the treatment of periprosthetic fracturesthe management of periprosthetic fractures is an issue of...

$: The Treatment of Periprosthetic FracturesThe management of periprosthetic fractures is an issue of increasing importance for orthopaedic surgeons. Because of the expand ing indica$
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This chapter reviews the current ev-idence regarding the management of periprosthetic fractures of the upper and lower extremities. Fracture fi xation and revision arthroplasty techniques are discussed.

Lower Extremity Proximal Femur Periprosthetic fractures of the fe-mur represent an important potential complication of total hip arthroplasty (THA). Although these are relatively

rare injuries, with an incidence of ap-proximately 1% after primary THA and 4% after revision THA, the con-sequences of these fractures are sub-stantial.1 The 1-year mortality rate after surgical fi xation of these injuries is as high as 11%, which parallels that of the hip fracture population.2

Classifi cationThe most commonly used classifi cation system for periprosthetic proximal fem-oral fractures is the Vancouver classi-fi cation, which stratifi es these injuries based on the location of the fracture and the stability of the implant3 (Ta-ble 1). This classifi cation system is

The Treatment of Periprosthetic Fractures

Aaron Nauth, MD, FRCSCMarkku T. Nousiainen, MD, FRCSC

Richard Jenkinson, MD, MSc, FRCSCJeremy Hall, MD, FRCSC, MEd

Dr. Nauth or an immediate family member has received research or institutional support from Capital Sports Entertain-ment, Synthes, Stryker, and Sonoma Orthopaedics. Dr. Nousiainen or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Zimmer; serves as a paid consultant to or is an employee of Zimmer; has received research or institutional support from Smith & Nephew and Synthes; and serves as a board member, owner, offi cer, or committee member of the Canadian Orthopaedic Association, the AOTK Group (Computer-Assisted Surgery Group for North America), and the Orthopaedic Trauma Association. Dr. Jenkinson or an immediate family member has received research or institutional support from Zimmer, Synthes, and Biomet. Dr. Hall or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Stryker and Zimmer; serves as a paid consultant to or is an employee of Zimmer; has received research or institutional support from Pfi zer, Zimmer, Synthes, Stryker, Smith & Nephew, Amgen, and Biomimetic; and has received nonincome support (such as equipment or services), commercially derived honoraria, or other non–research-related funding (such as paid travel) from Pfi zer, Zimmer, Synthes, Stryker, Smith & Nephew, and Amgen.

AbstractThe management of periprosthetic fractures is an issue of increasing importance for orthopaedic surgeons. Because of the expanding indica-tions for total joint arthroplasty (TJA) and an aging population with increasingly active lifestyles, the incidence of primary and revision TJA is increasing, and there is a corresponding increase in the prevalence of periprosthetic fractures about a TJA. The management of these fractures is often complex because of issues with obtaining fi xation around implants, dealing with osteopenic bone or compromised bone stock, and the potential need for revising loose TJA components. In addition, these injuries frequently occur in frail, elderly patients, and the literature has demonstrated that both morbidity and mortality in these patients is similar to that of the geriatric hip fracture population. As such, the early restoration of function and ambulation is critical in patients with these injuries, and effective surgical strategies to achieve these goals are essential.

Instr Course Lect 2015;64:161–173.

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162 © 2015 AAOS Instructional Course Lectures, Volume 64

relatively simple, is reliable, and serves to guide treatment.

ImagingDiagnosis, classifi cation, and subse-quent surgical management rely on the careful evaluation of AP and lateral radiographs of the entire femur and hip. Location, displacement, comminution, and the surrounding bone stock should be carefully assessed. Radiographs also should be critically assessed for signs of implant loosening to distinguish be-tween type B1 and B2 fractures. When-ever possible, preinjury radiographs should be obtained for comparison. The implant-bone, cement-implant, and cement-bone interfaces should be carefully evaluated. Radiographic signs of defi nite loosening include progres-sive periprosthetic or cement mantle lucency, a change in the position of the stem, and component or cement frac-ture.4 Radiographic signs of probable loosening include greater than 2 mm of periprosthetic or cement mantle lucency around the entire prosthesis, bead shedding, endosteal scalloping, and endosteal bone bridging at the tip of the stem. Occasionally, this chapter’s

authors fi nd CT useful for evaluating stem loosening if radiographic fi nd-ings are inconclusive. To differentiate between type B2 and B3 fractures, an assessment of bone stock is necessary and is based on the appearance of the cortices and the generalized density of the bone on radiographs.

