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Letters to the Editor to:

Scientific Articles:
M.A. Buttaro, G. Farfalli, M. Paredes Núñez, F. Comba, and F. Piccaluga
Locking Compression Plate Fixation of Vancouver Type-B1 Periprosthetic Femoral Fractures
J Bone Joint Surg Am 2007; 89: 1964-1969 [Abstract] [Full text] [PDF]
*Letters to the Editor: Submit a response to this article

Electronic letters published:

[Read Letter to the Editor] Dr. Buttaro and colleagues respond to Dr. Kolb
Martin A. Buttaro, Fernando Comba, Francisco Piccaluga   (31 October 2007)
[Read Letter to the Editor] Dr. Buttaro and colleagues respond to Dr. McGrory
Martin A. Buttaro, Fernando Comba, Francisco Piccaluga   (31 October 2007)
[Read Letter to the Editor] Biological, not Mechanical, Failure
Brian J. McGrory, M.D., Raymond White, M.D., George Babikian, M.D.   (31 October 2007)
[Read Letter to the Editor] Dr. Buttaro and colleagues respond to Dr. Tsiridis
Martin A. Buttaro, Fernando Comba, Francisco Piccaluga   (31 October 2007)
[Read Letter to the Editor] More technical tips for locking compression plate fixation of periprosthetic femoral fractures
Werner Kolb MD, Klaus Kolb   (23 October 2007)
[Read Letter to the Editor] Accuracy of Vancouver Classification of Periprosthetic Fractures
Eleftherios Tsiridis, Stylianos Velonis, Peter Bobak   (11 October 2007)

Dr. Buttaro and colleagues respond to Dr. Kolb 31 October 2007
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Martin A. Buttaro,
Hip Surgeon
Institute of Orthopedics “Carlos E. Ottolenghi,” Italian Hospital of Buenos Aires,
Fernando Comba, Francisco Piccaluga

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Re: Dr. Buttaro and colleagues respond to Dr. Kolb

martin.buttaro{at}hospitalitaliano.org.ar Martin A. Buttaro, et al.

We thank Dr. Kolb for offering additional technical points for locking compression plate fixation. We would like to add the following comments in response:

1. The 14 LCP plates in our series were placed at the tension band (lateral) side of the femur. As stated(1), we strictly followed the recommended techniques that have been described for the insertion of these devices (2,3).

2. We do not believe that all type B1 fractures are the same. There may be other important aspects that, although unpublished and not included in the Vancouver classification, could determine the prognosis of the lesion and should be strongly considered. Although the stem is stable, previous revision surgery may compromise bone quality and lead to biological failure. Other defining conditions could include cemented stems, which affect endosteal vascularization and bone healing potential, as well as the stability of the fracture type. These factors could explain different results among similar publications.

3. The case depicted in Figure 1 has 2 omitted holes on each side of the fracture. Case number 3 (Table II) had 4 omitted holes on each side of the fracture and presented a plate fracture at 8 months postoperative. We consider fracture of these plates could be related to the laboratory findings described by Fulkerson et al.(4), who described a catastrophic failure mode of locking compression plates consisting of proximal fragment fracture through the screw-holes during torsional loading.

4. Early failure of unicortical locked screws with cyclic loading as well as further displacement under axial loading compared with bicortical screws was also observed in another report by Fulkerson et al.(5). Due to the high incidence of plate pullout in our series, we are not convinced about using unicortical screws to avoid damage to the cement mantle.

References

1. Buttaro M, Farfalli G, Paredes Núñez M, Comba F, Piccaluga F. The use of locking compression plates for the treatment of Vancouver type B1 periprosthetic femoral fractures. J Bone Joint Surg Am 2007; 89:1964-9.

2. Koval KJ, Hoehl JJ, Kummer FJ, Simon JA. Distal femoral fixation: a biomechanical comparison of the standard condylar buttress plate, a locked buttress plate, and the 95-degree blade plate. J Orthop Trauma. 1997;11:521-4.

