of injury, management and outcomes
and to propose a classification system to aid further research.
Materials and methods This study is a multi-centered retrospective case series. Patients were identified from the orthopaedic
department trauma databases of public hospitals in Singapore and individual surgeon case series of members of the Singapore
Orthopaedic Research Collaborative (SORCE) group.
Results We collected a series of 60 NPPIFs in 53 patients. 38 fractures involved the femur, 12 the radius/ulna, 5 humeri, 3
tibia/fibula and 1 clavicle. 39 patients had fractures around plates and screws, 12 around nails, and 3 around screws. Fractures
were managed with a variety of surgical techniques. Six patients had surgical complications with refracture in four and non-
union in two cases. Two patients had multiple refractures (total 12 additional fractures). All surgical complications required
further surgery. Three patients had deep vein thrombosis and one patient died of post-operative pneumonia. Fractures were
classified according to the initial implant (plate or nail), the position of the new fracture relative to the original implant
(at the tip or distant) and the status of the original fracture (healed, not healed or failing). Surgical strategies for common
subtypes were reviewed.
Conclusions This study represents the largest series in the literature. NPPIFs are a challenging clinical problem with a high
rate of post-operative complications. They are distinct from peri-prosthetic fractures and should be understood as a separate
entity. We, therefore, propose a novel classification system. Further research is needed to determine the optimal treatment
for the various subtypes.
Level of evidence Therapeutic Level IV—case series.
Introduction
Members of the “Singapore Orthopaedic Research CollaborativE We define a non-prosthetic peri-implant fracture (NPPIF) as
(SORCE)” are listed in the acknowledgements section.
a fracture in a bone with an existing non-prosthetic implant
* Ernest B. K. Kwek such as an extramedullary plate and screws or an intramedul-
ernest_kwek@ttsh.com.sg lary nail. NPPIFs are often reported together with peri-pros-
thetic fractures (PPFs) that occur around joint replacement
1
Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, implants [1, 2]; they are, however, a distinct clinical entity
Singapore 308433, Singapore
with different conceptual and practical considerations. PPFs
2
Ng Teng Fong General Hospital, 1 Jurong East Street 21, have been extensively studied and there are multiple classifi-
Singapore 609606, Singapore
cation systems and guidelines for treatment in the literature
3
Singapore General Hospital, Outram Road, [3–5]. In contrast, the literature addressing NPPIFs is sparse.
Singapore 169608, Singapore
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Archives of Orthopaedic and Trauma Surgery
The term NPPIF does not include failures of primary distribution are shown in Fig. 1. A bimodal age distribution
fracture fixation such as sliding hip screw cut-outs and was noted.
implant breakages due to non-union. These have also been 40 patients sustained their NPPIF in a low velocity fall,
extensively studied. 12 had a road traffic accident (RTA) and 1 was the result
The aims of this study were to review patterns of injury, of the propagation of an unrecognized perforation of the
management and outcomes and to attempt to classify anterior femoral cortex by a long femur nail. All 12 RTA
NPPIFs into a system that may aid further research and patients were male and tended to be younger (mean age 47).
study. Because of the low incidence of these fractures a
multi-centre collaboration was sought. Previous injury details
This study is the first research effort of the Singapore
Orthopaedic Research Collaborative (SORCE): A group 12 fractures were around intramedullary nails, all of which
made up of orthopaedic trauma surgeons with representa- were in the femur, 45 fractures were around extramedullary
tives from public sector hospitals managing adult trauma plates and screws and 3 fractures were around cancellous
in Singapore. screws of the proximal femur. Distribution of cases accord-
ing to original implant and location is shown in Fig. 2.
The average time from primary fracture fixation to peri-
Materials and methods implant fracture was 6.2 years (range 0–30 years). There was
trend toward fractures around nails occurring earlier than
Ethics approval for this study was obtained prior to com- those around plates (3.0 versus 7.6 years, p = 0.14).
mencement (National Healthcare Group DSRB Ref:
2013/00893). Injury patterns
Cases were contributed by SORCE members from ortho-
paedic department databases and personal cases series. Based on our observations, we classified NPPIFs accord-
Patients aged 18 years and older with a NPPIF in a long ing to the type of implant (nail or plate), the position of the
bone were included. Fractures around prosthetic implants fracture relative to that implant (type 1—at the tip, type 2—
and patients with pathological bone conditions (except oste- distant to the implant) and the healing status of the original
oporosis) were excluded. fracture (A—healed, B—not healed, C—failing). The pro-
Suitable cases were identified and demographic, injury posed classification is shown in Fig. 3 and illustrated with
and outcome data were collected from case records and case examples in Fig. 4.
