Periprosthetic Fractures

Lisa K. Cannada MD

Disclosures

• Member: MAOA BOD• Research Grant Monies

Goals

• Learn decision making for periprosthetichip and knee fractures:–When to treat non-operatively–When to fix–When to revise

Overall

• Periprostheticfractures are increasing

• Very difficult to treat• Treatment can violate

the tenant of care “early mobilization”

Problems

• Patients are even more frail than hip fracture patients

• Many w/multiple comorbidities

• Are deconditioned from previous surgery

• Surgery can be difficult

Periprosthetic fractures

• Metabolic workup is very important

• Team Approach• Consider anabolic

supplementation

Vancouver Classification: PPFX Hip

• A: Trochanteric fractures• B: Around prosthesis

–1 intact stem–2 loose stem–3 with osteolysis and loose stem

• C. Below prosthesis

Vancouver A fractures

• Greater or lesser trochanter

• Often non operative• Reasons for surgery:

–hip dislocation–displacement– stem unstable

Trochanteric Fixation Options

• Cable plate• Don’t put cables on

the prosthesis• Constrained liner

Vancouver B1 and C: Stem stable

• Determine is B1/C or B2/3

• Is the stem really stable?• Loosening is thought to

be under diagnosed• X-rays are often poor

• 321 patients in 1999-2000• Swedish National Hip Arthroplasty

Register• 91 after revision: 51% loose stem• 220 after primary: 66% loose stem• 13% mortality at one year• 66 mo survival rate of implant was 74%

How to assess stability• Gold standard: Changes on radiographs

over time• Lucencies around implant• Subsidence• Cement breakage• Implants with poor track records• History of painful joint replacement

Loose or stable?

• Cemented

• Cement fracture

• Implant subsidence

Loose

Loose or stable?

• Uncemented

• Subsidence

• Lucency

Loose

Loose or stable?

• No lucency

• No subsidence

• Appears ingrown

Stable

Vancouver B1 and C Fixation:NOT LOOSE

• Reduction and internal fixation

• Limited approach if possible– Curved locking plate– Screws around the

implant– Cerclage

Plan your fixation

• To bridge or not to bridge

• Absolute or relative stability

• Don’t do both!

Preop planning

• Plan placement of screws–Locking versus non

locking• Think about the stiffness

of the construct• Long working length

• Cadaveric study for B1 periprostheticfemur fractures

• Long plate vs short plate• No differences in plate length or working

length• Bone density was biggest factor

Preop planning• Care in use of locking

plates• Plan placement of

screws & screw type• Long working length• Decide if you are

bridging• Good x-rays

Plating

• Make the plate as long as possible

• Consider non locking screws angled around the stem

• Use cables if necessary

B1 fractures• Oblique

–Reduce fracture –Get bony apposition

• Transverse–Troublesome–Difficult to tell when

healed–High stress on fixation

Vancouver C

• Fracture is below the prosthesis

• Prosthesis is stable

• Bridging plate fixation

Treatment: B1 oblique and C

• Condylar plate fixation distally

Additional screws around implant

Vancouver B1 with transverse fracture

• Difficult to treat with plate

• Consider stem revision• Sometimes this is very

difficult

Fix or Revise??

Intercalary fractures

• Use the implants you have in place

• Be creative• Overlap implants• Span the entire

bone

Vancouver B2/3

• Stem is loose• Revision THA

necessary• Bypass the

fracture with a long stem

Determine why stem is loose

• Is there in infection?• Validity of ESR and

CRP with fracture?• Aspiration if high

suspicion• Culture and frozen

section intra-op

Revision: Hip Posterior

• Posterior approach• Low index for an

extended trochanteric osteotomy

• Know the type of cup and have a liner available to upsize if possible

Revision

• Depends on amount of bone stock

• Achieve distal fixation• Cemented: proximal

replacement• Uncemented: conical fluted

stem• Total femur

Fractures About the Knee

Fractures around the knee

• Femur (Most)• Patella• Tibia

Initial X Ray

Traction View How to know if the implant is stable

• Lucencies around prosthesis

• Subsidence• Osteolysis• Not the same as hip

Unified classification system

• A. Implants are stable, minor fracture• B1. Implants stable• B2. Implants loose• B3. Implants loose and severe osteolysis• C. Fracture is away from prosthesis

How to know if you can fix?

• How many fracture pieces?

• How distal is the fracture?

