Management of peri prosthetic fractures

WACS Intensive Revision Course in Orthopaedics & Trauma
Management of Peri-Prosthetic Fractures
Dr Arojuraye Soliudeen
(MBBS, FWACS, FMCOrtho)
Consultant Orthopaedic & Trauma Surgeon
National Orthopaedic Hospital, Dala - Kano

Outline
 Introduction
 Definition
 Epidemiology
 Risk factors
 Common #s (Hip, Knee, Shoulder)
 General Principles of mgt
 Resuscitation
 Diagnosis
 Classifications
 Treatment (Goals, Options)
 Complications
 West African Peculiarities
 Conclusion
 Acknowledgments & References
(September 2019) doctoraroju@yahoo.com

Introduction
 Periprosthetic fractures
 #s that occur in association with Joint prosthesis
 They occur due to
 Trauma
 Osteolysis
 Osteoporosis
 Treatment is complex
 Prosthesis may be loose
 Bone cement may impede reduction
Expertise for optimal care:
• Fracture fixation &
• Joint reconstruction

Introduction…
 Arthroplasty
 An extremely effective procedure in relieving pain & joint dysfunction
 Now frequently performed worldwide
Periprosthetic #s
are now a standard problem that the
Arthroplasty surgeon has to deal
with fairly commonly either
intraoperative or later

Introduction…
Prevention is better than cure
....but when # occurs
Best outcome is achieved
when the surgeon has
good understanding of the
principles of treatment &
access to various fixation
and reconstruction devices

Epidemiology
 The largest series of periprosthetic fracture (THA)
 1% after primary and 4% after revision THA
 75% are due to low energy trauma
 For TKA:
 0.3% to 5.5% for primary TKA and up to 30% for revision
 Supracondylar femur fractures are the most common
 For Shoulder Arthroplasty:
 0.5 – 3%
 For both hemi & TSA

Risk Factors
Patients related
 Rh arthritis
 Chronic steroid use
 Neurological disorders
 Osteoporosis
 Female gender
 Advanced age

Risk Factors
Surgeon related
 Inadequate exposure
 Femoral Notching
 Underreaming
 Overzealous reaming
 Heavy impaction
 Malpositioning
 Patient / Prosthesis

General Principles of Management
 Resuscitation
 Diagnosis
 Clinical hx
 Biodata, Mechanism
 Pre-trauma hx, Comorbidity
 Details of the implant
 Hx of infection / malignancy
 Physical Examination
 Neurovascular status
 Investigations
 Radiologic
 X-ray
 CT
 Laboratory
 CBC
 ESR, CRP

General Principles of Management…

Periprosthetic Fractures (THR)

Classifications (Femur)
Several classification systems:
 American Academy of Orthopedic Surgeons (AAOS)
 Cooke & Newman (modified Bethea)
 Johansson classification
 Vancouver
 Most widely used, based on:
 Location of # relative to prosthesis
 Stability of prosthesis
 Quality of the surrounding bone

Vancouver Classification
 A: # involve the trochanteric area
 A(G): greater trochanter
 A(L): lesser trochanter
 B: around the stem or just below it
 B1: stem stable
 B2: stem loose
 B3: stem loose, bone stock inadequate
 C: well below the stem

Treatment
Goals:
 Prosthesis stability
 Fracture union
 Preserve hip function
Principles
 Stable fixation
 Extensile incision
 Minimize soft tissue damage
 Revision of loose components
 Accurate fracture reduction

Treatment…
Options
 Nonoperative
 Limited weightbearing, Brace
 Regular clinical & radiological monitoring
 Low threshold for surgery
 Operative
 ORIF (plate and screws, cables &/or strut allograft)
 Revision THA + ORIF

Treatment…
Vancouver type A
 Stable prosthesis
 Options:
 Nonoperative (undisplaced)
 Cable grip/cable plate
 Cerclage wires

Treatment…
Vancouver type B1
 Prosthesis well‐fixed
 Options
 Wires or cables
 Plate & screws &/or cables
 Cortical onlay allograft
 Combination

Treatment…
Vancouver type B2
 Prosthesis unstable
 Revision arthroplasty + ORIF
 Uncemented prosthesis:
 Extensive coated long stem
 Fluted long stem prosthesis
 Proximal fit
 Cemented prosthesis

Treatment…
Vancouver type B3
 Prosthesis loose
 Poor bone
 Options
 Proximal femoral reconstruction
 Composite allograft
 Proximal femoral replacement

Treatment…
Vancouver type C
 Prosthesis stable
 Plate & screws
 ± cables

Periprosthetic Acetabular Fractures

Acetabular #
 Rare: 0.07 % (Peterson et al 1996)
 Disastrous complication of THA
 Usually intraoperative
 Seen with Cementless THR
 Rare in Cemented THR

Classification (Acetabular #)
Many classifications have been proposed:
 Peterson and Lewallen
 AAOS
 Unified classification system (UCS)
 Della Valle
 Comprehensive
 Reproducible

Treatment
Goals:
 Rigid fixation for bony union
 Stable integration of component
 Re-establishing:
 CoR
 Offset
 Limb length

Treatment…
Surgical Options:
 Impaction bone grafting
 Plating & column screws
 Cup screw augmentation
 Highly-porous metal cups
 Antiprotrusio cages
 Jumbo cups
 Cup/cage constructs

Treatment (Acetabular #)
Intraoperative undisplaced
 Stable #s, stable implants
 Manage nonoperatively
If there is concern about
stability; additional screws
fixation of the component
& postop protected weight
bearing is advised!

