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ORIGINAL ARTICLE

Biomechanical Evaluation of Peri- and Interprosthetic Fractures of the Femur
Wolfgang Lehmann, MD, Martin Rupprecht, MD, Nils Hellmers, MD, Kai Sellenschloh, Daniel Briem, MD, Klaus Puschel, MD, Michael Amling, MD, Michael Morlock, PhD, and Johannes Maria Rueger, MD ¨

Background: Because of an increasing life expectancy of patients and the rising number of joint replacements, peri- and interprosthetic femoral fractures are a common occurrence in most trauma centers. This study was designed to answer two primary questions. First, whether the fracture risk increases with two intramedullary implants in one femur; and second, whether a compression plate osteosynthesis is sufficient for stabilizing an interprosthetic fracture. Methods: Twenty-four human cadaveric femurs were harvested and four groups were matched based on the basis of bone density using a peripher quantitative computer tomography (pQCT). All groups—(I) hip prosthesis with a cemented femoral stem; (II) hip prosthesis and retrograde femoral nail; (III) hip prosthesis, retrograde femoral nail, and lateral compression plate; (IV) all three implants with an additional simulated interprosthetic fracture—were biomechanically tested in a four-point bending in lateralmedial direction. Results: The second group with two intramedullary implants exhibited 20% lower fracture strength in comparison with group 1 with proximal femoral stem only. The stabilization of an interprosthetic fracture with a lateral compression plate (group IV) resulted in a fracture strength similar to femur with prosthesis only. Conclusion: Two intramedullary implants reduce the fracture strength significantly. If an interprosthetic fracture occurs, sufficient stability can be achieved by a lateral compression plate. Because two intramedullary implants in the femur may decrease the fracture strength, the treatment of supracondylar femoral fractures with a retrograde nail in cases with preexisting ipsilateral hip prosthesis should be reconsidered. Key Words: Interprosthetic fracture, Periprosthetic fracture, Femoral fracture, Locking plate. (J Trauma. 2010;68: 1459 –1463)

urrently, the prevalence of periprosthetic femoral fractures has been estimated from 0.1% to 3.2% for primary total hip arthroplasties without cement and from 3% to 12%
Submitted for publication February 3, 2009. Accepted for publication July 23, 2009. Copyright © 2010 by Lippincott Williams & Wilkins From the Departments of Trauma, Hand, and Reconstructive Surgery (W.L., M.R., D.B., M.A., J.M.R.) and Legal Medicine (K.P.); Center for Biomechanics and Skeletal Biology (W.L., M.R., M.A.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; and Biomechanics Section (N.H., K.S., M.M.), Hamburg University of Technology, Hamburg, Germany. First two authors contributed equally and therefore share the first authorship. Address for reprints: Wolfgang Lehmann, MD, Department of Trauma, Hand, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany; email: wlehmann@uke. uni-hamburg.de. DOI: 10.1097/TA.0b013e3181bb8d89

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for revisions performed with cement.1 With the increasing life expectancy of most patients, the physical activity of the elderly,2,3 and the increasing number of patients undergoing total hip or knee arthroplasty, the prevalence of periprosthetic fractures is expected to rise.3,4 As a consequence, orthopedic surgeons increasingly face complications that are associated with arthroplasties. The most common periprosthetic fracture of the femur is located immediately distal to the stem tip (Vancouver type B). Fractures of the femoral shaft between ipsilateral hip and knee arthroplasties or between an intramedullary nail and an endoprosthesis appear infrequently but challenge every trauma surgeon. The incidence of interprosthetic fractures is unknown. Kenny et al.5 found four cases among a total of 320 limbs with ipsilateral hip and knee arthroplasties, making it an incidence of 1.25%. Fink et al.6 have seen 11 interprosthetic fractures in 5 years in their institutions. There are a number of reports on the biomechanical testing of the various surgical treatment options for periprosthetic fractures.7–12 Two procedures are generally considered in these studies: (i) a revision arthroplasty with a long stem, which crosses the fracture distally, especially in cases where the hip prosthesis is already loosened and (ii) plate osteosynthesis that uses a broad variety of plates from different manufacturers. In addition, retrograde nails represent a further utility to stabilize supracondylar femoral fractures. Particularly, elder patients may benefit by such a therapy.13,14 Reports on a successful treatment of femoral fractures between two intramedullary implants are very limited in medical literature. Dave et al.15 successfully treated an interprosthetic femoral shaft fracture with a “Mennen” plate, which is a nonrigid internal fixation device. Jensen et al.16 used the Partridge Cerclage system, but loosening of the nylon band and a less stability were common problems. In contrast to this, Kenny et al.5 reported a 100% failure (4 of 4) of osteosynthesis with a dynamic compression plate. To the best of our knowledge, there is neither a biomechanical investigation of the risk getting an interprosthetic femoral fracture nor a biomechanical study analyzing the stability of these fractures after plate osteosynthesis. In recent years, we used a retrograde intramedullary nail for treatment of patients with a supracondylar femoral fracture in the presence of an ipsilateral hip prosthesis. This procedure allows early mobilization with timely rehabilitation and, depending on the fracture type, faster functional recovery and rapid weight bearing. However, in some cases, interprosthetic fractures occurred after minimal trauma (4 in
