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THE MENNEN PLATE IN PERIPROSTHELIC HIP FRACTURE : A Case Report with Review of Literature

Pradeep Moonot*, Vg Telang**
*Registrar; **Hon. Orthopaedic Surgery; Bhagwati Municipal Hospital, Borivali, Mumbai - 400 092.

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This study, shows that Mennen plate is a good implant for femoral peri-prosthetic fractures which are stable while for unstable and widely displaced fractures some other mode of fixation should be used.

 

INTRODUCTION

Femoral shaft fracture in association with previous total hip replacement or hemiarthroplasty is an uncommon but devastating complication of what may have been successful surgery. The treatment options include traction, limited internal fixation with circlage wires and interfragmentary screws, fixation with plates and screws, external fixators and revision arthroplasty using an extra long stemmed implant - either cemented or uncemented. Each option is associated with well defined complication and no one method is perceived as perfect.

Reports of the treatment of fracture of the femur in patients with ipsilateral total hip arthroplasty (THA) are relatively few in the orthopaedic literature. The first few cases were reported by Sir John Charnley. [1] Patients were managed non-operatively with bed rest and traction and fracture healing was reported. In 1974, McElfresh and Coventry reported six patients who sustained fractures below THA from a series of 5400 patients with THA, followed up in the Mayo clinic. The recommended treatment was again non-operative management with traction. In 1975 Scott et al3 reported 38 patients with periprosthetic fractures, only seven of which occurred in the post-operative period. They mentioned open fixation of such fractures, but described it hazardous and only to be used as last report if traction was unsuccessful.

In 1981, Johansson et al4 recommended non-operative treatment of periprosthetic fractures with traction. If loosening occurs, then revision can be carried out after fraction union. Only, 36% of patients results were considered satisfactory where fractures occurred postoperatively. By 1989, open reduction and internal fixation of periprosthetic fractures was more accepted.

The Mennen plate, or the paraskeletal clap-on plate, was first described and introduced by Ulrich Mennen in 1979, 5 as a mean of internal fixation of fractures. Proposed as a means of achieving semi-rigid, and hence more biological stability, combined with a supposedly lesser operative dissection and soft-tissue stripping, the technique was advocated for forearm fractures. Since the plate was thought not to be a load-sharing, its subsequent retrieval was thought unnecessary. Following this first description the plate was subsequently used to treat fractures of the humerus, metacarpals, fibula and the mandible. A study based at the CMW laboratories by Lam and Parkaystna established the Mennen plate as a suitable device for femoral peri-prosthetic fractures. [6]

CASE REPORT

A 71 year old male blind person had an accidental fall for which an Austin-Moore hemiarthroplasty was done in USA. Five months later he again fell down and sustained a femoral peri-prosthetic fracture with fracture proximal to the prosthesis but extending upto the tip of it (Fig. 1). It was decided to do open reduction and internal fixation with Mennen plate as theX-rays didn’t show any evidence of loosening. An open reduction was performed and the fracture was fixed with a Mennen plate and circlage wires (Figs. 2 and 3). No bone grafting was done and no blood was transfused. The prosthesis was not loose, the fixation was stable and the check X-rays post-operatively showed the plate adequately holding the fracture. No post-operative immobilization was given. Patient was mobilized non-weight bearing after two weeks. He was kept non-weight bearing walking on crutches till six weeks post-operative after which he was started partial weight bearing walking on crutches. The patient did not have any pain at fracture site. By end of four and half months, patient was walking full weight bear walking and X-rays had shown union of fracture although the Mennen plate had pulled off slightly from the distal fragment (Fig. 4). At the end of three years post-operative follow-up, patient had no complaints, was walking full weight bearing walking and X-ray was showing union of fracture with the plate slightly pulled off from the shaft of femur (Fig. 5).

