Periprosthetic fractures after hip replacement need skill full management. Key is to diagnose them appropriately and instate an early management.

1. Peri-prosthetic Hip #
Management: Algorithm
Dr Vaibhav Bagaria
Hip and Knee Surgeon
Sir HN Reliance Foundation Hospital
Mumbai India

2. Problem Statement
• Berry reported an incidence of 0.3% in primary
cemented and 5.4% in uncemented THAs from
the Mayo Clinic joint registry
• In Revision setting, higher rates of fracture were
seen with a rate of 3.6% in cemented and 20.9%
in uncemented THAs

3. Risk Factor
• Patient Related
• Surgical Technique
• Choice of Implant

4. Risk factors
• P: Female,age, DDH, RA, Paget disease,
osteoporosis, steroid.
• T: MIS approaches, Toothed Calcar Mills
• I: Uncemented. Acetabular under reaming;Heavy
Impaction on femoral side

5. Mechanism
• Fall or Osteolysis or combination thereof!
• Torsional forces caused intertrochanteric #
• Anterior loading caused supracondylar #
• lateral loading caused # at the tip of the stem

6. Initial Evaluation
• Mechanism, Co morbidties.
• Pain prior to fall may indicated Osteolysis.
• Details of the implant should be obtained,
including manufacturer, model, and size as this
will enable the desired extraction kit to be ordered

7. Acetabular #

8. 26. Della Valle CJ, Momberger NG, Paprosky WG: Periprosthetic fractures of the acetabulum associated with a total hip arthroplasty. Instr Course
Lect 52:281–290, 2003

9. Basics
• High Index of suspicion intra-operatively
• Imaging: Judet’s view
• Osteolysis evaluation
• Inventory planning - Implants/ Instruments
• Reconstruction armamentarium

10. Paprosky & Sekundiak
• Superior component Migration > 2 cm ( loss of
superior structural support)
• Ischial Lysis ( loss of posterior column Support)
• Destruction of tear drop Line ( loss of the inferior
part of anterior column)
• Break in the Kohler’s Line ( Anterior column
Deficiency)
• Radiographic Marker for severe bone loss
Paprosky WG, Sekundiak TD: Total acetabular allogra s. Instr Course Lect 48:67–76, 1999

11. Vancouver - Intraop
5Duncan CP, Masri AB: Fractures of the femur a er hip replacement.
Instr Course Lect 44:293–304, 199

13. Vancouver Postop

15. Aim - SPAM
• Stabilising the fracture
• Preserving hip function
• Achieving bony union
• Maintaining component orientation and stability

16. Type 1A Acetabulum
• Additional Screws
• Restricted weight Bearing

17. Type 1 B
• Column Injuries
• Remove the implant to assess #
• Anatomic recon & # Fixation
• Rim fit with additional screw

18. Medizinische Hochschule Hannover collection.

19. Type 1C
• Not recognised - hence difficult situation
• Additional Screw
• Autologous BG
• Restricted weight bearing
• Close observation

20. Type II - Acetabulum
• < 50% loss of bone stock (type IIA), then a
porous-coated hemispherical acetabular
component can be used after fracture has been
reduced and stabilized with internal Fixation.
• Contained defects filled with morselized bone
graft , larger defects may require structural graft
• > 50% bone loss (type IIB) Anti Protrusion Cage
or TM

21. Type III Acetabulum
• Post op traumatic #
• Mgmt Dictated by stability
• Stable IIIA: restricted weight bearing
• Unstable IIIB: Revision with Fracture Fixation

22. Type IV Acetabulum
• Severe osteolysis - hence management similar to
Revision arthroplasty.
• Reconstitute the bone stock with suitable graft
• Use adequate revision implant (e.g., cup-cage
construct) the fracture must also be held in rigid
internal fixation for optimal results.

23. Type V
• Pelvic Discontinuity
• Difficult Cases
• Adequate prep planning; 3D printed Biomodels
• Customised 3D printed Implants.

25. Femur

26. Preventing Intraop Femur #
• Adequate Exposure
• Avoid In-situ Cuts
• Femoral Torsion while dislocating
• Very Gentle in Protrusion cases
• Intra op Imaging

27. Femur Type IA
• Undisplaced cortical perforations in trochanteric
region,
• Treated with packed bone graft obtained from
acetabular reamings
• Restricted weight- bearing.

28. Type A2
• Un-displaced
• Require reinforcement with cerclage fixation
• To prevent propagation of #, implant failure,
decreased abductor muscle function, &
dislocation.

29. Type A 3
• Displaced & needs reduction
• Cerclage Cable Wires
• Claw Plates
• Changing to diaphysial fit

30. Type B1
• Cortical perf occurs during revision
• Bypass with longer stem/ Good fit
• Prophylactic Wire/ Cables
• Cortical Strut allograft where long stem not long
enough

31. Type B 2
• Undisplaced linear cracks
• Cause: hoop stresses during broach/ stem insertion.
• Treatment depends on implant stability.
• Stable: Protected weight bearing
• Implant Migration: Revision to Long stem and
Circulate wiring. If the stem not long enough cortical
strut +/- Plate fixation.

32. Type B3
• Displaced #
• Mgmt: ORIF + Long Stem
• Oblique or Spiral #: Cerclage Wire
• Transverse #: Cortical Strut Graft

33. Type C1
• Rare; Only Distal Perforation
• Following Cement removal or canal prep
• Morselized BG or Cortical Strut overlay to prevent
stress riser.

34. Type C2 & C3
• Undisplaced
• Recognised intra - op: Steps to prevent
propagation
• CEraclage Cable or locking Plate

35. Post Op Femoral #
• Elderly patient
• Trivial Fall
• Immediate Mgmt: Analgesia/ Fluid
resuscitation/medical co morbidities
• Skin/ Skeletal traction helpful

36. Type A
• Considered Stable
• < 2 cm displacement: NWB
• Displaced A G leads to loss of abductor function:
may need fixation
• Displaced AL: less common, loss of medial
support may comprise the Implant Stability.

39. Type B1
• At or around tip of the implant
• Implant is stable
• Treated with ORIF

41. Type B2
• Most common type
• Fracture Fixation
• Revision stem Bypassing the previous implant by
two cortical Diameter
• Both Cemented and uncemented

42. Type B 2
• Uncemented: Extensively coated diaphyseal
Stem
• Soft tissue balancing crucial
• Cemented revision ideal for osteoporotic canals.
• Cement in cement revisions.

43. Circalage Wires
• Require no intraosseous anchorage
• centripetal fracture reduction
• Shaft is not a ‘round tube’
• No micro #

45. Type B 3
• Bone loss either because of com munition or
Osteolysis
• Need to tackle both stem and the bone loss.
• Distal fixed Stems/ Cemented stem/ Allograft
prosthetic composites (APC)/

47. Type C
• Essentially a femur shaft/distal femur #
• Plating / Nailing
• Studies -> Non locking with longer bridging better
than rigid locking plates

54. Key Points
• Think Implant stability
• Think Fracture pattern & displacement: Long
oblique/ spiral vs transverse/ short oblique
• Think Bone Quality: Need for BG strut
• Armamentarium/ 3D printed model & preop
planning.