11/19/2018 Proximal Periprosthetic Fxs about THA: …...Klein GR, Parvizi J, Rapuri V, Wolf CF, Hozack WJ, Sharkey PF, Purtill JJ. Proximal femoral replacement for the treatment of

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Frank Liporace, MDChairman & VP, Dept of Orthopaedics

Chief of Trauma & Adult Reconstruction Jersey City Medical Center / RWJ Barnabas Health

Proximal Periprosthetic Fxsabout THA:

When/how to fix? When to Revise?

Goals

• Understand common classification scheme

• Understand when/how to ORIF

• Understand when/how to revise

• Develop treatment algorithm

Introduction

• Incidence– 0.1%-18%

• Increased after revision– 1% in primary THA

– 4% in revision THA

• Increase risk of death

Berry DJ. Epidemiology: hip and knee. Orthop Clin North Am. 1999;30: 183–190.

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Periprosthetic fractures

Risk factors -MECHANICAL• Implant loosening• Osteolysis

Risk factors - PATIENT– Rheumatoid arthritis– Chronic steroid use– Neurological

diseases/disorders– Osteoporosis/osteopenia– Female gender– Increasing age

Classification

• Vancouver Classification– Periprosthetic femur

fxs

• Based on:– Fracture location– Implant stability– Bone quality

• Reliable and valid

Brady OH, Garbuz DS, Masri BA,Duncan CP: The reliability and validity of the Vancouver classification of femoral fractures after hip replacement J Arthroplasty 2000;15:59-62.

Classification System

• Type A: Around trochanters

• Type B: Around stem

• Type C: Distal to stem

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Management

• Goals:– Stable fixation

– Avoid complications

– Allow early movement

– Restore alignment

– Minimize surgical trauma

Decision Matrix

Vancouver Classification

• A: Around greater or lesser trochanter (AGor AL)

BEWARE concomitant G.T. & L.T. Fx’s

Most likely CONTIGUOUS

Most likely LOOSE STEM

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Type A

– AG

– Stable prosthesis

– >2.5cm displacement

– abductor dysfunction

– Surgical treatment– Trochanteric Claw plate

– Cerclage wires

– AL

– Extension into calcar

– Effects implant stability

– Protected weight bearing

– Surgical treatment– Cerclage wires

Type A


• B– Around or just distal

to prosthesis

1: Prosthesis stable -- most common

2: Prosthesis unstable

3: Inadequate bone stock

B1 B2 B3

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Type B

• B1– Stable prosthesis

– ORIF

– Long, well-balanced plate construct

– Proximal fixation

Type B

• B1– Laterally based locking plate

– Sufficient plate length

– Minimum # screws bypassing implant?

– Hybrid fixation– Locking screws– Nonlocking screws– Cables

– PMMA augmentation

– TCP augmentation

– Compress when possible

– Percutaneous plating

– Be prepared to revise

Type B

• Subtype:

Loose?

Bone Stock?

B1

B2 B3

No Yes

Supportive Unsupportive

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Type B

Type B

• B2– Loose implant

– Good bone stock

– Revision arthroplasty

Type B

• B2

– Cementless revision stem– Bypass by 2 cortical

diameters

– Cemented stem– Less than 6cm diaphyseal

contact

– Wagner type stem

– Reconstruct tube

– Work through fracture as ETO

– Fix with cables

– Supplement with laterally based plate

– Change poly

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Type B

• B2

– Cementless revision stem– Bypass by 2 cortical

diameters

– Cemented stem– Less than 6cm diaphyseal

contact

– Wagner type stem

– Reconstruct tube

– Work through fracture as ETO

– Fix with cables

– Supplement with laterally based plate

– Change poly

Type B

• B3– Loose implant

– Poor bone stock

– Revision arthroplasty

– Consider PFR– Constrained liner

– Impaction grafting

Klein GR, Parvizi J, Rapuri V, Wolf CF, Hozack WJ, Sharkey PF, Purtill JJ. Proximal femoral replacement for the treatment of periprosthetic fractures. J Bone Joint Surg Am. 2005 Aug;87(8):1777-81.

