Periprosthetic fractures are the third most common reason for revision total hip arthroplasty. Surgical treatment of periprosthetic fractures belongs to the most difficult procedures due to the extensive surgery, elderly polymorbid patients and the high frequency of other complications. The aim of this study was to evaluate the results of operatively treated periprosthetic femoral fractures after total hip arthroplasty.
We evaluated 47 periprosthetic fractures in 40 patients (18 men and 22 women) operated on between January 2004 and December 2010. The mean follow-up period was 27 months (within a range of 12-45 months). For the clinical evaluation, we used modified Merle d'Aubigné scoring system.
In group of Vancouver A fractures, 3 patients were treated with a mean score of 15,7 points (good result). We recorded a mean score of 14,2 points (fair result) in 6 patients with Vancouver B1 fractures, 12,4 points (fair result) in 24 patients with Vancouver B2 fractures and 12,8 points (fair result) in 7 patients with Vancouver B3 fractures. In group of Vancouver C fractures, we found a mean score of 16,2 points (good result) in 7 patients.
Therapeutic algorithm based on the Vancouver classification system is, in our opinion, satisfactory. Accurate differentiation of B1 and B2 type of fractures is essential. Preoperative radiographic images may not be reliable and checking the stability of the prosthesis fixation during surgery should be performed.
Periprosthetic fractures are the third most common reason for revision total hip arthroplasty. Surgical treatment of periprosthetic fractures belongs to the most difficult procedures due to the extensive surgery, elderly polymorbid patients and the high frequency of other complications. The aim of this study was to evaluate the results of operatively treated periprosthetic femoral fractures after total hip arthroplasty.
Percutaneous fixation of bilateral anterior column acetabular fractures: A ca...Apollo Hospitals
The treatment of displaced acetabular fractures with open
reduction and internal fixation has gained general acceptance. This is done either by anterior, posterior or combined approaches depending on the location of these fractures. These procedures may be associated with various complications like significant blood loss, infection, lengthy operative times, heterotopic ossification and neurovascular complications.
There are clinical situations where open reduction is either
not feasible (due to associated medical problems) or when the fractures are not significantly displaced, then minimal invasive means of internal fixation of these fractures seems to be an attractive option. Percutaneous screw fixation of the anterior column of the acetabulum has been a challenging task because of its unique anatomy (narrow corridor of bone) and risk of intra-articular penetration.
Fractures and fracture dislocations of the tarsometatarsal jointMurugesh M Kurani
Here I have discussed an article from Journal of Bone and Joint Surgery. The presentation includes classification, treatment, results and complications. Lets share and learn.
Percutaneous fixation of bilateral anterior column acetabular fracturesApollo Hospitals
The treatment of displaced acetabular fractures with open
reduction and internal fixation has gained general acceptance. This is done either by anterior, posterior or combined approaches depending on the location of these fractures. These procedures may be associated with various complications like significant blood loss, infection, lengthy operative times, heterotopic ossification and neurovascular complications.
Periprosthetic fractures are the third most common reason for revision total hip arthroplasty. Surgical treatment of periprosthetic fractures belongs to the most difficult procedures due to the extensive surgery, elderly polymorbid patients and the high frequency of other complications. The aim of this study was to evaluate the results of operatively treated periprosthetic femoral fractures after total hip arthroplasty.
Percutaneous fixation of bilateral anterior column acetabular fractures: A ca...Apollo Hospitals
The treatment of displaced acetabular fractures with open
reduction and internal fixation has gained general acceptance. This is done either by anterior, posterior or combined approaches depending on the location of these fractures. These procedures may be associated with various complications like significant blood loss, infection, lengthy operative times, heterotopic ossification and neurovascular complications.
There are clinical situations where open reduction is either
not feasible (due to associated medical problems) or when the fractures are not significantly displaced, then minimal invasive means of internal fixation of these fractures seems to be an attractive option. Percutaneous screw fixation of the anterior column of the acetabulum has been a challenging task because of its unique anatomy (narrow corridor of bone) and risk of intra-articular penetration.
