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Original Article
Interprosthetic femoral fractures: Treatment with a lateral angular-stable plate
Fracturas interprotésicas femorales. Tratamiento con placa lateral de estabilidad angular
J. Albareda
Corresponding author
albaredajorge@gmail.com

Corresponding author.
, J. Gómez, L. Ezquerra, N. Blanco
Servicio de Cirugía Ortopédica y Traumatología, Hospital Clínico Universitario «Lozano Blesa», Zaragoza, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Interprosthetic femoral fractures occur in the femoral segment between hip and knee arthroplasties&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> These arthroplasties affect how the fractures occur and how they are treated&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;2</span></a> They only constitute 1&#46;26&#37; of femoral fractures<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> but the increase in life expectancy and prosthetic surgery procedures result in a larger at-risk population and therefore their greater frequency is to be expected&#46; These are not optimal patients since&#44; as they present limited bone stock&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> it is difficult to stabilise fractures due to prosthetic implants<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> and there is occasionally the presence of medullary canal cement which creates problems with biological union&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> In other words&#44; treatment of these fractures poses mechanical and biological challenges&#46; The fractures are always produced by low energy mechanisms&#44; the effect of implants and their features&#44; the effect of the presence and constriction of the knee implant<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> and the degree of osteoporosis<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> are discussed in clinical and biomechanical studies&#46; Because these fractures are so infrequent&#44; the published series are short with a modest number of patients<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#8211;5&#44;7&#8211;9</span></a> and various materials and osteosynthesis techniques have been used for their treatment&#44; sometimes with a high complication&#44; reoperation and failure rate&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> Lateral angular-stable plates have been recommended for the treatment of these fractures&#44; to cover the entire interprosthetic femoral segment in order to prevent the risk of fracture due to increased stress in the segment of femur without implant&#44;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2&#8211;5&#44;7&#44;8&#44;11</span></a> but there is no definitive algorithm for the treatment of these fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> In this short patient series&#44; our aim is to study the causes of these fractures&#44; the features of the patients in whom they occurred and the outcomes achieved using a single lateral angular-stable plate&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Material and method</span><p id="par0010" class="elsevierStylePara elsevierViewall">We undertook a retrospective review of patients treated between the years 2010 and 2013 with interprosthetic femoral fracture&#46; There were 7 patients in the study&#44; we studied their demographic characteristics&#44; age and gender&#44; causes of fracture&#44; type of fracture according to Platzer&#39;s radiological classification&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> degree of osteoporosis using the Singh index<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> measured in the contralateral hip&#44; anaesthetic risk &#40;ASA&#41;&#44; time since the arthroplasty implant&#44; union time&#44; ambulation&#44; general and local complications&#44; reoperations&#44; relationship of the type of implant with the type of fracture and clinical deterioration of joint function&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">All the patients have been treated surgically with spinal anaesthesia with reduction and internal fixation with an angular-stable plate&#46; Scheduled surgery was performed on average 2&#46;5 days from occurrence of the fracture&#44; overlapping the femoral stem of the hip implant between 3 and 10<span class="elsevierStyleHsp" style=""></span>cm&#44; placing 3 percutaneously and 4 by open surgery&#46; The plate was stabilised with screws using accessory wires in the proximal segment depending on the fracture line&#46; None of the hip or knee implants had been revised and no autologous or allografts had been used in any of the cases&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">All the patients were kept non-weight bearing on the fractured limb until union of the fracture&#44; physiotherapy was started immediately postoperatively&#46; The fracture was considered to have healed if clinically the patient could walk independently with no pain and two radiological projections showed fracture callus&#46; Delayed fracture union was considered if at 6 months there had been no fracture union but there had been some progress towards it since the last follow-up X-ray&#44; and pseudoarthrosis if no union had taken place at 9 months with no progress towards it within the past 3 months&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> Union with an angle greater than 5&#176; was considered non-union&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">All the patients were monitored as outpatients until clinical and radiological union of the fracture&#44; the minimum follow-up period was 12 months&#44; except one patient who was lost to follow-up after 6 months&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">Six of the 7 patients treated were females and one male&#44; with a mean age of 84&#46;7 years &#40;range 78&#8211;87&#41;&#46; All the patients had undergone knee arthroplasty due to gonarthrosis at least 5 years prior to incurring the fracture&#46; Ultracongruent polyethylene was used in 4 patients and posterior stabilised polyethylene in 3&#46; Furlong<span class="elsevierStyleSup">&#174;</span>-type partially cemented bipolar hip arthroplasty was performed on 6 patients &#40;the females&#41; and total non-cemented hip arthroplasty on one &#40;the male&#41; due to displaced&#44; low-energy cervical fracture&#46; All of the hip