Periprosthetic Fracture

TypesTHR Periprosthetic Fracture

 

Peri-operative

- incurred during operation

 

Post operative

- related to osteolysis / trauma / infection

 

Follow up

 

1994 National Institutes of Health Consensus on THR

 

Regular radiographic follow-up to avoid massive osteolysis & fracture

 

Incidence

 

Primary

 

0.6% cemented

0.4% uncemented

 

Revision

 

2.5% cemented revision

1.5% uncemented revision

 

Aetiology

 

1. Bone damage at insertion

- eccentric reaming

- perforation

- fracture

 

2. Osteolysis

 

3. Trauma

 

4. Infection

 

5. Osteoporosis

 

Vancouver Classification

 

Type A (4%)

 

Avulsion GT or LT

 

A1 Stem well fixed

A2 Stem loose

 

Type B (87%)

 

Fracture near stem tip or around stem

 

B1 Stem well fixed (20%)

B2 Stem loose (44%)

B3 Stem loose with marked osteolysis (36%)

 

Type C (10%)

 

Fracture distal to tip

 

Management

 

Most important is whether prosthesis is stable

- if loose requires revision

 

Type A

 

Avulsion GT or LT

 

Management

 

GT

- undisplaced - no treatment required

- ORIF GT if displaced > 2.5 cm / disruption to abductors

 

THR Periprosthetic Type A THR Periprosthetic Fracture A PlatingVancouver A Displaced GTVancouver A GT Wire Fixation

 

LT

- cerclage LT if large and supportive

 

Type B1 

 

Fracture around stem, likely well fixed

 

THR Periprosthetic Fracture B1THR Periprosthetic Fracture B1 Lateral

 

Options

 

1.  ORIF with cable plate + proximal unicortical locking screws +/- Cortical strut graft

 

Cable plate alone

- 90% union

 

Locking Cable plate + single strut graft

- 98% union

- distal bicortical screws

- proximal unicortical screws supplemented with cables

 

Cortical Strut Graft

 

2.  Long stem revision

 

Cemented

 

THR Periprosthetic Revision Long Cemented FemurTHR Periprosthetic Revision Cemented Femur 2

 

Uncemented

 

THR Periprosthetic Fracture Type B1THR Fracture Long Stem Revision

 

Type B2

 

Fracture around stem, femoral component loose

 

THR Periprosthetic Fracture B2Periprosthetic Fracture Vancouver B2

 

Options

 

Long stem revision

- distal fit (cemented / uncemented)

- must bypass distal extent of fracture by at least 2 cortical diameters

 

THR Periprosthetic Fracture B1 Long stem cemented revision

 

May in addition use

- cable plate + unicortical locking screws

- 1 x strut allograft

- autogenous BG + BMP to fracture site

 

Revision THR Periprosthetic Fracture Uncemented Stem Strut GraftRevision THR Periprosthetic Fracture Uncemented Stem Strut Graft 2Revision THR Periprosthetic Fracture Uncemented Stem Strut Graft 3Revision THR Periprosthetic Fracture Uncemented Stem Strut Graft 4

 

Vancouver B2 PFFRevision PFF with Modular Uncemented and Strut Allograft

 

Type B3

 

Fracture around stem with marked osteolysis

 

THR Vancouver B3 APTHR Vancouver B3 Lateral

 

Options

 

Young patient

- segmental allograft / prosthesis composite

 

Elderly

- tumour type proximal femoral replacement

 

Type C 

 

Fracture distal to tip of stem

 

Options

 

1.  ORIF Cable Plate

- can use MIPO

- overlap femoral stem to avoid stress riser

 

THR Periprosthetic Type C Plating

 

2.  ORIF Cable Plate + cortical strut graft

 

2.  Strut allograft alone

- use 2 x 1/2 femurs fresh frozen

- span fracture 10cm above & below

- 4 wires above & below

- preserve blood supply to linea aspera

- autogenous graft to fracture site