Amputation of arm after arterial thrombosis related to COVID-19 infection.

In this case report, a 75-year-old unvaccinated female patient presented with hypoxaemia, and she was admitted to an intensive care unit. After four days her left hand was discoloured blue, and fibrin D-dimer was elevated. An angiogram showed occlusion in the arteria radialis at the level of the bifurcature. Thrombolysis had no effect, and the patient's left arm was amputated above elbow level. COVID-19 is still a present problem worldwide, and it is important to be alert and aware of the risk of serious thromboembolic complications when treating unvaccinated patients.

Knee function, quality of life, pain, and living conditions after distal femoral resection knee arthroplasty for non-tumor indications.

BACKGROUND: Distal femoral resection knee arthroplasty is a limb salvage procedure. The impact of distal femoral resection arthroplasty on patient function and health status is unknown. The aim of this study was to report knee function, quality of life, knee pain, and living conditions after distal femoral resection knee arthroplasty for non-tumor indications. METHODS: Of 52 patients (52 knees) undergoing distal femoral resection knee arthroplasty in a single institution between 2012 and 2021, 22 were excluded as 3 patients had ≤90 days follow-up, 6 had died, and 13 declined or were unable to participate for unrelated reasons. Thus, 30 patients were included and interviewed by telephone in March 2021 (mean follow-up 3.5 years after surgery). Patient completed the Oxford Knee Score (0-48, 48 best), EQ-5D-5L, and the Copenhagen Knee ROM, and information on pain and living conditions was obtained. RESULTS: The mean age was 67.9 years (SD 13.6), and 21 (70%) were female. Mean total Oxford Knee Score was 29.9 (SD 10.5), mean Copenhagen Knee ROM flexion was 116° (SD 21.6), and mean extension was - 2° (SD10.1). Mobility aids were used by 18 (60%) patients, i.e. a cane (30%), walker (26.7%) or wheelchair (3.3%). Mean EQ-5Dindex score was 0.70 (SD 0.22) and mean EQ-5D VAS score was 55.4 (SD 23.9). Nine (30%) patients used paracetamol or NSAID and 2 (6.7%) used opioids for knee pain. Mean VAS knee pain score was 1.30 (SD 2.2) at rest and 2.8 (SD 3.1) when walking. Most (90%) patients lived in their own home, with only 3 patients in nursing homes. Two-thirds (66.7%) required no home care, 5 (16.6%) received home care 1-2 times over 2 weeks, and 5 (16.6%) every day. CONCLUSION: Distal femoral resection knee arthroplasty appears to be a viable treatment option for non-tumor indications. Acceptable patient outcomes were achieved in terms of functional status and quality of life, especially considering treatment alternatives such as femoral amputation.

The positive predictive value of ankle fracture diagnosis in the Danish National Patient Registry.

INTRODUCTION: Information on data validity is essential for understanding the precision of studies based on data from the Danish National Patient Registry (DNPR). Thus, the aim of this study was to validate the quality of ankle fracture data in the DNPR. METHODS: We identified all patients from four hospitals with a surgically treated ankle fracture between 1 January 2018 and 31 December 2018. The positive predictive value (PPV) was estimated for a random sample of 10% of patients with both a relevant ankle fracture diagnosis code and a relevant procedure code, as well as for patients with only a relevant ankle fracture diagnosis code or a relevant ankle fracture procedure code. We collected data from medical records and X-rays. Two consultants independently validated the ankle fracture diagnosis and procedure codes reported to the DNPR. RESULTS: Among the four centres, 651 patients were identified with both an ankle fracture diagnosis and a procedure code. Among these, data from 65 (10%) patients were extracted for validation. For these patients, the PPV for an ankle fracture was 0.95 (95% confidence interval (CI): 0.88-0.99). The PPV for the diagnosis code was 0.89 (95% CI: 0.79-0.95), and for the procedure code, the PPV was 0.82 (95% CI: 0.70-0.90). For patients with only an ankle fracture diagnosis code or only a surgical procedure code, the PPV for an ankle fracture was 0.77 (95% CI: 0.64-0.87). CONCLUSION: This study showed that ankle fracture diagnosis and procedure codes registered in the DNPR are of a high quality and thus constitute a valuable data source for research on ankle fractures. FUNDING: none. TRIAL REGISTRATION: The Danish Data Protection Agency approved the study (journal number 2015-18/62866).

Patient safety in distal femoral resection knee arthroplasty for non-tumor indications: a single-center consecutive cohort study of 45 patients.