arthroplasties&#44; except the total arthroplasty&#44; and 4 knee arthroplasties were implanted in our department &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The interprosthetic fractures occurred between 2 and 8 months after the hip surgery&#44; all of them were low-energy produced&#46; In four cases they were located at diaphyseal level and in three at supracondylar level&#44; two with ultracongruent and one with posterior stabilised polyethylene&#46; In all cases both implants were stable and not affected by the fracture line&#46; In two cases the fracture line affected the distal cement plug of the hip arthroplasty &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Following Platzer&#39;s classification&#44; the fractures were 4 type IA&#44; and 3 type IIA adjacent to the knee arthroplasties &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46; Four patients were assessed with a Singh index of 3 and 3 with an index of 4&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Four patients presented an ASA class II due to their background and general condition&#44; and 3 ASA III&#46; None of the patients died during the follow-up period&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">All of the patients walked with the aid of orthopaedic devices prior to the fracture&#44; 3 with a walking frame and 4 with crutches&#46; Union took place in all cases with a mean of 4&#46;5 months&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4&#8211;7</span></a> two of them had diaphyseal fractures with delayed union&#46; There were no angles in union greater than 5&#176;&#44; no reoperations or complications or evolutionary complications presented&#44; even in one patient with a short plate which only overlapped 3<span class="elsevierStyleHsp" style=""></span>cm who made satisfactory progress &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; All the patients regained their walking ability prior to the fracture except for one female patient who was lost to follow-up at 6 months&#44; the fracture having healed&#46; Clinically&#44; the three patients with a supracondylar fracture lost a mean of 20&#176; knee flexion&#44; previous hip mobility was not altered in any of the patients&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Interprosthetic fractures are rare in orthopaedic surgery departments&#44; therefore publications referring to them are also scarce&#44; and there is little information available on how they occur&#44; the features of the patients who suffer them&#44; the most appropriate treatment or the final outcome&#46; The treatment of 141 patients has been published&#44; the majority in the past 4 years<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#8211;5&#44;7&#8211;9&#44;11</span></a> which is an indication both of the rise in their frequency due an increase in life expectancy and arthroplasty surgery&#44; and the growing interest in their resolution due to the therapeutic difficulty they pose&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">These are fractures that are typical in the elderly&#44; much more common in women<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> and almost always low-energy produced&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> these features were also evident in our study&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The fractures occur in association with hip and knee implants which affect both their occurrence and their location&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> in some series they are more common at supracondylar level close to the knee arthroplasty<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> although not in others&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> and not in our study&#46; At this distal location&#44; their occurrence has been associated with constrained knee implants&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> and although this is clinically logical to an extent&#44; it has not been demonstrated in biomechanical studies&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">There are differing options regarding the influence of the stability of the implants in the occurrence of these fractures&#46; According to Hou et al&#46; of the 13 cases they present&#44; 4 presented loosening of one of the prostheses&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> although most published series find no relationship between the fractures and implant loosening because all of them were stable&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;3&#44;8</span></a> it is not clear whether the hip prosthesis being cemented or non-cemented affects occurrence of these fractures&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> or whether it is a total hip prosthesis or hemiarthroplasty&#46; The fact that the arthroplasty has been revised or changed<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> might have an influence&#44; but this is not the case for knee arthroplasty because almost all cases published were primary arthroplasties&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In an experimental study with cadaver femurs&#44; Lehmann et al&#46; found that the greatest risk of fracture was if the patient had a hip arthroplasty and a retrograde intramedullary nail and the risk of fracture did not increase if the patient had a knee arthroplasty&#44; even if the knee arthroplasty was constrained&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> These outcomes might change the concept of interprosthetic fracture&#44; fractures occurring in patients bearing two femoral prostheses&#44; whether or not they are arthroplasties&#44; should be considered&#44; since distal femoral implants such as a retrograde nail or a short plate&#44; affect the occurrence of fractures more than the presence of a knee arthroplasty&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> If we take this concept into account&#44; the number of fractures produced in femurs with two implants would increase considerably&#46; This study clearly applies in terms of the treatment to be given&#44; so that when a distal femoral fracture occurs in a bearer of a hip arthroplasty&#44; a retrograde implant should not be used in their treatment&#44; but preferably an extramedullary implant&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> The femoral area between two intramedullary femoral