Intraoperative Displaced #
 Unstable Prosthesis
 Plating of the posterior column
 +/- BG or metal augments
 Cup with multiple screws
 +/- Protrusion cage / Jumbo cups

Traumatic Nondisplaced #
 Stable prosthesis
 Protected weight bearing for 6 – 8wks
 Healed fractures in 80 %
 Closed radiologic monitoring for 2yrs
 High rate of loosening even in # union
CT Scan is
mandatory for
decision!

Traumatic displaced
 Loose prosthesis
 ORIF (Posterior or Bicolumnar)
 Revision of the acetabular component
 ± Antiprotrusio cage

Pelvic discontinuity due to osteolysis
 Small defect / Good bone quality
 Contained ant. & post. Acetabular rim
 ORIF with posterior column plate
 + Bone grafting
 + Revision cup

 Large defect / Good bone quality
 Bicolumnar plating + BG
 + Highly porous tantalum shell
 Alternatively: Protrusion ring + BG

 Large defect / Poor defect
 A cup-cage construct augment
 Reconstruction ring
 + Highly porous cup
 + Cemented Polyethylene cup
 Can be single or 2-Staged

Periprosthetic Fractures (TKR)

Periprosthetic Fractures (TKR)
 Can occur in the femur, tibia or patella
 Within 15 cm from the joint surface
 Or within 5 cm from the intramedullary stem
Elderly:
Combined medical
conditions often disrupt
postoperative recovery
and rehabilitation.

Classifications
Neer Classification
 I – undisplaced.
 II – displaced >1 cm.
 IIa – medial shaft displaced.
 IIb – lateral shaft displaced.
 III – comminuted.
 IV – diaphyseal # above TKR
 V – periprosthetic # of the tibia
 Limitation
 Stabilty of prosthesis ?
 Bone quality ?

Classifications…
Rorabeck & Taylor (1998)
 I - Non-displaced #
Stable prosthesis
 II - ≥5 mm displacement
Stable prosthesis
 IIA (non-comminuted)
 IIB (comminuted)
 III - fracture is accompanied by
component loosening
 Limitations
 Tibia ?

Classifications
 Felix classification
 For tibia
 Femur ?

Nonoperative Treatment
 Indication
 Some undisplaced fractures
 Severe comorbidity
 Options
 Cast, brace
High risk of knee
stiffness & malunion

Surgical Treatment
ORIF
 Indications
 Most # with stable prosthesis
 Options
 Plate & Screws
 IM Nails

Surgical Treatment…
Revision TKR
 Indications
 Loose prosthesis
 Inadequate bone stock
 Nonunion that requires tumor
prosthesis

Periprosthetic Fractures (Shoulder)

Periprosthetic Fractures (Shoulder)
(TSA/rTSA/hSA)
 Intraoperative
 Frequent during revision
 Postoperative
 High nonunion rate

Classification
 Wright and Cofield (1995)
 Worland et al (1999)
 Groh (2008)
 Campbell et al
 Duncan (UCS)
 Kirchhoff et al (2016)
 Most comprehensive to date
Kirchhoff takes into account:
Type of humeral prosthesis
Status of the rotator cuff
Location of fracture
Fracture pattern
Implant stability

Classification…
 Worland et al

Treatment Algorism (Kirchhoff et al )

Treatment

Treatment…

Complications
 Secondary fracture
 Non-union
 Infection
 DVT
 Dislocation
 Neurovascular injury
 Mortality

West African Perspectives
 TBS
 Ignorance
 Poverty
 Technical supports
 Health insurance
 Infrastructure

Take Home Message
 Periprosthetic #s are now not uncommon
 Severe complication in joint reconstruction
 Management is mainly surgical & can be challenging
 Prevention is better
 Proper assessment of # & prosthetic stability are crucial
Nonoperative therapy is only justified in
nondisplaced #s with stable prosthesis
and prolonged monitoring is mandatory

Acknowledgements

References
 Aaron G, Adam G, Timothy S, Michael K. Periprosthetic humerus fractures: classification, management, and review
of the literature. Ann Joint 2018; 3:49
 Harry R, Jonathan M. Femoral shaft, distal femoral and periprosthetic fractures. In: Sebastian DB, Pramod A,
Timothy B, Manoj R. Orthopaedic Trauma; The Stanmore and Royal London Guide. CRC Press Taylor & Francis
Group 2015; 18: 247 – 257
 Jae DY, Nam KK. Periprosthetic Fractures Following Total Knee Arthroplasty. Knee Surg Relat Res 2015;27(1):1-9
 Bassam AM, Dominic RM, Clive PD. Periprosthetic fracture evaluation & treatment. Clin Ortho 2004; 420: 80 – 95
 Gregory JD, Kwok SL, Hans-Christoph P. Periprosthetic Fractures: Epidemiology and Future Projections. J Orthop
Trauma 2011; 25: S66–S70
 Greiner S, Stein V, Scheibel M. Periprosthetic Humeral Fractures after Shoulder and Elbow Arthroplasty. Acta
Chirurgiae Orthopaedicae Et Traumatologiae Čechosl. 2011; 78: 490–500

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