3. Gautier E, Sommer C. Guidelines for the clinical application of the LCP. Injury 2003;34 Suppl 2:B63-76.

4. Fulkerson E, Koval K, Preston CF, Iesaka K, Kummer FJ, Egol KA. Fixation of periprosthetic femoral shaft fractures associated with cemented femoral stems: a biomechanical comparison of locked plating and conventional cable plates. J Orthop Trauma. 2006;20:89-93.

5. Fulkerson E, Egol KA, Kubiak EN, Liporace F, Kummer FJ, Koval KJ. Fixation of diaphyseal fractures with a segmental defect: a biomechanical comparison of locked and conventional plating techniques. J Trauma. 2006;60:830-5.
Dr. Buttaro and colleagues respond to Dr. McGrory 31 October 2007
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Martin A. Buttaro,
Hip Surgeon
Institute of Orthopedics “Carlos E. Ottolenghi,” Italian Hospital of Buenos Aires,
Fernando Comba, Francisco Piccaluga

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Re: Dr. Buttaro and colleagues respond to Dr. McGrory

martin.buttaro{at}hospitalitaliano.org.ar Martin A. Buttaro, et al.

We would like to add the following comments to the interesting letter written by Dr. McGrory :

These articles (1,2) were not intentionally omitted. Our original version included 41 references, and 29 of these articles dealt with fixation of periprosthetic fractures. Unfortunately, the final version included 11 clinical articles regarding this topic. Old et. al (2) published their article while ours was being under revision.

Case number 5 was treated with cancellous bone allograft, as presented in Table 1.

We were surprised by the 8% early postoperative mortality rate and the 7.5% incidence of infection described by Ricci et al. (1). The causes of death and the length of operative time were not detailed. Indirect reduction and the prolonged use of fluoroscopy may be related to this morbidity. It would be of interest to expand the technique to perform the insertion and retention of the cables - as it is shown in the postoperative radiographs (Fig. 2) – with a minimally invasive surgical exposure – as it is depicted in Fig. 1.

Although these articles (1,2,3) presented lesions characterized as B1 fractures, other factors such as previous revision surgery, cemented stems and the stability of the fracture may lead to biological failure independently of the stem´s stability. All our patients presented with cemented stems, 11 of 14 were revision procedures and all presented with transverse or short oblique fractures. These facts could explain different results among similar concomitant publications.

Fatigue fractures of the plate could be related to biological more than mechanical failure. However, these failures were not due to lack of preservation of soft tissues to place allogeneic bone. All the failures except one were observed in patients in whom a cortical strut allograft had not been used, and these failures were sucessfully treated with the same type of plate and strut allografts.

Finally, we have not stated locking plates may be contraindicated in the treatment of periprosthetic fractures. As we mentioned, we just observed no advantages over other types of plates.

References

1. Ricci WM, Bolhofner BR, Loftus T, Cox C, Mitchell S, Borrelli, Jr J. Indirect Reduction and Plate Fixation Without Grafting for Periprosthetic Femoral Shaft Fractures About a Stable Intramedullary Implant. J Bone Joint Surg Am 2005; 87:2240-5.

2. Old AB, McGrory BJ, White RR, Babikian GM. Fixation of Vancouver B1 Periprosthetic Fractures by Broad Metal Plates Without the Application of Strut Allografts J Bone Joint Surg Br 2006; 88:1425-9.

3. Buttaro M, Farfalli G, Paredes Núñez M, Comba F, Piccaluga F. The use of locking compression plates for the treatment of Vancouver type B1 periprosthetic femoral fractures. J Bone Joint Surg Am 2007; 89:1964-9.
Biological, not Mechanical, Failure 31 October 2007
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Brian J. McGrory, M.D.,
Co-Director
Maine Joint Replacement Institute, Portland, Maine,
Raymond White, M.D., George Babikian, M.D.

