a simplified version of periprosthetic fractures, easy to learn and understand with lots of images and classification. It includes hip, shaft of femur, knee, shoulder

1. PERIPROSTHETIC FRACTURES
Dr. PRAJITHV P
JUNIOR RESIDENT
DEPARTMENT OF ORTHOPAEDICS

2. CONTENTS
PERIPROSTHETIC FRACTURES OF FEMORAL SHAFT ABOUT HIP ARTHROPLASTY
STEM
PERIPROSTHETIC ACETABULAR FRACTURES
PERIPROSTHETIC SUPRACONDYLAR FEMUR FRACTURES ABOUT TOTAL KNEE
ARTHROPLASTY
PERIPROSTHETIC TIBIA AND PATELLA FRACTURES
PERIPROSTHETIC HUMERAL SHAFT FRACTURES ABOUT SHOULDER
ARTHROPLASTY
PERIPROSTHETIC GLENOID FRACTURES

3. INTRODUCTION
▪ Periprosthetic fractures (PF) are considered
fractures associated with an orthopedic implant,
whether a replacement or internal fixation device.
▪ The global incidence of all types of PF is increasing
constantly due to the growing number of primary
joint arthroplasties and revision surgeries.

4. INCIDENCE
▪ Rates of postoperative PF after primary total hip
arthroplasty (THA) ranging from 0.1 to 18%,
▪ after total knee arthroplasty (TKA) from 0.3 and
5.5% and
▪ after total shoulder arthroplasty (TSA) from 0.5 to
3%

5. ETIOLOGY,MECHANISM OF INJURY
▪ Low energy falls (most common)
Lower extremities Post operatively
Upper extremities Intra operatively
 High energy falls
 Revision arthroplasty
 Mismatch of shape of long prosthetic stems and the shape of bone.

6. HISTORY & PHYSICAL EXAMINATION
▪ Details of prosthesis
▪ Date of implantation
▪ Index diagnosis
▪ Additional secondary procedures
▪ Prior infection
▪ Handedness, occupation, ambulatory status
▪ Recent change in symptoms

7. ▪ Prior surgical wounds
▪ Associated lesions
Venous stasis
Diabetic ulcers
 Limb length evaluation
 Assessment of strength & neurological examination

8. IMAGING
▪ More subtle fractures can occur when associated with osteopenia or
osteolysis.
▪ Usual AP and lateral views of joint with bones above and below joint
is included.
▪ Useful for assessing prosthetic loosening, presence of osteolysis,
prosthetic limb alignment.
▪ Prefracture radiographs can give clues to any existing or impending
prosthetic failure, progression of cortical erosions, presence of any
cortical penetrations or notching.

9. PF OF FEMORAL SHAFT ABOUT HIP
ARTHROPLASTY STEM
▪ Incidence is from 1% to 2.3% (after primary
arthroplasty)
0.8% occurs at 5 years of time
3.5% occurs at 10 years of time
 After revision arthroplasty incidences climbs to
between 1.5% - 7.8%

10.  Risk factors are: Age
Gender
Index diagnosis
Osteolysis
Type of implant
Non cemented
Loose stems

11. VANCOUVER CLASSIFICATION (POST OPERATIVE)

12. VANCOUVER CLASSIFICATION
(INTRA OPERATIVE)

13. TREATMENT PROTOCOL
▪ VANCOUVER TYPE A
i. Lesser trochanteric PF are generally managed non – operatively
with symptomatic treatment unless substantial medial cortex is
involved.
ii. Protected weight bearing, Assist devices
iii. Limited medial cracks are treated with 1 or 2 cerclage cables
iv. Greater trochanteric stable fractures are also managed similarly.