implants&#44; is an area that logically should be at high risk of fracture due to an accumulation of stress&#44; as has been documented in a few cases&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> and the size of this area between implants would seem likely to affect the occurrence of a fracture&#44; so that the smaller the gap the greater the risk&#44; because there is a greater concentration of force in this area&#46; Segal et al&#46; in an experimental study using artificial bones into which they implanted a cemented hip arthroplasty and a revision knee arthroplasty&#44; found that if the gap was kept between 5 and 20<span class="elsevierStyleHsp" style=""></span>cm it did not affect fracture occurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In our series&#44; the arthroplasties&#44; both hip and knee&#44; were primary&#44; cemented except for one case and stable&#44; 4 cases were located in the diaphyseal segment without involvement of the implants and 3 cases were adjacent to the knee arthroplasty&#44; ultracongruent polyethylene was used in two of them&#58; in other words&#44; implant loosening&#44; prosthetic revision surgery&#44; or constrained knee implant had no effect&#46; All our patients were bearers of hip arthroplasties implanted due to a fracture&#59; a fact that might have more influence than the type of implant&#44; their advanced age and the indication for a cemented implant&#44; in most cases&#44; patients with poorer bone stock who have already suffered at least one osteoporotic fracture&#46; All our patients had bone fragility with low Singh indices&#46; The fact that the fracture occurred a few months after the hip fracture would indicate the functional limitations generated after the fracture which led to a fall and the consequent fracture&#44; which does not occur after implantation of a knee or hip arthroplasty due to degenerative disease&#46; The influence of femoral hip prosthetic implants in our series was much more fundamental than knee arthroplasty&#59; all of them implanted several years before the fracture occurred&#46; The influence of the degree of osteoporosis has already been noted by Lesaca et al&#46; who&#44; in an experimental study&#44; found the cortical thickness in the interprosthetic femoral segment to be the most important and decisive factor in the occurrence of interprosthetic fractures&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Variants of the Vancouver and de Lewis and Rorabeck classifications have been applied in order to adapt them to interprosthetic fractures&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;4&#44;5&#44;7</span></a> Platzer et al&#46; specifically classified these fractures as type I when the fracture is remote from both implants&#44; type II adjacent to one implant and type III adjacent to both implants&#46; These are further subdivided into type A&#44; both components stable&#44; type B&#44; one loose component&#44; B1 hip and B2 knee&#44; and type C&#44; both components loose&#46; The frequency of one or other type was 17&#37; type I and III and 66&#37; type II&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> Seventy-five percent had stable components and one or both components were loose in only 25&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> In our series all of the patients presented stable implants and none of the fractures affected the implants&#44; although the supracondylar fractures were adjacent to the knee arthroplasties&#44; and in two cases were affecting the cement distal to the femoral hip implant&#44; 4 cases were classified as type IA and 3 type IIA&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Treatments carried out a decade ago resulted in a great many failures&#46; Kenny et al&#46; in 1998 published 4 cases stabilised with the techniques available at the time and the treatment failed in all 4 patients&#44; some of them eventually had an amputation above the fracture&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> Different types of treatment have been used&#44; retrograde nails&#44; nail plates&#44; dynamic condylar screws&#44; allografts&#44; cerclage wiring&#44; prosthesis revision surgery&#44;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2&#44;4</span></a> tumour prostheses&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> etc&#46;&#44; but there is no standard treatment since this is determined by the characteristics of the fracture&#44; the presence of implants&#44; the time since they were placed&#44; the occasional presence of cement&#44; bone quality&#44; the patients&#8217; age and features&#44; etc&#46; These factors can affect mechanical stability<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> and the biology of fracture union&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Given these constraints&#44; treatment should be personalised&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The treatment objectives are to restore femoral length and rotation&#44; ensuring the functionality of the arthroplasty and to achieve sufficient stabilisation to enable early mobilisation&#44; providing the fracture the biomechanical features necessary for its union&#46; Currently the most used material&#44; when the implants are not loose&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4&#44;9</span></a> are angular-stable plates&#44; which has revolutionised the treatment in increasing stability of fixation&#44; especially in osteoporotic bone&#44; with minimum aggression to soft tissues&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;5&#44;8</span></a> The plate should cover the entire interprosthetic femoral segment<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">5&#44;7&#44;8&#44;11</span></a> from distal to proximal<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> and the screws should be fixed in at least 8 femoral cortical bones in the proximal segment using a cerclage or wire<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> accessory to increase the stability of the screws&#46; Cerclages&#44; as they do not provide rotational stability&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> should not be used for the main or primary fixation of the plate&#44; but rather as a complementary system to screws to provide greater stability and to be placed in the most proximal area of the plate&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Hou