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CASE REPORT Table of Contents   
Year : 2003  |  Volume : 37  |  Issue : 2  |  Page : 10
Treatment of periprosthetic hip fractures with Mennen plate-Report of five cases


Division of Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi, India

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How to cite this article:
Marya S, Thukral R. Treatment of periprosthetic hip fractures with Mennen plate-Report of five cases. Indian J Orthop 2003;37:10

How to cite this URL:
Marya S, Thukral R. Treatment of periprosthetic hip fractures with Mennen plate-Report of five cases. Indian J Orthop [serial online] 2003 [cited 2019 Dec 12];37:10. Available from: http://www.ijoonline.com/text.asp?2003/37/2/10/48508

   Introduction Top


Peri-prosthetic fractures after hip joint endoprostheses are now steadily on the increase due to the increase in the number and frequency of primary and revision hip arthroplasties. This complication presents a major treatment challenge to the orthopedic surgeon. Several factors are known to be associated, and predictive of the risk to fractures.

Although literature describes a variety of surgical techniques [2] , there is no consensus on the appropriate treatment for any given type of periprosthetic fracture. Conservative treatment is no longer advocated [3],[4],[5] , except where the patient is medically unfit. The rule of thumb is a tailored approach to each fracture depending on its characteristics, except of course, where some patient-controlled factors dictate otherwise. The options available to the present day operating orthopedic surgeon range from long-stemmed prosthesis, modular and allograft-substituted revisions, to the use of various metallic (plates) and non-metallic (Purham bands, Partridge & Dall-Miles systems) fixation devices [2] , with or without supplementation by bone graft.

Present concepts dictate the treatment of these fractures according to their individual characteristics (classification) [6] , implant-in-situ being affected (revised), associated medical disorders, and the patient's post-operative expectation of activity level. It is essential that a clearly defined plan of action exists before embarking on a surgical course, so as to minimize patient morbidity, and valuable hospital resources, apart from economic constraints. The adage "Forewarned is forearmed" aptly applies here. Various risk factors identified include the female gender, rheumatoid arthritis, cortical perforation intra-operatively, osteopenia, osteoporosis, pre-operative femoral deformities, revision surgery, osteolysis, stem loosening, and various patient factors.

The entire myriad of fixation systems propounded have received praise for their ingenuity when they were introduced, and criticism for their pitfalls, from time to time. To this effect, this study concerns the use of a paraskeletal clamp-on-plate - the MENNEN PLATE - in the fixation of periprosthetic fractures, the advantages of its use, and our experience in five patients.


   Case Reports Top


Five patients with periprosthetic femoral fractures operated by the senior author (SKSM) using Mennem plate were followed over a period of 5 years. Three patients had primary cemented total hip replacements in situ, and two were post-Austin Moore replacement hemi-arthroplasty [Table 1].

Mennen plate was used to treat periprosthetic fractures. [4],[8],[9] The Mennen plate is a paraskeletal clamp-on-plate that maintains the operatively reduced position of a fractured long bone during the healing phase, while minimally affecting the healing process itself. The plate consists of a central ridge with paired finger-like projections on each side constructed in such a manner that on head-on projection, the ridge and the two projections form more than a semi-circle. The points of the projections are wedge-shaped, and bent at right angles towards the center. These are squeezed into the bone with the help of a crimping tool during fixation. [10]

Fractures were classified according to a modification of the system of Betheal [1] , as it took into account the factors of bone stock, and implant stability, and at the same time was completely unambiguous.

Type A : transverse fracture at the stem tip; unstable, though prosthesis may not be loose.

Type B : oblique / spiral fracture around the shaft of the prosthesis; stability maintained by the presence of the prosthesis.

Type C : comminuted fractures around the stem of the prosthesis; prosthesis is always loose, and the fracture inherently unstable.

Type D : fracture entirely distal to the prosthesis; includes spiral fractures of the femoral shaft which extend proximally as far as the tip of the stem.

The acetabular cup was revised in only Case I. In Cases II and IV, the cup was secure, and hence not revised. The stem was loose in all cases, and was duly revised. The femoral fracture was spiral in all cases save one, and hence cerclage wiring was done to restore anatomy. Mennen plate was then clamped on the femur. The long stemmed prosthesis was then cemented in and the hip reduced. Patients were provided abduction hip braces for 12 - 16 weeks post-operatively, and kept on toe - touching gait for this period.

In Case V, after 8 weeks, check X-ray film showed the distal end of the Mennen plate slightly off the distal bone. However, it did not prevent either bone union or patient progress. Case III dislocated at 8 days post-surgery while using bedpan. It was reduced by closed means and put in the brace. No further problems were encountered. Our study showed an overall good result with respect to clinical and radiological outcome using this technique for revision of the femoral stem in periprosthetic fractures.