ManagementThe management of periprosthetic fractures of the femur about a THA is based on the Vancouver classifi cation. Type AL fractures involving the lesser trochanter are generally treated nonsur-gically, unless they extend substan tially into the calcar and affect prosthesis stability. (In this setting they are best classifi ed as type B2.) Type AG fractures involving the greater trochanter are managed nonsurgically if nondisplaced or only minimally displaced. Displaced fractures are treated with open reduc-tion and internal fi xation (ORIF) with or without bone grafting and liner ex-change if associated with eccentric wear of the polyethylene liner and substantial osteolysis. Type B1 fractures are treated with isolated ORIF. Type B2 fractures are treated with femoral component

revision and fracture fi xation. The stem should bypass the fracture by at least two cortical diameters. Type B3 fractures require revision, ORIF, and, oftentimes, allograft to restore bone stock. Type C fractures occur well below the stem and can generally be treated with isolated ORIF.

The focus of this section is the management of type B1 fractures that require fi xation around a well-fi xed implant. It is of critical importance to confi rm the stability of the implant in this setting because the most commonly cited reason for the failure of fi xation when treating these fractures is implant loosening, presumably caused by un-recognized loosening associated with the fracture.5 A careful assessment of preoperative imaging to evaluate for any signs of implant loosening is critical; if any doubt remains, implant stability should be confi rmed intraoperatively by either examining the bone-implant in-terface through the fracture site or with an arthrotomy of the hip and stressing of the implant. Corten et al6 reported that 20% of implants judged as stable based on preoperative radiographs were found to be loose at the time of surgery.

The optimal fi xation strategy for type B1 fractures continues to be an issue of substantial controversy, with some authors advocating for cable plat-ing combined with an anterior allograft strut (Figure 1) and others advocat-ing for isolated lateral locked plating7,8 (Figure 2). Regardless of the fi xation strategy used, several biomechanical and surgical principles must be adhered to when treating these fractures. First, proximal fi xation around the stem is best achieved with a combination of wires or cables and screws, and it is critical that suffi cient overlap of the femoral prosthesis be obtained to avoid

Table 1 Vancouver Classifi cation of Periprosthetic Femoral Fractures in Total Hip Arthroplasty

Type Fracture Description Treatment

A Fracture around the trochanters Mainly conservative. ORIF for dis-placed greater trochanter fractures or loose stems

AG Greater trochanter

AL Lesser trochanter

B Fracture about the stem or just distal

B1 Stable implant ORIF (cable/locking plate, strut allograft)

B2 Loose implant with good bone stock Diaphyseal engaging implant

B3 Loose implant with poor bone stock Diaphyseal engaging implant; con-sider allograft supplementation

C Well below the implant ORIF

ORIF = open reduction and internal fi xation.

The Treatment of Periprosthetic Fractures Chapter 13


mechanical failure9 (Figure 3). Second, it is imperative that the fracture is fi xed without the stem in varus because in-creased rates of fi xation failure have been reported with varus positioning of the stem.10 On rare occasions, this can require revision of a well-fi xed implant if it has been implanted in substantial varus. It is important to adhere to the principles of absolute versus relative stability, which depend on the type of fracture healing desired. In the setting of a simple transverse or spiral fracture, absolute stability and compression at the fracture site should be achieved using compression plating or lag screw fi xation. This is in contrast to commi-nuted fractures, which require relative stability and spaced fi xation to allow for fracture healing indirectly by callus formation.

This chapter’s authors prefer to use a cable plate with an anterior allograft strut in a 90-90 confi guration, partic-ularly in the setting of fracture com-minution, impaired fracture biology

(for example, diphosphonate-associat-ed fractures, diabetes, and smoking), or osteopenic bone. The biomechan-ical literature supports this construct as being the most stable and further suggests that there is no advantage to locked versus nonlocked plating when combined with an allograft strut.11 Ad-vocates of isolated lateral locked plating have reported good results and suggest that this technique has the advantages of minimally invasive application and the preservation of fracture biology.7,8

Comparative literature between the two techniques is lacking, and there is in-suffi cient evidence to provide a strong recommendation for one strategy over the other.