• What implant?• Consider CT scan

Treatment algorithm: Femur

• Non operative: stable implants and fracture

• Fixation-Plating: work horse

• Revision replacement: distal femoral replacement

Non operative

• Implants must be stable• Well aligned fracture• Patient will not tolerate

surgery

Plating

• Implants are not loose• Enough bone to

achieve distal fixation• Pre op Planning• WB decision

IM rod

• Implants are not loose• Enough bone to fix

distally• CR implant wear box is

big enough to place a rod through implant

Revision

• Loose implants• No distal bone• Need for

immediate weight bearing?

Distal Femoral Replacement• Pluses:

–Relatively straightforward

– Immediate weight bearing

• Minuses–Rotating hinge–Problem if this needs to

be revised

Distal Femoral Replacement• Tips:

–Mark center of rotation on the femur before removing bone

–Often biggest challenge is rotation

–Use one sided sagittal saw to cut tibialimplant

–Try not to lengthen leg

Tibial fractures with stable implants: non op treatment

Tibial fractures

• Plating versus non op• Can reduction be

maintained in cast or brace• If not consider plating• IMN for adventurous and

right indication

Tibial fractures

• Loose implants• Revision surgery

–Stem fixation distally–Supplemental plating

IMN CaseExample

Patella fracture

• Beware….• Most are due to AVN of the

patella–Previous lateral release–Poor rotational

alignment • These due poorly with

surgery

Surgical treatment

• Removal of implant• Is rotational

alignment of wrong?• Rare fixation of

fracture –Use supplemental

fixation with cable

If the extensor mechanism is broken

• If aligned well consider non operative treatment

• Consider fixation if displaced and unable to reduce

• May need extensor allograft reconstruction or fusion

What is worse?

Retrospective, age and gender matched• 106 PP 12 died = 11%• 309 hip fx 51 died = 17%• 311 THA/TKA 9 died = 2.9%

Vancouver B

• 49 revision arthroplasty–6 died = 12%

• 24 ORIF–8 died = 33%

• Thus, if feasible, revision arthroplasty treatment preferred

• Retrospective• 291 patients• Mortality = 13%

–Contributing factors unmodifiable• Rate of reoperation = 12%

–Decreased w/greater span of fixation–Decreased w/revision arthroplasty

• Ideal treatment unclear• Retrospective, 70 and older• 38 patients

–82 average age–10 DFR–28 ORIF

ORIF Not as Promising

• No difference in mortality• 10% reoperation rate in DFR

–All ambulatory at 1 year• 11% reoperation ORIF

–24 weeks TTU–18% Nonunion–23% WC bound at 1 year

• Retrospective, 58 patients–ORIF and DFR

• Average age: 80 (61-95)• Follow up: 30 mos (5-81)• DFR patients older: 83 v. 75• 20.5% mortality• Age > 85 predictive of ambulatory status

and living situation

Pitfalls

• Make sure implants are stable

• Make sure it is not infected

• Plan your internal fixation

• Surgery is big (1-2L blood loss)

Pitfalls

• Evaluate and treat osteoporosis

• Difficult to tell if a fracture has healed

• When to start weightbearing?

• 54 fractures/52 patients• Retrospective• 38 returned to pre injury ambulatory

status• 3 implant failures, 1 nonunion, 2

malunion• 10 thromboembolic events

• Conclusion: Immediate WB acceptable• Take home lessons:

–Early mobilization did not decrease DVT/PE (19%)

–7/54 (13%) fracture/implant issues–70% to previous ambulatory status

Case Example

Healed

If It Does Not Heal

ConstructConstruct

What If It Does Not Heal?

• What about the biology?• What could have been done better?

Teaching/Learning

• Pre op planning• Ok to shorten• Don’t make too stiff• Tons of screw not necessary

• 88 patients• All osteoporotic• Peri-implant fractures after

bone union in 5%• Stiffness/screw selection

matters

Heavy Metal: When All Else Fails

Conclusions

• Plan your surgery

• Get good fixation but not too stiff

• Determine stem stability

• Know when to revise and when to refer

Parting Thoughts

Pass It On and Give Back

• Help those behind you• Make the path easier• Never forget those who

helped you• Always lead by

example

Imitation…

Thank You!jcannada@aol.com

MC

• 87 yo F• CC: Transfer after fall from standing• PMHx: Hypertension• SHx: R THA in 2011• R TKA x2 revisions with DFR in 2013• ppfx with plate 2016• Painful since last 2 surgeries• lives at home, community ambulator