BACKGROUND: Distal femoral resection knee arthroplasty may be a viable option for several indications other than bone tumors. Resection knee arthroplasty appears to be becoming more common, but patients requiring this type of surgery are often elderly and with high comorbidity. The aim of this study was to report in-hospital complications, readmissions, reoperations, and mortality after distal femoral resection knee arthroplasty for non-tumor indications. METHODS: We retrospectively identified a consecutive cohort of 45 knees (45 patients) treated with distal femoral resection knee arthroplasty in a single institution between 2012 and 2021. Indications for surgery were failure of osteosynthesis (8), primary fracture treatment (2), periprosthetic fracture (22), and revision arthroplasty with severe bone loss (13). A major reoperation was defined as a major component exchange procedure or amputation. Mean follow-up was 3.9 years. RESULTS: The mean age was 71.3 years (SD 12.3), and 64.4% were female; 8.9% were ASA I, 40% ASA II, and 51% ASA III. Median length of stay was 7 days (range 3-19) with no major in-hospital complications, but 55.6% (n = 25) required blood transfusion. The 90-day readmission rate was 17.8% (n = 8), of which 50% was prosthesis-related. Four patients (8.9%) underwent major reoperation due to infection (n = 2), mechanical failure (n = 1), or periprosthetic fracture (n = 1). The mortality rate was 0% ≤ 90 days and 2.2% ≤1 year. CONCLUSIONS: Distal femoral resection knee arthroplasty in this fragile patient population appears to be a viable and safe option considering that it is a limp salvage procedure most cases.

X-ray Follow-up after Open Reduction Internal Fixation of Distal Forearm Fracture.

Background Following surgery, the standard regimen for fractures of the distal forearm includes radiographs taken 2-weeks postoperatively. However, it is unclear whether these radiographs have any therapeutic risks or benefits for patients. Objective The purpose of this study is to determine the importance of radiographs taken 2-weeks after surgery on distal forearm fractures, especially if it leads to further operations, and to establish whether this practice should be continued. Materials and Methods This is a retrospective cohort study of patients with a distal forearm fracture treated surgically with a volar locking plate at two university hospitals in Denmark. Standard aftercare at both departments is 2 weeks in a cast. Patients attend a 2-week follow-up, at which the cast is replaced with a removable orthosis and radiographs are taken. It was recorded whether these radiographs had resulted in any change of treatment in terms of further operations, prolonged immobilization, additional clinical follow-up, or additional diagnostic imaging. Results A total of 613 patients were included in the study. The radiographs led to a change of standard treatment for 3.1% of the patients. A second operation was required by 1.0%; 0.5% were treated with prolonged immobilization, and 1.6% had additional outpatient follow-up due to the findings on the radiographs. Additional diagnostic imaging was performed on 1.9% of the patients. Conclusion The radiographs taken at the 2-weeks follow-up resulted in a change of treatment in 3.1% of the cases. Given the low cost and minimal risk of radiographs of an extremity, we concluded that the benefits outweigh the costs of routine radiographs taken 2 weeks after surgical treatment of distal forearm fractures.

Pain, osteolysis, and periosteal reaction are associated with the STRYDE limb lengthening nail: a nationwide cross-sectional study.

Background and purpose - Observing serious adverse events during treatment with the Precice Stryde bone lengthening nail (NuVasive, San Diego, CA, USA), we conducted a nationwide cross-sectional study to report the prevalence of adverse events from all 30 bone segments in 27 patients treated in Denmark.Patients and methods - Radiographs of all bone segments were evaluated regarding radiographic changes in February 2021. We determined the number of bone segments with late onset of pain and/or radiographically confirmed osteolysis, periosteal reaction, or cortical hypertrophy in the junctional area of the nail.Results - In 30 bone segments of 27 patients we observed radiographic changes in 21/30 segments of 20/27 patients, i.e., 19/30 osteolysis, 12/30 periosteal reaction (most often multi-layered), and 12/30 cortical hypertrophy in the area of the junction between the telescoping nail parts. Late onset of pain was a prominent feature in 8 patients. This is likely to be a prodrome to the bony changes. Discoloration (potential corrosion) at the nail interface was observed in multiple removed nails. 15/30 nails were still at risk of developing complications, i.e., were not yet removed.Interpretation - All Stryde nails should be monitored at regular intervals until removal. Onset of pain at late stages of limb lengthening, i.e., consolidation of the regenerate, should warrant immediate radiographic examination regarding osteolysis, periosteal reaction, and cortical hypertrophy, which may be associated with discoloration (potential corrosion) of the nail. We recommend removal of Stryde implants as early as possible after consolidation of the regenerate.

