PERI PROSTHETIC FRACTURE AROUND HIP

1. PERI-PROSTHETIC
FRACTURES AROUND HIP
Moderator: Dr. DHARMENDRA KUMAR (MS)
Additional Professor
Department of Orthopedic Surgery
KGMU, Lucknow
Presented by:
Dr. AMIT KUMAR
JR-3
Department of Orthopedic Surgery
KGMU, Lucknow

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

3. Introduction
• Peri-implant Fracture: fracture around implant (plate, rod, prosthesis)
• Peri-prosthetic Fracture: is a type of peri-implant fracture which occurse
around joint replacement 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 (Total hip Arthroplasty)
I. 1% after primary and 4% after revision THA
II. 75% are due to low energy Trauma
More commonly seen in
• Females
• Old age 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 and due to incorporation of bone
cement with medullary canal.
• Risk of peri-prosthetic increases when there is mismatch between shape of long
prosthesis stem & the shape of bone

6. Risk Factors
Poor bone quality
• Major Risk factors:- female, Revision
surgery, elder age group.higher BMI
• Osteopaenia, Osteolysis, Osteoporosis
• Medication related such as Chronic
steroid
• Diabetes
• OA
• Inflammatory arthritis RA
• Infection
• Pagets disease
• Stiffness
• Neurological condition:- Epilepsy,
Parkinson’s, Ataxia, Myasthenia.
• Infection
Surgery related
• Inadequate exposure
• Under-reaming
• Overzealous Reaming
• Heavy impaction
• Mal-positioning of prosthesis
• Cemented Arthroplasty correlate with
low prevalence
• Over resection
• Cement mantle fracture
• Lucency at cement-bone/cement
mantle

7. Intra-operative risks:
• Risk factors to intra-operative #
• Under ream >2mm
• Impaired bone quality
• Cementless component
• Dysplastic bone
• Signs of intra-operative #
• Sound of crack
• Sudden change in resistance
• Abnormal movement

8. Sign and Symptoms
• Start up of abrupt pain
• Increase difficulty with ambulation
• Progressive limb shortening
• Increasing deformity of the extremity

9. Investigations
• Radiologic
• X-ray
• CT scan
• MRI
• DEXA
• Laboratory
• Routine blood investigations
• ESR
• CRP
• Calcium profile

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
 A: fracture 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: fracture well below the stem

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. Intra-operative Principles
• Stable Intra-operative
• Observation
• Bracing
• Use of cast
• Protected weight bearing
• Unstable intra-operative
• Revision with screws/ exchange of cup / exchange of implant
• Open reduction and internal fixation
• Bone graft application
• Protected weight bearing

17. Intra-operative Principles Cont’d
• Revision Principle
• Use the fracture for access to remove implant
• Bypass the fracture with long stem
• Stabilize fracture
• Get stable implant fixation

18. Vancouver Classification - Intraoperative Periprosthetic Fracture

19. Management principles

20. Management : Intraoperative fractures

21. Management : postoperative fractures

22. Pitfalls and prevention

23. Pitfalls & prevention

24. 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

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

26. • 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

27. • Vancouver type B
• Identified mostly intra-operatively and treated mostly with
intervention
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

28. 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

29. • 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

30. • 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

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

32. 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

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

35. Complications
• Dislocation
• Infection
• Instability
• Re-fracture
• Non-union
• Aseptic loosening
• Implant failure
• Scar complications

36. Periprosthetic
Acetabular Fractures

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

38. Acetabular Fracture
• The incidence is 0.2%. cemented THA
• The incidence has increased Cementless
• Under-reaming of the acetabulum
• Press-fit stability with a cementless.
• Under-reaming by as much as 4 mm is acceptable
• Now agree that 2 mm or less is safer

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

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

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

42. 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!

43. Treatment (Acetabular #)
Intraoperative Displaced #
 Unstable Prosthesis
 Plating of the posterior column
 +/- Bone grafting or metal
augments
 Cup with multiple screws
 +/- Protrusion cage / Jumbo
cups

44. Treatment (Acetabular #)
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!

45. Treatment (Acetabular #)

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

47. Treatment (Acetabular #)

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

49. Treatment (Acetabular #)
Pelvic discontinuity due to osteolysis
 Large defect / Good bone quality
 Bicolumnar plating + Bone grafting
 + Highly porous tantalum shell
 Alternatively: Protrusion ring + Bone
grafting

50. Treatment (Acetabular #)

51. Treatment (Acetabular #)
Pelvic discontinuity due to osteolysis
 Large defect / Poor defect
 A cup-cage construct augment
 Reconstruction ring
 + Highly porous cup
 + Cemented Polyethylene cup
 Can be single or 2-Staged

52. Treatment (Acetabular #)

54. Conclusion
• Principle of management of PF is still an evolving technique
• Fracture pattern, Patient factors, and healing potential must be
considered
• Emphasis on simultaneously creating strong, durable mechanical
construct
• Optimization of the biologic environment for fracture healing

55. Thank You