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The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 68, Number 6, June 2010

subcortex.. 10 mm. KG. (A) Cross-sections of the condylar region and the femoral diaphysis. Mean value for the diaphysis was 785 mg/cm3 (SD. all screws were locked. Group I: The first group (n 6) consisted of femurs with a hip prosthesis (Fig. Based on own preliminary examinations on healthy human femurs and because of the findings from other groups for the BMD of the femur. At least three unicortical screws were placed on each side of the prosthesis of the nail tips. Twenty-four fresh femurs were frozen at 20°C directly after dissection and defrosted before the biomechanical testing. 1.7 years).e. Stratec Medizintechnik. Colors illustrate the corresponding bone mineral density (BMD). 1. The Journal of TRAUMA® Injury. (B) The femurs were randomized on the basis of pQCT data in four groups. T2 Femoral Nailing System. The nail was always locked on with two locking screws on the proximal and one locking screw (diameter.4 years.17 1460 Figure 1. NJ) crossing the tips of both implants.5 mm. 8). Furthermore. 5. There was no statistical significance between the BMD and cortical thickness of all groups.59 mm 0. 11. MATERIALS AND METHODS Specimens A matched-pair experimental design using human femurs was used. June 2010 6 years). Infection.0 mm) on the distal side. Allendale.01). Number 6. 79. We sought to determine whether two intramedullary implants. Therefore. Group III: In the third group (n 6). The plate design allows choosing between locking and compression screw insertion separately for each screw. two bicortically anchored screws were inserted (Fig. The specimens were from 12 men and 12 women. the femurs were divided into the different groups to obtain maximum comparability (Fig. Femur length was defined as the distance between the distal end of the condylus and tip of the greater trochanter. all aged 65 years and older (average age. Duisburg. 38) and for the condylar region 186 mg/cm3 (SD. 2).0 mm diameter (Fig. diameter. © 2010 Lippincott Williams & Wilkins . it is conceivable that two intramedullary implants may alter the stiffness in the longitudinal direction of the femur. Stryker. A). i. pQCT Measurements Matched femur pairs were selected based on bone density using a pQCT (XCT-2000. In the space between the two femoral components. so-called “kissing implants. Howmedica Osteonics. A 2-mm thick single tomographic slice with a pixel size of 0.. The total femoral cross-sectional area was separated into three parts (i. The pQCT device was calibrated using a standard phantom and a cone phantom provided by the manufacturer.e. 2).000 mg/cm3.” may alter the biomechanical stability of the femur and may therefore be associated with a higher fracture risk. The femurs were randomized on the basis of pQCT data. cortex. An osteoporotic bone model was chosen because patients with osteoporosis represent the group with the highest incidence of periprosthetic fractures. Germany). The total volumetric bone mineral density (vBMD) was defined as the quotient of total bone mineral content on the volume. the femur is additionally stabilized on its lateral side with a locked compression plate (width. The tips of the screws were flattened to allow a maximum depth of insertion onto the prosthesis and respectively onto the nail. On the basis of these data. The results of this study have important clinical implications not only for the management of ipsilateral hip prosthesis but also for conditions in which hip prosthesis and long-stem knee prosthesis or retrograde nails are present on the same side. and Critical Care • Volume 68. 220 mm. Image processing and calculation were performed using the manufacturer’s software package (version 2. Additional parameters were used to assess the cortical structure of the femoral shaft. Germany). which may then lead to decreased stability in the region between the implant tips. The specimens of the first group were match paired with the femurs of the second one and femurs of the third with them of the fourth group. Locking Compression Plate.Lehmann et al. 2).59 mm is taken from the transverse plane of the condylus and the middle of the diaphysis. Stryker GmbH & Co. it is unclear whether lateral plating provides sufficient biomechanical stability in cases of interprosthetic fractures. B). The screw holes were drilled with a 4. and marrow cavity) based on two thresholds: 710 mg/cm3 distinguishes the cortex from the subcortex and 100 mg/cm3 separates the subcortex from the marrow cavity. SD. the threshold for the specimens to be considered osteoporotic was defined lower than 1. Group II: Six femurs with an implanted hip prosthesis and a distal femur nail (length. Pforzheim. The cortical thickness and the bone mineral density were analyzed by pQCT. pQCT measurements. The total cross-sectional area was defined as the area enclosed within the outer bone border. In this study. 4. The diaphysis and the supracondylar region of the femur were scanned (Fig.