14. ▪ Unstable and widely displaced
greater trochanteric fractures are
treated operatively with ORIF when
associated with pain, weakness,
limp or instability.
▪ Claw plates are generally used
▪ Distal fixation is with cables.
▪ If substanstial osteolysis is present,
bone grafting is indicated

15. ▪ VANCOUVER TYPE B
i. In case of well fixed stable implants ORIF with plate and screws or
cortical onlay allografts or combination of both.
ii. A bowed plate to accommodate sagittal bow of femur is preferred.
iii. Reduction is achieved by using soft tissue traction while obtaining
axial and rotational alignment and the correct length. It minimize
soft tissue disruption and preserve vascularity.
iv. Long plates which extend to lateral femoral condyle
v. Locked screws are used distally in case of osteoporotic bone

16. ▪ Distally the plate should either have minimum of 6-8 holes covering
the femur distal to stem
▪ 3 or more equally space cables are used proximally between LT and
tip of the stem.
▪ 2 screws are placed immediately distal to the prosthesis
▪ The distal extent of plate is secured with additional screws

17. ▪ Addition of cortical struts allografts offers prolonged construct
stability.

20. VANCOUVER TYPE B2 AND B3
▪ Revision of femoral component
▪ Fracture fixation with lateral plate or reconstitution of bone stock
with allograft strut or combination of both in addition to it.
▪ Revision strategy depends on quality of remaining bone stock,
diameter of the femoral canal distal to thee fracture and patient
factors like age and baseline functional status.
▪ Through fracture, cement and cement restrictors can be removed.
▪ If necessary proximal fracture fragment can be split coronally to
allow excellent access for stem removal and direct visualization of
distal canal to allow accurate reaming

21. ▪ Acetabular component is exposed after
femoral component is removed.
▪ The liner is removed if modular and
acetabular component is tested for
stability
▪ If loose acetabular revision is
performed.

22. ▪ Cemented long stem revision is considered
especially in very osteopenic bone with capacious
canals.
▪ If fracture is anatomically reduced and fixed with
cerclage cables and if cement is not vigorously
pressurized, cement extravasation will no typically
occur.

23. ▪ Extensively coated uncemented long stem prosthesis with or without
lateral plate augmentation if canal diameter is < 18mm, simple
fracture and 5 cm of parallel endosteal diameter is available.
▪ Fluted titanium tapered modular stems if canal diameter is > 18 mm.
▪

24. ▪ If proximal bone is so deficient,
then either proximal femoral
replacement or proximal femoral
allograft is used.
▪ Since it is osteopenic bone,
cemented distal fixation is
recommended.

26. ▪ A sleeve of remaining proximal bone is preserved so that it provides
some some tissue attachment.
▪ The new implant is cemented into distal fragment and then proximal
sleeve of remaining bone and soft tissue can be cerlaged around

28. ▪ Post operatively patients are mobilized typically
with 50%Weight bearing initially followed by full
weight bearing being at 6-8 weeks.
▪ A brace is applied to avoid hyperflexion and
adduction

29. VANCOUVER TYPE C
▪ Usually supracondylar and intercondylar
fractures
▪ Lateral locking plates are used rather
than retrograde nails to provide fixed
angle stability of the end segment and
improved fixation in osteoporotic shaft
fragment.

30. ▪ Plates should overlap distal femoral stem
▪ Proximal fragment is fixed with multiple screws
distal to stem
▪ Cables are supplemented around the plate in the
zone of femoral prosthesis

32. PERIPROSTHETIC ACETABULAR FRACTURES
▪ Intra operative fractures are most common; usually with non
cemented components, elliptical monoblock designs
▪ Post operative fractures can be due to fall from standing height,
reduced bone quality/quantity and osteoporosis

34. PETERSON & LEWALLEN CLASSIFICATION
• Radiologically stable component
• Passive range of motion of hip causes little pain
TYPE
1
• Radiologically loose component
• Displaced acetabular component
• Notable pain
TYPE
2

35. ▪ Treatment algorithm depends on medical condition and functional
demands of patient, time of fracture, displacement, location and
stability of component
▪ Careful reaming
▪ Avoid excessive force
▪ Underreaming of acetabulum > 2mm should be avoided

36. TREATMENT
▪ INTRAOPERATIVE
▪ AP/Obturator/Oblique views are taken
▪ Small fractures of anterior/posterior walls will not affect the stability.
▪ Large wall fractures or fracture that traverses one of the acetabular columns
needs fixation
▪ Non displaced fractures are fixed by screws

37. Displaced column fractures need plate and screw fixation
along with bone grafting
After fixation acetabulum is reamed line to line for new
multi hole component.
6 weeks weight bearing restriction.

