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. 2023 Feb 4;38:102123. doi: 10.1016/j.jcot.2023.102123

Outcomes of osteosynthesis of periprosthetic fractures of the greater trochanter with an anatomic claw plate☆

Bernd Fink a,b,∗, Arman Ahmadian a
PMCID: PMC9945795  PMID: 36846072

Abstract

Background

The treatment of periprosthetic trochanteric fractures, especially older fractures, is often a challenge. The aim of this study was to investigate the clinical and radiological outcomes of periprosthetic fracture treatment with the anatomic Peri-Plate claw plate.

Material and methods

Thirteen new fractures (≤6 weeks after occurrence) and 8 older Vancouver AG fractures (35.4 ± 26.1 weeks after occurrence) were followed radiologically and clinically with a follow-up of 44.6 ± 18.8 (24–81) months.

Results

At 6 months, osseous consolidation had occurred in 12 cases and fibrous union in 9 cases. At 12 months one additional osseous consolidation was shown. The Harris hip score (HHS) increased from 37.2 ± 10.3 preoperatively to 87.6 ± 10.3 12 months after surgery. Thirteen patients reported no, 7 mild and one patient significant local trochanteric pain.

Conclusions

The Peri-Plate claw plate can achieve reproducibly good outcomes in terms of fracture stabilization and bony consolidation, as well as with regard to clinical outcomes in the treatment of new and older periprosthetic trochanteric fractures.

Keywords: Periprosthetic fracture –- greater trochanter, Osteosynthesis, Claw plate

1. Introduction

Periprosthetic fracture of the greater trochanter (type AG fracture according to the Vancouver system1 or type IV.3AG in the Unified Classification System2) is a rare complication during and after implantation of hip endoprostheses. It occurs between 0.4% and 2% in primary implantation, is more common in the direct anterior approach at up to 2%, but can occur with an incidence of up to 12% in association with revision surgery.3, 4, 5, 6, 7, 8

Displacement of the trochanteric fragment is a nearly regular occurrence as a result of traction of the gluteal muscles. The gluteal insufficiency caused by this leads to significant impairment of function with Trendelenburg signs or even limping.9, 10, 11 Furthermore, local pain and more frequent dislocation occur on a regular basis.9,12 Older fractures with trochanteric displacement are usually very difficult or impossible to reconstruct due to persistent shortening of the gluteal muscles. Therefore, prompt and effective osteosynthesis is necessary after such fractures have occurred.10

Osteosynthesis options include the use of wires, cables, claw plates, or locking plates.13,14 There are a few reports that concern the outcomes of these osteosynthesis procedures, all of which are characterized by non-homogeneous patient populations, mostly only describing collectives with trochanteric osteotomies, and only a few with actual descriptions of periprosthetic trochanteric fractures. Non-union rates as high as 47% have been reported for wire cerclages after trochanteric osteotomies during primary implantation of total hip prostheses.9,15, 16, 17, 18 In vitro studies have demonstrated that wiring technologies have worse resistance to fatigue and lower breaking strength than other fixation methods.19 Thus, comparisons between claw plates and cerclage techniques showed significant biomechanical advantages for the former method.17,20,21 However, even for claw plates and locking plates, when used in revision arthroplasty and for fractures and non-union of the trochanter, average non-union rates have been reported of 16% and 10% respectively, trochanter migration rates of 15% and 4% respectively, rates of bursitis of 12% and 14% respectively, and weakness of the abductors in 25% and 18% respectively.13 Even for modern third-generation plates (Cable-Ready (ZimmerBiomet, Warsaw, IN), Dall-Miles (Stryker, Portage, MI), or Accord Cable Plate System (Smith&Nephew, Memphis, TN), local soft tissue irritation of the gluteal musculature and fascia latae associated with bursitis has been described for between 10% and 30% of cases because these implants impact the area around the trochanter.13,16,18,22

Therefore, the aim of the present study was to investigate the outcome of an anatomical claw plate (Peri-Plate, Merete Medical GmbH, Berlin, Germany) and to answer the following questions:

What is the union rate of periprosthetic fractures of the greater trochanter for osteosyntheses with this claw plate?

What are the clinical outcomes with this claw plate in these cases?