   Discussion Top


The incidence of periprosthetic femoral fractures has shown an exponential increase following a similar increase in the number of primary and revision procedures in all age groups, especially in the young. It is now increasingly becoming a leading indication of revision hip arthroplasty, along with implant loosening, dislocation and infection, with an overall prevalence as reported in several studies of 0.1 - 1.1 %, with 10 postoperative fractures found in 5400 patients in one of the largest series studied. Lowenheilm et al, reporting on a series of 1442 primary hip arthroplasties performed with the use of cement, calculated the cumulative post-operative risk of fracture to be around 25.3 per 1000 at 15 years. [12] Recent studies [3],[4],[5] have firmly established that there is no role for conservative treatment of these fractures, excepting in medical conditions precluding surgery. [13]

The offered modalities have been shown to have less generalized use as fixation systems, catering only to specific situations, viz. the use of the Wagner Revision prosthesis for bridging large femoral defects, the Dall-Miles cable and plate system [14],[15] , the Ogden concept [16] , the Partridge plate osteosynthesis [17] , long-stemmed cementless components [18],[19] , structural allografts [20] and onlay cortical allograft struts [13] , which however carried the disadvantages of being expensive, not routinely available, showing delay in incorporation, greater bulk, potentially disease transmitting.

Studies comparing the use of different fixation devices have proved that plate osteosynthesis scored over tumor prosthesis in clinical outcome and mobility; and that fixation with at least unicortical screws (over bands, tapes and cables) in the proximal femur and bicortical screws in the distal femur were the most stable plate constructs. [2]

The individual therapy concept first evolved in 1995, including the specific fracture type, general condition and age as factors deciding the correct modality of treatment and is a good model to follow even today. Plate osteosynthesis is proving to be an established procedure in patients above 70 years of age with total hip replacements, even when loosened, offering the advantages of comparably low aggressive standard operation techniques and acceptable success rates, thus allowing for short pre-operative waiting period, and faster recovery. In younger patients, simultaneous exchange of the hip prosthesis should always be considered. It has been firmly established that there is no role for conservative treatment of these fractures. [4],[8] The use of the Mennen plate is recommended as the treatment of choice in fracture fixations around the tip of the prosthesis, as well as a good option for fractures distal to the tip. [4]

Various studies have been performed using the Mennen paraskeletal clamp-on-plate [4],[8],[9] and have reported wonderful long-term post-operative clinical and radiographic results, strongly recommending its use for all periprosthetic fractures. The technique is simple, the operating time sufficiently reduced, the healing time noticeably shortened. Fracture union is solid without evidence of disuse osteopenia, stress protection or damage to the bony architecture due to drill holes. A second surgery for removal is not necessary, and the complication incidence is remarkably low. By preserving the periosteal supply, the time required for bone graft incorporation, where used, is also shortened, thereby resulting in an early final outcome.

The Mennen plate has increasingly been gaining acceptance as an ideal fixation device in the treatment of complex fractures around the prosthesis, with and without cortical allograft struts [8] , cancellous bone graft, cerclage wires and revision of the stem where indicated. Studies approaching 80 - 90% good results have been reported repeatedly [4],[9] .

Cases of breakage of the Mennen plate [21] , and others of failure of union [22],[23] , have been reported. Other articles have described the Mennen plate as unsuitable for elderly periprosthetic fractures [24] , but these were attributable to non-observance of the post-operative protocol and inadequate physiotherapy.

Prevention of fractures of the femur following total hip replacement is preferable to even the most successful treatment described with the best clinical outcomes [7] . Periprosthetic femoral fractures can present a major reconstructive challenge to the operating surgeon, and a wide variety of treatment options have been described. Classification of the fracture on the basis of not only its site but also the stability of the implant, and the quality of the surrounding bone should govern the treatment instituted. Tailored treatment interventions based on the status of the periprosthetic interfaces and the fracture type increase the chances of a favorable treatment outcome.

The use of the Mennen plate has shown tremendous promise in the past (as also evident in our study) especially in management of the B type of periprosthetic fracture. Use of this plate (with cerclage wiring) in the fixation of a complicated periprosthetic femoral fracture offers a minimally traumatic surgery, simple technique, retaining the periosteal blood supply and permitting supervised mobilization10,while also being financially acceptable.

In our study of five post-operative femoral fractures treated with revision to a long-stemmed prosthesis, cerclage wiring and supplementary cancellous bone grafting in addition to the Mennen plate, we achieved excellent results, both clinically and radiologically, in terms of mobility, pain, and the carrying out of the activities of daily living. A strict supervised post-operative physiotherapy and weight-bearing regime should be followed, thus avoiding any undue stress on the fracture or implant during the period of recovery; ensuring an improvement in the quality of life, and a return to a pre-fracture level of activity.[Figure 1]