et al&#46; indicate that the plate used should overlap the intramedullary femoral implant by at least two femoral diameters to prevent areas of stress&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> i&#46;e&#46;&#44; between 6 and 8<span class="elsevierStyleHsp" style=""></span>cm&#46; In our series the overlap was between 3 and 10<span class="elsevierStyleHsp" style=""></span>cm&#44; no failures occurred as a result of limited overlap in some&#46; Some authors<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;3&#44;8</span></a> use locked plates with the same concepts&#44; but introduced by minimally invasive or percutaneous surgery&#44; offering the advantages of preserving fracture haematoma and reducing injury to soft tissues to a minimum&#46; Union is achieved using these treatments in between 80 and 100&#37;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;2&#44;7&#44;8</span></a> of the cases treated&#44; very much depending on good technical surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Ochs et al&#46; based on Platzer&#39;s classification&#44; created a therapeutic algorithm in which&#44; depending on the type of fracture and the stability of the implants&#44; they indicate treatment with angular-stable plates or prosthesis revision surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> If knee revision implants with intramedullary stem are used&#44; a complementary osteosynthesis plate should be added to prevent areas of stress between the two intramedullary implants&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">We have followed the abovementioned criteria&#44; using a single lateral angular-stable plate in all cases covering the entire interprosthetic femoral segment&#44; achieving union in all cases with no reoperations or failures&#46; The only problem that we found was achieving an adequate overlap of the osteosynthesis plate to the femoral hip implant&#44; since the reduced availability of plate lengths means that occasionally we have to make a rather limited or excessive overlap&#59; a choice has to be made between one or the other&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">A wide approach and femoral bone removal are required in order to place a graft&#44; and therefore their use is disputed&#46; Spongy bone allografts have occasionally been used in the fracture site&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> but the use of allografts in palisade&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> seeking to increase fracture stability and long-term increase of bone quality or stock&#44; is exceptional due to the good stability provided by angular-stable plates&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Another point of discussion is mortality&#46; These are serious&#44; high-risk fractures in the elderly patient&#46; To a greater or lesser degree&#44; the majority of published series report mortality&#44;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2&#8211;5&#44;7</span></a> it is difficult to establish rates due to the limited number of patients included in these series&#44; as in ours&#44; with no mortality but with very limited review time&#44; and therefore we have nothing to contribute on this point&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Our study&#44; despite the homogeneity of the treatment&#44; presents limitations due to the limited number of patients and because it is retrospective&#44; but we can conclude that interprosthetic fractures are very rare&#44; although an increase in the short-term is predicted&#44; and has already started&#46; The majority occur in females of advanced age&#44; the presence of implants&#44; the functional deterioration which occasionally presents after their placement for hip fracture and above all bone quality&#44; are determining factors&#46; Treatment should be personalised according to the features of the patient and the fracture but along with prosthetic implant stability&#44; the best mechanical and biological solutions are lateral angular-stable plates that should be placed percutaneously or in a minimally invasive manner without using allografts&#44; covering the entire interprosthetic femoral segment&#44; overlapping the femoral hip implant between 6 and 8<span class="elsevierStyleHsp" style=""></span>cm and using&#44; if necessary&#44; cerclages to enhance the fixation and stability of the implant in its proximal portion&#46; Outcomes using this technique tend to be good with a high rate of union&#44; low risk of fracture callus&#44; and there has been a major decrease in the number of reoperations and failures&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Level of evidence IV&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Ehtical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Protection of human and animal subjects</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that neither human nor animal testing have been carried out under this research&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Confidentiality of data</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that they have complied with their work centre protocols for the publication of patient data&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Right to privacy and informed consent</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that no patients&#8217; data appear in this article&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interests</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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          "titulo" => "Ehtical disclosures"
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            0 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Protection of human and animal subjects"
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            1 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Confidentiality of data"
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              "titulo" => "Right to privacy and informed consent"
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    "fechaRecibido" => "2015-12-05"
    "fechaAceptado" => "2016-09-20"
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          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:4 [
            0 => "Interprosthetic fracture"
            1 => "Peri-prosthetic fracture"
            2 => "Femoral fracture"
