Periprosthetic fracture AROUND HIP JOINT

1. PERI-PROSTHETIC
FRACTURES
DR ANSHUL SETHI

2. OUTLINE
1. INTRODUCTION
• DEFINATION
• EPIDEMOLOGY
• RISK FACTORS
2. GENRAL PRINCIPLES OF MANAGEMENT
• DIAGNOSIS
• CLASSIFICATION
• TREATMENT
• COMPLICATIONS

3. Introduction
• Fractures that are associated with the Joint prosthesis
• They occur due to :
1. Trauma
2. Osteolysis
3. Osteoprosis
It occur mostly in old age with osteoporosis making standard fixation
technique difficult

4. EPIDEMOLOGY
• The largest series of peri-prosthetic fracture (THA)
I. 1% after primary and 4% after revision THA
II. 75% are due to low energy Trauma
More commonly seen in
• Females
• Young patient

5. • Low energy falls account for mechanism of injury in most patient with
Peri-prosthetic fracture in both lower limb
• Lower limb fractures occur most commonly Post-operatively where as
upper limb fracture most commonly occur in Intra Operatively
• 75% of all prei-prosthetic femur fracture occur post operatively with
low energy trauma
• Peri-prosthetic fracture most commonly post revision surgery then
primary surgery because of reduced bone stock

6. • Risk of peri-prosthetic increases when there is mismatch between
shape of long prosthesis stem & the shape of bone

7. Risk Factors
1. Patient Related :
• Age of patient (younger > older)
• Gender (female > male)
• Index diagnosis
• Presence or absence of osteolysis
• Type of prosthesis used (uncemented > Cemented)
• Coexisting medical co-morbidties
• Osteoporosis
• Rheumatoid Arthrities

8. 2. Surgeon Related :
• Inadequate exposure
• Underreaming
• Overzealous Reaming
• Heavy impaction
• Malpositioning of prosthesis

9. Sign and Symptoms
• Start up of abrupt pain
• Increase difficulty with ambulation
• Progressive limb shortening all this lead to implant loosening
• Increasing deformity of the extremity

10. DIAGNOSIS
• If trauma is absent /trivial – suggestive of Osteopaenia / Osteolysis
• Skiagram of joint involved in AP and Lat view and full length of bone
above and below the joint
Evaluate prosthesis relative to fracture and prosthesis relative to native
bone

11. Tells about
1. Prosthesis loosening
2. Presence of bone loss
3. Osteolysis
Prosthetic and limb alignment

12. Classification
• There are many classification for peri-prosthetic fractures :
1. American Academy of Orthopaedic surgeons (AAOS)
2. Cooke and newman (modified Bethea)
3. Johansson Classification

13. 4.Vancouver Classification
• Most widely used
• Based on location of fracture relative to prosthesis
• Stability of prosthesis
• Quality of surrounding bone

14. Vancouver Classification

15. GOALS of treatment
• Timely and uncomplicated fracture union
• Restoration of alignment
• Return of pre injury level of pain and function
• Stability of prosthesis
• Restoration of adequate bone stock to maximize potential success

16. TREATMENT
Vancouver Type A
• Peri-prosthetic femur fracture around trochanteric areas
• Usually non displaced or minimally displaced
Stabilized by opposite pull and continuity of soft tissue sleeve connecting
abductors and vastus lateralis
Can be managed conservatively with symptomatic management and partial
weight bearing with regular follow up

17. • Widly Displaced of Unstable type of A (gt) type
Associated with minimal pain ; weakness ; limp
ORIF with Claw Plating

18. • A (L) : large fracture involving segment of proximal medial femoral
cortex associated with tapered press fit stem design
• Treated with CERCALAGE wires/ Cables with or without Revision of
prosthesis

19. • Vancouver type B
• Identified mostly intra-operatively and treated mostly with
intervention
A. INDICATION OF CONSERVATIVE MANAGEMENT
• Stable femoral stem and non displaced diaphyseal fractures
• Proximal fragment related to osteolysis with adequate distal stem
fixation
• Minimally displaced trochanteric fractured

20. • INDICATION OF SURGICAL TREATMENT
1. Loose implant
2. Proximal Metaphyseal fracture with proximal fit stem
3. Displaced diaphyseal fracture or distal fractures
4. Widely displaced Gt fractures with alter abductor function

21. Treatment for VANCOUVER TYPE B
• TYPE B1 – it has well fixed prosthesis
So can be treated with
1. Wires or cables
2. Plate and screws or cables
3. Cortical allograft
4. Combination of above methods

22. • Type B2 – its prosthesis is unstable
• So the treatment options available are
1. Revision Arthroplasty + ORIF
2. Replacement with Long Stem Prosthesis
3. Cemented prosthesis

23. • Type B3 – it has unstable prosthesis with Poor bone stock
• Available options are
1. Proximal femoral Reconstruction
2. Composite allograft
3. Proximal femoral replacement

24. Treatment for VANCOUVER TYPE C
• Fracture line well distal to Stem so its treatment is irrespective of
Stem by
1. ORIF WITH plating + screws
2. Cables

25. COMPLICATIONS
1. Extensive soft tissue stripping during reduction
2. Extensive soft tissue destruction during cable application
3. Mismatch between plate contour and bone causing malreduction
4. Inadequate proximal fragment fixation
5. Inadequate stability

27. Case
• Name : Atar Singh
• Age/sex :74yr /male
• Presented to emergency with A/H/O of trivial trauma With c/o
1. Pain, swelling and deformity in left knee and thigh region
2. Inability to move left lower limb
Attitude: left lower limb flexed ,abducted
Diagnosed as : periprosthetic fracture distal 3rd of shaft of left femur
(Vancouver type C )
Managed with Orif with plating with augmentation with S.S wire

28. Pre Op

29. Post op

30. • Thanking you !!