Distal Femur and Stable Total Knee ArthroplastiesThe published incidence of peripros-thetic fractures of the distal femur above a total knee arthroplasty (TKA) is be-tween 0.2% and 2.5% for pri mary TKAs and up to 30% for revision TKAs.12

These fractures present a unique set of management challenges. The goals of treatment of a periprosthetic fracture around a well-fi xed TKA include (1) a healed fracture; (2) appropriate length, alignment, and rotation of the limb; (3) a painless, stable TKA; and (4) functional range of motion of the knee.

Imaging and InvestigationsHigh-quality radiographs of the affected knee and femur should be carefully re-viewed to determine the location and the displacement of the fracture lines, identify any comminution, assess the stability of the femoral component of the TKA, and quantify the bone stock available for distal fi xation. CT scans are valuable in evaluating these fractures, particularly in regard to assessing the distal bone stock and determining if the femoral box is open and large enough to accommodate a retrograde nail. When-ever possible, previous surgical notes should be obtained to identify the exist-ing prosthesis, confi rm that the femoral

Preoperative AP radiographs of the hip (A) and femur (B) showing a periprosthetic femoral fracture below a well-fi xed total hip arthroplasty (Vancouver type B1) in an elderly woman. Postoperative AP radiographs of the hip(C) and femur (D) and lateral view of the femur (E) demonstrating fi xation with a lateral plate, an anterior allograft strut, and cables.

Figure 1

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Preoperative AP radiograph of the hip (A) and lateral view of the femur (B) showing a periprosthetic fracture of the femur below a well-fi xed total hip arthroplasty (Vancouver type B1) in an elderly woman. Postoperative AP radio-graphs of the hip(C) and femur (D) demonstrating fi xation with an isolated lateral locking plate.

Figure 2

Six-week postoperative AP (A) and lateral (B) radiographs of the hip and femur showing a periprosthetic femoral fracture treated with a lateral plate, anterior allograft strut, and cables. Inadequate overlap of the femoral compo-nent was obtained proximally and the fi xation failed into varus. Postoperative AP (C) and lateral (D) radiographs of the hip and femur demonstrate revision fi xation with a lateral plate, anterior allograft strut, and cables with adequate overlap of the femoral prosthesis.

Figure 3



box is open and replacement is possible, and verify that trial polyethylene liners are available if a retrograde nailing tech-nique is chosen for management.

Classifi cationThe Rorabeck and Taylor classifi cation system is the most commonly used clas-sifi cation system for periprosthetic frac-tures of the distal femur above a TKA13

(Table 2). Although it remains useful, this classifi cation lacks some important information that pertains to manage-ment, including distal bone stock and the location of the fracture.

TreatmentIn nondisplaced fractures, nonsurgi-cal treatment in the form of a cast or a hinged brace with protected weight bearing may be considered. Close ra-diographic surveillance is required to ensure that fracture displacement does not occur. As a result of high rates of nonunion, malunion, and knee stiffness after the nonsurgical management of displaced periprosthetic fractures of the distal femur, nonsurgical treatment is reserved for nonambulatory patients or those who cannot tolerate anesthesia.14

Surgical treatment is indicated for most patients. Modern options for the surgical treatment of fractures with a stable implant (type 1 or 2) include locked plating or retrograde intramed-ullary nailing. Two separate systematic reviews have shown that both locked plating and retrograde intramedullary nailing have important advantages over nonlocked plating in regard to improved union rates and decreased rates of mal-union and secondary surgical proce-dures.15,16 As such, it is generally agreed that these fractures are best treated with one of these two constructs. However, there is substantial controversy in the

literature regarding locked plating ver-sus retrograde intramedullary nailing. In general, the literature has shown good outcomes with either technique, but comparative literature between the two is lacking.17-25 A recent systematic review by Ristevski et al16 compared locked plating with retrograde intra-medullary nailing for the treatment of distal femoral fractures above a TKA. The authors reported that retrograde intramedullary nailing had a statistical-ly signifi cant higher rate of malunion compared with locked plating (Fig-ure 4); however, there was a nonsignif-icant trend toward increased nonunion

rates with locked plating. The authors concluded that locked plating may offer some advantages over retrograde intra-medullary nailing, but further research is needed.

