Periprosthetic femoral fractures are becoming increasingly common and are a major complication of total hip arthroplasty (THA) and bipolar hemiarthroplasty (BHA). We report a retrospective review of the outcomes of treatment of 11 periprosthetic fractures after femoral revision using a long stem. Eleven female patients with a mean age of 79.2 years (70 to 91 years) were treated for a Vancouver type B1 fracture between 1998 and 2013. The status of the initial arthroplasty was THA in 5 patients and BHA in 6 patients. The original diagnosis was femoral neck fracture in 5 patients, osteoarthritis in 5 patients, and avascular necrosis of femoral head in 1 patient. Seven patients had had a cemented femoral component and 4 had had a cementless femoral component. The mean numbers of previous surgeries were 3.2 times (2 to 5 times). A previous history of fracture in the same femur was found in 7 hips including 5 femoral neck fractures, 3 periprosthetic fractures. The cause of the latest revision surgery was aseptic loosening in 6 hips, periprosthetic fracture in 3 hips, and infection in 2 hips. The average time to fracture after femoral revision using a long stem was 106.5 months (12 to 240 months). The average follow-up was 58.9 months (8 to 180 months). The fracture pattern was a transverse fracture in 6 hips and an oblique fracture in 5 hips. The type B1 fractures were treated with open reduction and internal fixation in 9 hips, 6 of which were reinforced with bone grafts. Seven patients were treated with a locking compression plate and cerclage wiring, and 2 patients were treated with a Dall-Miles system. Two other periprosthetic fractures were treated with femoral revision. One was revised because of stem breakage, and the other was a transverse fracture associated with very poor bone quality, which received a femoral revision with a long stem and a locking compression plate. All fractures except one achieved primary union. This failed case had a bone defect at the fracture site, and revision surgery using a cementless long stem and allografts was successful. These finding suggest that a type B1 fracture after revision using a long stem associated with very poor bone quality or bone loss might be considered as a type B3 fracture, and femoral revision might be the treatment of choice.

In 1999, we developed a technique for biological reconstruction after excision of a bone tumour, which involved using autografts of the bone containing the tumour treated with liquid nitrogen. We have previously reported the use of this technique in 28 patients at a mean follow up of 27 months (10 to 54).

In this study, we included 72 patients who underwent reconstruction using this technique. A total of 33 patients died and three were lost to follow-up, at a mean of 23 months (2 to 56) post-operatively, leaving 36 patients available for a assessment at a mean of 101 months 16 to 163) post-operatively. The methods of reconstruction included an osteo-articular graft in 16, an intercalary in 13 and, a composite graft with prosthesis in seven.

Post-operative function was excellent in 26 patients (72.2%), good in seven (19.4%), and fair in three (8.3%) according to the functional evaluation system of Enneking. No recurrent tumour occurred within the grafts. The autografts survived in 29 patients (80.6%), and the rates of survival at five and ten years were 86.1% and 80.6 %, respectively. Seven of 16 osteo-articular grafts (44%) failed because of fracture or infection, but all the composite and intercalary grafts survived.

The long-term outcomes of frozen autografting, particularly using composite and intercalary grafts, are satisfactory and thus represent a good method of treatment for patients with a sarcoma of bone or soft tissue.

Cite this article: Bone Joint J 2014;96-B:555–61.

We studied the safety of external fixation during post-operative chemotherapy in 28 patients who had undergone distraction osteogenesis (17, group A) or vascularised fibular grafting (11, group B) after resection of a tumour. Four cycles of multi-agent post-operative chemotherapy were administered over a mean period of 14 weeks (6 to 27). The mean duration of external fixation for all patients was 350 days (91 to 828). In total 204 wires and 240 half pins were used.

During the period of post-operative chemotherapy, 14 patients (11 in group A, 3 in group B) developed wire- and pin-track infection. A total of ten wires (4.9%) and 11 half pins (4.6%) became infected. Seven of the ten infected wires were in periarticular locations.

External fixation during post-operative chemotherapy was used safely and successfully for fixation of a vascularised fibular graft and distraction osteogenesis in 27 of 28 patients. Post-operative chemotherapy for malignant bone tumours did not adversely affect the ability to achieve union or cause hypertrophy of the vascularised fibular graft and had a minimal effect on distraction osteogenesis. Only one patient developed osteomyelitis which required further surgery.