Shah, R. et al. Principles of Treatment for Periprosthetic Femoral Shaft Fractures around Loose Total Hip Arthroplasty


• C: Below prosthesis

Span the distal part of the stem

AT LEAST 2-3 Cortical Diameters

COMBINATION screws and circlage

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Type C

• Laterally based locking plate

• Minimally invasive

• Submuscular

• Hybrid fixation

• IMN– IDD <2cm or >10cm

Type C?

3

JN

Now What ???

IMN – Stress Riser ??

Plate – Proximal Fixation

How to WB early???

74 Year Old – EtOH abuse, multiple falls

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Periprosthetic Fractures of the Acetabulum

• Rare– Female sex– Inflammatory arthropathy

• Early– During cup impaction– Poor bone quality– Posttraumatic arthritis– Underreaming

• Late– Osteolytic involvement– Loss of cup fixation– fracture

Periprosthetic Fractures of the Acetabulum

• Early– If cup is stable leave

alone– If cup is unstable

– Revise to multi-hole shell– Bone graft fx line from

reamings– Posterior column plating

• Late– Jumbo cup– Posterior column plating– Modular trabecular metal

aguments– Triflange cage

– PERI-HHA ACETAB FX / DISLOC

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– PERI-HHA ACETAB FX / DISLOC – Infxn. Intra-op bx 25 PMN / hPf


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Fx / Dislocation / Subsidence



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Case Examples…

Acute Primary THA

• 53 year old male

• THA done at outside institution– “Cup smaller than template”

– “Stem bigger than template”

• ?????

• Films in recovery room

Night 1Return to OR for cerclage

“May I transfer to you with the VAC?We don’t have a plastic surgeon.”

Now what?????

2 weeksBrought to OR for BG & ORIF“saw no callus in office xray”

4 weeksER for erythema and drainageGiven po abx for “staple erythema

6 weeksReturn to ER for 15 cm dehiscence3 I&D’s later with open wound

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Principles

• Stem issue– ? Loose

– Gapping fracture open

• Open wound– Infection

– Implant

– Fracture

– “Tube” of femur

Principles – To do list

• Remove implant

• Stabilize bone

• Treat infection

• Stage / replantation

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12 weeks

3 years

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3 years

8 years

PREVIOUS ORIF PROXIMAL FEMUR3 weeks post-THA; Progressive pain

ISSUES:-SUBSIDENCE-FX AROUND STEM-GREATER TROCH FX

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3 weeks post-THA; Progressive pain

SITE OF MALUNION

3 weeks post-THA; Progressive pain

MUST ALWAYS BE PREPARED FORCUP REVISION:

-BEARING SURFACES-CUP & BEARING SURFACES-SCREWS

ProphylacticCable

8 yrs s/p THA, now w/ dementia & falls

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8 yrs s/p THA, now w/ dementia & falls

MODULARITY

3 years after THA

3 years after THA

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75 yo– 3 yrs no walking, h/o infection

Issues:-Varus remodeling-Infection history-Leg length Discrepancy



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– 85 yo F, 15 years s/p revision THR w/ “problem” at the time of Sx & new fall

Bone quality???

Bone stock ???

FAL

No specific medical complicaiton

Passed away within 6 months

FAL

THA disaster – 2011 / 2012

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THA disaster - 2013

THA disaster 2014

THA disaster – 2017

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THA disaster – Final 2018

80 year old female – Fx around THA

-Bone quality???

-Bone stock ???

-Proximal Fx

-Distal Fx Extension

-Varus Stem

80 year old female – FINAL

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Conclusion

• Obtain complete radiographs

• If implants are stable, consider indirect reduction techniques

• Consider polyaxial implants and bone substitutes for augmentation

• Don’t leave loose implants

• Don’t use incompetent fixation

• Don’t delay post-op ROM

• Don’t delay surgery in the elderly

Thank you

Documents

11/19/2018 Proximal Periprosthetic Fxs about THA: …...Klein GR, Parvizi J, Rapuri V, Wolf CF, Hozack WJ, Sharkey PF, Purtill JJ. Proximal femoral replacement for the treatment of