There are several important situa-tions in which retrograde intramedul-lary nailing cannot be used, including the presence of a closed femoral box or a stemmed femoral component (Fig-ure 5), an ipsilateral THA, or an ex-tremely distal fracture where suffi cient fi xation cannot be obtained with distal locking screws.19 In these situations, the fracture is best treated with locked plating. When using a locking plate, it is

Table 2 Rorabeck and Taylor Classifi cation of Periprosthetic Distal Femoral Fractures in Total Knee Arthroplasty

Type Fracture Description

Type 1 Nondisplaced fracture with no loosening of components

Type 2 Displaced fracture (>5 mm of displacement or 5° of angulation) with no loosening of components

Type 3 Any supracondylar fracture associated with loosening of components

A, Preoperative AP radiograph of the left knee and femur of an el-derly man showing an open periprosthetic distal femoral fracture above a well-fi xed total knee arthroplasty. Postoperative AP (B) and lateral (C) radiographs of the left knee and femur demonstrate fi xation with retrograde intramedullary nailing. Extension deformity on the lateral radiograph demonstrates the typical malunion deformity that occurs with retrograde intramedullary nailing.

Figure 4

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important to adhere to the principles of absolute versus relative stability. Simple fracture patterns should be treated with a construct that provides absolute sta-bility to promote primary bone healing. Multifragmentary fractures should be treated with a construct that provides relative stability (such as bridge plating) so as to lead to secondary bone healing.

The management of distal femoral fractures above a stable TKA requires careful consideration of the issues de-scribed earlier because there is sub-stantial controversy regarding the ideal fi xation construct. Further research is needed to clarify these issues and guide management.

Proximal Tibial Fractures and TKAsPeriprosthetic t ibial fractures around knee prostheses are relatively

uncommon, and there is very limited literature available.

Classifi cationThe Mayo classifi cation subdivides these fractures based on the ana tomic location: (1) medial or lateral tibial pla-teau, (2) adjacent to stem/keel (meta-physeal), (3) distal to stem (diaphyseal), and (4) involving the tibial tubercle. Injuries are further subclassifi ed based on whether the fracture is associated with a well-fi xed prosthesis, is associ-ated with a loose prosthesis, or occurs intraoperatively.26

TreatmentRevision arthroplasty is required for most type 1 fractures involving the tib ial plateau because these usually oc-cur in association with a loose TKA secondary to polyethylene wear and

osteolysis. Metaphyseal (type 2) frac-tures occur around the keel/short stem of modern primary TKA designs. Re-vision arthroplasty is required if the prosthesis is loose or failing or if there is insuffi cient bone stock available for fracture fi xation. Revision is typically performed with a stemmed revision prosthesis to bypass the defect, com-bined with a strategy for managing ex-pected bone loss. For smaller defects, bone loss can be managed with metal augments; however, large defects may require bulk allografts or trabecular metal cones.

ORIF is preferred when the TKA is stable and there is suffi cient bone for stable fi xation. This situation is the norm for diaphyseal periprosthetic tib-ial fractures (type 3) and often the case for metaphyseal fractures (type 2). The main challenge to surgical treatment is

Preoperative AP radiographs of the knee (A) and distal femur (B) of an elderly woman show a periprosthetic distal femoral fracture above a well-fi xed total knee arthroplasty. The stemmed femoral component precludes intramed-ullary nailing. Postoperative AP (C) and lateral (D) radiographs of the distal femur and knee demonstrate fi xation with a lateral locking plate.

Figure 5



the presence of the tibial component, which precludes the use of an intra-medullary nail and complicates proxi-mal fi xation. Strategies to manage this situation include locking plate fi xation (plus or minus variable angle-locking screws) as well as the use of multiple plates to stabilize the proximal segment (Figure 6). Infection is a serious com-plication in the setting of an arthroplas-ty. The soft tissue should be respected, and minimally invasive strategies can be attractive to possibly reduce infection rates and promote union.

Revision Arthroplasty for Periprosthetic Fractures and TKAsWith a stable prosthesis, fi xation is usu-ally preferable to revision arthroplasty to avoid the creation of very large bone defects. There is some controversy in the literature regarding the necessary amount of distal bone for fracture fi xa-tion.25 This determination is most often made based on a thorough radiographic review, typically including CT scans if the quality of the distal bone stock is in question (Figure 7). In the absence of

a universally agreed-on threshold with regard to distal bone stock, a tailored approach is required, with the treating surgeon understanding the available fracture implants and whether they will have suffi cient purchase in the available distal bone.