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Re: Biological, not Mechanical, Failure

mjri{at}yahoo.com Brian J. McGrory, M.D., et al.

To The Editor:

We read, with interest, the article by Buttaro, et al. (1) in the September 2007 Journal of Bone and Joint Surgery. It was curious that the article did not reference or comment on two recent articles published in the Journal dealing with a similar topic (2,3).

It is striking that the conclusions of these studies (2,3) are in direct opposition to the findings presented in the current article. In looking carefully at the differences between the three papers, in Ricci, et al.(2), locking plates were not utilized nor was bone grafting. Of the patients available for follow-up, all fractures healed in satisfactory alignment. In the study by Old, et al.(3), 18 of 19 patients with adequate follow-up had satisfactory healing. There was one case of non-union but there was no pull-out nor was there fracture of any plate. Of interest, of the 20 patients in that study(3), 5 had locking compression plates, and all of these went on to union. Screws were utilized without trying to avoid the cement mantle in patients with a cemented prosthesis (each of the patients in which a locking plate was used had a cemented femoral component). No bone graft was utilized for these patients.

Buttaro and his co-authors reported use of morselized cancellous bone allograft in all 11 displaced fractures and use of strut allograft in 5 patients. In the 3 cases in which bone graft was not utilized (cases 1, 5, and 6), union was achieved in all three without reoperation. Of note, in case 6, there was plate pullout 6 months postoperatively.

We would appreciate if the authors would comment on their interpretation of these other reports, which demonstrate a high union rate without evidence of plate fracture or pullout of screws when bone graft was not utilized. Although Ricci, et al.(2) did not use locking plates, about one fourth of the patients treated by Old, et al.(3) had locking plate treatment.

It is our theory that the nonunions and failures of fixation in the current article likely represent biological failure to unite and subsequent mechanical failure. We think that if the soft tissues of the fracture site are preserved, specifically by not placing allogeneic bone graft at the fracture site, the chance of healing will be higher and that this is likely a major factor in early mobilization and fracture healing. We can not comment with certainty if locking plates may be contraindicated in the treatment of periprosthetic fractures, and appreciate Dr. Buttaro and his coauthors pointing out that this may be an issue.

The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

References:

1. M.A. Buttaro, G. Farfalli, M. Paredes Núñez, F. Comba, and F. Piccaluga Locking Compression Plate Fixation of Vancouver Type-B1 Periprosthetic Femoral Fractures J Bone Joint Surg Am 2007; 89:1964-1969

2. W.M. Ricci, B.R. Bolhofner, T. Loftus, C Cox, S. Mitchell, and J. Borrelli, Jr. Indirect Reduction and Plate Fixation Without Grafting for Periprosthetic Femoral Shaft Fractures About a Stable Intramedullary Implant J Bone Joint Surg Am 2005; 87:2240-2245

3. A.B. Old, B.J. McGrory, R.R White, G.M. Babikian Fixation of Vancouver B1 Periprosthetic Fractures by Broad Metal Plates Without the Application of Strut Allografts J Bone Joint Surg Br 2006; 88:1425-1429
Dr. Buttaro and colleagues respond to Dr. Tsiridis 31 October 2007
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Martin A. Buttaro,
hip surgeon
Institute of Orthopedics “Carlos E. Ottolenghi,” Italian Hospital of Buenos Aires,
Fernando Comba, Francisco Piccaluga

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Re: Dr. Buttaro and colleagues respond to Dr. Tsiridis

martin.buttaro{at}hospitalitaliano.org.ar Martin A. Buttaro, et al.

We thank Dr. Tsiridis for his interest in our recent article and we would like to make the following comments in response:

Concerning the case depicted in our article (1) (Fig. 1), the patient was previously operated by us using an impaction grafting revision technique and presented with this fracture 6 months after the reconstruction. We accept the observations of. Dr. Tsiridis in which radiolucent lines are present (Fig. 1A and B). Although it has been demonstrated in autopsy retrievals by other authors that after a few months, partial allograft bone incorporation is observed (2), radiolucent lines are initial frequent radiographic findings related to this biological revision method.

