Orthogonal Plating of Vancouver B1 and C-type Periprosthetic Femur Fracture Nonunions

Michael Blankstein Christopher E Birch Craig S Bartlett III
Orthopaedics and Rehabilitation, University of Vermont Medical Center, Burlington, USA

Purpose: Periprosthetic femoral shaft fractures are a significant complication after total hip arthroplasty. Plate osteosynthesis with or without onlay strut allograft has been the mainstay of treatment around well-fixed stems. Nonunions are a rare and challenging complication of this fixation method. In this series, we report the outcomes of a novel orthogonal plating surgical technique for addressing nonunions in the setting of Vancouver B1 and C-type periprosthetic fractures that previously failed open reduction internal fixation (ORIF).

Methods: A retrospective chart review of all patients with Vancouver B1/C total hip arthroplasty periprosthetic femoral nonunions was performed. All patients were treated primarily with ORIF. After removal of the previous hardware and necrotic bone, bone ends were actively compressed by application of a lateral plate with hybrid screw principles and an articulated tensioning device to create a lateral tension band plate construct. This was followed by application of a shorter anterior plate with locking screws. Supplemental allograft with BMP was required in every case to fill the entire bone defect.

Results: Six Vancouver B1/C periprosthetic femoral nonunions were treated. Five patients were female with an average age of 80.3 years (range 72-91). The fractures occurred at a mean of 5.8 years (range 1-10) from their initial arthroplasty procedure. No patients underwent further revision surgery; there were no wound dehiscence, hardware failures or infections. All patients had a minimum of eleven-month follow up. All fractures achieved osseous union and pain free, independent ambulation, at an average of 24.4 weeks.

Conclusions: To our knowledge, this is the first case series describing 90-90 locked compression plating using modern implants for periprosthetic femoral nonunions. This is a rare but challenging complication of total hip arthroplasty and we present an alternative solution to cortical strut allograft with good outcomes. Orthogonal locked compression plating utilizing an articulated tensioning device and autograft with adjuvant osteoinductive allograft should be considered in periprosthetic femur fractures around a well-fixed stem.