Nonunion - consensus from the 4th annual meeting of the Danish Orthopaedic Trauma Society.

Nonunions are a relevant economic burden affecting about 1.9% of all fractures. Rather than specifying a certain time frame, a nonunion is better defined as a fracture that will not heal without further intervention.Successful fracture healing depends on local biology, biomechanics and a variety of systemic factors. All components can principally be decisive and determine the classification of atrophic, oligotrophic or hypertrophic nonunions. Treatment prioritizes mechanics before biology.The degree of motion between fracture parts is the key for healing and is described by strain theory. If the change of length at a given load is > 10%, fibrous tissue and not bone is formed. Therefore, simple fractures require absolute and complex fractures relative stability.The main characteristics of a nonunion are pain while weight bearing, and persistent fracture lines on X-ray.Treatment concepts such as 'mechanobiology' or the 'diamond concept' determine the applied osteosynthesis considering soft tissue, local biology and stability. Fine wire circular external fixation is considered the only form of true biologic fixation due to its ability to eliminate parasitic motions while maintaining load-dependent axial stiffness. Nailing provides intramedullary stability and biology via reaming. Plates are successful when complex fractures turn into simple nonunions demanding absolute stability. Despite available alternatives, autograft is the gold standard for providing osteoinductive and osteoconductive stimuli.The infected nonunion remains a challenge. Bacteria, especially staphylococcus species, have developed mechanisms to survive such as biofilm formation, inactive forms and internalization. Therefore, radical debridement and specific antibiotics are necessary prior to reconstruction. Cite this article: EFORT Open Rev 2020;5:46-57. DOI: 10.1302/2058-5241.5.190037.

Knee pain and associated complications after intramedullary nailing of tibial shaft fracture.

INTRODUCTION: The treatment of choice for unstable diaphyseal fractures in the tibia is reamed insertion of an intramedullary nail (IMN). The most common complication to this treatment is chronic knee pain with reported rates ranging from 10% to 87% with a mean of 47.4% in meta-analyses. METHODS: This study evaluates the long-term outcome after IMN insertion in adult patients with a tibial shaft fracture using the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire. The study includes patients operated on one of five Danish hospitals in a five-year period. The patients received a KOOS questionnaire with questions regarding knee-specific symptoms, stiffness, pain, function and quality of life. Data were subsequently compared to those of a reference population. RESULTS: A total of 391 patients were enrolled from the trauma centre's database search. 55 patients did not meet the inclusion criteria. Questionnaires were sent out to 336 patients and 223 (66%) responded. Mean age was 47.9 years at the time of surgery; 63% were men. The follow-up time ranged from 1.7 to 6.7 years. CONCLUSIONS: With a follow-up time of more than six years after receiving an IMN, patients in this study experienced more knee-specific symptoms, pain, limitations in sports and daily living than a reference population who had not undergone surgery. The study population also reported poorer quality of life outcomes than the reference population. FUNDING: none. TRIAL REGISTRATION: Approved by the Danish Data Protection Agency. Clinical trials: NCT03649360.

[AB0 blood groups and the risk of venous thromboembolism in connection with surgery].

It is increasingly recognised that individuals with non-0 blood groups may be at elevated risk of venous thromboembolism (VTE) compared with blood group 0 individuals. Multiple studies suggest that individuals with a non-0 blood group have an approximately twofold increased risk of VTE. The largest risk is seen in individuals with combined factor VLeiden mutation and non-0 blood group. In this review, we outline an overview of the existing literature regarding AB0 blood groups and the risk of VTE.

Tourniquet use in lower limb fracture surgery: a systematic review and meta-analysis.

BACKGROUND: Tourniquets are commonly used in today's orthopaedic surgical practice, but little evidence is available regarding the links between the use of a tourniquet and the amount of post-operative pain and other complications. The aim of the study was to conduct a systematic review and meta-analysis comparing tourniquet versus non-tourniquet use during fracture surgery of the lower limb in adult patients. METHOD: A search was performed using the keyword "tourniquet" in EmBase and as a MeSH term in PubMed, and no limitations (including language) were applied. Available studies were screened using the Covidence software, and demographic as well as outcome data were extracted from the final studies. Critical appraisal was performed according to Cochrane Risk of Bias guidelines. Pooled data were assessed for heterogeneity using Chi-squared and I2 tests. RESULTS: Five studies were included, and no statistically significant difference was found in the amount of pain and post-operative complications between tourniquet and non-tourniquet groups. Length of in-hospital stay was longer in the tourniquet groups. An overall high risk of bias was found in the included studies. CONCLUSION: Although the validity and statistical strength of our results are not strong enough to suggest a change in practice in tourniquet use, the operating surgeon should still carefully consider his or her decision to use a tourniquet in lower limb fracture surgery, as there are indeed complications associated with it and no current evidence to support its continued use. LEVEL OF EVIDENCE: Level I, systematic review of randomized controlled trials.