Can older periprosthetic fractures of the greater trochanter be treated promisingly with this claw plate?

2. Material and Methods

The Peri-Plate (Merete Medical GmbH, Berlin, Germany) is an anatomical claw plate that differs from other plates on the market in that the two branches of the proximal claw plate diverge, thereby engaging the fractured trochanteric fragment not only from above but also from the side. This is designed to achieve increased rotational stability. In addition to the sharp edges of the branches that engage the trochanteric fragment, cerclage wires or threads can be passed through the holes in the branches to additionally fix the trochanteric fragment via a transosseous route (Fig. 1). The holes of the plate can also be optionally fitted with screws or with a clip, in which a cerclage wire or band can be threaded around the distal femur. We prefer the double cerclage with a 1.5 cerclage wire to the use of bands or the single cerclage loop because of the biomechanically better traction and stability, as well as the lower corrosion effects compared to cables.22, 23, 24 This claw plate comes in 6 different lengths (2-hole, 3-hole, 5-hole, 7-hole, 9-hole, and 11-hole) (Fig. 1).

Fig. 1.

Fig. 1

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Illustration of the different sizes of the Peri-Plate claw plate.

To make the shape of the branches and the transition to the stem of the plate as anatomical as possible, 500 radiographs of proximal femurs and 100 cadaver femurs were measured during development of the claw plate.

The data of twenty-one periprosthetic Vancouver-type AG fractures were prospectively collected and retrospectively reviewed. The follow-up was 44.6 ± 18.8 (24–81) months. The study involved 14 women and 7 men with an age of 77.4 ± 11.1 (41–92) years and a BMI of 27.5 ± 5.1 (18.3–42.0). There were 13 new fractures, treated within 6 weeks of occurrence, and 8 older fractures with a mean time between treatment and occurrence of 35.4 ± 26.1 (10–96) weeks. Among the older fractures, 5 persisted longer than 6 months and were thus classed as non-unions. Among the new fractures, two had occurred intraoperatively during implantation of a hip prosthesis in our own hospital and had been treated with the claw plate directly during surgery and 11 fractures had occurred after a fall. The extent of displacement of the trochanteric fragment, which was measured on the radiograph of the hip (anteroposterior in a standing position with the prosthesis ball as a reference), was 11.1 ± 4.5 (4–17) mm in the acute fractures and 15.1 ± 7.5 (5–31) mm in the older fractures.

All operations were performed via a posterolateral approach. After mobilization of the trochanteric fragment the branches of the Peri-Plate were hammered into this trochanteric fragment. The trochanteric fracture was repositioned by pushing on the plate from the top and by placing the first screw of the plate in the distal fragment (femur), thus achieving retention of the fragment. Then, screws or clips for the cerclage-wires were placed in the other holes of the plate, depending on the availability of space beside the prosthesis stem into which screws could be placed. Additional fixation of the branches to the proximal trochanteric fragment was achieved with transosseous fibre wire suturing through the holes of the branches. In the 5 non-unions, demineralized bone matrix (DIZG, Berlin, Germany) was also applied locally.

Post-operatively, weight-bearing was restricted to 20 kg on the operated side for six weeks. Thereafter the weight-bearing was gradually increased to full weight-bearing three months post-operatively. Active abduction against resistance was permitted for 3 months.

Patients were clinically and radiologically studied preoperatively, 6 weeks, 3 months, 6 months, and 12 months after surgery. The Harris hip score25 and the Koval categories for activity level26 were determined in each case, and the extent of bony consolidation was assessed radiologically.

According to Huang et al.,10 Harris hip score25 was defined as follow: excellent (90–100 points), good (80–89 points), fair (70–79 points), poor (<70 points). Activity levels were defined as: level I, independent community ambulator, level II, community ambulatory with cane, level III, community ambulator with walker or crutches, level IV, independent household ambulator, level V, household ambulator with cane, level VI, household ambulator with walker or crutches, level VII, nonfunctional ambulatory.26 Finally, the hip abductor was deemed to be restored when the patient could abduct hip joint against gravity in the lateral decubitus position; the Trendelenburg test was also used to assess abductor function.27

Concerning the radiological analysis, according to Huang et al.10 union of the greater trochanter could be considered to have occurred if there was osseous continuity between the femur and the greater trochanter and displacement of the trochanteric fragment or failure of internal implants had not occurred. Similarly, fibrous union could be considered existent if there was radiographic evidence of non-union without displacement of the greater trochanter, symptoms of pain or limp. Non-union could be defined by migration of the greater trochanter, absence of osseous continuity between the femur and the greater trochanter, or failure of implants.

