Minimally invasive surgery of femoral periprosthetic fractures increases the rate of consolidation and decreases time to bone healing without a higher rate of complications

Background

Knee periprosthetic femoral fractures (KPPFF) are becoming more frequent due to the increasing number of arthroplasties and the aging population, for whom maintaining autonomy and function remains a challenge. The use of locking plates has improved functional results and promoted the development of “minimally invasive” surgical (MIS) approaches. Despite the availability of literature comparing between different types of osteosynthesis for KPPFF, there is a paucity of information available on the complications of osteosynthesis using locking plates, depending on the approach. We therefore carried out a retrospective multicenter study (nine centers: Dijon, Grenoble, Lille, Marseille, Nice, Paris, Saint-Étienne, Strasbourg, Colmar) as part of a Symposium of the French Society of Orthopedic Surgery and Traumatology (SOFCOT). Following osteosynthesis of KPPFF by locking plates carried out by a standard approach or by a minimally invasive approach (MIS), the objectives were: (1) to compare the complications, (2) to evaluate whether the radiological and clinical results (rate and time of consolidation, resumption of weight bearing, lack of reduction, postoperative autonomy) were comparable in the two groups.

Hypothesis

The hypothesis was that performing an MIS approach in these indications does not confer more complications than a standard approach, and rather, the MIS approach offers better functional and radiological results.

Material and method

Five hundred and seventy-three patients presented with KPPFF over the periods studied (retrospective series from January 2012 to December 2016, then prospective series from January to December 2019). After applying the inclusion criteria (KPPFF by locking plate) and exclusion criteria (tumor context, infectious, intraoperative fractures, fractures on loose prostheses, other osteosynthesis methods, treatment by prosthetic revision, patients under the age of 18, follow-up less than 1-year, incomplete files), a global series of 306 patients was retained. Two groups were created according to the approach performed: a standard approach group (S, n = 228) and a minimally invasive approach group (MIS, n = 78). The demographic data of the population were recorded, as was the criteria for autonomy (Parker score, place of living). Postoperative complications were sought (infection, mechanical complication, surgical revision). Finally, the radiological and clinical results were evaluated (rate of, and time to consolidation, resumption of weight bearing, lack of reduction, postoperative autonomy).

Results

The comparison of the two subgroups, S and MIS, found complication rates are comparable in the two groups in terms of infections [S group: n = 18 (7.9%), MIS group: n = 2 (2.6%)], mechanical complications [S: n = 23 (10.1%), MIS: n = 2 (2.6%)], and surgical revision [S: n = 33 (14.5%), MIS: n = 7 (8.9%)], and a lack of difference in postoperative autonomy [Parker; S group: 4.7 ± 2.4 (0–9) vs. MIS group: 5 ± 2, 7 (0–9)]. On the other hand, the time to return to weight bearing was shorter in the MIS group [4.3 ± 3.5 weeks (0–12) versus 10.1 ± 10.1 weeks (0–110), p < 0.001]. The rate of nonunion was lower in the MIS group [n = 1 vs. n = 20, i.e. 1.7% vs. 11.1% (p = 0.031)] and the time to consolidation was shorter [7.5 ± 4.3 weeks (6–30) versus 15.2 ± 9.4 weeks (5–78) (p < 0.001)].

Conclusion

Performing an MIS approach in the management of KPPFF by locking plate osteosynthesis does not cause any more complications than a standard approach. In addition, higher consolidation rates can be obtained in shorter periods of time. This study suggests that it proposing osteosynthesis using the MIS approach as a primary surgery is a reasonable choice when treatment using locking plates is chosen for a KPPFF, subject to technical expertise.

Level of evidence

III; observational study.