Fractures and fracture dislocations of the tarsometatarsal jointMurugesh M Kurani
Here I have discussed an article from Journal of Bone and Joint Surgery. The presentation includes classification, treatment, results and complications. Lets share and learn.
Percutaneous fixation of bilateral anterior column acetabular fracturesApollo Hospitals
The treatment of displaced acetabular fractures with open
reduction and internal fixation has gained general acceptance. This is done either by anterior, posterior or combined approaches depending on the location of these fractures. These procedures may be associated with various complications like significant blood loss, infection, lengthy operative times, heterotopic ossification and neurovascular complications.
Ligamentotaxis in the Intraarticular and Juxta Articular Fracture of Wristiosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
The presentation discusses evidence based medicine in the stream of Orthopaedics. Here I have discussed a case of Ipsilateral Intertronchanteric and Femoral shaft Fracture and its various treatment modalities. The presentation was done at J.N. Medical College Belagavi, India. Lets share, discuss and keep learning.
Pain from acute vertebral fracture appears to be due in part to instability (non-union or slow union at the fracture site), while more than 1/3 of patients become chronically painful.
Traditional treatment for patients with painful VCFs includes bed rest, narcotic analgesics and bracing, resulting in increased pain because of acceleration bone loss and muscle weakness.
By replacing all or a portion of the meniscus with donor cartilage, the patient can regain the natural “shock absorber” in the knee and experience many additional years of activity, even in the presence of arthritis. Being "bone on bone" does not always mean that the joint needs to be artificially replaced, often the "bone on bone" is isolated to a portion of the knee joint and this can be repaired using meniscus transplant alone or in combination with any of the Biologic Knee Replacement procedures.
Ligamentotaxis in the Intraarticular and Juxta Articular Fracture of Wristiosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
The presentation discusses evidence based medicine in the stream of Orthopaedics. Here I have discussed a case of Ipsilateral Intertronchanteric and Femoral shaft Fracture and its various treatment modalities. The presentation was done at J.N. Medical College Belagavi, India. Lets share, discuss and keep learning.
Pain from acute vertebral fracture appears to be due in part to instability (non-union or slow union at the fracture site), while more than 1/3 of patients become chronically painful.
Traditional treatment for patients with painful VCFs includes bed rest, narcotic analgesics and bracing, resulting in increased pain because of acceleration bone loss and muscle weakness.
By replacing all or a portion of the meniscus with donor cartilage, the patient can regain the natural “shock absorber” in the knee and experience many additional years of activity, even in the presence of arthritis. Being "bone on bone" does not always mean that the joint needs to be artificially replaced, often the "bone on bone" is isolated to a portion of the knee joint and this can be repaired using meniscus transplant alone or in combination with any of the Biologic Knee Replacement procedures.
Open debridement and radiocapitellar replacement in primary and post-traumati...Alberto Mantovani
Background: Postmortem and clinical studies have shown an early and prevalent involvement of the radiohumeral
joint in primary and secondary arthritis of the elbow. The lateral resurfacing elbow (LRE) prosthesis
has recently been developed for the treatment of lateral elbow arthritis. However, few data have been
published on LRE results.
Materials and methods: A prospective multicenter study was designed to assess LRE preliminary results.
There were 20 patients (average age, 55 years). Preoperative diagnosis were primary osteoarthritis in 11
and post-traumatic osteoarthritis in 9. All patients underwent open debridement and LRE prosthesis.
Patients were evaluated preoperatively and postoperatively with the Mayo Elbow Performance Score
(MEPS), modified American Shoulder Elbow Surgeons (m-ASES) elbow assessment, and the Quick
Disabilities of the Arm, Shoulder and Hand (Quick-DASH). Mean follow-up was 22.6 months.
Results: At the last follow-up, the mean improvement of MEPS and m-ASES was 35 (P ¼ .001) and 34
(P ¼ .001) respectively; the average Quick DASH decreased by 29 (P ¼ .001). Average range of motion
was improved by 35 (P ¼.001). MEPI results were excellent in 12 patients, good in 2, and fair and poor in
3 each. Mild overstuffing was observed in 5 patients, and an implant malpositioning in 3. The implant
survival rate was 100%.