38. ▪ POSTOPERATIVE
i. FRACTURES ABOUT STABLE COMPONENT
• Protected weight bearing for 6-12 weeks
• Frequent follow up for any evidence of early
loosening
• If widely displaced immediate surgical
treatment

39. ii. FRACTURES ABOUT LOOSE
COMPONENT
• Revision of acetabular
component
• Supplemental fracture fixation
with plate and screws
• If associated severe osteolysis is
present; bone grafting or
reconstruction cage or both

42. PERIPROSTHETIC SUPRACONDYLAR FEMUR
FRACTURES ABOUT TKA
▪ Incidence rate is 0.3% - 2.3%
▪ Upto 38% after revision arthroplasty
▪ Risk factors include
i. RA
ii. Osteolysis
iii. Frequent falls
iv. Disuse osteopenia
v. Anterior femoral notching
vi. Posterior stabilized femoral component that removes bone from intercondylar
n region

43. LEWIS & RORABECK CLASSIFICATION
TYPE 1
• Stable; minimal or no displacement
• Intact prosthesis-bone interface
TYPE 2
• Displaced
• Maintain an intact prosthesis-bone interface
TYPE 3
• Displaced/non-displaced
• Have a loose femoral component

45. SU CLASSIFICATION
TYPE 1
• Proximal to
femoral
component
TYPE 2
• Originate at
proximal end
of the
component
and extend
proximally
TYPE 3
• Extend distal
to the
proximal
border of
femoral
component

47. TREATMENT
▪ Treatment options include RETROGRADE IM NAIL, LOCKING PLATE
AND SCREWS AND REVISION KNEE ARTHROPLASTY
▪ Various challenges for fixation are:
▪ Presence ofTKA prosthesis interfere with fixation.
▪ Narrow or closed intercondylar notch limits retrograde nail insertion.
▪ Traditional condylar buttress type plates are more prone for varus
collapse particularly if comminution is present.

48. Retrograde intramedullary nailing provides less chances of non
union.
Used in metaphysio-diaphyseal fractures.
But in patients with wide metaphyseal areas or associated
osteopenia can lead to loss of fixation and Malalignment.
Also when someTKA designs because of closed or narrow
intercondylar notch there will be potential diffiuclties in nailing
and also maximum diameter should be limited.

50. ▪ Blocking screws/poller screws are
used for fixation
▪ These screws place anterior to
posterior to control varus-valgus
alignment and from medial to
lateral to control flexion,
extension alignment.

51. ▪ Newer locked plates with multiple distal locking screws provides fixed angle and
useful in osteoporotic fractures.
▪ Used in fractures distal to metaphysio-diaphyseal junction
▪ Combination of bicondylar and unicondylar screw fixation provide excellent
fixation.
▪ a lateral plate is applied and fixed distally first with non locked then with locked
screws.
▪ Proximal fixation is with non locked or locked screws depending on the presence
of osteoporosis

53. ▪ If the fracture is associated with loose prosthesis or inadequate bony
stock or supracondylar non union REVISION KNEE ARTHROPLASTY
is preferred
▪ Various challenges are :
▪ Large bony defect secondary to comminution, multiple procedures
or broken hardware.
▪ Areas of osteolysis
▪ Short peri articular fragments

54. ▪ RevisionTKA with large intramedullary
femoral stems are used if there is adequate
bone stock is present
▪ Cemented may also be used.
▪ If needed allograft struts with cerclage
wiring can be used to reinforce the
stability.

