This document discusses hip periprosthetic fractures that occur around the stem of a total hip arthroplasty. It describes risk factors, classifications, evaluations, and treatments for these fractures. For acetabular fractures, the Letournel classification is used and treatment depends on stability and motion. For femoral fractures, the Vancouver classification is based on fracture site, stem stability, and bone quality. Types A, B1, B2, and C fractures are described along with appropriate fixation methods like plates, screws, cables or cerclage wires depending on the specific situation.

1. Hip Periprosthetic fracture
Around the stem of a
THA

2. Introduction
• A difficult surgical problem for orthopedic
surgeons.
• Occurred during or after the operation.
• Acetabulum, the femur, or both.

3. Risk Factors for Acetabular Fracture
• Osteoporosis
• Poor bone stock.
• Uncemented acetabular components.
• Under-reaming of the acetabulum.
• Revision of an acetabular stem.
• Early weight bearing on pathologic bone

4. Risk Factors for Femoral Fracture
• Osteoporosis.
• Poor bone stock.
• Uncemented femoral stem.
• Revision of a femoral stem.
• Previous fracture neck of femur treated THA
• Osteolysis and aseptic loosening.

5. 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

6. Femoral Fracture
• Incidence of 0.1% to 1% cemented stems.
• Higher incidence in uncemented THAs.
• Force to achieve primary stem stability.
• Berry reported:
- 0.3% in (20,859)cemented stems
- 5.4% in (3121) uncemented stems.

7. Diagnosis
Intraoperative
• Direct observation or radiographs.
• Occur during:
1- previous implant removal.
2- bone preparation.
3- placement of the revision implant.

8. Postoperative fractures
• History and physical examination.
• A cute onset of pain.
• Deformity .
• History of a fall.
• During follow up.

9. Radiographic Evaluation
• Full-length views of the femur ( AP, lateral view)
• AP pelvic radiograph.
• Judet views - to evaluate the floor, roof, and columns
of the acetabulum.
• CT and MRI
• unusual complexity, especially around the
acetabulum.

10. Evaluation
• Exclude the possibility of infection.
• Inflammatory markers.
• Intraoperative testing : frozen section analysis of
periprosthetic tissues.

11. Classification: Acetabular Fractures
• Classification developed by Letournel.
• Posterior wall
• Posterior column
• Anterior wall
• Anterior column
• Transverse injuries
• Both columns,
• Transverse plus posterior wall,
• Anterior wall/column plus posterior hemitransverse,
• Posterior column plus posterior wall
• T-shaped injuries.

12. Classification Letournel

13. Classification: Femoral Fracture.
• Vancouver classification.
• This system is based on
- Site of the fracture.
- Stability of the stem.
- Quality of bone.

14. A B1 B2 B3 C

15. Type A
(AG - AL )

16. Type B1
implant stable , good bone stock

17. Type B2
unstable implant , good bone stock.

18. Type B3
unstable implant, poor bone stock.

19. Type C
Distal to stem

20. Management

21. Stability of implant
• X-ray.
• Continuous lucency at the cement-bone
interface or cement-implant interface.
• If questionable, it must be tested
intraoperatively.
• Generation of shear force along the
longitudinal axis between the implant and
bone.

22. Treatment -Acetabular Fractures
1. Stable fractures require no additional fixation.
2. If considerable motion:
- additional screw fixation.
- non–weight bearing postoperatively.
3- If motion and pelvic dissociation
- ORIF a pelvic reconstruction plate.

23. Type A Intraoperative Fractures
1- Cerclage wires.
2- Cables.
3- Trochanteric claw plate and cables.

24. Type A Postoperative Fractures.
greater trochanter
• Usually stable
• Treated nonoperatively if displacement < 2 cm.
• Protected weight bearing .
• Take 6 to 12 weeks.
• Displaced > 2 cm.
• A painful and weak abduction
• Need reduced and fixed.

25. Type A
Trochanteric claw plate and cables

26. Type A Postoperative Fractures
lesser trochanter
• uncommon.
• nonoperatively.

27. Type B1- stable implant, good bone stock
• Treated with a plate and screws, with cerclage wires
or cable fixation.
• Locking plates with unicortical screws.

28. B1

29. Type B2- unstable implant, good bone stock
• A longer stem ((bypassing the distal extent of the fracture by
at least two diaphyseal diameters)).
• A cerclage wire or cable
• If the fracture too distal:
-a cortical strut graft.
- a plate and screws.

30. Type B2

31. Type B3: unstable implant, poor bone stock
• Reconstructive techniques
1- Replacement of the proximal femur with allograft prosthetic
2- A proximal femoral replacing prosthesis.
• Gross popularized the use of segmental allograft to reconstruct
bone deficiency when revising total hip replacements with B 3
fractures.

32. proximal femoral replacement

33. Type C Fractures
• Undisplaced linear fractures
-cerclage wires with or without a cortical graft.
• Displaced fractures: locking plates with cerclage
wires or cables .

34. Type C Fractures

35. Postoperative care
• According to the patient characteristics.
• Stability of the implant.
• Toe-touch weight bearing is recommended for
12 weeks.
• Appropriate thromboprophylaxis and
antibiotic prophylaxis should be given.

36. Thanks