Management of Periprosthetic Femoral Shaft Fractures

after Hip Arthroplasty

Presented by

Berhe Gebreslassie KassaMD equivalent to Egypt‘s M.B.B.Ch, (2006)

Faculty of MedicineAddis Ababa University

ACKNOWLEDGEMENT

Prof. Adel Ghazal Prof. Yassin El Ghoul Dr. Sameh Mahmoud Abo El-Fadl

Prof. Masri BA Prof. Duncan CP All members SCUOD MUNDO

Def: It is fracture around the joint replacement prosthesis.

effect ranges from being minor, with minimal or no effect on the outcome, to being catastrophic and possibly creating an unreconstructable problem.

Introduction

now steadily increasing due to increase:

a. number of primary hip arthroplasties - young - active - osteopenic elderly patients b. revision hip arthroplasties c. life expectancy

classified as:

a. Intraoperative PPFs: - occur during the operative

procedure and/or on the postoperative radiograph in the recovery room.

b. postoperative PPFs: - occur outside of this time frame

Incidence

cemented THR uncemented 0.1 - 1% & revision THR

3.6% - 20 %

fracture after THR Primary: 0 - 1.2

% Revision: 4 %

Etiology and Risk factors

low-energy falls High-energy trauma spontaneous fractures

excessive torque during surgical exposure or bone preparation

prosthesis is dislocated cement is removed prosthesis is inserted

decrease in the quality and mechanical strength of the host bone

The common risk factors are categorized into systemic and local risk factors

Systemic Factors: osteopenia, osteoporosis,

rheumatoid arthritis, paget's disease, osteopetrosis, osteogenesis imperfecta, thalassemia, osteomalacia, & neuromuscular disorders

Local Factors: cementless femoral prostheses, complex proximal femoral deformities, revision arthroplasty, & loose femoral prostheses

There are different types but at present the Vancouver classification probably comes closest to the ideal system for clinical practice.

Classification

takes into account the location, pattern, and stability of the fracture

classified as: type A - proximal metaphysis type B - diaphyseal type C - distal to the stem

tip Each type subclassified - subtype 1 : cortical perforation - subtype 2 : nondisplaced crack - subtype 3 : displaced unstable fracture

The Vancouver classification for intraoperative fractures

takes into account

–Site of the fracture

–Stability of the implant –Surrounding bone stock

The Vancouver classification for postoperative fractures

relies upon one or more techniques:

I. direct observation II. clinical suspicion III. radiographic evaluation (full-

length)

cross-sectional imaging has not been routinely used

Diagnosis

Prevention of fractures is preferable even to the most successful treatment options.

Preventive measures during the initial arthroplasty include

- avoiding the creation of cracks, defects or windows in the bone

*if these stress-risers are present bypassing them with a stem that end two to three cortical diameters distal to the defect.

Prevention

preoperative planning to asses risk factors

- detailed history - preoperative radiographs - formulating operative plan

** Adequate soft-tissue releases, hip dislocation, cement removal, canal preparation, and component insertion.**

Regular radiographic follow-up of all patients to detect major osteolytic defects & loosening of the implant

- AP, LA, & Obliq at 1, 2, 5, 7, & 10 Mos then every 2-3 yrs.

objectives: - to promote early healing - to preserve or

reconstitute the bone - to restore the correct

alignment and length - to achieve a stable

fixation of the prosthesis - Restore mobility and

function

Management

1. Conservative

2. Surgery

Management

Highest

High Failure RateHigh Failure Rate

*Only for simple & Stable # and medically unfit *Only for simple & Stable # and medically unfit

Fracture configuration Implant stability Bone stock

Surgery

Reconstruction

Impaction grafting Impaction grafting . Proximal femoral . Proximal femoral

replacementreplacement

Revision THRORIF

Cerclage Plate Strut grafts combination

Long stems Cemented Uncemented

Impaction grafting Proximal femoral

replacement

Current indications

Prophylactically • Increase hoop stress resistance (Incavo 1991)

Temporary (Jando 2007)

• until further intramedullary or extramedullary fixation

Definitive (Jando 2007)

• Simple periprosthetic # - alone Trochanteric # Spiral #

• Complex periprosthetic # - with other devices Plates or strut graft

ORIF with Cables

•

ORIF with Plates

Advantages No transcortical fixation High union rate when

used with intramedullary device (De Ridder 2001))

Disadvantages Can’t used alone

Partridge nylon plates and straps

Proximal cables, distal screws satisfactory result in over 80% of cases

(Zenni 1988))

Ogden plates

Advantages Minimal skill set Stronger than strut

graft Early mobilization High union rate when

used with cortical struts (Wang 2000)

Disadvantages Requires dissection to

plate length

Compression plates

Advantages Minimal dissection Preserves blood supply Rigid internal fixation

Disadvantages More expensive than

dynamic plate Requires special

training More fluoroscopic

exposure

LISS plates

‘internal external fixator’ Two anatomical models

• diaphyseal plates• distal femoral plates

no advantage to the locking screw system (Buttaro 2007 & Zdero 2008)

encouraging results for B1 & C (Berlusconi 2004, Chakravarthy 2007, Bryant 2009, & Ehlinger 2010a)

extra-periosteal application --------- periosteal blood supply

Locking plates

good option in the elderly (Baker 2004 )

Carbon fibre plates

Advantages No transcortical

fixation

Disadvantages Requires extensive

dissection Prone to fracture or

bend

Mennen plates

Advantages Allow adequate

attachment of cables, wires & screws

Early mobilization High union rate when

used with cortical struts

Disadvantages High failure rate when

used alone

Dall-Miles plates

Advantages High union rate Easily contoured Low elastic modulus

Disadvantages May weaken after

implantation Expensive Graft/host interaction Not as strong as plates

Cortical strut allograft

Consider when the Implant• Loose• Implant #

Revision hip arthroplasty

prosthesis must bridge the fracture by at least two shaft diameters (Duncan 1995)

options are cemented stems cementless stems

• proximally coated• extensively coated• modular

revision stems that are cemented, or rely on proximal fixation

revision in total hip arthroplasty is often complicated by insufficient proximal bone stock

remaining bone is inadequate to provide structural support, osteogenic potential for bone ingrowth, or a surface that allows for cement interdigitation.

cemented stems

Indications:•older + simple fracture pattern that

can be reduced anatomically •osteoporotic bones where a change to

a cementless fixation would be more difficult

increasingly popular because they provide the potential for long term biologic implant fixation

biological ingrowth around the porous coating provides the potential for long-term prosthetic stability

Cementless stems

proximally porous-coated stem • disappointing (Mulliken 1996)

extensively porous-coated stem• superior fixation (Springer 2003)

Hydroxyapatite-coated stem • enhance early fixation (Karrholm 1994)

proximal femoral replacement • last option

Indication:• elderly with limited life expectancy where

severe bone loss precludes a simpler reconstruction

TREATMENT STRATEGIES

Claw plate

Claw plate

Confirm implant stability intraoperatively

Type C fractures •Ignore implant & treat fracture

gold standard treatment of this # is surgery with an exception of selected simple # .

Evaluate Stability of the Implant & bone quality If the implant is stable and bone quality is adequate

for fixation…..the implant should be retained while the # is fixed following standard principles or conservative

If the implant is loose or bone quality is poor ….the implant should be revised while fixing the fracture

When there is massive bone loss, proximal femoral replacement with allograft or with a massive structural prosthesis is used

Conclusions