X-rays. Data were reviewed for patterns of injury, trends, 65%(39/60) of NPPIFs were directly adjacent to the tip
management strategies and outcomes. of the implant (type 1). 33%(20/60) were distant to the tip
of the implant (type 2). One patient had an unusual injury
that was not classified by our system (no. 44). This patient
initially had a long cephalomedulary femur nail that was
Results inserted without distal locking screws and subsequently sus-
tained a spiral fracture around the shaft of the nail.
A total of 53 patients were identified with 60 NPPIFs. A 79%(46/58) of primary fractures were healed (subtype
summary of cases is shown in Table 1. A). 17%(10/58) were not healed but stable (subtype B) and
42 of these fractures (39 patients) were of the lower limb. in 3% (2/58) the fracture fixation was failing (subtype C).
18 fractures (14 patients) involved the upper limb. Of the
39 patients with lower limb injuries, 2 patients sustained Management
fractures above and below an implant in the same injury.
Two patients sustained double bone fractures (radius/ulna Of 60 fractures, 57 were treated surgically. Three fractures
or tibia/fibula) and one patient sustained a bilateral double in two patients (no. 44 and 53) were treated conservatively.
forearm fracture. These were regarded as separate NPPIFs. One patient (no. 45) underwent minimal surgery with
Average follow-up was 16 months (range 0–75). Seven removal of prominent screws without internal fixation due
patients were lost to follow-up or had less than 3 months to comorbidities.
follow-up. Of the ten patients with intramedullary nails treated surgi-
cally, four had retention of the original nail and extramed-
Demographics ullary fixation around the nail, five had the original nail
removed and were fixed with either an extramedullary
The average age was 64 years (range 20–100). There were 31 implant or a longer nail. One had removal of reconstruction
male and 22 female patients. Demographics and anatomical screws alone.
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Table 1 Summary of cases
Case no Age Sex Side Bone Mechanism Time to Original Originala NPPIF type Subtype Implant New implant Follow up Complications
NPPIF implant removed? (months)
(months)
13
Table 1 (continued)
Case no Age Sex Side Bone Mechanism Time to Original Originala NPPIF type Subtype Implant New implant Follow up Complications
NPPIF implant removed? (months)
13
(months)
ing revision
L Ulna Ulna shaft P1 A Y 3.5 LCDCP Refractured
twice recquir-
ing revision
32 74 F L Femur Low energy 13 DHS ITa P1 A N Retrograde 2 N
fall femoral nail
33 60 F L Femur Low energy 483 Old plate Femur shaft P1 A Y 4.5LCDCP 9 N
fall
34 20 M L Radius Low energy 2 DR locking DRa P1 A Y 2.4 mm DR 12 N
fall plate locking plate
35 78 F L Femur Low energy 122 DCSs—broken Distal femur P2 A N Hemiarthro- 4 N
fall fracture plastys—
Zimmer ML
taper
36 94 M L Femur Low energy 8 PFLPs—short ITa P2 A N Zimmer MDN 14 N
fall retrograde
nail
37 38 M R Tibia RTA 13 Low bend dis- Distal tib-fib P1 A Y Screw fixation 19 N
tal tib plate fracture
R Fibula 13 1/3 tubular Distal tib-fib P1 A Y LCDCP 19 N
fracture
38 53 M R Humerus Low energy 238 LCDCP Humerus shaft P1 B N LCDCP 5 N
fall
39 77 F L Femur Low energy 64 DHS ITa P2 A N Retrograde 13 N
fall femoral nail
40 95 M L Femur Low energy 1 Cancellous NOFa S1 A Y Cemented 3 DVT
fall screws bipolar with
cerclage
wires
41 38 F R Femur Low energy 142 Short retro- Supracondylar N1 A Y Long retro- 11 Refracture and
fall grade nail fracture grade nail reoperation
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Table 1 (continued)
Case no Age Sex Side Bone Mechanism Time to Original Originala NPPIF type Subtype Implant New implant Follow up Complications
NPPIF implant removed? (months)
13
(months)
RTAroad traffic accident, IM intramedullary, CM cephalomedullary, DR distal radius, DHS dynamic hip screw, DCS dynamic condylar screw, LCP locking compression plate, LCDCP low con-
tact dynamic compression plate, LISS less invasive stabilization system (Synthes), PFNA proximal femoral nail antirotation (Synthes), IT intertrochanteric, NOF neck of femur, A2FN antegrade
femoral nail (Synthes)
a
Fracture
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Complications
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Overall 11% (6/53) of patients experienced surgical com- fracture at the distal end of the nail. The 1st generation
plications. All these patients required further surgery. Gamma Nail (Howmedica Ltd) suffered from early peri-
implant fracture rates of up to 17% [6]. Subsequent improve-
ments in nail design markedly reduced the fracture rate; the
Discussion most recent data suggest a rate of 0.7–3.5% for CM nails
and 0.3–1% for the SHS [7–15]. Add muller et al., Frisch.
