periprosthetic fractures of hip - basics & tips & tricks!

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Peri-prosthetic Hip # Management: AlgorithmDr Vaibhav BagariaHip and Knee SurgeonSir HN Reliance Foundation HospitalMumbai India

Problem StatementBerry reported an incidence of 0.3% in primary cemented and 5.4% in uncemented THAs from the Mayo Clinic joint registry In Revision setting, higher rates of fracture were seen with a rate of 3.6% in cemented and 20.9% in uncemented THAs

Risk FactorPatient RelatedSurgical TechniqueChoice of Implant

Risk factorsP: Female,age, DDH, RA, Paget disease, osteoporosis, steroid.T: MIS approaches, Toothed Calcar MillsI: Uncemented. Acetabular under reaming;Heavy Impaction on femoral side

MechanismFall or Osteolysis or combination thereof!Torsional forces caused intertrochanteric # Anterior loading caused supracondylar #lateral loading caused # at the tip of the stem

Initial EvaluationMechanism, Co morbidties.Pain prior to fall may indicated Osteolysis.Details of the implant should be obtained, including manufacturer, model, and size as this will enable the desired extraction kit to be ordered

Acetabular #

26.Della Valle CJ, Momberger NG, Paprosky WG: Periprosthetic fractures of the acetabulum associated with a total hip arthroplasty. Instr Course Lect 52:281290, 2003

BasicsHigh Index of suspicion intra-operativelyImaging: Judets viewOsteolysis evaluationInventory planning - Implants/ InstrumentsReconstruction armamentarium

Paprosky & SekundiakSuperior component Migration > 2 cm ( loss of superior structural support)Ischial Lysis ( loss of posterior column Support)Destruction of tear drop Line ( loss of the inferior part of anterior column)Break in the Kohlers Line ( Anterior column Deficiency) Radiographic Marker for severe bone loss Paprosky WG, Sekundiak TD: Total acetabular allogra s. Instr Course Lect 48:6776, 1999

Vancouver - Intraop5Duncan CP, Masri AB: Fractures of the femur a er hip replacement. Instr Course Lect 44:293304, 199

Vancouver Postop

Aim - SPAMStabilising the fracturePreserving hip functionAchieving bony unionMaintaining component orientation and stability

Type 1A AcetabulumAdditional ScrewsRestricted weight Bearing

Type 1 BColumn InjuriesRemove the implant to assess #Anatomic recon & # FixationRim fit with additional screw

Medizinische Hochschule Hannover collection.

Type 1CNot recognised - hence difficult situationAdditional ScrewAutologous BGRestricted weight bearingClose observation

Type II - Acetabulum< 50% loss of bone stock (type IIA), then a porous-coated hemispherical acetabular component can be used after fracture has been reduced and stabilized with internal Fixation. Contained defects filled with morselized bone graft , larger defects may require structural graft> 50% bone loss (type IIB) Anti Protrusion Cage or TM

Type III AcetabulumPost op traumatic #Mgmt Dictated by stabilityStable IIIA: restricted weight bearingUnstable IIIB: Revision with Fracture Fixation

Type IV AcetabulumSevere osteolysis - hence management similar to Revision arthroplasty.Reconstitute the bone stock with suitable graftUse adequate revision implant (e.g., cup-cage construct) the fracture must also be held in rigid internal fixation for optimal results.

Type VPelvic DiscontinuityDifficult CasesAdequate prep planning; 3D printed BiomodelsCustomised 3D printed Implants.

Femur

Preventing Intraop Femur #Adequate ExposureAvoid In-situ CutsFemoral Torsion while dislocatingVery Gentle in Protrusion casesIntra op Imaging

Femur Type IAUndisplaced cortical perforations in trochanteric region, Treated with packed bone graft obtained from acetabular reamings Restricted weight- bearing.

Type A2Un-displaced Require reinforcement with cerclage fixation To prevent propagation of #, implant failure, decreased abductor muscle function, & dislocation.

Type A 3Displaced & needs reductionCerclage Cable WiresClaw PlatesChanging to diaphysial fit

Type B1Cortical perf occurs during revisionBypass with longer stem/ Good fitProphylactic Wire/ CablesCortical Strut allograft where long stem not long enough

Type B 2Undisplaced linear cracks Cause: hoop stresses during broach/ stem insertion.Treatment depends on implant stability. Stable: Protected weight bearingImplant Migration: Revision to Long stem and Circulate wiring. If the stem not long enough cortical strut +/- Plate fixation.

Type B3Displaced #Mgmt: ORIF + Long StemOblique or Spiral #: Cerclage WireTransverse #: Cortical Strut Graft

Type C1Rare; Only Distal PerforationFollowing Cement removal or canal prepMorselized BG or Cortical Strut overlay to prevent stress riser.

Type C2 & C3UndisplacedRecognised intra - op: Steps to prevent propagationCEraclage Cable or locking Plate

Post Op Femoral #Elderly patientTrivial FallImmediate Mgmt: Analgesia/ Fluid resuscitation/medical co morbiditiesSkin/ Skeletal traction helpful

Type AConsidered Stable< 2 cm displacement: NWBDisplaced A G leads to loss of abductor function: may need fixationDisplaced AL: less common, loss of medial support may comprise the Implant Stability.

Type B1At or around tip of the implantImplant is stableTreated with ORIF

Type B2Most common typeFracture FixationRevision stem Bypassing the previous implant by two cortical DiameterBoth Cemented and uncemented

Type B 2Uncemented: Extensively coated diaphyseal StemSoft tissue balancing crucialCemented revision ideal for osteoporotic canals.Cement in cement revisions.

Circalage WiresRequire no intraosseous anchoragecentripetal fracture reductionShaft is not a round tubeNo micro #

Type B 3Bone loss either because of com munition or OsteolysisNeed to tackle both stem and the bone loss.Distal fixed Stems/ Cemented stem/ Allograft prosthetic composites (APC)/

Type CEssentially a femur shaft/distal femur #Plating / NailingStudies -> Non locking with longer bridging better than rigid locking plates

Key PointsThink Implant stabilityThink Fracture pattern & displacement: Long oblique/ spiral vs transverse/ short obliqueThink Bone Quality: Need for BG strutArmamentarium/ 3D printed model & preop planning.