This femoral stem was stable, a fact that was intraoperatively confirmed at the time the femoral fracture was stabilized at first and second reoperations. There are no radiolucent lines 2 years after the reconstruction in Fig. 1C. If it had been a Vancouver type B2 or B3, this femoral reconstruction would have failed already. The most recent follow-up radiographs available are 4 years after the first revision surgery.

The probable causes for periprosthetic fracture could be the incidental perforation that occurred during cement removal, which has been reported as a predisposing factor for this complication in revision surgery with the bone impaction grafting technique (3).

We do not believe that all transverse or short oblique fractures must be treated with long revision stems to achieve stability. We still consider revision to a long stem even for well fixed components. This concept is based on the majority of cases that were sucessfully treated by us1 and other authors using plate and screws and strut allografts (4-7).

If the cement within cement technique and a long revision stem is indicated, polymethylmethacrylate leakage through the femoral fracture could be a potential problem that can lead to nonunion and fatigue fracture of the revision long stem or plate in the future. We would prefer to leave this indication as a salvage procedure in the eventual case previous stabilization fails.

References

1. Buttaro M, Farfalli G, Paredes Núñez M, Comba F, Piccaluga F. The use of locking compression plates for the treatment of Vancouver type B1 periprosthetic femoral fractures. J Bone Joint Surg Am 2007; 89:1964-9.

2. Linder L. Cancellous impaction grafting in the human femur: histological and radiographic observations in 6 autopsy femurs and 8 biopsies. Acta Orthop Scand. 2000;71(6):543-52.

3. Farfalli G, Buttaro M, Piccaluga F. Femoral fractures in revision hip surgeries with impacted bone allografts. Clin Orthop 2007;462:130-6.

4. Chandler HP, King D, Limbird R, Hedley A, McCarthy J, Penenberg B, Danylchuk K. The use of cortical allograft struts for fixation of fractures associated with well-fixed total joint prostheses. Semin Arthroplasty. 1993; 4(2):99-107.

5. Haddad FS, Duncan CP, Berry DJ, Lewallen DG, Gross AE, Chandler HP. Periprosthetic femoral fractures around well-fixed implants: use of cortical onlay allografts with or without a plate. J Bone Joint Surg Am. 2002; 84(6): 945-950.

6. Emerson RH Jr, Malinin TI, Cuellar AD, Head WC, Peters PC. Cortical strut allografts in the reconstruction of the femur in revision total hip arthroplasty. A basic science and clinical study. Clin Orthop Relat Res. 1992; (285):35-44.

7. Malinin T, Latta LL, Wagner JL, Brown MD. Healing of fractures with freeze-dried cortical bone plates. Comparison with compression plating. Clin Orthop Relat Res. 1984; (190):281-286.
More technical tips for locking compression plate fixation of periprosthetic femoral fractures 23 October 2007
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Werner Kolb MD,
Oberarzt
Department of Trauma Surgery Friedrich-Schiller-Universität Jena, Germany,
Klaus Kolb

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Re: More technical tips for locking compression plate fixation of periprosthetic femoral fractures

drwerner.kolb{at}t-online.de Werner Kolb MD, et al.

To The Editor:

We read with great interest the article, “Locking Compression Plate Fixation of Vancouver Type-B1 Periprosthetic Femoral Fractures”(1). We have used the LCP for five years and would like to offer some technical tips:

1. The plate should be placed at the tension-band (lateral) side of the femur (2).

2. The MIPO technique was developed to optimise the potential of a specific implant to fulfill the mechanical demands of fracture immobilization while preserving the biological competence of the involved tissue(3). In 50 consecutive patients treated with MIPO technique all periprosthetic femur fractures healed without the use of allograft struts(4).

3. More than one hole should be omitted on each side of the fracture in cases with loss of endosteal healing potential to initiate spontaneous fracture healing, including the generation of callus formation(5).