After determining that a revision is required, two major scenarios are pos-sible. The fi rst scenario is that there will

be insuffi cient bone for distal fi xation alone but enough salvageable bone that, after healing, some support for the prosthesis and supporting ligaments will be present (Figure 8). In this sit-uation, limited ORIF of the condyles can maintain bone stock and the lig-amentous attachments, thus reducing the amount of constraint required in the prosthesis while preserving anatomy

A, Preoperative AP radiograph of the left tibia of an elderly man showing a periprosthetic fracture in the me-taphyseal region (type 2) below a well-fi xed total knee arthroplasty. Postoperative AP view of the left tibia (B) and lateral view of the knee (C) demonstrate fi xation with medial and lateral locking plates. D, Intraoperative photograph showing minimally invasive insertion of the medial plate.

Figure 6

Lateral radiograph (A) and CT scan (B) of a very distal peripros-thetic femoral fracture above a total knee arthroplasty (TKA) with very limited distal bone stock in an elderly woman. Postoperative AP radiograph (C) shows revision with a semiconstrained TKA and distal femoral allograft.

Figure 7

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for potential future revisions. The re-vision construct will require stems that bypass the metaphyseal region as well as a partially constrained prosthesis ( varus-valgus constrained) to protect the repaired ligamentous origins. How-ever, a fully constrained hinge is usually not required.

The second scenario occurs when there is essentially no functional distal bone to support the revision prosthesis. This is the more common scenario, usu-ally occurring in elderly patients with very poor bone quality. Revision arthro-plasty with management of the massive bone defect is required. Options include using either a distal femoral allograft (Figure 7) or a tumor-type distal fem-oral replacing prosthesis (Figure 9). For younger patients with expected longevity to require future revision, the retention of bone stock or the replace-ment of bone stock with bulk allograft is an attractive but more technically

demanding option. Arthroplasty using a distal femoral replacement is a tech-nically easier and quicker procedure, but it is associated with high prosthesis cost and diffi culties with later revision. However, distal femoral replacement offers the advantage of immediate sta-bility and weight bearing in a patient population that is typically elderly and prone to complications from prolonged immobilization. A carefully considered and individualized approach is required to optimize the outcomes in these situ-ations, taking into account patient fac-tors and institutional expertise.

Upper Extremity Periprosthetic fractures in the upper ex-tremity are relatively uncommon com-pared with those of the lower extremity. However, with increasing numbers of upper extremity joint arthroplasties be-ing performed each year, these fractures will likely be seen more commonly. Risk

factors for such fractures include ad-vanced age, female sex, a prior history of fracture, osteoporosis, rheumatoid or infl ammatory arthritis, and revision surgery.27-31 Periprosthetic fractures in the upper extremity may occur intra-operatively or postoperatively.27,32 In general, intraoperative fractures most frequently occur during the insertion of trial or defi nitive components or the removal of components during re-vision surgery.27,33 Fractures also may occur during reduction or dislocation maneuvers, positioning of retractors, retraction against resistant soft tissues, overzealous reaming or broaching, or during procedures for joints with substantial deformity. Postoperative fractures may be a late presentation of an unrecognized intraoperative event, occur as the result of a low-energy fall or (less frequently) high-energy trauma, or present in association with a loose component.30

Preoperative AP (A) and lateral (B) radiographs of the right knee of an elderly woman showing a peripros-thetic distal femoral fracture above a total knee arthroplasty (TKA) with limited distal bone stock. Postoperative AP (C) and lateral (D) radiographs of the right knee show revision to a partially constrained TKA with limited open reduction and internal fi xation of the femoral condyles.

Figure 8



Shoulder ArthroplastyThe incidence of periprosthetic frac-tures about a shoulder arthroplasty has been reported to range from 0.6% to 3%, with most fractures occurring ei-ther intraoperatively or postoperatively as a result of low-energy trauma.30,33

