modern techniques in management of periprosthetic femoral fractures after total hip arthroplasty

8/2/2019 Modern Techniques in Management of Periprosthetic Femoral Fractures After Total Hip Arthroplasty

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Prof. Dr. Ashraf Abd-Elkader ElnahhalProfessor of orthopedic surgery Faculty of Medicine Cairo University

Dr. Omar SolimanAss.prof. of Orthopedic Surgery Faculty of Medicine Cairo University


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Periprosthetic femoral fractures after THR

Introduction

Periprosthetic fracture of the femur after hip arthroplastysurgery was first described by Horwitz et al., in 1954.

(Lindahl, Injury; 2007)


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Factors leading to increase incidence ofPFF.

Introduction

Contentious increase No. of patients withTHA.

More younger patients.

Increased average life expectancy.

Increase number of patients with revised and

rerevised hips.


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Periprostheticfemoral fractures

Intraoperative

fracturesPostoperative

fractures

Introduction


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Incidence and etiologyof intraoperativefractures:

Incidence and etiology

Regarding the incidence of intraoperativefracture of the femur in primary hiparthroplasty they are estimated to occur in

about 1% of cemented stems and 3

18% ofuncemented stems .

The incidence is higher in revision settings up

to (21%).(Tsiridis et al., Injury

2003)


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Use of cementless femoral components.


(JamesW & John R. Campbells Operative Orthopaedics.


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Revision surgery:

Older patients.

Disuse osteopenia.

Femoral bone stock is oftendeficient.

Creation of corticalwindows for cementremoval.

Longer and larger diameterprosthesis.

Impaction graftingtechnique.



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Complex deformities of the proximal femur.



I id d


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Intra-pelvic protrusion:

Incidence andetiology



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Incidence and etiologyof postoperativefractures:

Incidence and etiolog

The incidence in postoperative periprostheticfemoral fractures, has been estimated to be


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Low-energy trauma:

o The most common etiology for late periprosthetic

fractures.

o 84% of periprosthetic fractures resulting as a

consequence of a fall

o 8% after other kinds of injuries

o 8% as spontaneous fractures

(Beals and Tower 1996).


nc ence an


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Areas of cortical stress risers.

nc ence anetiology


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Loosening of femoral component.



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Osteolysis.Incidence and etiology

(William et al., JBJS am.; 1995)

I id d i l


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Heterotropic bone formation.



I id d ti l


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Systemic risk factors;

Diseases that may lead to generalized osteopenia e.g.;

rheumatoid arthritis

severe osteoporosis

Osteomalacia Pagets disease

Osteopetrosis

Osteogenesis imperfecta Thalassemia

Some neuromuscular disorders such aspoliomyelitis or parkinsonism



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Management

The principle underlying the surgicalmanagement of periprosthetic fractures is thatconsideration needs to be given to the

fracture location, the stability of thecomponentsand the quality of theunderlying bone stock.


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Vancouver classification:classification

Most recent and comprehensive.

Address important factors needed in management

ofperiprosthetic femoral fractures:

1. Fracture location.

2. Stability of the implant.

3. Quality of the femoral bone stock.

Simple, excellent interobserver reliability & validity.

(Sanjeev et al., Current Ortho. 2006)

classification


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Vancouverclassification

Postoperativefractures Intraoperativefractures

classification


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Intra-operative fracture classification:

The femur is divided into three zones, eachrepresenting a major type of fracture.

Each type then is divided into 3 subtypes:-Subtype 1: Simple cortical perforation.

Subtype 2: Undisplaced linear crack.

Subtype 3: Displaced or unstable fracture.

(Masri et al., clinical Orthopedics 2004)

classification

classification


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Type A:Fractures are proximal metaphyseal, not

extending into the diaphysis.classification

Subtype 1: Subtype 2: Subtype 3:

classification


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Type B:Fractures are diaphyseal.

Subtype 1 Subtype 2 Subtype 3

classification

classification


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Type C: The fracture is distal to the stem tip and not amenable

to insertion of the longest revision stem.Subtype 1 Subtype 2 Subtype 3

classification

c ss c o


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Post-operative fracture classification:

Consists of three major types based uponthe location of the fracture.

Each type A or B, subdivided into subtypesdepending on the stability of the implantand remaining bone stock.

(Duncan & Masri. AAOS; 1995)

classification

classification


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Type A fractures:

Fractures in the Trochanteric region.