Conclusion: LRE showed promising results in this prospective investigation. Most patients had an
uneventful postoperative course and have shown a painless elbow joint, with satisfactory functional
recovery at short-term follow-up. Further studies with longer follow-up are warranted.
Short Term Analysis of Clinical, Functional Radiological Outcome of Total Kne...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Treatment of displaced midshaft clavicle fracture with locking compression plate provides better biomechanical stability, good fracture union rates, high post-operative constant score, early pain resolution, early return to activity, high patient satisfaction rates and excellent functional outcome. These benefits of plating overweigh complications when used in specific indications like displaced with or without comminuted middle third clavicle fracture (Robinson Type 2B1, 2B2).
Arthroscopic Anterior Cruciate Ligament Reconstruction Using Four-Strand Hams...Apollo Hospitals
In this study, we analyzed the clinical outcomes at two years following reconstruction of the anterior cruciate ligament with use of a four-strand hamstring tendon autograft in patients who had presented with a symptomatic torn anterior cruciate ligament.
Medcrave Group - Open Locked Nailing Using an Expandable NailMedCrave
A retrospective study was performed using the hospital records. The mechanism of injury, the time between injury and surgery, blood transfusion requirements, blood loss, surgical times, time taken to weight bear (for the femoral/
tibial fractures), time for commencement of upper limb use (for humeral fractures), complication rates and the average follow up times were documented. Fifty-seven long bone fractures in 57 patients were included in this study. Complete results including preoperative X-Rays were available for 27 patients. In 30 cases, the actual X-Rays were not located but documentation by the treating surgeons was available.
Comparison of Clinical Efficacy of Surgical Approaches for Acetabular Fracturessemualkaira
To compare the different approaches and effects of pararectus approach, modified stoppa approach and ilioinguinal approach in the treatment of acetabular fractures.
Comparison of Clinical Efficacy of Surgical Approaches for Acetabular Fracturessemualkaira
: To compare the different approaches and effects
of pararectus approach, modified stoppa approach and ilioinguinal
approach in the treatment of acetabular fractures.
Comparison of Clinical Efficacy of Surgical Approaches for Acetabular Fracturessemualkaira
To compare the different approaches and effects
of pararectus approach, modified stoppa approach and ilioinguinal
approach in the treatment of acetabular fractures.
Comparison of Clinical Efficacy of Surgical Approaches for Acetabular Fracturessemualkaira
Through regression sorting, 44 patients with acetabular fractures who were hospitalized in our unit from September 2012 to September 2017 were summarized. Three surgical methods were used, and the operation time, intraoperative blood loss, postoperative complications, fracture reduction satisfaction and hip function were recorded in the three groups.
Tibitalokalkaneární déza - naše zkušenosti 2016-2019Martin Korbel
Tibitalokalkaneární déza je efektivní cesta k zajištění nebolestivé a stabilní zadní nohy u pacientů s postižením TT a TK kloubu. V některých případech v našem souboru je déza poslední možností před bércovou amputací. Hodnotíme soubor našich pacientů po TTK déze v letech 2016-2019.
Patellar clunk syndrome je poměrně častá komplikace po implantaci totální endoprotézy kolenního kloubu. Symptomy se obvykle projeví do 1 roku od operace. Typické je bolestivé přeskočení při vstávání ze sedu. Konzervativní terapie je obvykle bez efektu. Proces vzniku vazivového uzlu není zcela jasný, ale pravděpodobně vzniká na podkladě hypertrofické jizvy po parapatelárním přístupu.
Naše zkušenosti s korekcí hallux valgus Lapidusovou artrodézou v letech 2015-...Martin Korbel
Dle Lapiduse je příčinou valgozní deformity palce nohy insuficience vazivového aparátu I. TMT kloubu, která vede k metatarsus primus varus. Artrodéza I. TMT kloubu koriguje hallux valgus na apexu deformity a proto nabízí v porovnání s bazální nebo distální osteotomii metatarzu největší korekční potenciál. V prezentaci hodnotíme výsledky operační léčby hallux valgus Lapidusovou artrodézou na ortopedické klinice FNHK v letech 2015-2017.