The statistical analyses were conducted using the computer program SPSS for Windows (SPSS Inc, Chicago, IL). All subjects gave informed consent to participate in the study and the protocol was approved by the research ethics boards of the institution.

3. Results

At 6 months after surgery, osseous consolidation was seen on radiographs in 12 cases, 3 of which had older fractures and one of which presented as a non-union (Fig. 2a–c). In 9 cases there was a fibrous union. Of these, 5 patients had an older fracture and 2 patients exhibited a non-union (Fig. 3a–c). In the radiographs at 12 months, one patient with fibrous union of an older fracture showed osseous consolidation. The other radiographs were unchanged with respect to the fracture union. The Harris hip score increased continually from 37.2 ± 10.3 points preoperatively to 66.2 ± 8.2 points 6 weeks postoperatively and to 87.6 ± 10.3 points 12 months postoperatively (Table 1). There were 10 patients achieving excellent, 6 patients good, 4 patients fair, and 1 patient poor Harris hip scores. Regarding the activity level 12 months postoperatively, 13 patients achieved an activity level I, 5 patients an activity level II, and 3 patients an activity level III (Table 1). Twelve months postoperatively 13 patients had no Trendelenburg sign, 8 a positive Trendelenburg sign, and of these, 3 additionally had a Trendelenburg limp. Thirteen patients reported no pain at all in the trochanteric area, 7 mild pain, and 1 patient significant pain. Metal removal was performed after one year in 4 patients (3 with mild local discomfort and one without discomfort) who exhibited bony consolidation of the fracture.

Fig. 2.

Fig. 2

Fig. 2

Fig. 2

Fig. 2

Fig. 2

Fig. 2

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Treatment of a new Vancouver AG fracture on the right after a fall suffered by an 80-year-old female patient. Fig. 2a: preoperative radiographs (a1 pelvic overview a.p., a2 right hip lateral). Fig. 2b: radiographs 5 days after surgery (b1: a.p., b2 right hip axial). Fig. 2c: Radiographs 6 months after surgery showing osseous consolidation of the fracture (c1: a.p., c2: right hip axial).

Fig. 3.

Fig. 3

Fig. 3

Fig. 3

Fig. 3

Fig. 3

Fig. 3

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Treatment of a 7-month-old, dislocated Vancouver AG fracture on the left with recurrent dislocations in an 86-year-old patient. Fig. 2a: preoperative radiographs (a1 pelvic overview a.p., a2 left hip lateral). Fig. 2b: radiographs 5 days after surgery following prosthesis replacement, osteosynthesis of trochanteric fracture and implantation of demineralized bone matrix (b1: a.p., b2 right hip axial). Fig. 2c: Radiographs 6 months after surgery showing fibrous union of the fracture (c1: a.p., c2: right hip axial).

Table 1.

Harris-hip-score and activity level (Act.-Level).

Pre-operative 6 weeks postop. 3 months postop. 6 months postop. 12 months postop.
Harris-Hip-Score (Points) 37.2 ± 10.3 (21–60) 66.2 ± 8.2 (60–75) 74.6 ± 10.5 (55–90) 75.9 ± 19.6 (55–95) 87.6 ± 10.3 (65–95)
Act.- Level 1 (N) 6 10 13
Act.- Level 2 (N) 8 8 5
Act.- Level 3 (N) 5 10 7 3 3
Act.- Level 4 (N) 1
Act.- Level 6 (N) 13 10
Act.- Level 7 (N) 3
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4. Discussion

Successful treatment of acute and older periprosthetic fractures of the greater trochanter could be achieved with the Peri-Plate device. Successful trochanteric fixation requires adequate compression at the fracture site and resistance against abductor forces in the vertical, antero-posterior, and rotational planes.13 These destabilizing forces can exceed 4 times the body weight during routine daily activities such as climbing stairs and rising from a chair.28,29