 
   References Top

1.Brady OH, Garbuz DS, Masri BA, Duncan CP. Classification of the hip. Orthop Clin North Am 1999;30(2):215-20  Back to cited text no. 1    
2.Dennis MG, Simon JA, Kummer FJ, Koval KJ, DiCesare PE. Fixation of periprosthetic femoral shaft fractures occurring at the tip of the stem: a biomechanical study of 5 techniques. J Arthroplasty 2000;15(4):523-8  Back to cited text no. 2    
3.Barfod G, Steen Jensen J, Hansen D, Larsen E, Menck H, Olsen B, Rosenklint A. Hemi-arthroplasty of the hip followed by ipsilateral fracture of the femoral shaft. Injury 1986;17(2):104-6  Back to cited text no. 3    
4.Kligman M, Otramsky I, Roffman M. Conservative versus surgical treatment for femoral fracture after total or hemiarthroplasty of hip. Arch Orthop Trauma Surg 1999;119(1-2):79-81  Back to cited text no. 4    
5.Somers JF, Suy R, Stuyck J, Mulier M, Fabry G. Conservative treatment of femoral shaft fractures in patients with total hip arthroplasty. J Arthroplasty 1998;13(2):162-71  Back to cited text no. 5    
6.Beals RK, Tower SS. Periprosthetic fractures of the femur. An analysis of 93 fractures. Clin Orthop 1996;327:238-46  Back to cited text no. 6    
7.Haddad FS, Masri BA, Garbuz DS, Duncan CP. The prevention of periprosthetic fractures in total hip and knee arthroplasty. Orthop Clin North Am 1999;30(2):191-207  Back to cited text no. 7    
8.Kligman M, Othrimski I, Roffman M. Revision arthroplasty of femoral cortex defect using a noncemented stem, Mennen plate, and bone graft. Orthopedics 1998;21(3):325-7  Back to cited text no. 8    
9.Radcliffe SN, Smith DN. The Mennen plate in periprosthetic hip fractures. Injury 1996;27(1):27-30  Back to cited text no. 9    
10.Mennen U. The paraskeletal clamp-on plate. Part I. A new alternative for retaining the surgically reduced position of bone fractures. S Afr Med J 1984;66(5):167-70  Back to cited text no. 10    
11.Bethea JS, DeAndrade JR, Fleming LL, Lindenbaum SD, Welch RB. Proximal femoral fractures following total hip arthroplasty. Clin Orthop 1982;(170):95-106  Back to cited text no. 11    
12.Lewallen DJ, Berry DJ. Instructional Course Lect, American Acad of Orthopedic Surgeons - Periprosthetic fractures of the femur after total hip arthroplasty. J Bone Joint Surg [Am] 1997;79(9):1881-90  Back to cited text no. 12    
13.Brady OH, Garbuz DS, Masri BA, Duncan CP. The treatment of periprosthetic fractures of the femur using cortical onlay allograft struts. Orthop Clin North Am 1999;30(2):249-57  Back to cited text no. 13    
14.Kamineni S, Vindlacheruvu R, Ware HE. Periprosthetic femoral shaft fractures treated with plate and cable fixation. Injury 1999;30(4):261-8  Back to cited text no. 14    
15.Venu KM, Koka R, Garikipati R, Shenava Y, Madhu TS. Dall-Miles cable and plate fixation for the treatment of periprosthetic femoral fractures-analysis of results in 13 cases. Injury 2001;32(5):395-400  Back to cited text no. 15    
16.Zenni EJ Jr, Pomeroy DL, Caudle RJ. Ogden plate and other fixations for fractures complicating femoral endoprostheses. Clin Orthop 1988;(231):83-90  Back to cited text no. 16    
17.de Ridder VA, de Lange S, Koomen AR, Heatley FW. Partridge osteosynthesis: a prospective clinical study on the use of nylon cerclage bands and plates in the treatment of periprosthetic femoral shaft fractures. J Orthop Trauma 2001;15(1):61-5  Back to cited text no. 17    
18.Eingartner C, Volkmann R, Putz M, Weller S. Uncemented revision stem for biological osteosynthesis in periprosthetic femoral fractures. Int Orthop 1997;21(1):25-9  Back to cited text no. 18    
19.Macdonald SJ, Paprosky WG, Jablonsky WS, Magnus RG. Periprosthetic femoral fractures treated with a long-stem cementless component. J Arthroplasty 2001;16(3):379-83  Back to cited text no. 19    
20.Wong P, Gross AE. The use of structural allografts for treating periprosthetic fractures about the hip and knee. Orthop Clin North Am 1999;30(2):259-64  Back to cited text no. 20    
21.Hagroo GA, Qurashi V, Butt MS. Breakage of Mennen femur device. Injury 1996;27(8):593-5  Back to cited text no. 21    
22.Liu AM, Flores M, Nadarajan P. Failure of Mennen femoral plate. Injury 1995; 26(3):202-3  Back to cited text no. 22    
23.Petersen VS. Problems with the Mennen plate when used for femoral fractures associated with implants. A report of 5 patients. Int Orthop 1998;22(3):169-70  Back to cited text no. 23    
24.Kamineni S, Ware HE. The Mennen plate: unsuitable for elderly femoral peri-prosthetic fractures. Injury 1999;30(4):257-60.  Back to cited text no. 24    

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Correspondence Address:
SKS Marya
1193A, Sector - B1, Vasant Kunj, New Delhi - 110 070
India
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Source of Support: None, Conflict of Interest: None


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