Prezentace určená převážně medikům na téma pes equinovarus congenitus, pes calcaneovalgus, talus verticalis, metatarsus varus congenitus, pes planovalgus, hallux valgus, hallux rigidus, pes transversoplanus, deformity prstů nohy, aseptické kostní nekrózy nohy, bolesti paty, syndrom diabetické nohy.
Leukocytární esteráza je enzym, který se hojně vyskytuje v neutrofilech. Jejich rozpadem se uvolňuje do výpotku. Pomocí kolorimetrických testačních proužků lze diagnostikovat přítomnost leukocytární esterázy a tím i neutrofilů ve výpotku. Tím lze zjistit, zda je výpotek infekční či neinfekční etiologie. Cílem studie je stanovení senzitivity a specificity vyšetření leukocytární esterázy pomocí testačních proužků AUTION Sticks (Arkray) ve výpotcích různé etiologie získaných při zánětlivých postiženích pohybového aparátu.
Leukocytární esteráza je enzym obsažený v leukocytech. Rozpadem leukocytů se enzym uvolňuje do okolního postředí. Stanovením přítomnosti leukocytární esterázy v kloubním výpotku lze s vysokou senzitivitou i specificitou diagnostikovat infekční etiologii výpotku.
Brandes Kellerova operace je často diskutovaná jako překoná metoda. Dle našeho názoru má u vymezených indikací stále své uplatnění. V prezentaci se zaměřujeme na naše výsledky v období 1/2012-12/2015.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
Welcome to Secret Tantric, London’s finest VIP Massage agency. Since we first opened our doors, we have provided the ultimate erotic massage experience to innumerable clients, each one searching for the very best sensual massage in London. We come by this reputation honestly with a dynamic team of the city’s most beautiful masseuses.
Anatomy and Physiology Chapter-16_Digestive-System.pptx
Periprosthetic fractures
1. Results of Treatment of Periprosthetic Femoral Fractures after Total
Hip Arthroplasty.
Martin Korbel (1), Pavel Šponer (1,2), Tomáš Kučera (1,2), Egon Procházka (1), Tomáš
Proček (1)
1) University Hospital in Hradec Králové, Dep. of Orthopedic Surgery, 50005,
Hradec Králové, Czech Republic
2) Charles University in Prague, Faculty of Medicine in Hradec Králové, Dep. of
Orthopedic Surgery, 50005, Hradec Králové
Key words: total hip arthroplasty, periprosthetic femoral fracture, Vancouver
classification, complication
Author: Martin Korbel, University Hospital in Hradec Králové, Dep. of Orthopedic
Surgery, 50005, Hradec Králové, Czech Republic, tel. +420728762617, email:
korbemar@fnhk.cz
SUMMARY
Periprosthetic fractures are the third most common reason for revision total hip
arthroplasty. Surgical treatment of periprosthetic fractures belongs to the most difficult
procedures due to the extensive surgery, elderly polymorbid patients and the high
frequency of other complications. The aim of this study was to evaluate the results of
operatively treated periprosthetic femoral fractures after total hip arthroplasty.
We evaluated 47 periprosthetic fractures in 40 patients (18 men and 22 women)
operated on between January 2004 and December 2010. The mean follow-up period
was 27 months (within a range of 12-45 months). For the clinical evaluation, we used
modified Merle d'Aubigné scoring system.
In group of Vancouver A fractures, 3 patients were treated with a mean score of 15,7
points (good result). We recorded a mean score of 14,2 points (fair result) in 6 patients
with Vancouver B1 fractures, 12,4 points (fair result) in 24 patients with Vancouver B2
fractures and 12,8 points (fair result) in 7 patients with Vancouver B3 fractures. In group
of Vancouver C fractures, we found a mean score of 16,2 points (good result) in 7
patients.
Therapeutic algorithm based on the Vancouver classification system is, in our opinion,
satisfactory. Accurate differentiation of B1 and B2 type of fractures is essential.
Preoperative radiographic images may not be reliable and checking the stability of the
prosthesis fixation during surgery should be performed.