The advantage of the Peri-Plate described here is that the two branches of the proximal claw diverge. This means that the trochanter or trochanteric fragment is engaged not only from above but also from the side, thereby not only preventing proximal migration of the fragment but also neutralizing the anteriorly directed muscle traction and/or rotational forces of the muscles acting on it.30 This corresponds to the effect of double plate osteosynthesis with locking plates, with one plate positioned anterolaterally and the other posterolaterally. Using this latter technique, Laflamme et al.11 were able to achieve bony healing of non-union of the trochanter in as many as 87% of cases. Fixing screws in the shaft area of the Peri-Plate also serves to neutralize rotational forces on the trochanteric fragment; this is also possible with other third-generation claw plates and locking plates.11,16,18,22,31,32 Fixation of the claw plate with only wires or cables in the trochanteric and shaft regions of the femur does not lead to this neutralization of rotational forces and thus increases the risk of osteosynthesis failure.16 The high rate of bony consolidation and stable fixation, even in older fractures, of 57% in our study argues for the stable fixation of the fragments by the Peri-Plate. Furthermore, the design of the claws of the Peri-Plate results in a lower impact of the proximal claw in the trochanteric region and less soft tissue irritation of the fascia lata and bursitis. This is confirmed by the outcomes of this study with a relatively low rate of discomfort around the plate of 33.3% mild and 4.8% marked discomfort.

In the last year other newer plates for the treatment of periprosthetic fractures of the greater trochanter have appeared on the market, for example Trofix (ZimmerBiomet, Warsaw, IL, USA); Trochantus (Intercus GmbH, Bad Blankenburg, Germany). These plates use the principle of angle-stable screws for solid fixation of the fragments. To the best of our knowledge, results of these plates being used for the treatment of periprosthetic fractures of the greater trochanter have not yet been reported.

The additional implantation of demineralized bone matrix may have supported the healing of non-unions in our study. A similar observation was made by Peretz et al.33 in a case report.

Even with osseous union and successful reattachment of the trochanter, full recovery of the hip cannot be expected in all cases, and abductor weakness may remain. Functional consequences such as a limp or the need for a walking aid were still present in 38% of the cases. All functional scores did improve significantly throughout the follow-up, and 76% were rated as excellent to good (HHS). In addition, pain relief was excellent, with 66% graded as none. This matches or even exceeds the outcomes of Laflamme et al.11 for double plate osteosynthesis with angle-stable plates, with 38.5% patients with excellent and good Harris-Hips scores and 64% of patients without pain.

The study has some limitations. One is the small number of patients. However, periprosthetic trochanteric fractures are rare and this is, to the best of our knowledge, the first reported study that deals solely with periprosthetic trochanteric fractures. The majority of studies in the literature deal with osteosyntheses of trochanteric osteotomies.13 A further limitation is the lack of a comparison group that uses an alternative implant. However, the majority of the published studies detail the outcomes with a single implant and we believe that these provide ample evidence for demonstrating the advantages of this newer device.

5. Conclusions

In summary, the Peri-Plate claw plate can be used to achieve reproducibly good outcomes in terms of stabilization and bony consolidation of the fracture as well as clinical outcomes in the treatment of acute and older periprosthetic trochanteric fractures. Future multicenter studies with higher case numbers and control groups should allow an even better understanding of the value of this implant.

Ethical approval

This study was performed in line with the principles of the Declaration of Helsinki. This research study was conducted retrospectively from data obtained for clinical purposes. We consulted with the Institutional Review Board of the Ärztekammer Nordwürttemberg who determined that our study did not need ethical approval because of the retrospective nature of the study. Also the need for informed consent was waived because of the retrospective nature of the study.

Authors' contributions

BF designed the study, wrote the paper and analyzed the datas and performed the statistics. AA collected and analyzed the datas. All authors read and approved the final manuscript.

Funding

There is no funding source.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declaration of competing interest

The authors declare that they have no competing interests. BF is a consultant for the company of the device mentioned in this paper.

Footnotes

☆

Investigation performed at the Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Articles from Journal of Clinical Orthopaedics and Trauma are provided here courtesy of Elsevier

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