55. ▪ Another option if there is not enough bone to support is distal
femoral replacement with modular megaprosthesis
▪ These are particularly used in elderly patients with refractory
supracondylar non union and also in acute fracture with inadequate
bone stock
▪ Cemented fixation is typically used.
▪ If the patient is young and active allograft prosthetic composite is a
better alternative.

57. PERIPROSTHETIC TIBIA AND PATELLA
FRACTURES ABOUT TOTAL KNEE ARTHROPLASTY
▪ Frequency of periprosthetic tibia and patella fractures are less common when
compared to femoral side of prostheses
▪ 0.4% in tibia, 0.7% in patella
▪ Fractures of patella generally occur postoperatively
▪ Directly associated with trauma
▪ Most fractures during first 2 years after arthroplasty

58. ▪ Etiologic factors include, osteopenia, RA and those taking
corticosteroids
▪ Specific etiologic factors include component design, excessive
resection of bone, limb and prosthesis alignment, presence or
absence of a lateral release (causing devascularisation of patella)
▪ Intraoperative fractures can be due aggressive clamping of patella
component, bone resection (leaving 10-15 mm of bone)

59. ▪ Local risk fractures of tibial periprosthetic fractures are
i. Osteotomy of tibial tubercle
ii. Prior bony defects such as tunnels fromACL reconstructions
and from bone-patellar-tendon-bone donor sites
iii. Prior holes from fixation devices for tibial plateau fractures
or high tibial osteotomy.
iv. Prior fracture malunion
v.Technique of implantation

60. ORTIGUERA AND BERRY CLASSIFICATION

61. FELIX CLASSFICATION

62. TREATMENT
▪ PATELLA
i. When the extensor mechanism is intact non operative
management is recommended.
ii. When there is disturbance of extensor mechanism integrity, loose
patellar component and patellar maltracking ORIF withTBW or
cerclage wiring is done.
iii. Presence of fracture and a loose implant requires either removal
or revision of patellar component

63. iv. When adequate bone stock (>10mm) is there, revision of patellar
component is done.
v. When there is bone deficiency patellar revision arthroplasty with
partial or complete patellectomy
Operative management is highly associated with non union and
infections. It can be due to the relatively small and avascular fracture
fragment and also by surgical dissection.

66. ▪ TIBIA
i. When associated with well fixed component, non
operative management with cast or brace if non
displaced and ORIF for displaced fractures
ii. Frequent radiographic surveillance for
maintenance of limb alignment
iii. If satisfactory alignment is not attained, then it is
converted to ORIF

67. i. ORIF is advisable for displaced fractures in the metaphyseal-
diaphyseal junction
ii. Locked screws proximally and either locked or non locked screws
distally with a lateral plate
iii. Often supplemented by postero medial locking plate and bone
grafting

68. ▪ When associated with loose component, revision arthroplasty with
long stem is done.
▪ If extensive osteolysis is present, structural or morselized bone
grafting, use of metal wedges
▪ In severe osteolysis, proximal tibial megaprosthesis or allograft
prosthetic composite is used.
▪ Contemporary techniques include metaphyseal filling sleeves

71. PERIPROSTHETIC HUMERAL SHAFT
FRACTURES ABOUT SHOULDER
ARTHROPLASTY
▪ Incidence is between 0.6% - 2.3%
▪ Intraoperative fractures are more common
▪ Risk factors include RA, osteopenia or severe cortical thinning.
▪ Excessive external rotation required to provide exposure in patients
with large muscles or scars
▪ Overreaming of diaphysis causing notching of endosteum may
produce spiral fractures.
▪ Oversized prosthesis can cause transverse or oblique fractures

72. WRIGHT AND COFIELD CLASSIFICATION
TYPE A
• Centered at tip of stem and extend proximally
more than 1/3 the length of stem.
TYPE B
• Centered at the tipoff stem but with less
proximal extension
TYPE C
• Involves distal humeral diaphysis, distal to the tip
of the stem and extending into the metaphysis