AUTHOR´S CONTACT ADDRESS
Author: Martin Korbel, University Hospital in Hradec Králové, Dep. of Orthopedic
Surgery, 50005, Hradec Králové, Czech Republic, tel. +420728762617, email:
korbemar@fnhk.cz
2. INTRODUCTION
Periprosthetic fractures are the third most common reason for revision total hip
arthroplasty (8,19). The incidence of postoperative periprosthetic femoral fractures is
around 1% for primary and 4% for reimplantation (1). The most common causes of
postoperative periprosthetic fractures are aseptic loosening of the arthroplasty and the
patient suffering a fall. Surgical treatment of periprosthetic fractures belongs to the most
difficult procedures due to the extensive surgery with increased blood loss and the high
frequency of other complications (22). The treatment is often performed on elderly
patients with mobility problems. Due to a reduction in both mobility and cognitive
abilities, such patients often do not keep to the recommended postoperative regime.
Particularly difficult to achieve is a sufficiently stable osteosynthesis. In addition, elderly
patients are more at risk for of falling and injuring themselves. Johansson in his article
on the treatment of periprosthetic femoral fractures demonstrated up to two thirds of
cases with unsatisfactory results (11). Bhattacharyya, in a retrospective study on 106
patients with a periprosthetic fracture of the femur, revealed an 11% patient mortality. In
the same study, the mortality rate in the control group after primary implantation of total
prosthesis was 2,9% (3).
The aim of this retrospective study was to assess the results of operatively treated
periprosthetic femoral fractures after total hip arthroplasty and evaluate the indications
for surgery in our patients to improve the therapeutic approach.
MATERIAL AND METHODS
In a retrospective study, we focused on postoperative periprosthetic femoral fractures
treated in our department from January 2004 to December 2010. The following were not
included in the study group: periprosthetic acetabular fractures, intraoperative and
conservatively treated femoral fractures. In total, we evaluated 47 periprosthetic
fractures in 40 patients (18 men and 22 women). The mean age of the patients was 72
years (age range 54 to 88 years). The average interval between total hip arthroplasty
and surgery for fracture was 7 years and 3 months. Periprosthetic fractures were
classified according to the Vancouver classification (Figure 1, Table 1) (6). Regarding
comorbidities, we focused primarily on diseases affecting patient mobility. 4 patients
were post-stroke, 3 patients were being treated for Parkinson's disease, 3 patients for
Bechterew's disease, 2 patients suffered from peripheral nerve paresis and one patient
was being treated for alcoholism.
3. Figure 1: Vancouver classification
Table 1: Vancouver classification
Surgical Procedure:
The anterolateral approach to the hip was used in cases of Vancouver A or B fractures
and the lateral approach to the femur was done in cases of Vancouver C fractures. The
stability of the stem was checked. In the case of a loosened stem, we performed
reimplantation of the femoral component. In the case of well fixed stem, we used plate
fixation. The wound was drained by two drains and the drains were extracted in the
second postoperative day. The perioperative antibiotics utilized were Cefazolin 2 g
intravenously 30 minutes prior to incision, followed by 1 g after every two hours of the
operation and 1 g 8 and 16 hours after the first dose. In prevention of thromboembolism,
we used low molecular weight heparin in doses according to the patient´s weight.
Postoperative verticalization occurred from the first up to the sixth postoperative day.
The patients were monitored clinically and radiographically at 6 weeks after surgery, at
3, 6 and 12 months after surgery and then at intervals of 1 year. The mean follow-up
period was 27 months (within a range of 12-45 months). For the clinical evaluation, we
used modified Merle d'Aubigné scoring system (Table 2) (16).
4. Table 2: Modified Merle d´Aubigne scoring system
RESULTS
In group of Vancouver A fractures, 3 patients were treated by cerclage fixation. We
achieved good result with a mean score of 15,7 points according to the Merle d'Aubigné
scoring system. In each case the fracture had healed within 3 months after the surgery.
No complications were reported.