NPPIFs are an under-reported entity. The orthopaedic litera- The literature regarding non femoral NPPIFs is extremely
ture has focused on fractures of the proximal femur. In the sparce [16]. Studies reporting upper limb NPPIFs are
early 1990s cephalo-medullary (CM) nails were introduced focused on the effect of removal of implants as this appears
for fixation of peri-trochanteric fractures; CM nails had to be associated with a significantly higher risk of re-fracture
theoretical biomechanical advantages over extramedullary compared to if they are retained [17].
implants such as the sliding hip screw (SHS), unfortunately, This paper represents the largest series of NPPIFs in the
these advantages were offset by a high rate of peri-implant literature and we hope that the following observations and
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use. For this reason, we did not aim to take into account all changing the implant to a longer implant, such as exchang-
possible variables but chose the most important variables ing a short proximal femoral nail for a long nail that bridges
affecting treatment. In a given location, these were the type the original fracture zone and the new NPPIF. This would
of implant (intramedullary or extramedullary), the position not usually be possible with a type 2 fracture, which is more
of the NPPIF relative to that implant (at the tip or distant) likely to require a second implant. In such a case, a decision
and the status of the original fracture (healed, healing and has to be made regarding whether the implants should over-
failing construct). We were aware that some fracture patterns lap or if the distance between implants is of sufficient length
would not be classified by our system, however, we deemed to avoid significant stress concentration.
that these were either infrequently encountered fracture pat-
terns or fractures for which the management is relatively Healing status of the original fracture
straightforward (for example, fractures at the apophysis and
fractures around screws alone). The status of the original fracture is the third determining
We made the following observations regarding the factors factor. The type A NPPIF with a healed original fracture may
in the classification. be amenable to removal of the original implant, however, the
quality of the healing and the effect of empty screws holes
Type of implant must be taken into account. Type B with a stable but not
healed original fracture usually steers management toward
The majority of NPPIFs were around plates and screws (48 retention of the original implant. Type C is the equivalent
fractures) with fractures around nails forming a smaller of a double level fracture requiring revision of the original
group (13 fractures). Inferences regarding relative inci- fixation in addition to fixation of the NPPIF.
dence are limited as the prevalence of extramedullary ver-
sus intramedullary implants in the community is unknown. Management strategies
Short and long cephalomedullary nails and medullary nails
were similarly represented in our series; again, we are unable Surgical management strategies differed according to loca-
to draw firm conclusions regarding relative incidences as tion. We used the classification to identify management
the prevalence of long versus short CM nails is unknown, strategies that were applied to the common fracture types in
however, in keeping with the existing literature there does the femur (see Table 2). Figure 5 shows the use of the classi-
not appear to be an excess of fractures in either group [15, fication in developing a management algorithm for proximal
18, 19]. femur-based implants. Similar algorithms can be developed
The type of original implant (intramedullary/extramed- for other locations (e.g., fractures around distal femur-based
ullary) affects the subsequent placement of implants. If the implants or humerus shaft implants).
implant is retained, other devices must be positioned around Cases in our series were managed using standard osteo-
it. If the implant is removed, bone defects and areas of synthesis implants including locking plates, intramedullary
potential weakness must be taken into account and bridged nails and cerclage wires. Two patients were treated with
if necessary. In either case, areas of high stress concentra- variable angle locking plates. No patients had ‘piggyback’
tion between implants or at screw holes must be avoided. type plates or specialized cable plate systems.