Comparing case-control study for treatment of proximal tibia fractures with a complete metaphyseal component in two centers with different distinct strategies: fixation with Ilizarov frame or locking plates.

BACKGROUND: The purpose of this study was to compare two methods of stabilization for proximal tibia fractures (AO 41) with a complete metaphyseal component, external fixation with the Ilizarov wire frame, and internal fixation with locking plates. METHODS: Patients from two level 1 trauma centers treated between 2009 and 2015 were included in a retrospective comparing cohort study. The first center stabilized the non-pathological, proximal tibia fractures exclusively with external fixation and the second with internal plating. Combined clinically and radiologically evaluated, bone healing was the primary outcome. The secondary outcomes included complications, range of motion (ROM) and axial alignment of the knee, the reoperation rate within 6 months, heterotopic ossifications (HTO), and signs of posttraumatic osteoarthritis (PTOA). A logistic regression analysis corrected for uneven distributed parameters. RESULTS: The 62 patients treated with Ilizarov frame and the 68 patients treated with plate fixation were comparable regarding epidemiological parameters, injury characteristics, and comorbidity except for injury severity score (ISS) and smoking behavior. The time of healing was shorter in the group undergoing plate fixation (p = 0.041); however, the incidence of non-unions was equal. Furthermore, there was no difference regarding the rate of deep infections, thrombosis, alignment, reoperations, PTOA, and ROM. Heterotopic ossifications were more prevalent following plate fixation (13.2 vs 1.6%, p = .013). External fixation was associated with a higher rate of superficial infections (40.4 vs 2.9%, p = .000). The initial displacement, the incidence of deep infections, and the classification significantly influenced the incidence of non-unions in both groups (p < 0.02). CONCLUSIONS: Fixation of proximal tibia fractures with plates resulted in a slightly shorter healing time compared to Ilizarov frame stabilization. Furthermore, the complication profiles differ with more heterotopic ossifications and less superficial infections following internal plating. TRIAL REGISTRATION: DRKS, DRKS00013275 , Registered 11/2/2017, Retrospectively registered.

[Treatment of distal radius fractures in the elderly]. / Behandling af håndledsbrud hos ældre.

Evidence on the treatment of distal radius fractures (DRF) in the elderly is lacking. Over the last decade new volar locking plates have increased in popularity as other means of treating DRF are pushed aside. No definitive evidence exists to support the use of volar locking plates especially among the elderly. There is some evidence that Disabilities of the Arm, Shoulder and Hand-scores improve the first 3-6 months after treatment with volar locking plates only to become insignificant after 12 months. This article examines the evidence of the different modes of treatment.

Time to Surgery Is Associated with Thirty-Day and Ninety-Day Mortality After Proximal Femoral Fracture: A Retrospective Observational Study on Prospectively Collected Data from the Danish Fracture Database Collaborators.