In Vancouver B1 fractures, 4 patients were treated by Locking Compression Plates with
cerclage tape fixation and 2 patients with plates fixation only. According to Merle
d'Aubigné, we achieved a fair result with a score of 14,2 points. The complications were
found in two patients. In one case the femoral stem was loosened and therefore the
plate fixation was broken. This patient was subsequently treated with longer revision
stem reimplantation with cerclage fixation. In one case a superficial infection occurred
5. during the postoperative period and was successfully treated with local care and
antibiotics.
In Vancouver B2 fractures, we treated 18 patients with reimplantation of a revision stem
and 6 patients with plate osteosynthesis. According to the Merle d'Aubigné scoring
system we achieved a fair result of 12,4 points. In subgroup of 18 patients treated by
revision stem reimplantation, the prosthesis was dislocated in two cases. This was
successfully treated by closed reduction. Two patients suffered incomplete femoral
nerve palsy with complete restoration in 3 months. The femoral stem was loosened and
therefore broken in one case. The patient was successfully treated by reimplantation of
a longer revision stem with cerclage tape fixation. Substantial intraoperative blood loss
(2500 ml) occurred in one case. It required blood substitution to combat the developing
hemorrhagic shock. In subgroup of 6 patients treated with plate osteosynthesis, the
complications were found in 3 patients. The plate osteosynthesis was broken in all 3
patients. We performed long revision stem reimplantanion in 2 cases and in one case,
the fracture was fixed by plate osteosynthesis and the prosthesis was removed due to
the polymorbid condition of the patient and the limited mobility expectations.
In the group of Vancouver B3 fractures, we treated 3 patients by long revision stem
implantation with cerclage fixation, 3 patients by stem implantation with proximal femoral
replacement, and 1 patient by means of prosthesis extraction. According to the Merle
d'Aubigné system, we achieved a fair result of 12,8 points. The complications included 1
superficial infection succesfully treated with local care and antibiotics.
In the group of Vancouver C fractures we treated all seven patients with plate
osteosynthesis using bicortical screw fixation. We achieved a good result with a score of
16,2 points according to the Merle d'Aubigné system. The operations took place without
complications. One patient complained a persistent moderate postoperative pain.
The average Merle d´Aubigne clinical score is presented in table 3. The complications
found in particular Vancouver type fractures are summarized in table 4.
Table 3 : Evaluation of treatment results based on the Merle d’Aubigne classification
6. Table 4: Complications of particular fracture types.
Figure 2: A/B
A patient with a Vancouver type A fracture 11 years after primary implantation, treated
with cerclage of the greater trochanter.
7. Figure 3: A/B
A patient with a Vancouver type B1 fracture 4 years after primary implantation, treated
with plate osteosynthesis.
Figure 4: A/B
A patient with a Vancouver type B2 fracture 12 years after primary implantation, treated
by revision stem reimplantation and cerclage tape fixation.
8. Figure 5: A/B
A patient with a Vancouver type B3 fracture 12 years after primary implantation, treated
by revision stem reimplantation and cerclage fixation.
Figure 7: A/B/C
A polymorbid patient with a Vancouver B2 fracture; due to the limited mobility
expectations of the patient, plate osteosynthesis was chosen. Three months after the
operation, failure of the osteosynthesis occurred.
9. DISCUSSION
Overall health status of the patient, localization and type of the fracture and femoral
stem status, whether the stem is intact or loose, should be considered, when we choose
the type of the surgery. Historically various classification systems have been proposed,
but none of them did reflect all the factors essential for therapeutic decision (2).
Nowadays the Vancouver classification treatment algorithm for postoperative
periprosthetic fractures is generally considered satisfactory. This classification takes into
account the localization of the fracture in relation to the femoral component, the fixation
of the femoral component in the femur and the quality of the bone tissue (8).
Vancouver A fractures includes both the greater and lesser trochanter. These fractures
are further divided into stable and unstable types. Stable types can be treated
conservatively by reducing limb weight bearing and avoidance of active abduction (10).
Unstable types are treated by cerclage fixation.