A servohydraulic testing machine was used (MTS 858. Figure 2. a four-point bending test was conducted. 3) with a constant bending moment according to Eq. SD. Group IV: all three implants additional osteotomy simulating an interprosthetic fracture. A servohydraulic testing machine was used (MTS 858. Eden Prairie. the fracture occurred between the two “kissing” implants in all cases examined. MN). length. The hip prosthesis cracked the cement and caused a pertrochanteric fracture around the proximal part of the prosthesis.01).591 N. 2). Fig. p 0. Group III: hip prosthesis retrograde femoral nail lateral compression plate. A and B). radiographs are taken after specimen preparation and implantation of the prosthesis. l2: distance between the inner supports.692 N (SD. The difference to group I failed to reach statistical significance (p 0. Group IV: The femurs in the fourth group (n 6) were additionally osteotomized in an oblique plane at the level of the tip of the prosthetic stem. Group II: hip prosthesis retrograde femoral nail. Load was applied at a constant speed of 0. the fracture always occurred at the distal end of the plate at the level of the most inferior screw hole. Group I: hip prosthesis with a cemented femoral stem. SD. position. Statistics Statistical analyses were performed using SPSS for windows. Noncemented stems were not tested because it is impossible to simulate osseous ingrowth in a laboratory setting. l: lever arm length. Therefore. F: applied force. Before testing.692 N. starting medially and extending laterally at 45 degrees. This setup omitted transverse force across the femur (Fig. In lateral-medial direction.020 N. SD. As predicted.1 mm/s until fracture. All femurs were stripped of soft tissue and the medullary canals were prepared for prosthesis implantation. which is significantly higher than in femurs instrumented with hip prosthesis and intramedullary nail (group II: F 3. Student’s t test was used for normally distributed independent variables. 3).04). 4. Infection.2. RESULTS All femurs with hip prosthesis only (group I) exhibited a periprosthetic fracture around the tip of the stem. Group arrangement. In femurs with lateral plating (groups III and IV). p 0. Karlskron.01. Fig.and Interprosthetic Fractures middle two supports (length l2 in Fig. The probability of a type I error was set to 5%. Goßl&Pfaff. Data are presented as mean and SD. Fig. Group IV had a similar fracture strength as group I (F 4. p 0. The group with lateral plating construct without an osteotomy (group III) exhibited a higher fracture strength than group II and showed the highest strength of all test configurations (group III: F 5.591 N. similar to those of group I (4. Each femur was implanted with an Exeter V40 stem (Stryker. 1 M F l1 l2 l 2 2 l1 2 l2 8 cm (1) with: l1: distance between the outer supports. The femur was loaded between the middle two supports (length l2) with a constant bending moment according to. we tested different loading directions. 690 N.79. the fractures occurred in the supracondylar region. 4. This further minimizes the variation in the distance between cement and end of the retrograde nail. A and B). bones were embedded in polyurethane (Ureol FC53.37).875 N. 229 N. 1461 . Biomechanical testing. 690 N. The cement stopper was implanted to a depth that allowed inserting the nail from the distal side. we were able to create fractures between the two intramedullary implants. The femur was loaded between the © 2010 Lippincott Williams & Wilkins Figure 3. June 2010 Peri.The Journal of TRAUMA® Injury. 639 N. MN). Mean fracture strength is 4. SD.2. Howmedica Osteonics). Eden Prairie. and Critical Care • Volume 68.8 Four-Point Bending Test In preliminary studies. SD. p 0. A and B). Number 6. 4. In group II. Howmedica Osteonics) with Simplex P Bone Cement (Stryker. 183 N). and orientation. the femurs with osteotomy (group IV) needed a smaller force to failure (4. Pure torsional loading alone was insufficient to bring about a fracture between the implants. If the force was directed from anterior to posterior. to simulate an interprosthetic fracture (Fig. To determine the fracture strength in the boneimplant constructs. To ensure an adequate cement mantle. 183 N. Germany) in ¨ steel pots. The lever arm was adjusted to 8 cm. we used this loading condition in all specimens.