Fig 1: X-ray showing the peri prosthetic fracture upto the tip

Fig 2	Fig 3
X ray after Mennen plate and circlage wires

 

Fig 4 : X - ray showing Menne plate pulled off slightly from the distal fragment

Fig 5 X - ray showing healed fracture even with slightly pulled of plate

 

DISCUSSION

The para-skeletal device is a steel plate with paired, semi-circular tooth like projections that embrace two-thirds of the circumference of the fractured bone. The tips of these projections are pressed into the cortex by a crimping tool. During this process, the plate is usually bent into a slightly oval shape and a small gap is created - at least in part - between the device and the bone allowing its inventor to claim that the periosteum, muscles andtendon insertion remain undisturbed. The blood supply and venous drainage of the bone are said to be minimally adversely affected so facilitating bony union. [5]

In the elderly and frail, it is an alternative to non-operative management with traction, or to revision surgery. Mennen plate fixation is not as ‘major’ as revision hip surgery for the patient who is a poor anaesthetic risk and on average only two units of blood are required after surgery.[7]

The disadvantage of the mennen plate is that as the plate does not give rigid fixation, angulation or rotation at the fracture may occur, and this should be borne in mind in post-operative mobilization of the patients. Large fragment AO screws whose heads fit nicely between the prongs of the plate can be inserted above and below the fracture to limit this. [7]

Radcliffe and Smith reported five femoral periprosthetic fractures. All five fractures united at an average time of 4.8 months, with bone grafting done in four out of five cases, with an average of two units of blood transfused and an average time of mobilization with partial weight hearing being nine weeks. There was no fixation failures. Reviewing the literature, a series of 14 cases report by Otremski et al8 and a case report by Liu et al , [9] shows that fixation failure by Mennen plate is seen in peri-prosthetic fractures either at tip or distal to the prosthesis. In the study of 14 cases by Otremski et al, [8] 12 out of 14 cases ultimately united with two nonunions in peri-prosthetic fractures at the tip of prosthesis which were unstable fractures. In the case of report by Liu et al, [9] the fracture was reported to be just below the femoral prosthesis.

Thus, it is seen that mennen plate fixation provides good results in peri-prosthetic fractures proximal to tip of femoral prosthesis and stable fractures while in unstable and widely displaced fractures, it may lead to some disappointed and serious complications.8 For such fractures it does not give the support strong enough for early mobilization. Further research should aim at the design of a biomechanically better plate and modification of the post-operative management.

REFERENCES

1.Charnley J. The healing of human fractures in contact with self-curing acrylic cement. Clin Orthop 1966; 47 : 157.

2.McElfresh EC, Coventry MB. Femoral and pelvic fractures after total hip arthroplasty. J Bone Joint Surgery (A) 1974; 56A : 483.

3.Scott RD, Turner RH, Leitzer SM, Aufranc OE. Femoral fractures in conjunction with total hip replacement. J Bone Joint Surgery (A) 1975; 57A : 494.

4.Johansson JE, McBrown R, Barrington TW, Hunter G. Fracture of the ipsilateral femur in patients with total hip replacement. J Bone Joint Surgery (A) 1981; 63A : 1435.

5.Mennen U. The paraskeletal clamp-on plate. Part 2. Clinical experience with fractures of the radius and/or ulna. S Afr Mrd J 1984; 66 : 170-2.

6.Lam SJS, Purkaystna A. The Mennen plate : a unique indication for internal fixation. Dentsply, CMW laboratories. 1982.

7.Radcliffe SN, Smith DN. The Mennen plate in peri-prosthetic hip fractures. Injury 1996; 27 (1) : 27-30.

8.Otremski I, Nusam I, Glickman M, Newman RJ. Mennen paraskeletal plate fixation for fracture of the femoral shaft in association with ipsilateral hip arthroplasty. Injury 1998; 29 (6) : 421-3.

9.Liu A, Flores M, Nadarajan P. Failure of Mennen femoral plate. Injury 1995; 26 (3) : 202-3.

 

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