OUR EXPERIENCES WITH THE TREATMENT OF PERIPROSTHETIC FRACTURES OF FEMUR

In the statement authors want to draw attention to the possibilities of treatment of periprosthetic fractures of femur. They present their own experiences with the treatment of these fractures by using various types of internal and external fixation evaluated from 1996 to 2003. They present some less common types of internal fixation as e.g. fixation by clamp plates.

In the statement authors want to draw attention to the possibilities of treatment of periprosthetic fractures of femur.They present their own experiences with the treatment of these fractures by using various types of internal and external fi xation evaluated from 1996 to 2003.They present some less common types of internal fi xation as e.g.fi xation by clamp plates.

PREFACE
Change in lifestyle, increased age and development of endoprosthetics are connected with increased occurrence of periprosthetic fractures in recent years.First mentions of these fractures were published in seventies (Mc Elfresh) later then in eighties and nineties of last century (Culp) 1 .There were descriptions of several possibilities of treatment of these fractures including their complications.
Incidence of periprosthetic fractures after the application of the total arthroplasty varies.The incidence between 0.6-2.5 % was described in cases of supracondylar fractures above the femoral component of knee arthroplasty 2 .
The creation of these fractures is preceded by accident (as in case of other fractures) or there is a slow process of bone corruption for various reasons.The fracture then is caused by minimal trauma.In many cases patient does not even mention the accident.The fracture turns up during a common activity.
The treatment of periprosthetic fractures depends on the type of fracture (comminutives etc), location -distance from arthroplasty and other factors (osteoporosis, general condition of patient).Generally we can divide methods of treatment to conservative and surgical -70 % success in both methods if correctly implemented 3 .
The plaster of Paris, skeletal traction or a combination of both can be used as a conservative method.Individual or fabricated orthesis can be used during after-treatment.
Concerning surgical method, the descriptions of practically all types of internal and external fi xation or their combinations appear in specialized literature 4 .

PATIENTS AND METHODS
From 1996 to 2003, we treated 21 periprosthetic fractures of the femur at our Centre of Trau-matology University Hospital Ostrava (Table 1).Some were after total hip arthroplasty, some after total knee arthroplasty (Table 2).In two cases, we used conservative method, in 19 cases we chose surgical method (Table 3).

Femur fractures under arthroplasty of hip 4x
Femur fractures above arthroplasty of knee 17x Table 3. Method of treatment.

Internal fi xation (nail) 13x
In two cases we treated periprosthetic fractures above total knee arthroplasty using conservative technique.Two comminutive fractures were very close to femoral compo- In three cases we treated fractures by external fi xation, in one case external fi xation of round type (Fig. 2), in two cases using external frame fi xation (Fig. 3).We noticed no infectious complications during the treatment.We removed external fi xation in 95 days at average (Fig. 4).
In thirteen cases of supracondylar fractures above the total knee arthroplasty we used intramedullary nailing.Time of hospitalization was 21 days at average, time of restoration to full weight bearing and mobility condition of limb before accident was 148 days at average (Fig. 5).
In one case we used plate osteosynthesis for treating the periprosthetic fracture after the application of hemiarthroplasty of the hipp (Fig. 6).
In two cases of periprosthetic fractures under the femoral component of total hip arthroplasty we used internal fi xation by clamp plates.This is a plate which consists of the fi rst half part with holes for screws and second half part with caverns for bedding of the so called clamps.The plate and clamps are constructed in such a way as to allow using them for bone diaphysis as well as in the supracondylar area for asymmetrical construction of some clamps.Clamps allow fi xation of the plate to the part of the bone in which the component of arthroplasty is intramedullary placed (Fig. 7-10).
During the following observation of the patients we did not notice any post-surgical complications.Average hospitalization time was 28 days.After the checkup after 3 months we have allowed gradual weight bearing.Hip mobility was restored to the original condition before the fracture (Fig. 11-13).Their diversity from other types of fractures consists in the fact that they are fractures of bone with the implants of total arthroplasty and therefore the method of treatment must often be diff erent from therapeutical as in case of other types of fractures.Among the general risk factors we can include osteoporosis, rheumatoid arthritis, treatment with corticosteroids and naturally other diseases which may aff ect healing processes of patients.Emergence of these fractures can be additionally caused by technical problems e.g.anterior notching of the femoral cortex of total knee arthroplasty 2 , damage of proximal femur at application of the total hip arthroplasty and other 3,5 .Among other possible complications there can be postoperative treatment and patient's personality -early weight bearing.The complications may occur at conservative treatment as well as after the surgical treatment and they are aff ected

CONCLUSION
In our announcement we wanted to draw attention to possibilities of treatment of peri-prosthetic fractures of femur after the application total knee arthroplasty as well as after the total hip arthroplasty.We present our patients and our own experiences with the treatment of these complicated fractures.We have pointed out some less common type of internal fi xation (clamp plate).