This can be achieved by implants that bridge all areas of
potential weakness or overlapping implants. Studies based Complications
on peri-prosthetic fracture models have demonstrated the
biomechanical superiority of such strategies [20]. We noted a relatively high incidence of complications such
We did not classify fractures around screws alone as the as non-union and further occurrence of an NPPIF. Higher
management of these injuries is usually straightforward. complication rates may be anticipated in the setting of revi-
sion surgery through scar tissue, requiring more extensive
Position of the NPPIF dissection and soft tissue stripping. Securing stable fixa-
tion can be challenging because of the position of existing
Fractures at the tip and distant to the tip of the implant differ implants, screws holes and stress risers. Loss of bone stock
in terms of the mechanism of fracture as well as the treat- from stress shielding and disuse osteopenia may also con-
ment options available. Mechanically, in type 1 fractures, the tribute to the surgical difficulty. While not all factors are
implant has acted as a stress riser and predisposed the bone modifiable, there were technical errors that increased the
to further fracture. In type 2, the implant has not directly risk of fracture in three of the four cases that went on to have
contributed to the fracture, which has occurred through further NPPIFs. These included leaving a short unprotected
a distant area of weakness (usually the far metaphysis). segment of bone between implants or ending an implant near
In terms of treatment, a type 1 fracture may be treated by a previous screw hole (see Fig. 6).
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Limitations
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Acknowledgements This manuscript was prepared by the Singapore 8. Bhandari M, Schemitsch E, Jönsson A, Zlowodzki M, Haiduke-
Orthopaedic Research CollaborativE (SORCE), c/o Lester W. M. Chan, wych G (2009) Gamma nails revisited: gamma nails versus com-
MBBS, FRCS(Ed) and Ernest B. K. Kwek MBBS, MRCS(Edin), pression hip screws in the management of intertrochanteric frac-
M.Med(Ortho), FAMS, FRCS(Edin)(Ortho). Principal Investiga- tures of the hip: a meta-analysis. J Orthop Trauma 23(6):460–464
tor: Lester W. M. Chan. Manuscript Preparation: Lester W. M. Chan, 9. Yli-Kyyny T, Sund R, Juntunen M, Salo J, Kröger H (2012) Extra-
Antony W. Gardner, Ernest B. K. Kwek, Merng Koon Wong, Kenon and intramedullary implants for the treatment of pertrochanteric
Chua. Case contributors: Lester W. M. Chan (Tan Tock Seng Hospital/ fractures—results from a Finnish National Database Study of
Khoo Teck Puat Hospital), Antony W. Gardner (Ng Teng Fong Gen- 14,915 patients. Injury 43(12):2156–2160
eral Hospital), Ernest B. K. Kwek (Tan Tock Seng Hospital), Merng 10. Chirodian N, Arch B, Parker M (2005) Sliding hip screw fixation
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phy (National University Hospital), Kein Boon Poon (Changi General 11. Matre K, Havelin L, Gjertsen J, Espehaug B, Fevang J (2013)
Hospital). Intramedullary nails result in more reoperations than sliding hip
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Compliance with ethical standards 12. Matre K, Havelin L, Gjertsen J, Vinje T, Espehaug B, Fevang J
(2013) Sliding hip screw versus IM nail in reverse oblique tro-
Funding The authors have no sources of funding to declare. chanteric and subtrochanteric fractures. A study of 2716 patients
in the Norwegian Hip Fracture Register. Injury 44(6):735–742
Conflict of interest All authors declare that they have no conflict of 13. Liu M, Yang Z, Pei F, Huang F, Chen S, Xiang Z (2010) A meta-
interest. analysis of the Gamma nail and dynamic hip screw in treating
peritrochanteric fractures. Int Orthop 34(3):323–328
Ethical approval For this type of study formal consent is not required. 14. Müller F, Galler M, Zellner M, Bäuml C, Marzouk A, Fücht-
This article does not contain any studies with human participants or meier B (2016) Peri-implant femoral fractures: The risk is more
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(2016) Long versus short cephalomedullary nail for trochanteric
femur fractures (OTA 31-A1, A2 and A3): a systematic review. J
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16. Reyes-Cabrera J, González-Alconada R, García-Mota M (2013)
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