BACKGROUND: We hypothesized that undergoing surgery as soon as possible reduces early mortality in patients with a proximal femoral fracture. Our aim was to evaluate the association between surgical delay and early mortality in these patients. METHODS: We performed a retrospective analysis of prospectively collected data from the Danish Fracture Database and the Civil Registration System on patients who were fifty years of age or older and had undergone surgery for a proximal femoral fracture. Femoral head fracture (classified as OTA/AO 31C per the OTA/AO classification system), high-energy trauma, pathological fractures, multiple fractures, and surgeries performed with implants not commonly used were excluded. End points were adjusted odds ratios for thirty-day and ninety-day mortality. RESULTS: For the 3517 surgeries included in this study, the median patient age was 82.0 years (range, fifty-one to 107 years), 2458 patients (70%) were female, and 1720 surgeries (49%) were performed because of a trochanteric fracture. Within twelve hours, 722 of the surgeries (21%) had been performed; within twenty-four hours, 2482 surgeries (71%); within thirty-six hours, 3024 surgeries (86%); within forty-eight hours, 3242 surgeries (92%); and within seventy-two hours, 3353 surgeries (95%). Unsupervised surgeons with an education level below that of an attending surgeon performed the surgery in 1807 (51%) of all cases. The thirty-day mortality was 380 (10.8%) and the ninety-day mortality was 612 (17.4%). The risk of thirty-day mortality increased with a surgical delay of more than twelve hours (odds ratio, 1.45; p = 0.02), more than twenty-four hours (odds ratio, 1.34; p = 0.02), and more than forty-eight hours (odds ratio, 1.56; p = 0.02); the risk of ninety-day mortality increased with a surgical delay of more than twenty-four hours (odds ratio, 1.23; p = 0.04). An education level of the surgeon below that of an attending surgeon increased the risk of thirty-day mortality (odds ratio, 1.28; p = 0.035) and ninety-day mortality (odds ratio, 1.26; p = 0.016). Increasing American Society of Anesthesiologists score and male sex significantly increased both thirty-day and ninety-day mortality. CONCLUSIONS: In this study, a surgical delay of more than twelve hours significantly increased the adjusted risk of thirty-day mortality and a surgical delay of more than twenty-four hours significantly increased the adjusted risk of ninety-day mortality. The adjusted risk of both thirty-day and ninety-day mortality increased significantly when the education level of the surgeon was below that of an attending surgeon. The study findings challenge orthopaedic departments to facilitate fast surgical treatment supported by attending orthopaedic surgeons.

The Danish Fracture Database can monitor quality of fracture-related surgery, surgeons' experience level and extent of supervision.

INTRODUCTION: The importance of supervision and of surgeons' level of experience in relation to patient outcome have been demonstrated in both hip fracture and arthroplasty surgery. The aim of this study was to describe the surgeons' experience level and the extent of supervision for: 1) fracture-related surgery in general; 2) the three most frequent primary operations and reoperations; and 3) primary operations during and outside regular working hours. MATERIAL AND METHODS: A total of 9,767 surgical procedures were identified from the Danish Fracture Database (DFDB). Procedures were grouped based on the surgeons' level of experience, extent of supervision, type (primary, planned secondary or reoperation), classification (AO Müller), and whether they were performed during or outside regular hours. RESULTS: Interns and junior residents combined performed 46% of all procedures. A total of 90% of surgeries by interns were performed under supervision, whereas 32% of operations by junior residents were unsupervised. Supervision was absent in 14-16% and 22-33% of the three most frequent primary procedures and reoperations when performed by interns and junior residents, respectively. The proportion of unsupervised procedures by junior residents grew from 30% during to 40% (p < 0.001) outside regular hours. CONCLUSION: Interns and junior residents together performed almost half of all fracture-related surgery. The extent of supervision was generally high; however, a third of the primary procedures performed by junior residents were unsupervised. The extent of unsupervised surgery performed by junior residents was significantly higher outside regular hours. FUNDING: not relevant. TRIAL REGISTRATION: The Danish Fracture Database ("Dansk Frakturdatabase") was approved by the Danish Data Protection Agency ID: 01321.

Early results and future challenges of the Danish Fracture Database.

INTRODUCTION: The Danish Fracture Database (DFDB) was established in 2011 to establish nationwide prospective quality assessment of all fracture-related surgery. In this paper, we describe the DFDB's setup, present preliminary data from the first annual report and discuss its future potential. MATERIAL AND METHODS: The DFDB collaboration includes 13 hospitals and covers a population of 3.7 million. Data registration is performed online by the surgeon following surgery, and it includes patient-, trauma- and surgery-related data. Primary procedures, reoperations and planned secondary procedures are registered. Indication for reoperation is also recorded. The reoperation rate and the one-year mortality are the primary indicators of quality. RESULTS: Approximately 10,000 fracture-related surgical procedures were registered in the database at the time of presentation of the first annual DFDB report (currently 15,000). 85% of all procedures were performed on adult fractures and 15% on paediatric fractures. Proximal femur (33%), distal radius (15%) and malleolar fractures (12%) were the three most common primary adult fractures. Pain and discomfort from orthopaedic hardware, infection and failure of osteosynthesis were the three most common indications for reoperation and accounted for 34%, 14% and 13%, respectively. CONCLUSION: The DFDB is an online database for registration of fracture-related surgery that allows for basic quality assessment of surgical fracture treatment and large-scale observational research by registering primary surgery, reoperations and planned secondary procedures. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Implementing, adapting, and validating an evidence-based algorithm for hip fracture surgery.