Type AG:fractures of

greater trochanter

Type AL:fractures of the

lesser trochanter

classification

classification


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Type B fractures:

Fractures just distal or around the femoral stem.classification

Type B1:Stem well fixed

Type B2:Stem loose, good bone stock

Type B3:Stem loose, poor bone stock

classification


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Type C Fractures:

Fractures well below the stem tip.

classification


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Diagnosis of intraoperative fractures:diagnosis

Sudden change in the stability of the shaft.

Change in the sound of impact of the prosthesis.

Any suspicion of fracture an immediate

intraoperative radiograph is done.

(Callaghan , Instr. Course Lect. 1998)

diagnosis


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Diagnosis of postoperative fractures:

Clinical features.

Radiographic features.

CT. or MRI.

diagnosis

Treatment options


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TREATMENT

Non-

operative Operative

Treatment options

Treatment options


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Current options for operative

treatment

Treatment options


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Cerclage wire fixationTreatment options

Using stainless steel wires or multifilament cables. considered for:

Fixation of long oblique or spiral fractures around a well-fixedprosthesis.

Trochanteric fractures. (Sanjeev ,Current Orthopaedics:2006)

Treatment options


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Plating:Treatment options

Indicated in diaphysealfractures that occuraround well-fixed

implants and distaldiaphysealmetaphyseal fractures.(Vancouver type B1, C)

(Tadross et al., J. Arthroplasty 2000)

Treatment options


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Treatment options

Treatment options


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Plate options:

Conventional compression plates:

Treatment options

(Haidar et al., Injury; 2005)

Treatment options


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Plate options:

Cable and plate system:

Treatment options

Dall-Miles cable and plate system(Mabrey, Rockwood & Green's Fractures in Adults; 2006)

Treatment options


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Plate options:

Locked plates:

Act as internalexternal splints.

Useful in fixation ofosteoporotic bone,

The periosteal

vascular supply isleast disturbed.

Can be Inserted

indirectly(MIPO).

Treatment options

Plate options: Treatment options


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Plate options:

The Minimally invasive plate osteosynthesis(MIPO)

technique:

Indications:

Vancouver type B1 & typeC

Advantages:

Preserve bl. Supply.

Fracture hematoma.

plastic fix.

Treatment options

(Kumar, Journal of Arthroplasty; 2008

Treatment options


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Plate options:

Less invasive stabilization system (LISS).

Treatment options

(Farouk et al., Journal of Orthopaedic Trauma1999)

Treatment options


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Cortical allograft struts:

Treatment options

(Allan et al.,The Journal of Arthroplasty;

Treatment options


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Revision hip arthroplasty:

Indicated in casesof periprosthetic

fractures with loosefemoral component.

The goal is to by-pass it by at least

two shaft diameters.

Treatment options

Treatment options


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Treatment options

Treatment options


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Revision options:

Cemented long stem implants:

Discouraging results.

Appropriate in the frailelderly patient with

limited functionaldemands and lifespan.

(Sanjeev, Current Orthopaedics; 2006)

Treatment options

Treatment options


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Revision options:

Cementless long stem implants.

Recentlymodularcementless longstem.

Extensive porouscoated.

Long stem with distal

locking screws.

Tapered stems.

Treatment options

(Kwong et al., J Arthroplasty; 2003)

Treatment options


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Revision options:

Proximal femoral replacement:

Post- operative Vancouver B3fractures associated with severe,segmental bone loss

Elderly patients with limited life

expectancy can be treated bytumor-type proximal femoralreplacement prosthesis.

Younger patients the proximalfemoral allograft composite is

recommended.

(Sanjeev, Current Orthopaedics; 2006)

Treatment options


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Revision options:

Impaction Grafting:

High union rate in

revision settings:

With severe osteolysis

or deficient bone stockof the proximal femur.

Together with structural

cortical allograft and orplates.

With long cementedfemoral prostheses.

(Tsiridis et al., Injury 2007)


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Treatment algorithmbased on Vancouver

classification.Intraoperative

fracturesPostoperative

fractures


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Conclusion

Management of these fractures is oftenparticularly demanding, complex and expensive.In many cases, the surgeon has simultaneouslyto deal with the problems of implant loosening,bone loss and fracture. A systematicunderstanding of the unique characteristics of thedifferent fracture types, of the principles of PFF

treatment and a familiarity with the variousfixation devices, grafts and prosthetic implantsare all of paramount importance.


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Thank you

modern techniques in management of periprosthetic femoral fractures after total hip arthroplasty

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