Unstable simple fractures around or distal to stable femoral stems are amendable to traditional compression plating techniques.
The goal is to create a stable environment for the arthroplasty and for the femoral diaphysis.
These fractures include:
Direct lateral approach
Direct lateral approach to the femoral diaphysis is typically utilized. This can be performed in a minimally invasive fashion for some fracture patterns and proximal and/or distal extension of deep surgical approach can be utilized in a fracture specific manner.
Positioning for direct lateral approach
This approach can be performed in the supine or lateral position. If there is any suspicion of prosthetic loosening that may be discovered intraoperatively, the surgeon should position the patient for a potential revision arthroplasty.
Other approaches that can be used to perform this procedure are:
These approaches can be performed with the patient in a lateral or supine position.
Option: use of a radiolucent or fracture specific table
A radiolucent table or a fracture specific table may be used.
The choice depends on surgeon experience and preference. The control of the fracture may often be more difficult on a traction table.
Reduction is typically carried out using a combination of direct and indirect methods. Limb manipulation will help in an indirect manner. Direct reduction with clearance of fracture hematoma and stabilization with pointed bone reduction clamps can then be completed.
The Collinear reduction clamp can be extremely helpful in facilitating reduction. It is applied from the direct lateral incision with proximal extension.
For short oblique or spiral fractures, provisional wire stabilization can be extremely helpful. Care must be taken to avoid applying wires in the pathway of planned definitive stabilization.
Option: traction aids
The reduction can be facilitated with manual traction and/or distal femoral skeleton traction.
Skeletal traction may be placed in the distal femur or the proximal tibia, depending on surgeon's preference. However, the distal femur is much more effective in facilitating direct reduction of periprosthetic femur fractures.
Note: Traction in osteoporotic patients should be used with caution, because it may injure the patient. In case of severe osteoporosis, this may result in the traction pin pulling through the bone into the knee joint.
Fixation can be achieved with either lag screw and neutralization or traditional compression plate technique.
Femoral plate length should be three times the length of the fracture zone and care should be taken to prophylactically prevent future fracture either in between implants or at the end of the zone of fixation.
The femur has a sagittal bow and proximal or distal fixation may be desired. If available, a precontoured or anatomic plate should be selected.
Compression plate application
The plate is applied on the lateral cortex of the femur.
A screw is applied to create an axilla.
A compression screw is applied at the other side in compression mode to achieve fracture compression.
If the fracture is at the tip of the stem of a well-fixed prosthesis, fracture compression may be achieved with a different technique.
The bone is removed from the tip of the stem with a rongeur or a high-speed burr.
Note: This technique will result in a shortening of the extremity but will avoid the morbidity of femoral stem revision.
The stem is inserted into the distal femoral portion and compression applied utilizing standard techniques over the top of the tip of the prosthesis.
5. Aftercare following ORIF
Postoperative management should include careful monitoring of hematocrit and electrolytes particularly in the elderly patients.
Postoperative IV antibiotics should be administered up to 24 hours.
Consideration should be given to anticoagulation for a minimal course of 35 days. If there are thromboembolic complication this treatment is extended.
Drains can be discontinued when output is less than 30 to 50 cc per 12 hours.
Immediate mobilization of the patient should commence. If fracture stability will allow, the patient should be made weight bearing as tolerated as soon as possible. Long periods of limited weight bearing are extremely detrimental to patient recovery.
Avoidance of edema postoperatively is critical for both wound healing and patient mobilization. This can be aided by pneumatic compression devices. If negative pressure wound therapy is utilized, it can be discontinued after 5 to 7 days. Staples or sutures are typically removed at 14 to 21 days.