ADULT RECONSTRUCTION AND JOINT REPLACEMENT The Periprosthetic Fracture: When and How I Fix Michael B. Cross, MD Assistant Attending Orthopaedic Surgeon
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 3 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 4 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 5 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 6 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 7 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 8 ADULT RECONSTRUCTION AND JOINT REPLACEMENT
The Late Periprosthetic FX 3 features of fracture classification : Location of fracture Integrity of fixation Quality of bone 9 ADULT RECONSTRUCTION AND JOINT REPLACEMENT
Type A Fracture of the trochanter Typically associated w/ osteolysis or early post-op 10 ADULT RECONSTRUCTION AND JOINT REPLACEMENT
Type A “Rigid” fixation + Bearing surface exchange 11 ADULT RECONSTRUCTION AND JOINT REPLACEMENT
Type B1 Fracture around the prosthesis Stem well fixed Rare (be wary) Most common mistake is classifying a B1 incorrectly! 12 ADULT RECONSTRUCTION AND JOINT REPLACEMENT
Type B1 Typically treated with locked plating 13 ADULT RECONSTRUCTION AND JOINT REPLACEMENT
Ideal Construct for B1? 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 14 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 15 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 16 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 17 ADULT RECONSTRUCTION AND JOINT REPLACEMENT
Type B2 Stem is loose and must be revised 18 ADULT RECONSTRUCTION AND JOINT REPLACEMENT
Type B2 If you don’t revise the loose stem… 19 ADULT RECONSTRUCTION AND JOINT REPLACEMENT The Periprosthetic Fracture: When and How I Fix
Type B2 Revise with a cementless stem that bypass fx 20 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 21 ADULT RECONSTRUCTION AND JOINT REPLACEMENT
ETO for Vancouver B2 ETO to fracture site Distal fixation achieved Fracture/Osteotomy fragments wrapped around the stem E T Prophylactic cerclage wire O distal to osteotomy/fracture site PRIOR to reaming and stem Prophylactic insertion Cerclage Modularity helps! Levine et. Al, J Arthroplasty 2006 22 ADULT RECONSTRUCTION AND JOINT REPLACEMENT
Type B3 Poor bone stock Little isthmus for distal fixation 23 ADULT RECONSTRUCTION AND JOINT REPLACEMENT
Type B3 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 24 ADULT RECONSTRUCTION AND JOINT REPLACEMENT
Type B3 Treatment: PFR 25 ADULT RECONSTRUCTION AND JOINT REPLACEMENT The Periprosthetic Fracture: When and How I Fix
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 26 ADULT RECONSTRUCTION AND JOINT REPLACEMENT
Type C: Locked Plates Fracture distal to stem 27 ADULT RECONSTRUCTION AND JOINT REPLACEMENT
Beware… ADULT RECONSTRUCTION AND JOINT REPLACEMENT
ADULT RECONSTRUCTION AND JOINT REPLACEMENT
Conclusions 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 30 ADULT RECONSTRUCTION AND JOINT REPLACEMENT
ADULT RECONSTRUCTION AND JOINT REPLACEMENT THANK YOU
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