Vancouver B fractures occur at the level of the femoral stem or just below its tip. In the
B1 subgroup, the femoral stem is stable and surrounding bone stock is adequate. In B2
type fractures, the femoral stem is loosened while there is still good quality of the
surrounding bone stock. In B3 fractures, the femoral stem is loosened with substantial
bone loss. Vancouver C fractures are fractures of the femur distal to the stem. The
important weakness of the Vancouver classification is the clinical difficulty in
distinguishing between B1 and B2 fractures (5,7,8,21). Lindhal reported a high
percentage of periprosthetic failure in type B fractures treated with plate osteosynthesis
in his publications (13,14,15). The reason given was an error in judgment by the
surgeon, who mistook an unstable type of prosthesis for a stable prosthesis.
Bhattacharyya (3) in a retrospective study surprisingly reported significantly lower
mortality in patients with type B fractures treated with reimplantation of the femoral
component with cerclage versus those treated by plate osteosynthesis. Plate
osteosynthesis is, however, a less extensive type of surgery with a shorter operating
time and less blood loss. Bhattacharyya claims that the possibility of faster verticalization
of patients when stable stem reimplantation methods are used accounts for the lower
mortality rate (3,12,18). Fousek (8,14) recommended performing an intraoperative
stability test of the stem whenever X-rays fail to determine the type of fracture, i.e. B1 or
B2. When there is doubt as to whether a fracture is B1 or B2, the longer revision stem
bypassing the fracture with cerclage fixation to enhance the rotational stability should be
performed. Unfortunately in earlier cases of our study group, the uncertain fractures
were not considered as B2 types and were not treated with reimplantation of the revision
stem and the cerclage fixation. In these 6 cases of B2 fractures, we used plate
osteosynthesis. In half of cases, failure of the osteosynthesis occurred. This confirms the
claim that plate osteosynthesis does not provide enough stability in cases where the
prosthesis is loosened.
In the case of implantation of the revision stem, we prefer to use modular cementless
revision stems that have vertical stability. Cemented stems are rarely used, except in
cases of severe osteoporosis. The fracture line should be anatomically reduced during
the cementing to avoid cement getting into fracture line. This in turn could lead to
nonunion (10).
B3 type fractures are difficult to solve. The most difficult task is to ensure sufficient
anchoring components to deficient bone and good stability to the hip joint prosthesis
10. (20). Soft tissues are often insufficient, and despite the restoration of the limb adequate
stability in these cases is lacking. We prefer the long modular cementless stems with
vertical stability. In elderly patients with minimal mobility expectations, the tumor
endoprosthesis with a proximal femur replacement should be performed.
Vancouver C fractures can sometimes be treated as a standard femoral fracture using
plate osteosynthesis bicortically fixed above and below the line of fracture. If the plate is
in the proximal part and extends up to the stem of the cemented prosthesis, it is
preferable to fix the plate with cerclage to prevent damage to the cement mantle and
release of the prosthesis (10, 20). From a biomechanical point of view, overloading of
the femur can occur due to the high sum total of force at work in the area between the
rigid components of the prosthesis and the plate osteosynthesis (10). In cases such as
these a stress fracture may occur at this given spot. This can be avoided by overlapping
the components (10) (Fig. 6 A/B).
CONCLUSION
Therapeutic algorithm based on the Vancouver classification system is, in our opinion,
satisfactory. Accurate differentiation of B1 and B2 type of fractures is essential.
Preoperative radiographic images may not be reliable, and we always recommend
checking the stability of the prosthesis fixation during surgery. When in doubt a fracture
should be treated like type B2, i.e. requiring reimplantation of the stem, thus facilitating
quicker postoperative verticalization of the patient. For reimplantation we prefer the
modular cementless stems with vertical stability. When using a cemented prosthesis in
elderly patients, it is necessary to achieve anatomical reduction of fragments during
cementing to prevent the leak of cement into the fracture line, which in turn could lead to
nonunion. In the case of B3 fractures, the aim should be to maintain the proximal femur
and its fixation to the prosthesis.
11. Acknowledgments: This article was supported by the programme PRVOUK P37/04
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AUTHOR´S CONTACT ADDRESS:
Martin Korbel, Ortopedická klinika, Fakultní nemocnice Hradec Králové, 50005, tel.
728762617, email: korbemar@fnhk.cz