Glenoid FracturesThere is a paucity of literature pertain-ing to periprosthetic glenoid fractures. These fractures are relatively rare and most often occur intraoperatively. It is anticipated that the incidence of these fractures may increase as uncemented

glenoid components in the setting of both total shoulder arthroplasty and reverse shoulder arthroplasty become more popular. Periprosthetic glenoid fractures noted intraoperatively require a careful assessment of remaining gle-noid bone stock and the anticipated stability of the implanted prosthesis. Often, the fracture occurs during preparation or impaction of an unce-mented glenoid component, leading to a split of the anterior or the posterior aspect of the glenoid surface.29 If the fracture can be reduced and appropri-ately stabilized and the prosthesis can be placed on stable host glenoid bone, then insertion of the glenoid compo-nent can proceed. In the setting of reverse shoulder arthroplasty, screw fi xation placed through the base plate may further facilitate both fracture and implant stability. If stability of the im-plant cannot be achieved with fracture fi xation, consideration should be given to staging the procedure with a humer-al hemiarthroplasty or an excision ar-throplasty and a plan to return after the glenoid fracture has healed suffi ciently to implant a stable glenoid component. Postoperative glenoid fractures are of-ten displaced and may be associated with glenoid component wear and/or loosening. Most often, this necessitates

revision surgery. At the time of surgery, glenoid bone stock must be assessed, and consideration should be made for using structural bone graft if primary fi xation of the fracture is not possible. After reconstruction of the glenoid, the construct should be evaluated, and the anticipated stability of the glenoid assessed. If there is uncertainty regard-ing the stability of the glenoid, consid-eration should be given to a staged procedure.

Humeral FracturesPeriprosthetic humeral fractures associ-ated with either hemiarthroplasty of the shoulder or total shoulder arthroplasty are relative uncommon, occurring at a rate of 0.5% to 3%.30,34

There are several classification systems for periprosthetic humeral fractures. The Wright and Cofi eld clas-sifi cation system describes the location of the fracture relative to the prosthe-sis31 (Table 3; Figure 10).

Intraoperative periprosthetic humer-al fractures often occur secondary to poor bone quality in association with overzealous reaming, broaching, and trialing, particularly with uncement-ed prostheses. Careful preoperative templating to anticipate implant siz-ing may help decrease fracture risk. Metaphyseal fractures can occur with aggressive proximal humeral retraction for access to the glenoid. When iden-tifi ed intraoperatively, humeral shaft and metaphyseal fractures should be reduced and stabilized with cerclage wires and/or plate and screw fi xation or allograft struts combined with a long-stem humeral component to bypass the fracture by at least two cortical diam-eters.28,34,35 Tuberosity fractures should be addressed with anatomic reduction and suture fi xation to the surrounding

Intraoperative photo-graph of a distal femur-replacing tumor prosthesis.

Figure 9

Table 3 Wright and Cofi eld Classifi cation of Periprosthetic Humeral Fractures in Shoulder Arthroplasty

Type Fracture Description

Type A Begins at the tip of the prosthesis and extends proximally

Type B Begins at the tip of the pros-thesis and extends distally

Type C Occurs well distal to the stem

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bone and/or prosthesis. Humeral com-ponent stability must be assessed; if a

stable, uncemented construct cannot be achieved, the surgeon should consider

cementing the component and accept-ing the associated increase in nonunion risk.35

Periprosthetic fractures of the hu-merus noted in the postoperative period can occur because of trauma or may be a delayed presentation of an intraopera-tive fracture. Nonetheless, treatment is dictated by the stability of the hu meral component and the overall fracture alignment. Substantially displaced tu-berosity fractures will inevitably lead to poor rotator cuff function, and con-sideration should be made for recon-struction.36 Fractures of the humeral shaft associated with a stable prosthesis and reasonable fracture alignment can be treated nonsurgically.30,35 However, consideration can be given for surgi-cal fi xation to allow for early range of motion. Fractures associated with unstable humeral components require revision surgery and fracture fi xation. Humeral shaft fractures with substan-tial displacement or unacceptable align-ment should be considered for surgical fi xation and are often treated with a combination of plate and screw, cable, and allograft strut fi xation (Figure 11).

Periprosthetic Fractures After Total Elbow ArthroplastyThe incidence of fractures after total elbow arthroplasty has been reported to be approximately 5% after primary surgery.37 Fractures of the humerus or the ulna associated with total elbow ar-throplasty are treated in a similar man-ner to periprosthetic humeral fractures associated with shoulder arthroplasty.

Classifi cationPeriprosthetic fractures about a total elbow arthroplasty are described by the Mayo classification37 (Fig-ure 12). Type I fractures occur in the

Illustrations of the Wright and Cofi eld classifi cation of periprosthetic humeral fractures after shoulder arthroplasty. A, Type A fractures begin at the tip of the prosthesis and extend proximally. B, Type B fractures begin at the tip of the prosthesis and extend distally. C, Type C fractures occur well distal to the stem. (Reproduced with permission from Wright TW, Cofi eld RH: Humeral fractures after shoulder arthroplasty. J Bone Joint Surg Am 1995;77[9]:1340-1346.)

