Peri-prosthetic Hip # Management: Algorithm

Dr Vaibhav BagariaHip and Knee Surgeon

Sir HN Reliance Foundation HospitalMumbai India

Problem Statement• Berry 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 Factor

• Patient Related• Surgical Technique• Choice of Implant

Risk factors

• P: Female,age, DDH, RA, Paget disease, osteoporosis, steroid.

• T: MIS approaches, Toothed Calcar Mills• I: Uncemented. Acetabular under

reaming;Heavy Impaction on femoral side

Mechanism• Fall or Osteolysis or combination thereof!• Torsional forces caused intertrochanteric # • Anterior loading caused supracondylar #• lateral loading caused # at the tip of the

stem

Initial Evaluation• Mechanism, 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 52:281–290, 2003

Basics• High Index of suspicion intra-operatively• Imaging: Judet’s view• Osteolysis evaluation• Inventory planning - Implants/ Instruments• Reconstruction armamentarium

Paprosky & Sekundiak

• Superior 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 Kohler’s Line ( Anterior column Deficiency)

• Radiographic Marker for severe bone loss

Paprosky WG, Sekundiak TD: Total acetabular allogra s. Instr Course Lect 48:67–76, 1999

Vancouver - Intraop

5Duncan CP, Masri AB: Fractures of the femur a er hip replacement.

Instr Course Lect 44:293–304, 199

Vancouver Postop

Aim - SPAM• Stabilising the fracture• Preserving hip function• Achieving bony union• Maintaining component orientation and

stability

Type 1A Acetabulum

• Additional Screws• Restricted weight Bearing

Type 1 B

• Column Injuries• Remove the implant to assess #• Anatomic recon & # Fixation• Rim fit with additional screw

Medizinische Hochschule Hannover collection.

Type 1C• Not recognised - hence difficult situation• Additional Screw• Autologous BG• Restricted weight bearing• Close 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 Acetabulum• Post op traumatic #• Mgmt Dictated by stability• Stable IIIA: restricted weight bearing• Unstable IIIB: Revision with Fracture

Fixation

Type IV Acetabulum• Severe osteolysis - hence management

similar to Revision arthroplasty.• Reconstitute the bone stock with suitable

graft• Use adequate revision implant (e.g., cup-

cage construct) the fracture must also be held in rigid internal fixation for optimal results.

Type V• Pelvic Discontinuity• Difficult Cases• Adequate prep planning; 3D printed

Biomodels• Customised 3D printed Implants.

Femur

Preventing Intraop Femur #

• Adequate Exposure• Avoid In-situ Cuts• Femoral Torsion while dislocating• Very Gentle in Protrusion cases• Intra op Imaging

Femur Type IA

• Undisplaced cortical perforations in trochanteric region,

• Treated with packed bone graft obtained from acetabular reamings

• Restricted weight- bearing.

Type A2• Un-displaced • Require reinforcement with cerclage

fixation• To prevent propagation of #, implant

failure, decreased abductor muscle function, & dislocation.

Type A 3

• Displaced & needs reduction• Cerclage Cable Wires• Claw Plates• Changing to diaphysial fit

Type B1• Cortical perf occurs during revision• Bypass with longer stem/ Good fit• Prophylactic Wire/ Cables• Cortical Strut allograft where long stem not

long enough

Type B 2• Undisplaced linear cracks• Cause: hoop stresses during broach/ stem

insertion.• Treatment depends on implant stability. • Stable: Protected weight bearing• Implant Migration: Revision to Long stem and

Circulate wiring. If the stem not long enough cortical strut +/- Plate fixation.

Type B3

• Displaced #• Mgmt: ORIF + Long Stem• Oblique or Spiral #: Cerclage Wire• Transverse #: Cortical Strut Graft

Type C1

• Rare; Only Distal Perforation• Following Cement removal or canal prep• Morselized BG or Cortical Strut overlay to

prevent stress riser.

Type C2 & C3

• Undisplaced• Recognised intra - op: Steps to prevent

propagation• CEraclage Cable or locking Plate

Post Op Femoral #• Elderly patient• Trivial Fall• Immediate Mgmt: Analgesia/ Fluid

resuscitation/medical co morbidities• Skin/ Skeletal traction helpful

Type A• Considered Stable• < 2 cm displacement: NWB• Displaced A G leads to loss of abductor

function: may need fixation• Displaced AL: less common, loss of medial

support may comprise the Implant Stability.

Type B1

• At or around tip of the implant• Implant is stable• Treated with ORIF

Type B2• Most common type• Fracture Fixation• Revision stem Bypassing the previous

implant by two cortical Diameter• Both Cemented and uncemented

Type B 2• Uncemented: Extensively coated

diaphyseal Stem• Soft tissue balancing crucial• Cemented revision ideal for osteoporotic

canals.• Cement in cement revisions.

Circalage Wires

• Require no intraosseous anchorage• centripetal fracture reduction• Shaft is not a ‘round tube’• No micro #

Type B 3• Bone loss either because of com munition

or Osteolysis• Need to tackle both stem and the bone

loss.• Distal fixed Stems/ Cemented stem/

Allograft prosthetic composites (APC)/

Type C

• Essentially a femur shaft/distal femur #• Plating / Nailing• Studies -> Non locking with longer bridging

better than rigid locking plates

Key Points• Think Implant stability• Think Fracture pattern & displacement:

Long oblique/ spiral vs transverse/ short oblique

• Think Bone Quality: Need for BG strut• Armamentarium/ 3D printed model & preop

planning.