OBJECTIVES: Reoperations are common after surgical treatment of hip fractures but may be reduced by optimal choice of implant based on fracture classification. We hypothesized that implementing a surgical treatment algorithm was possible in our hospital and would result in a reduced reoperation rate. DESIGN: Retrospective comparative study. SETTING: Provincial level III trauma center. PATIENTS: The evidence-based "Hvidovre Algorithm" for treatment of hip fractures was adopted and implemented at our provincial institution in September 2008. Three hundred eighty-six consecutive patients older than 50 years admitted with a hip fracture in the first year after implementation were prospectively included and compared with 417 retrospectively included similar patients admitted within the last year before implementation. INTERVENTION: Implementation of an evidence-based treatment algorithm for hip fracture surgery. RESULTS: Eighty-five percent (330 of 386) patients were operated according to the algorithm after implementation, compared with 67% (280 of 417) of procedures before implementation (P < 0.001). After implementation, the overall reoperation rate showed a tendency toward a reduction to 8% (32 of 386) from 12% (48 of 417) (P = 0.1). Among all the 803 included patients, the reoperation rate was lower if procedures had been performed according to the algorithm recommendations: 9% (53 of 610) versus 14% (27 of 193) (P = 0.009). CONCLUSIONS: The algorithm for hip fracture surgery was easily implemented, and our results support that using it facilitates a low reoperation rate. The reoperation rate may be further reduced with higher adherence to algorithm recommendation. LEVEL OF EVIDENCE: Therapeutic level III. See instructions for authors for a complete description of levels of evidence.

Completeness and data validity for the Danish Fracture Database.

INTRODUCTION: Fracture-related surgery is among the most common orthopaedic procedures. However, to our knowledge, register-based quality assessment of fracture-related surgery has not previously been conducted. The Danish Fracture Database (DFDB) has been developed for the purpose of web-based quality assessment, but its properties as a valid data source have not previously been explored. We therefore investigated: 1) the completeness of data in the DFDB, and 2) if the entered data are valid data sources for future quality assessment. MATERIAL AND METHODS: We have developed the internet-based DFDB in which data entry is performed by the surgeon. Data collection includes primary fracture surgery and reoperations. After full implementation of the database at two orthopaedic departments, we assessed the completeness and validity of the entered data for 322 patients operated during a one-month period. Validity was calculated as observed agreement. RESULTS: We recorded 83% completeness for all types of data entry, with 88% completeness for primary fracture surgery and 77% for reoperations, respectively. Patient- and trauma-related data were 82-100% valid. Surgery-related data included method of osteosynthesis and was valid in 89-99% of the cases. CONCLUSION: The DFDB is an easy to use web-based database for registration of fracture-related surgery. Shortly after its implementation, we recorded satisfactory completeness and high data validity, which makes the DFDB a valuable tool with potential for nationwide quality assessment of fracture-related surgery.

Periprosthetic Vancouver type B1 and C fractures treated by locking-plate osteosynthesis: fracture union and reoperations in 60 consecutive fractures.

BACKGROUND AND PURPOSE: Historically, the treatment of periprosthetic femoral fractures (PFFs) has been associated with a high frequency of complications and reoperations. The preferred treatment is internal fixation, a revision of the femoral stem, or a combination of both. An improved understanding of plate use during internal fixation, and the introduction of locking-plate osteosynthesis may lead to improved outcome. We evaluated the outcome of Vancouver type B1 and C PFFs treated by locking-plate osteosynthesis, by assessing rates of fracture union and reoperations and by analyzing failure cases. PATIENTS AND METHODS: From 2002 through 2011, 58 consecutive patients (60 fractures) with low-energy PFF around or below a stable femoral stem, i.e. Vancouver type B1 and C fractures, underwent osteosynthesis with a locking plate. All patients had a total hip replacement (THR). They were followed up clinically and radiographically, with 6 weeks between visits, until fracture union or until death. Fracture union was evaluated 6 months postoperatively. RESULTS: At a median follow-up time of 23 (0-121) months after PFF, 8 patients (8 fractures) had been reoperated due either to infection (n = 4), failure of fixation (n = 3), or loosening of the femoral stem (n = 1). All the patients who had been followed up for at least 6 months-and who did not undergo reoperation or die-went on to fracture union (n = 43). INTERPRETATION: Locking-plate osteosynthesis of periprosthetic Vancouver type B1 and C fractures gives good results regarding fracture union. It appears that spanning of the prosthesis to avoid stress-rising areas is important for successful treatment. Infection is the major cause of failure.