74. CAMPBELL CLASSIFICATION
• GREATER/LESSER
TUBEROSITIES
REGION 1
• PROXIMAL METAPHYSISREGION 2
• MID AND DISTAL
DIAPHYSIS
REGION 3
REGION 4
• PROXIMAL HUMERAL
DIAPHYSIS

76. GROH CLASSIFICATION
TYPE 1
• PROXIMAL
TOTHETIP
OF
PROSTHESIS
TYPE 2
• PROXIMAL
TOTHETIP
AND EXTEND
DISTALTO IT
TYPE 3
• ORIGINATE
BELOWTHE
TIP

78. WORLAND CLASSIFICATION

80. TREATMENT
▪ Non or minimally displaced
LESSERTUBEROSITY fractures
and cracks of GREATER
TUBEROSITY are repaired by
using heavy non absorbable
sutures

81. ▪ Intraoperative displaced shaft of humerus is
corrected with long stemmed non cemented
prosthesis with adjunctive cerclage cables in
case of spiral fractures
▪ In case of transverse fractures, long
stemmed prosthesis with either plate or strut
stabilization

82. ▪ Post operatively non or minimally displaced stable fractures
especially in elderly are managed non operatively by immobilisation
with brace.
▪ If the fracture is associated with loose prosthesis long stem revision
arthroplasty with non cemented technique is preferred
▪ If severe osteolysis is present, impaction bone grafting
technique/allograft prosthesis composite/tumor prosthesis is
substituted.

84. PERIPROSTHETIC GLENOID FRACTURES
ABOUT SHOULDER ARTHROPLASTY
▪ They occur intraoperatively
▪ A retractor that is on the posterior glenoid margin to retract the
humerus posteriorly can cause fracture.
▪ Risk factors include patients undergoing revision surgery and severe
osteopenic patients.
▪ No generally accepted fracture classification exists.

85. ▪ Large fragments may be treated with screws or
plates.
▪ If fragments are small and comminuted they are
not amenable to screw fixation.
▪ If bone support is inadequate, bone grafting is
supplemented.
▪ After fracture healing, conversion of
hemiarthroplasty to total shoulder arthroplasty
can be thought off.

86. COMPLICATIONS
i. NON UNION
 Most common complication
 Damage to endosteal blood supply related to the intramedullary
implant
 Prosthesis inhibiting optimal fixation leading to compromised
fixation
 Biologic reduction techniques and locking plates improve rates of
non union

87. ▪ Correction of any systemic processes that inhibit fracture
healing
▪ It includes smoking cessation, discontinuation of NSAIDS,
strict control of diabetes
▪ Operative stratagies include long stem prosthesis along
with extramedullary strut and plate fixation
▪ Generous use of osteogenic and osteoinductive grafts and
graft substitutes.

88. ii. NEUROLOGIC INJURY
 Commonly seen with fixation of humeral shaft fractures.
 Risk factors include proximity of radial and ulnar nerve to
the fracture, fixation devices, securing cerclage cables
 Appropriate choice of surgical approach – POSTERIOR
APPROACH
 Gentle soft tissue handling
 Avoidance of forceful and prolonged retraction of nerves

89. iii. INFECTION
 Fracture healing is compromised
 C&S
 Long term oral suppression of specific antibiotics
 Aggressive early surgical treatment with irrigation and
debridement.
 Failure to control infections results in resection
arthroplasty or amputation at or above the involved joint.

90. iv. JOINT STIFFNESS
 Due to contracture and scar of the surrounding soft
tissues
 Immobilization of joint as part of fracture care
 Minimize the requirement for joint immobilization
 Allow as early as possible range of motion
exercises.

91. REFERENCES
▪ Rockwood and Greens’s fractures in adult;seventh edition;volume 1