Figure 10

A, Preoperative AP radiograph of a periprosthetic humeral shaft fracture below a loose and failing hemiarthroplasty of the shoulder. Postoperative lateral (B) and AP (C) radiographs show revision to a long-stemmed component and fi xation of the fracture with allograft strut and cables.

Figure 11



periarticular or the metaphyseal region, including the humeral condyles and the olecranon. Type II fractures occur at the level of the humeral or the ulnar component, and type III fractures occur either proximal to the humeral component or distal to the ulnar com-ponent. These are further subdivided to account for bone quality and implant stability.

Humeral FracturesSimilar to the shoulder, intraoperative humeral fractures occurring during to-tal elbow arthroplasty can occur as a result of poor bone quality, retraction, or overzealous reaming and broach-ing.37 Fractures proximal to the tip of the prosthesis (type III) should be exposed, reduced, and reconstructed using allograft strut or plate and screw or cable techniques. Fractures about the stem (type II) may be treated with reduction, cemented long-stem com-ponents, and cerclage wiring with or without allograft struts38 (Figure 13). Fractures involving the medial or lateral columns of the distal humerus (type I) may be left in situ, reconstructed, or resected in the setting of a semicon-strained hinged prosthesis.39 In the set-ting of an unconstrained elbow implant, these fractures must be anatomically reduced and fi xed because postopera-tive elbow stability depends on these structures; otherwise, revision to a constrained implant may be necessary.40

Postoperative fractures associated with substantial displacement or prosthesis loosening should undergo revision and fi xation, whereas fractures with stable components and reasonable alignment may be considered for nonsurgical man-agement in selected patients.38 Because bone stock is often an important issue with these fractures, the frequent use

of allograft struts is required in their management.

Ulnar FracturesPeriprosthetic ulnar fractures are un-common. In general, these fractures are managed surgically to maintain forearm function. Intraoperative ulnar fractures may occur secondary to poor bone quality and ulnar component prepara-tion. Periprosthetic olecranon fractures (type I) must be evaluated for stability. Very proximal unstable fractures can be treated with either suture fi xation or triceps advancement techniques. More distal olecranon fractures may ade-quately be treated with a tension-band wiring technique or plate fi xation.41

Ulnar metadiaphyseal fractures (type II) can be treated with cerclage wires and long-stem components, whereas fractures occurring distal to the implant (type III) often require fi xation with plate and screw or allograft and cer-clage wire constructs.42,43 Fractures of the ulna noted in the postoperative pe-riod commonly require surgical fi xation and/or revision based on the stability of the implant. As with periprosthetic humeral fractures, allograft struts are often required.

SummaryPeriprosthetic fractures associated with total joint arthroplasty are expected to increase dramatically in the future.

Illustration of the Mayo classifi cation of periprosthetic humeral and ulnar fractures about a total elbow arthroplasty. Type I fractures occur in the periarticular or the metaphyseal region, including the humeral condyles and the olecranon. Type II fractures occur at the level of the humeral or ulnar component, and type III fractures occur either proximal to the humeral component or distal to the ulnar component. (Reproduced with permission from Ricci WM, Haidukewych GJ: Periprosthetic fractures, in Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P III, eds: Rockwood and Green’s Fractures in Adults, ed 7. Philadelphia, PA, Lippincott, Williams and Wilkins, 2010, p 584.)

Figure 12

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Determining the ideal management requires a careful analysis of fracture patterns and implant stability. The goals of treatment are fracture reduction and healing, while allowing for early mo-bilization of both the patient and the affected joint. Ultimately, both frac-ture fi xation techniques and revision arthroplasty expertise are required for effective management.

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Preoperative AP (A) and lateral (B) radiographs of the right elbow of an elderly woman showing a periprosthetic humeral shaft fracture above a loose and failing total elbow arthroplasty (TEA). Postoperative AP (C) and lateral (D) radiographs show revision TEA and fracture fi xation with allograft struts and cables.

Figure 13



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Video Reference Nauth A, Henry P, Schemitsch EH: Video. Periprosthetic Fracture Fixation With Cable Plate and Strut Allograft, Toronto, Canada, 2014.

the treatment of periprosthetic fracturesthe management of periprosthetic fractures is an issue of...

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