            3 => "Locking plate"
          ]
        ]
      ]
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:4 [
            0 => "Fractura interprot&#233;sica"
            1 => "Fractura periprot&#233;sica"
            2 => "Fractura femoral"
            3 => "Placa bloqueada"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To study the causes and outcomes of patients with interprosthetic femoral fractures&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective review conducted on 7 patients treated between 2010 and 2013&#46; The knee arthroplasties had been implanted for at least 5 years&#44; and those of the hip less than a year&#46; They were bipolar cemented in 6 patients and totally non-cemented in one patient&#44; all of them implanted due to a displaced femoral neck fracture&#46; They were treated using osteosynthesis with angular stability plate covering the whole interprosthetic femoral segment&#46; Except for one patient&#44; all have been reviewed at least 12 months&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The patients included 6 women and one man&#44; with a mean age of 84&#46;7&#46; The fracture&#44; always by low energy&#44; occurred between 2 and 8 months after that of the hip without the implants being mobilised&#46; Four of them were located at diaphyseal level&#44; and 3 at supracondylar level&#44; and unrelated to the type of knee implant&#46; There was consolidation in all patients at a mean of 4&#46;5 months&#44; without a re-operation in any of them&#44; and with no mortality during the follow-up period&#46; All patients walked independently at the time of the fracture&#44; and all of them have managed to return to walking independently&#44; having lost as average 20&#176; of knee flexion in cases of supracondylar fracture&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The most important factors in our patients regarding the producing of the fracture have been the changes in the ability to walk after knee replacement and bone fragility&#46; Angular stability plates give good results in the treatment of interprosthetic femoral fractures&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
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          2 => array:2 [
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            "titulo" => "Results"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Estudiar las causas de producci&#243;n y resultados en los pacientes tratados con fractura interprot&#233;sica femoral&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Revisi&#243;n retrospectiva de 7 pacientes tratados entre 2010 y 2013&#46; Las artroplastias de rodilla ten&#237;an al menos 5 a&#241;os desde su implantaci&#243;n y las de cadera menos de un a&#241;o siendo cementadas bipolares en 6 pacientes y total no cementada en un paciente&#44; implantadas todas por una fractura desplazada del cuello femoral&#46; Han sido tratadas mediante osteos&#237;ntesis con placa de estabilidad angular abarcando todo el segmento femoral interprot&#233;sico&#46; Excepto un paciente&#44; los dem&#225;s han sido revisados 12 meses como m&#237;nimo&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Han sido 6 mujeres y un hombre con edad media de 84&#44;7 a&#241;os&#46; La fractura&#44; siempre por baja energ&#237;a&#44; se ha producido entre 2 y 8 meses tras la de cadera sin encontrarse movilizados los implantes&#44; estando localizadas 4 de ellas a nivel diafisario y 3 a nivel supracond&#237;leo&#44; sin relaci&#243;n con el tipo de implante de rodilla&#46; Se ha producido la consolidaci&#243;n en todos los pacientes a los 4&#44;5 meses de media sin reintervenci&#243;n en ninguno de ellos y sin mortalidad en el tiempo que han sido controlados&#46; Todos los pacientes deambulaban en carga en el momento de producirse la fractura y todos ellos han conseguido volver a deambular en carga&#44; habiendo perdido como media 20&#176; de flexi&#243;n de rodilla en los casos de fractura supracond&#237;lea&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Los factores m&#225;s importantes en nuestros pacientes con respecto a la producci&#243;n de la fractura han sido la alteraci&#243;n de la capacidad de deambulaci&#243;n tras la artroplastia de cadera y la fragilidad &#243;sea&#46; La placa de estabilidad angular concede buenos resultados en el tratamiento de las fracturas interprot&#233;sicas femorales&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Albareda J&#44; G&#243;mez J&#44; Ezquerra L&#44; Blanco N&#46; Fracturas interprot&#233;sicas femorales&#46; Tratamiento con placa lateral de estabilidad angular&#46; Rev Esp Cir Ortop Traumatol&#46; 2017&#59;61&#58;1&#8211;7&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Interprosthetic fracture IIA &#40;Platzer&#39;s classification&#41;&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Interprosthetic fracture resolution IIA&#46;</p>"
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Interprosthetic femoral fractures&#46; Treatment with an angular-stable plate&#46;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">PS&#58; posterior stabilised&#59; UC&#58; ultracongruent&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Gender&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Union &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">UC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IIA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">UC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Partially cemented&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Partially cemented&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Partially cemented&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IIA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Partially cemented&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">UC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-cemented total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Gender&#44; age&#44; ASA&#44; fracture type &#40;Platzer&#41;&#44; radiological union&#44; type of knee implant &#40;ultracongruent&#44; posterior stabilised&#41;&#44; and type of femoral implant&#46;</p>"
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    ]
    "bibliografia" => array:2 [
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ISSN: 19888856
Original language: English
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