(A) Average load to failure in groups I to IV. there is only limited information on the biomechanics of periprosthetic fractures and until now. Simple load application in anteroposterior direction led to supracondylar fractures. it should be seriously considered to protect patients from a higher fracture risk in the endangered area between the implant tips. used a lengthening of the indwelling prosthesis by a custom-made slotted hollow intramedullary nail for treating periprosthetic femoral fractures. regardless of the presence of an implanted retrograde nail in the distal femur. (B) Presentable forcedisplacement diagrams for matched pairs for the four groups.e. Furthermore.and interprosthetic fractures of the femur. it is unknown whether fracture strength is altered by the implantation of two intramedullary carriers into a single femur. We further evaluated plates in tension banding because plates represent currently the gold standard for fracture treatment of osteoporotic bones (i. torsion and shear are difficult to apply in an ex vivo model because the load application often causes failure at undesired sites of the bone. Fracture strength. we performed a series of experiments where we analyzed the fracture strength and biomechanical stability in four different paradigms. Note the steepened incline with two intramedullary components (group II). and Critical Care • Volume 68. In preliminary experiments.11 We did not include torsional testing in our study because of technical restrictions. the screws on the proximal part of the plate can be applicated throughout a targeter by minimal invasive approaches. resulting in a pertrochanteric fracture.18 A further important finding of our study demonstrates that the locking compression plate between the tip of the stems leads to a remarkable stability regardless of the presence of an inter© 2010 Lippincott Williams & Wilkins . The Journal of TRAUMA® Injury. These studies simulated a periprosthetic fracture by osteotomy similar to a Vancouver C fracture and compared the stability by a variety of parameters including torsional testing. we observed that the loading force.Lehmann et al. on the lateral cortex). After open reduction of the mostly comminuted fractures. Number 6. Moreover. To address these questions. Because the dynamic force from the lateral side is considered to be the main trauma direction. If additional plating cannot be considered as a treatment option. Therefore. However. we used postmortem femurs. a possible bias by local material tiredness at the contact point is minimized. The locking condylar plates can be usually applied through a small incision along the lateral condyle and locked percutaneously at the proximal end. Although such a procedure is not totally consistent with the concept to develop treatment strategies that minimize invasive surgery. there has been no biomechanical investigation of interprosthetic femoral fractures or the treatment of those fractures. surgeons will be more frequently confronted with peri.. they observed fracture healing.8. Our data indicate that two intramedullary implants decrease the fracture strength significantly. in preliminary studies. to date.7. to stress shield the area between the tips of the two implants. Because the load is split between the two middle supports. we observed that torsional testing without an osteotomy burst the cement mantle. a subsequent prosthesis loosening. The femurs with a lateral plating construct (group III) exhibited the highest fracture strength. which causes peri. Previously. we conducted the further experiments in a four-point bending test in this direction. Infection. Furthermore. an extramedullary stabilization or an in situ lengthening of the indwelling prosthesis may be used to avoid the problem of two intramedullary components. DISCUSSION As the incidence of prosthetic joint replacement is continually rising. our results suggest that patients with two ipsilateral intramedullary femoral implants may benefit by lateral femoral plating. and in only one case. We used a four-point bending with a constant moment that acts between the middle of the two supports allowing failure at the less resistant region. In all cases.and interprosthetic fractures. as determined by reduced cortical thickness and bone density. An aggravating factor is that those patients often suffer from reduced bone quality and severe osteoporosis. To enhance the clinical significance. is the load application from the lateral side. 1462 which had considerable osteoporosis. From a clinical perspective. June 2010 Figure 4. Meyer et al. The maximum load to failure of group II (femurs with two intramedullary implants) was significantly reduced in comparison with femurs with prosthesis only (group I). various stabilization methods have been tested for the fixation of periprosthetic fractures around the tip of a single implanted stem for hip replacement surgery. we chose the four-point bending that produces a constant moment between the two middle support points.