4. The pull-out resistance of the hole construct can be improved when the plate is slightly bent forth and back resulting in divergent and convergent locked screw directions(3).

The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

References:

1. Buttaro MA, Farfalli G, Nunes MP, Comba F, Piccaluga F. Locking compression plate fixation of vancouver type-B1 periprosthetic femoral fractures. J Bone Joint Surg Am. 2007;89:1964-1969.

2. Josten C, Muhr G. Tension band principle. In Rüedi TP, Murphy WM, editors. AO principles of fracture management. New York: Thieme; 2000.pp.187-94.

3. Gautier E, Sommer C. Guidlines for the application of the LCP. Injury 2003; 34 Suppl 2: B63-76.

4. Ricci WM, Bolhofner BR, Lotus T, Cox C, Mitchell S, Borelli J jr. Indirect reduction and plate fixation, without bone grafting, for periprosthetic femoral shaft fractures about a stable intramedullary implant. J Bone Joint Surg Am. 2005;2240-5.

5. Stoffel K, Dieter U, Stachowiak G, Gächter A, Kuster MS: Biomechanical testing of the LCP – how can stability in locked internal fixators be controlled? Injury 2003; 34 Suppl 2: B11-19.
Accuracy of Vancouver Classification of Periprosthetic Fractures 11 October 2007
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Eleftherios Tsiridis,
Consultant Orthopaedic and Trauma Surgeon
Academic Orthopaedic Unit, Leeds General Infirmary, School of Medicine, Leeds, UK,
Stylianos Velonis, Peter Bobak

Send letter to journal:
Re: Accuracy of Vancouver Classification of Periprosthetic Fractures

etsiridis{at}doctors.org.uk Eleftherios Tsiridis, et al.

To The Editor:

We read with great interest the paper by Buttaro et al.(1) on locking compression plate fixation for Vancouver Type B1 periprosthetic femoral fractures. As an example of the concerns raised by Lindall et al.(2) about the accuracy of classifying Vancouver B1 fractures, in our view, the fracture presented in this paper(1) should be classifed as Vancouver B2 if not B3 considering the degree of osteoporosis. The stem is failing in varus in figure 1-C and there is a circumferential radiolucent line in all seven Gruen zones at the cement-bone interface.

We fully agree with the authors that single plating is not sufficient to treat these fractures, especially transverse or short oblique fractures, as they are inherently unstable. Our published data confirm the latter observation(3,4).

In their Discussion, the authors state that they now consider revision to a long stem even for well fixed components. Our current experience indicates that transverse or short oblique fractures must be treated with long revision stems to achieve stability and if the cement mantle is intact, then a cement in cement long stem revision is also recommended(5).

The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

REFERENCES:

1. Buttaro MA, Farfalli G, Nunez MP, Comba F, Piccaluga F. Locking compression plate fixation of vancouver type-b1 periprosthetic femoral fractures. J Bone Joint Surg Am 2007;89:1964-9.

2. Lindahl H, Malchau H, Herberts P, Garellick G. Periprosthetic femoral fractures classification and demographics of 1049 periprosthetic femoral fractures from the Swedish National Hip Arthroplasty Register. J Arthroplasty 2005;20:857-65.

3. Tsiridis E, Narvani AA, Timperley JA, Gie GA. Dynamic compression plates for Vancouver type B periprosthetic femoral fractures: a 3-year follow-up of 18 cases. Acta Orthop 2005;76:531-7.

4. Tsiridis E, Haddad FS, Gie GA. Dall-Miles plates for periprosthetic femoral fractures. A critical review of 16 cases. Injury 2003;34:107-10.

5. Briant-Evans T, Tsiridis E, Hubble M. Cement-in-cement stem revision for Vancouver type B periprosthetic femoreal fractures after total hip arthroplasty. European Federation of Orthopaedics and Traumatology (EFORT) 2007.Florence, Italy