The Periprosthetic Fracture: When and How I Fix Michael B. Cross, - - PowerPoint PPT Presentation

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

The Periprosthetic Fracture: When and How I Fix

Michael B. Cross, MD Assistant Attending Orthopaedic Surgeon

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Disclosures

• Consultant:
• Smith & Nephew
• Link Orthopaedics
• Exactech Inc.
• Intellijoint
• Acelity
• Theravance Biopharma
• Zimmer Biomet
• Honorarium
• Acelity
• Editorial Board
• Techniques in Orthopaedics
• Bone and Joint Journal 360
• Journal of Orthopaedics and Traumatology

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Periprosthetic FX of the Femur after THA

• Incidence increasing
• Intraoperative Fx: Technical errors
• Postoperative Fx: Technical Errors, Loosening

and/or Osteolysis

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Intraoperative Periprosthetic Fracture

• More common in uncemented THA, especially

during revision THA

• Vary from 3% to 20% after uncemented hip

replacement

• Usually occur around the trochanteric/calcar

area – Single cerclage wire around the calcar – WBAT

• Distal Fx: long stem bypass and cables

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

The Early Postop Periprosthetic FX

• Early Postoperative fx on the rise!

Cementless implants Desire to get a tight press fit

• Rush Experience

5,313 THA over 10 years 32 Early postop fx that required surgery (0.6%) 21 Vancouver B2 fractures

Sheth, Della Valle et. al J Arthroplasty 2012

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Risk Factors for Early Fx

• Fractures associated with

Increasing age (6% increased risk per year) Female Sex Flat wedge taper cementless stems Dx of DDH vs. OA

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Intra-Operative Prevention

• Appropriate exposure!

Increased risk with “MIS” exposures Particularly in the “learning curve”

• Stop hitting the broach when it fails to advance
• Be VERY wary if the implant goes past broach

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Treatment for the Early Periprosthetic FX

• Cable around the calcar
• WBAT
• If not good stable fixation

with wire in place switch to diaphyseal engaging stem

• However…higher risk of

complications/reoperation – Infection – Nutrition – Skin – Brooker III/IV HO – Prevent with XRT or NSAIDs

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

The Late Periprosthetic FX

• 3 features of fracture classification:

 Location of fracture  Integrity of fixation  Quality of bone

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Type A

Fracture of the trochanter Typically associated w/ osteolysis or early post-op

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

“Rigid” fixation + Bearing surface exchange

Type A

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

• Fracture around the

prosthesis

• Stem well fixed
• Rare (be wary)
• Most common mistake is

classifying a B1 incorrectly!

Type B1

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Typically treated with locked plating

Type B1

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

 15 synthetic femurs with simulated Vancouver B1 periprosthetic FXs  3 proximal fixation methods used: (1) Bicortical screws, (2) Unicortical screws

with cables, & (3) 3 cables through plate

 Conclusion:

– Bicortical screw placement achieved the highest load to failure and the highest torsional/sagittal bending stiffness – Additional unicortical screws improved axial stiffness when using cable fixation – Lateral bending stiffness was not different between the 3 fixation groups

Ideal Construct for B1?

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Do you need a strut?

 Biomechanical analysis using 15 Synthetic femurs  3 constructs:

– Lateral plate only – Lateral plate and medial strut – Lateral plate and anterior strut

 Conclusion: A combination of a plate with a medial strut allograft

provides more mechanical stability on periprosthetic femoral fractures near the tip of a total hip arthroplasty

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Do you need a strut?

• Meta analysis of 37 manuscripts with 687 B1 fractures treated with or

without a strut allograft

• Results:

 Percent union was similar for Vancouver B1 fractures treated with or

without an allograft strut (90.7% vs. 91.5%)

 Time to union (4.4 vs. 6.6 months) and deep infection (3.8% vs. 8.3%)

were increased with use of allograft struts

• Conclusion: due to increased infection and time to union, allograft struts

should be used cautiously during operative treatment of Vancouver B1 factures

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

How far distal do you go?

• Moloney GB et al, 2014

 N = 58 patients with Vancouver B1  36 short plates, 21 long plates to femoral condyle  No nonunions in long plate group  3 nonunions with plate failure and reoperation in short plate group

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Stem is loose and must be revised

Type B2

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

If you don’t revise the loose stem…

Type B2

The Periprosthetic Fracture: When and How I Fix

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Revise with a cementless stem that bypass fx

Type B2

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Extended Trochanteric Osteotomy

“Why would I want to take something that is broken and create more pieces?”

• Facilitates:

 Exposure  Component and/or

cement removal

 Component insertion

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

• ETO to fracture site

Distal fixation achieved Fracture/Osteotomy fragments wrapped around the stem Prophylactic cerclage wire distal to osteotomy/fracture site PRIOR to reaming and stem insertion Modularity helps!

ETO for Vancouver B2

E T O

Prophylactic Cerclage

Levine et. Al, J Arthroplasty 2006

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

• Poor bone stock
• Little isthmus for distal

fixation

Type B3

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

• The majority addressed

with a modular taper

• However good results also

reported with fully porous coated monoblock stems

Paprosky 2001 Garcia CORR 2013

Occasionally consider proximal femoral replacement in elderly

Type B3

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Type B3 Treatment: PFR

The Periprosthetic Fracture: When and How I Fix

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Modular Tapered Stems for B2/B3

• Stem survival at 54 months = 96%
• No difference in survival between B2 and B3

fractures

• Tapered stems are a useful option in revision for

femoral fracture across the spectrum of femoral bone deficiency

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Fracture distal to stem

Type C: Locked Plates

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Beware…

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

• Vancouver Classification helps guide treatment
• Be wary of the B1 (rare)
• B2 fractures are most commonly encountered

Extended osteotomy facilitates management Diaphyseal fitting stem to bypass the fracture

• B3 commonly managed with a modular taper vs

proximal femoral replacement

Conclusions

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

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