46 mm. A technical limitation is the variability of the distance between the tips of the ipsilateral femoral component and the retrograde nail (mean. Ebrahim S.26:695– 699. Orthopedics.20:89 –93.5:123–126. Shaw M. J Arthroplasty. Quinlan W. J Orthop Trauma.20 suggests that a variable gap size may only have a minor influence on stability and resistance of femoral stems in humans. Koka SR. Dennis MG. 2005. our data are not only in line with previous biomechanical studies. Retrograde femoral nailing in elderly patients with supracondylar fracture femur. Meyer C. Stress risers between two ipsilateral intramedullary stems: a finite-element and biomechanical analysis. Kummer FJ. Techapongvarachai T.84(suppl 1): 415– 422. an extramedullary fixation technique for supracondylar femoral fractures should be preferred instead of an additional intramedullary implant. Peripheral ¨ quantitative computed tomography in human long bones: evaluation of in vitro and in vivo precision. Frei H. 1998.36:813– 822. 12. Clin Orthop Relat Res. 2005. Schmotzer et al. Rice J. No pull out of the screws was observed. J Orthop Trauma. we implemented the cement mantle always as deep as possible. Arch Orthop Trauma Surg. Tchejeyan GH.. J Bone Joint Surg Am. Berry DJ. Dave DJ. 3. Heiss C. Koval K. Plate-screw-wiring technique for the treatment of periprosthetic fracture around the hip: a biomechanical study. Injury. Shalaby H. Furthermore. Trends in hip and knee joint replacement: socioeconomic inequalities and projections of need. Fuerst M.and Interprosthetic Fractures prosthetic fracture. 10. This construct resulted in a very high degree of stability comparable with those of the femur without osteotomy and retrograde nailing. 2004. Number 6. Singer J. 18 mm). Schmotzer H. we simulated the most unstable situation in group IV by application of an additional osteotomy. Tower SS. Dennis et al. J Arthroplasty. 7.e. 2. To facilitate the comparability of different studies. Berry DJ. the stress riser effect of an intramedullary metal stem inside a femur is clearly dependent on the femurs cortical density instead of gap distance.327:238 –246. 1463 . J Arthroplasty. Clin Biomech. J Med Assoc Thai. Fulkerson E. Dixon T. which further implicates a strong connection between screw and plate as well as plate and bone. Masri BA. Treatment of periprosthetic femoral fractures by effective lengthening of the prosthesis. The loading scheme does not replicate adduction forces or tension provided by the iliotibial band. Schnettler R. Epidemiology: hip and knee. 14.15:177–180. The role and efficacy of retrograding nailing for the treatment of diaphyseal and distal femoral fractures: a systematic review of the literature. provided the best fixation until pull out of the proximal screws occurred. 1996. According to this study. Infection. a plate with proximal unicortical screws.31:83– 86. In these experiments. Clin Orthop Relat Res.The Journal of TRAUMA® Injury.13:361–364. and distal bicortical screws did yield the most benefit in terms of biomechanical stability. i. 2001. noncomminuted interprosthetic femoral fracture. 5. 1993. Ann Rheum Dis. J Bone Joint Surg Am. To take this issue into further account. Springer BD. 8. An analysis of 93 fractures. In a series of experiments. Papadokostakis G. 2007. comminuted fractures are most common. we used nails with the same length and femurs of a comparable size. Beals RK. 2005. Preston CF. Lewallen DG. Interprosthetic fracture of the femoral shaft. 2006. Moftah A.8 compared a locked plating construct with the Ogden construct and found that a locking plate is stiffer than the Ogden construct in axial loading and torsion. El-Kawy S. and Critical Care • Volume 68. Davitt JS. Schroeder L. James SE.85:2156 –2162. Itiravivong P. Alt V. so that the nail almost directly touched the cement. Kannus P. Osteoporosis and anterior femoral notching in periprosthetic supracondylar femoral fractures: a biomechanical analysis. The present data also demonstrate that this osteosynthesis is a sufficient procedure for stabilizing a fracture between two intramedullary implants. 16. 2005. This study is limited by the use of nonliving tissue and failure to account for soft tissue contributions to stability.63:825– 830. Therefore. Orthop Clin North Am. 2003. Fixation of periprosthetic femur fractures: a biomechanical analysis comparing cortical strut allograft plates and conventional metal plates. In cases of an oblique. Light of these findings. Dimitriou R. 1996. 1990. Fulkerson et al. J Bone Miner Res. Wilson D. Treatment of periprosthetic femoral fractures following total hip arthroplasty with femoral component revision. proximal cables. Periprosthetic fractures of the femur associated with hip arthroplasty. Kuptniratsaikul S. 2001. They concluded that a well-fixed implant. Dall DM. Kummer FJ. 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